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1643 MAIN STREET (COTUIT)
r 1 "i 1� uo kv 0 4 �a �Se n . tao ja 4 � i � nP� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 00 3 vol Permit# r Health Division ��' � `�? 7� r Date Issued Conservation Division FS, 161MAn Fee. Tax Collector Treasur C1,A lit, (Do SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE Planning Dept. WITH TITLE 5 ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board • �=� TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address I to q3 M.XI M, S� Village Owner N cad "eg-r,- Address Telephone (� �'S`1 ` O-7�'l Permit Request IS— MnA- 2.. s► LA ��l na y (Oil 2 ►e,v � �e � Square feet: 1st floor: existing 1400 proposed _ 2nd floor: existing 130b proposed k6 Total new I' Valuation 1(p,660 Zoning District' Flood Plain Groundwater Overlay Construction Type )6(O6C �e A vv,(-- Lot Size NA, Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family a"" Two Family ❑ Multi-Family(#units) Age of Existing Structure -A7ro)2 36 YO-s Historic House: ❑Yes a No On Old King's Highway: 0 Yes ❑ No Basement Type: C�Full ❑Crawl • ❑Walkout ❑Other Basement Finished Area(sq.ft.) I Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing T5 new Total Room Count(not including baths): existing I I new 0 First Floor Room Count (D Heat Type and Fuel: ❑Gas JOil ❑ Electric ❑Other Central Air: ❑Yes La No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes ZN Detached garage:❑existing .❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage: existing ❑new size Shed: 2(existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes &No If yes, site plan review# q Current Use SC'ccwL� ��r. Proposed Use S A r� BUILDER INFORMATION Name J";RC.,< K l I M. Telephone Number Ada 3h2- 37G(.n Address S rt(S Ou Rw ti yvv\ P— License# 617 3la (70 w.wkA,G0 G Home Improvement Contractor# l 1 R2-Z C Worker's Compensation#rwe0 S8 6700 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Com\oe-c Swu• � SIGNATURE DATE f f FOR OFFICIAL USE.ONLY PERMIT NO. ` DATE ISSUED MAP/PARCEL NO.., " f 1 •. � .._ f,a .,'.' _ _.:f� +' , f ADDRESS ' , VILLAGE'... OWNER' .. . :.. . DATE OF INSPECTION:, r� ` r FOUNDATION ` FRAME s INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' GAS: ROUGH : 4.r FINAL _ �bG� j s FINAL BUILDING, 3z r.1 . � � m DATE CLOSED OUT -x -, �CD G ASSOCIATION PLAN NO. n -;,..—.,r..--._..y. .:t�z�.a r ..,,,,.�_ - fr,. •' ;:_ ��,,�'.,".;.-s.w,.;�,�"e-�C�.:rk�v�a�-or°''`,�.'''ti.�,..,..vL-�-2i�k4si�u.r`'"`"'T-,y, The Town of Barnstable , - - inRxsrnste, • 9� " �0� Department of Health Safety and Environmental Services '°rFC Mop" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner PLAN REVIEW Owner: ID00 A(V Crh/G,6 Orct Map/Parcel: 017--Gy 3 00 (. J `— Project Address: fl 1Y1 S� + Builder: j-�C,f� Y" The following items were noted on reviewing: , s t `Please call 508 862-4038 for re-inspection. fins ep ct�eed-b_y: Date: q:building:forms:review LIVING SPACE - (high end construction) square feet X$115/sq.'foot= (above average construction) IUD square feet X S96/sq. foot= (average construction) square feet,X S57/sq. foot= GARAGE (UNFINISHED) square feet X S25/sq. foot= PORCH square feet X S20/sq. foot= DECK square feet X SI5/sq. foot= OMER square feet X S??/sq. foot= Total Estimated Project Cost L c�aU For OJtce Use Only Inclusionary Affordable Housing Fes 17 Residential Q Commercial** Property Owner's Name Project Location Project Value Permit er "Existing Sq. Ft. **Proposed N Sq.Ft. Fee$ MFORM 113100 M CUR Appama 1 Table.l =(eondnmd) "criptive Paelrages for Oae and Two-FamW ReaidmmW BniblbW Seated with Fom7 Ruda MAXIMUM MINIMUM Coming ma=8 coins Will Floor 8aammt Slab HeatiaglCooiinB U vailwz Rwawce &*%I , z-valud Wag At:imetaSwipm= fficierrY' Par�caIIe - Rrvalttst R.valtte� 5"1 to 690 Heads;Oewm Darr' . Q 12% 0A0 3E 13 19 . 10 6 Ntrmal R 12% a52 30 19 19 10, 6 Normai S 12% 0.50 3E 13 19 Ao . 6 U AFUE Tr=lsv-, 0.36 3E 13 23 WA WA N=W l U 046 3E 19 19 10 6 Normal V 0.44 3E 13 25 WA WA UAEEJE W OM 30 19 19 10 6 M AFUE X 12% 0,32 3E 13 2S WA WA Normal Y 19% 0.42 3E 19 25 WA WA Nomml Z 18% 0.42 3E 13 19 10 6 "AFUE AA IEV 0.30 30 19 19 10 6 90AFVE 1. ADDRESS OF PROPERTY: P&P t U 51 r 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 3 S. SELECT PACKAGE(Q—AA-see chart above): w4,A �60 2 Z � ✓ ��a�c [Sr a nor Li�,�� NOTE: OTHER MORE INVOLVED METHODS OF Dil RMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f980303 a 780 CMR Appendix J 4 Footnotes to Table J5.2.1b: ' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall area, expressed as a percentage. Up to I%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 fl of glazing area. Z After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table JI.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-39 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. •Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding,structural sheathing, and interior drywall.For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R 13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-flame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces, basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls...Windows and sliding glass doors of conditioned basements must be included with the.other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2:for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3,4, or 5. If you plan to install more .w: than one piece of heating equipment or more than one piece of cooling.equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. h 'For Heating Degree Day requirtmerti of the closest city or town see Table JSZ.Ia NOTES: a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 035. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may.be excluded from this requirement(i.e.,may have a U-value greater than 035). _c) If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes.nvo or more areas with different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(035 for doors). i t 1 43 I —_�_ The Commonwealth of Massachusetts r•. Department of Industrial Accidents - VNCV ef/firesgooffeos 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: p� location S \S (,�V 1�'T V►ti\ "C city v• # Sa'k' 31 376� ❑ I am a homeowner performing all work myself ❑ I am a sole rietor and have no one workin in achy I am an employer providing workers'compensation for my employees working on this job. ::.:. .. �ompanv name" : �.:..'.. ............. .:......... ::...:.......::::.::::. .:.::::.:.. ::::..:: . ::.....:::.::..:. ::::::::::.::.. X.......'` Je - ✓4�"�ac 1 ^� .<: :> city ., .. ... ....' .. phone# -"' . � in3urance co: W AL � �irG �.�: alicti�;#;::". : :.... ........... _.... ❑ I am a sole proprietor,general contractor,or homed er(circle one)and have hired the contractors listed below who have the following workers'compensation o...lic.es.:.......... . . . : :: :: > >:<«:<:>:?> ?: } :;«.; .».:: : :: :: : .?::}:?;:;;:;;:: ; ? .> .. . . riim'an':.pant X. ..:................................:...:.................................. :. ....................... .......................................... ...................................... :.......................... :.. . ....n..:::::.....:. ...... :..::::.:. .:::::::..............:::::::.::::.:::::::.:::::.::::.::::.:::..::::::.::.:::::::::.:::..:::.::.:::::::.......,.... ................................ .......,.................................:...:.....................................................................:....... � line rih ..... ?:?i}:::.::::.:• .................................................v. Or ......... ? ??C.............................. ...................... .................. ..................................... ...i.... . ...... ........... .......................,....... :................:.........v::.�:.�. x.::.mot... bsnran li _ ._ _ .. an address xx is Ib ::..... �/ Foam to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a nne 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 fy t and penalties of perjury that the information provided above is trrw bud correct Sigliats�re Date 6 \6(O0 Print name a�� C�\wA Phone# 5"0� 3�2-376 L official use only do not write in this area to be completed by city or town official city or town: petmit/llcense# (]Building Department OUcensing Board ❑checkif immediate response is required ❑Selectrnen'a Office _ ❑Health Deparhnent contact person: phone#; ❑Other. oevxW 9195 PJA) 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. co oration of other le al entity, or an two or more of partnership, association, � Y An employer� defined as an individual,parts p, corporation g_ �3' 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 Y, employing employees. However the owner of a who resides there' or the occupant of the dwelling house of dwelling house having not more than three apartments and m, p 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 n 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 s`'' being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law'or if you t 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 permitllicense number which will be used as a reference num_ber. The affidavits maybe returned tr 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 Office of lnvesugations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 1 : Ta'aVWeal hvpertyCasualty , j0k Gateway Center d , 1000 Legion Place = P.O. Box 3558 Orlando FL 32W2-3556 FAX 407 649-M74 Jammry 21,2000 IC LXK JOHN..F ,3 55 POWDERHILL RO BARNSTABLE MA 02630 Policy No: 587X946700 Effective Date: 01.07-00 The Travelers Tnsuratroe Company has been assigned as the servicing carrier fo your Assrgbed Risk Workers . . .wft>t TIZimleta and it ,L' ti ire! —Comfy to service your policy,and we welcome you as a customer. l 4 We have received your,applic adoa aral pa�emium four policy will be issued shortly. In the meantime,should you find it necessary to file a claim or communicate with tease note fo �.P the llowing• . For Clsims Reporting: For Policy Serves: 14MO-832_7339 14KKW 42.9886.s3577 " The Travelers li Company Direct Assignment Division P.O.Box 3556. Orlando,FL 32802 T'he Claim Reporting system is a toll-free service that is available men days a twenty-four hours a day.Usage of Ads system has been proven to.provide aignifia�mt bendits,with the immediate.."go of of a Managerautomatic ' production of tie First Report of Injury form,and earlier resolution of employed claims. Safety and Loss Prevention are critical concerns to any business..We have long;been a,pioneer in the field of accident PM, lion,having the experience,rr aoerrcea and capabilities to provide a complete range of safety services.Your policy will include more details mpnftg these services. Please keep this in metion available. Reference the above policy number on any correspondence and have it available when contacting us or snbrni#ag_ooara;ondence. It is our plaasure to work with you. Uwe can be of service,please call. Sincerely LAUM PSOTROWSKI i Aoeount Manger UW writei i Orlando Service Center t' •4 Ce.1toGns A GRAY V(S AGCY INC "01YANOUG' ID RYAK= MA.02661 I 'Y�:--- .....,:r.?:}.i:{:t::::•;.:::,n:!.f..:::..:./. 'r:;,::':y:v.:.}r'i:.v.,r,v.�::•::• r a TIE •r:: ::i:.y. 02-02-22 H Oil, 1>6 Iti61,1 Ass A R OF INFORIIIA ROfiERS rM GRAY. YAI ®NLYAIMP �N . NO RII$H'Ig UPON THE CERTIFICATE T IA IITIFICA DOlEE NOT AME E1�TENO OR ROUT E 113OUf3H.ROAD A THE alE AirFORDED byTHE POLIOIEs�EELOW. RDUT .132. 14YANN15. MA 02601 00IE6 AFFORDING C¢VERA©E COMPANY 74JWP A THE TRAVELERS INDEMNITY. .COMPANY OF ILLINOIS COMPANY KLI'M, JOHN F 55 POWDERHILL RD BARNSTABLE MA. 02S30 COMPANY, C COMPANY : ,wr,;:;: y �,..�r�•:7::.:-:.ztx.°}n:r.,}1-•r,f�r�h?xF} t 7�4r +-.....:.,,.:. .:Cc+;:...r.r....: ,........}.:,y:.+,{ rr `y r/.., r..5 0-.,.1.:•ry oR}xs. f........ - ::....,.,�:...,..,...r.::,..i.,..•:::r„�..frcr.!,�.�.r�?:.gc;S.;..,•r...r..i�:•::rr?,.:Y........., .r.... .v::;•:::.::.....:......::??}?}:;.::�, .:?:'.v:::•:"v:�'w:::':.::vi::ii it��:J:�';-. ...:... .. , v..A,:w,Q•r.,,• ,...:::•:. v`isL:4}}:•}`?}Xt:•}:J:t•;,..;:.}v+.;::t:vr:4}}::i4:}i}'<:?:+?i^::::ii:;iiY.:�:v}ii4:i:•i:�:`. THIS 18 TO CEFItIFY THATT , OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE. INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,,NOTIIVRH$TANDINQ'ANY REOUIR$MIt TERM OR CONDITION OF ANY OONTRA T OR;OTHER DOCUMENT WRH REeRECT TO Wi1ION THIS OEFITIFI.- MAY BE Is18UED O.R.MAY;PBRTAIN, TllE"INSURANCE AFFORDED BY THE POL E8 DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS— AY AND CONDRtONB OF$UCH,POLK�IE8 LIMlITB 8H N`MAY HAVE BEEN RIE UM 9 PAID CLAIMS. 'dp , L IYF!OR INpWS1AMCE ►oUCY 1NP11NlI SOY EPl�ECTIYEOLIOV EI�INAm OA1E(YMQp1YM) 7R QgIV4Y1f) 9iME1lAL NMILRY GENERAL AGGREGATE S COMMEACWL.09NERAL LIABILITY PROOUGTB- COMPlOP AGO. CLAIMS MADE OCCUR. PERSONAL 6 ADV:INJURY St i t OVSlM6R'S Sk CONTRACTOR'BPRJT. EACH OCCLWMN, E S FIRE DAMAGE(Any one fire) AUTOMOW!tSIA�It11Y MEO.EXPENSE{Any onA Pws-) 8 e ANVAUTO COMBINED SINGLE 8 LIMIT ALL OWNED AUTOS. s " BODILY INJURY . SCHEDULED AUTOS (Por Potion) i HIRED;AUTOS NON•OWNEO AUTOi :. .. li. BODILY INJURY (Por Aocldwn) I PROPERTY DAMAGE 8 AUTO ONLY E;A ACCIDENT': 8 ANY AUTO OTHER THAN AEJTO'ONLY:. EACH ACNT:'.' .`.......r.,: 3t<ti AGGREGATE 8 dui 11ASIIJir , ;'�, UMIMELLA POW AGGREGATE' { 3HAN.UMBRE6LAP f' AWOIr01Ms"ooY►lNM70oM ANQ' ;: MU�IArE14"iL111iI�li (U8-S8TXIi46RT ). O,i-07-00; Q.1-07-01 8TA UAMTB. <:. ..>., :.. THE PtGAl. INCL. - CFi A +1T 8 PAR 11V8R$IB1{ECtf tNE, POLICY LIMIT S 500 13PPIES IRE: )C'. IEkCL.. DI86ASE-EACH EB+IPLOYEE S 100,000 rx- THI$:,R PLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE H LDER; AFFECTING ,WORKERS COMP, COVERAGE. .• .................e.. .,, ....:..... ...n+,.n. ............. :. .... tin.......... .. ...... + : ........:....r,..r.../.......,,.:::+:.:::,::::::n+::1r:.�:::.�::..:�::v;f•::::::.. v:rim:::;:. 1..........r............:;, •':r:t?'is X`.:v........:r.v.v••:F.•: .•.. .. :}.,,:•:h::?.,•. r,} 8110YLB AIIV D} ABOYB,0100 SEo'PoUe S W CMC#LLSep: OIIl3 'THE T9oM OATS T!lIOP, T11E ISf11p1A OOIIPAIIrTYBI:BMDEAVOII TOIWL .y .. .. 10 DAYS Wh9lTTEIO'NOT=TO THE OEIITIROATE M(iAM O M r fa THE DAMES ,KARUKAS LEFT, g11T FAILIN4 TO'11A1L.:WCN NOTICg at11�tL EIE oWW1TfAp oR. 40l3 LAK.4 ;DE DRIVE CENTERVI LE MA 02652 ior AWX 6000 TFIECosI1rAff* 00NP1a�xTAMBS. A'EENT AUMOMM' /M1YE 4-Y,'r•::•:y.;.r.r.:.,; r.r:..{.. '!.. r.{,>.;3.., ..,:....r.:,..n:„ ..•r x.:!,i,?. .c.;,;,.., r ,p•:fi'.,`rT: � : ':.::,.,..y..,ti,H:.:..:.•n..r:;...'••:.::Zv,:":,+,:...:'.}.^'Yt::.:ti�.,,!).?•..,.:....•..!_.. : e ,: .y ::S> , u':;,t 2t,•Na^;.#:.,.,: f.ir`:}:::!.�:... ., • dl ...;" r„ ..v- i V�e i�o��z/nza�zurra� a� ac�ude�6 } Y BOARD OF BUILDING REGULATIONS - License: CONSTRUCTION SUPERVISOR Number: CS 017310 Expires:04/23/2002 Tr.no: 20133 Restricted To: 00 JOHN F KLIM _ 5 TISQUANTUM RD .�r CUMMAQUID, MA Administrator f i ' r i. s 00-35,000 cf enclosed space (MGL C.112 S.60L) 1A-Masonry only 1G-1,12 Family Homes Failure to poste a current edition of the Massachusetts State auilding Code is cause for revocation of this license. DIG SAFE CALL CENTER: (888)344-7Z33 HOME IMPROVEMENECQNTRACTOR Registrati�on �117922" w. �z� Type LXPiration �i. t JACK KLIM BUILDER ; �= s f''POU " 0DER HILL'RD L r f. ADMINISTRATOR BARNSTABLE ..j:'4,�' ,.q.y. dk h,�'.'7 rY',1Y"n�4W,q"J�C7r�7�`F�i::�i �?�ar'S",r'.-1�"yW.ti;.:. • f ,'.]•;5.1'�ti:+..4 �aj•w.n�.y 1..._ ,I.r rt:a...a ! DEPARTMENT OF PUBLIC SAFETY CONSTRUCThBN SUPERVISOR LICENSE Nuattr Expires:• Ott 44 66 POWDER'HILL RD 4 BRRNSTRBLE, NA 12631 f�non3F9 Ib'oaarma _-� 600T.a0OF mew Gakrcer -s r' ' 1 — G SW�+4lE•CKYDs. 71 �—J i_ 1_fl 44%voHvt4 1wu"Pawce 1&43 t91.1N 6T- CtJ"�1 tT,t'U4 I 1 d ....a.�..: v..... z» 10-10 ....W JACK KL1M VLXLVNW "" - �(I'if• HOI��E BEYOND k6w V.&O C AT PVAJr I fiWFMLV HS.4 Mg.MLW' % — New csx&wr — . II L77►ditn C,GLfl$A�4'R�nENG6 IG4s hA1 N ' 'pRLNN JA(iC KLin EMJRI ric .i 'A�.�ev1d4#?ly� �:.EWCflOt�l �Zo=6 1 _.P 1 Ls FY suf__ec0?`PO►K EXI-'1—f•-90R r16R ....._.._ NF1J Lt7Rr7GR -I!__O_ NE1.1 8E9_KOOH S9ec.F 1 ego Roor1 1 e cv goon G_ou} 6tIbT•/No.l ww.L*PLU60 -- 134 D II Bw.,coon.4, -n' li Jrria 11 V4 -.-- t�xlt,T.Zx4 wbi LLb -ro FEr-WW L ---'-- - wilsr. 2�14 W4LL4 TO BE RBrtOVEfl - HEW Zx4 WLLLAi - pcl5f 80 Rn, rwyr• J70►�L419��OL98tRq �iIR!1.iG1[ 1444 rwN ST.-wTurr,r�A- �c�u:1�ps w�wwm w: eMw�• JXCK KLlrl-1!6Uit.PP—W` tgy LC1 r y�N �SoF6 er4wv.4U.La $eto cm aaz VIc".Sp-L#FAM15Nm"r tyercM Exltsf.6rLL . R�s19r NMl-r0oR- �x T.gWvF purr. Zx et;a I�"o:G.W 1/2 K CAP XKE1'1SlY-'. SNTY*-IG4-t wArma IE1.4-moG New 1CooJf-NA.1/w¢aw.1cwf•.14-v6H 2- feels R-8olmwu u/pKOIi[R�/iN{ >L C 82'o.e-- b 6Gal. __ iA4sGK es0.-.�iOFAt G.P. iZ`4Yf•eo.OIV fvzvio Golan. 60FW IZKW . I �.-~i AN!6 t~A G• 116TGN Inc✓Jf•T•RI[eLi So .. n/�u cx,vr. R t-M W.I.I ) I 2,ct•4.I+o6-Ih'cpc e�rn'4- (G4VC 'Tlvmlc•rw." tw1wr Slvl"el a� to eloY0laD I I�= 4'-4°= vl: " -P iac lYf•.0f0 RH� I yl NcW.90Fn�R Aaxi wlCr�[R u+u- " NtW Ugl'&OR tA10*C 1&0'0•c. 1 I W/Yp`"l! kt ftf1_M MAI" 44 C lx./NeuFiuflteigu+ea �'-- Z-C 8•Ekwlh WWe 30 j1t10 4-Zi 6 - Exl4f. Exwr. Fri Ewe• .. IOI-s'�{ a�-71'/sr, Q'1 4n1 — — -- --14'4 ._._.............__._--__....... —..- ---- ..._._._..... }1 - —. ... .. ... .. Newel c44CUP ctivr• VIM.Kr'1) wpfpyT. �rt4T• KlTGN6N �' I ��rdrT I`-'Ftx•� 1 Nam+5ouv of oocl"4 NW�sz°m .cal,. 1 New so'r od x 60`17 1 Neu a Ev RGbrl 0mrl e• PONA lA 440I.',;'6,E94 C644'P NG� wrr.1p-Ip-PO - .arrm JACK ICI tn- eolLvm �izxnu.lG Li>.cTlort r;T NW 310swcUle HEW zcs°OR Lee RAnMf1-Ore..'D1RtCf v! Ectrl.en-u% 2Ws, `I9••A N AS REO. om ! -or t I I �I &UnLIN6 Of z BO P•IU -I 6HONU 1YTr7C0 1 I I I � ��ST• fbsr noun" ! v . I UNMgA-T MALL t on � I IN•4.6f�NT {I t WEW taco KDOH • c7K"Lr I&" mA;w ST- COR)R,-t"^ -- 0-10-00 .avwao JACx KUM-au.'-VM 'fkAMIW,L RJiN-Z LDOR p••5oc6 F NEN %rzri V RcnF f1 usH u/VXtyf••pORr1KR 'K0 i 1 � Y i E,clsT• RavF U��OiJ 1 _ . NEI.1 u•T��+. .. GIGGw�C-vtWFf AT!11 1 a1 9~ oK Tx 1� - �%lyf• L1XR. I � � i Raap_ • � CM•tur. VbRntz iranF i . CW K1a I CR I ZK Z C19 1 Li FE-15, C><IYF �9r Wt.16cp To -�/ f 'L� II pc19f•Wyk ROuF . 1 Q►.p(ER6 v � 5 F ` N 6U Bev KOOP I 'r'3C'T&M S�O►JALD �pl-DS�t+<{ RYY,.IS7{aNGI'o :Gas ruin <sr.-coTu m rut. -1Auc rcun-0006VO e WIr.19�M1�F ,� ROOF FRxr�i N 4 'Pt.4N G of L r • • BARNSPABLL MAS�� `�$ Regulatory Services i639,',,rEn ti Thomas F. Geiler, Director Building Division Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax:' 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction alterations, . ons,renovation,repair,modernization conversion, onverston, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied buildins 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:Z^�q,004' wod�' �. l c�,,�-.cti Estimated Cost lb,y�y Address of Work: l A10 Owner's Name: Date of Application: �0 o 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 he apply t the agent of the owner. 9 2Z- Date Contractor Name Registration No. OR Date Owner's Name q:forms:A ffidav i Engineering Dept.(3rd floor) Map 01-1 - Parcel O O 3 ."I- Permit# 3 Q�? House# Date Issued Board of Health(3rd floor)(8:15 9:30/1:00-4:30) 56^l — Fee Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) Definitive Plan Approved by Planning Board 19 ^, o r , TOWN OF. BARNSTABLE Building'Permit Application Project Street Address t�t{ !k a t - �Q 1�) tT Village Owner' '`7D0 A b _C Address Telephone Permit Request ` i '�'C�06' 'WadcS -N Vii Y? First Floor `�row square feet Second Floor square feet Construction Type W C9d�'1z;Z yVk Estimated Project Cost Z.4 co Q v te" Zoning District Flood Plain Water Protection• Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure r-0-6 3c 9 Historic House ❑Yes Efgo On Old King's Highway ❑Yes Lr1VO Basement Type: ❑Full �rawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 5� Number of Baths: Full: Existing New_} Half: Existing New /1� No.of Bedrooms: Existing qw, New )!c — G Total Room Count(not including baths): Existing !f' New G`C First Floor Room Count S' r Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air ❑Yes t6o Fireplaces: Existing New Existing wood/coal stove ❑Yes o Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) XAttached(size) 2( X 2 - ❑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 -� ,G► Telephone Number SUS 3(-2- Address sS powk_i_ A,"� �� License# a•l 11 3 �d- :a A`niz$ r 1 r A Home Improvement Contractor# 2-2- Worker's Compensation# `J- 6 L F 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 BUILDING PER IT ENIED FOR FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED - • 4 ±mot - s >" � � � - ..,,y I•• 4 �:..,� MAP/PARCEL NO. ADDRESS '; '� VILLAGE OWNER • . _ - etr` _, + 3 ti _ s' t. ~'� . . i 'k .. t.' .' t ,e ' .. ... • ' ' 4Y ,. DATE OF INSPECTION:' FOUNDATION FRAME t i INSULATION i FIREPLACE •-% w' - ,: ' ELECTRICAL: ' ROUGH FINAL PLUMBING: 'ROUGH ,FINAL-; GAS. ROUGH FINAL FINAL BUILDIN%' p'�.�,/��;'�,r�£,. "'ems '• _ . DATE CLOSED OUT ASSOCIATION PLAN NO. , THE F, - : . '+�, The Town of Barnstable • MARNsTABM • 9� mma �m�' Department of Health Safety and Environmental Services 10rEvr�' 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 AFFIDAVIT = -- HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ' • i . 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: W,4,Wx Est. Cost lS 00 O Address of Work: y F Owner's Name —P)dv"O�l�_ �a �a Date of Permit Application: U I hereby certify that: 1 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 Date Owner's Name q. The Coninronwealth of Afassataiusettti M. �'--�tv Department of Industrial Accidents •>, ;'' t' ! 011lceallttyesl/gatlons _ 5�':- \�:;..:..__r 6001Vu.v/itz,, Street Burson.Alas. (12111: . Workers' Compensation lnsurance Affidavit 'Ialicant information'• Please PRlNT'Ie-,'1�'V name <A%hn Iticalinn� �JS • 'QOW�C� ���� �C ' tits �IPt�KS � (• vW O?aL 3 V. nhonc {oL ❑ I am a homeowner performing all work myself. (�I am a sole proprietor and have no one workina in any capacity ❑ 1 am-an mplover providing workers compensation for my employees working µon this job. � eontunm•name: a d d resa ct[v nhnne#• insurance rn. Jtniicr# [eam a'sole proprietor. general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comnnny name: ;Itidresc• cin•: t nhonc#t insurancr rn. nnlic� # ' ...�.::•+... Vw..._.�.�«_ .T..Y..:.....: «_ �r�-sb7��1a�•T•'J!�ww•y_ �.�.t._ ��....y. _ .. comnnnc• name: addrescr rim: phone#• insurance co. "olio•# Attach additional sheet if necei_sarZ =•�_•:�'- - •+ --_+�- -. Z."'- -- - •��• •^'••T'•'-""•+•• +•—+--=`�� _:..... •,._— .��.''�-'� failure to secure coverage as required under Section Z5A of AIGL 153 can lead to the imposition of criminal penalties of a line up to S1.500M abdiur unc\cars•imprisonment as well as civil pCn21tics in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a COP)'of this statement mac be furn•arded to the Olrce of Investigations of the DIA for coverage verification. 1 do/rerehv ce ifi nr t/c pains and penalties of perjrrn•that the information provided above is true and correct. Signature Date S I f 8 Print name Phone `L {' .:.. w ofricial use unip do not write in this area to be completed by tiny or town official cite•or town: permit/license# nBuilding Department ❑trccnsing Board { a check if immediate response is required,, oSeleetmen's Office i E311calth Department contact person: phone#• nUthcr Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the � •• from the "laN%-'*. an enr l(,ree is defined as every person in the service of anoiher under any employees. As quoted p . contract of hire, express or implied, oral or written. An emplorer is defined as an individual. partnership, association. corporation or other legal entity, or an} two or nor the foregoing cnuagcd in a joint enterprise, and including the;legal representatives of a deceased employer, or the rccciver.or. trustee of an individual , partnership. association or other legal entity, employing employees. However th 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 spch dwelling ho or oft the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe 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. Add itionalIy. 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 been presented to the contracting authority. i' Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law'or if you are require,- to obtain a workers' compensation policy. please call the Department at the number listed below. . City or towns Please be sure that tite affidavit is complete and printed legibly. The Department has provided a space at the bottom c the affidavit for you to fill out in ttte event the Office of Investigations has to contact you regarding the applicant. Pie be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned the Department by mail or FAX unless other arrangements have been made. The Office of Investi_ations would like to thank you in advance for you cooperation an 11 d should you have am'question please do not hesitate tblgive us a call. - , The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations 600 Washing,ton Street �a Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409.or 375 WON ESIR 4HONE jKpROVENENT CONTRACTOR G;7 , a sa; TYpe I' Expiration v12/26y/98 ' Ft 3 �N��+�'a;4 dCKv.��.FiFm3•+'��A�ii.'��1 ,q•,":fi,�s z5 i 1L ,ry� qj jJACK KLIN7W BUILDER $`"POWDER HILL.RD i AnNISTWGOR BARNSTABLE NA 026304 � = 3 fi _"r r #�1 tiF'17 ys,�,t 4.r rit+s+l''..`pj 2 ;•.w �`' ` s "',:i •rrl.a'� -+� ,zSL:',-�.�"Yk':2i4 t a ,.r a DEPARTMENT OF PUBLIC SAFETY ` COMST66liN,.S.UPERVISOR LICENSE Nuebe G 1• ;Expires: . :. Restrdted ta;� !0 AN 1CIM 55 POWDER HILL RD ".. BARNSTABLE, NA 12630 }: � l i �i /.d 0.95AC STANDARD LEGEND \/ 19.7 ("I nose:not all symbols will appeoi an a map /\ U/ #1611 /\4.3 GOLF COURSE FAIRWAY - DECIDUOUS TREES r EDGE OF BRUSH i \ ORCHARD OR NURSERY \-- ""' - __ — _ .r CONIFEROUS TREES \ `..� 0.81 AC MARSH AREA EDGE OF WATER \ r '/ /�/� \\ � � i,• #0 _ — DIRT ROAD 1T.,,A���DRIVEWAYS PARKING LOT (� / ` n 1 J `� ( 11 PAVED ROAD 19.5 i//! i +,_.f; �' //, r ��', 1 {l`=:"\ 'J t 1 - L DITCHES #1623� 1 ��� PATH/TRAIL \\\ PROPERTY LINESLOT ACREAGE J bOAC`•,., / .�' ',• '! ., t..� ) ai'F—PARCEL NUMBER i ,=/�/ — — — _ .... `° HOUSE NUMBER 2 _. _.._.... LLJ #129 / - j l 2FOOT CONTOUR LINE �"— 1° 10 FOOT CONTOUR LINE SPOT ELEVATION A 0;6 t i 1607 ;7ij f? S _ STONEWALL #9:999 �' FENCE ,�. ' 1.85 AC %0.93 AC RETAINING WALL ...7 �1� ' -15-2 RAIL ROAD TRACKS ' #0 TELEPHONE POLE _ #1643 STONE JETTY l 16 e 1DEN SWIMMING POOL rl PORCH DECK S; BUILOI NGS/STRUCTURES 7°kJ W-t+- DOCK/PIER/JETTY � ✓/ 16.1 ASSESSOR'S MAP BOUNDARY/\ , , 1 �. SITE MAP 2.37 AC T.O.B.GEOGRAPHIC INFORMATION SYSTEMS UNIT \ Z ; 7,9 SCALE in feet 17.1 A 0 52 ( 0 50 100 ; I1 1 INCH = 100 FEET #1664 N 9.2 w e /,..... i� s TEIn,n 1 1.20 AC "' E E a 18,4 , 1� THE PARCEELINESARE ONCY GRAPHI(REPRESEXTATIONS OF 1 l,': PROPERTYROUIIOARIFS,MEY ARE NOTTRUE IOCAlIONS,mh93-9A r. #1665 ".,• y 17. �4 ' VEGETATION TOPOGRAPHY AND P ANIMETRIC DATA INTERPRETED — DIGITIZED FROM 1—100 %,... L MAPPED AT IAE0.1ADOVPAR(EL DATA DIGOGRAPIIY AT I"^BOD' ENGINEERING ASSESSORS MAPS 1995 l tsocawtAppaWki Table JS21b(condoned) Preeriptive Packages for One and Two-Famdy Residential Boiidlap Seated with Fossil Faeb MAXIMUM MINIMUM Glazing Glazing ceiling Well Floor, Basement Slab Headug/Cooling Areal U-value= R-value' R-value' R value Wall Ptrmuta Equipment Ellicieacy' Package R-values° R-value' 5701 to 6500 Hating Degree Days' Q 12% 0.40 38 13 19 IO 6 Norrmal R 12% 032 30 19 19 10 6 Normal S 12% 0-50 38 13 19 10 6 85 AFUE T 13% 0.36 38 13 23 WA WA Normal U 139G 0." 38 1 19 19 10 6 Normal V 15% 0.44 38 13 25 N/A WA 85 AFUE W 15% 0.52 30 19 19 10 6 8S AFUE X 18% 0.32 38 13 23 WA, WA Normal Y 18% 0.42 38 19 25 WA WA Normal Z ISM. 0.42 38 113 19 10 6 90AFUE AA 18% 0.30 30 19 19 1 10 6 90 AFUE I. ADDRESS OF PROPERTY: (o i3 KAI N 5 k 6:nrru Y- 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 140 3. SQUARE FOOTAGE OF ALL GLAZING: Z(o 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q—AA-see chart above): X NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. 1 BUILDING INSPECTOR APPROVAL: YES: NO: q-fo=4980303a ;. 780 CMR Appendix J Footnotes to Table J5.2.1 b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall ;t area,expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area. 'After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing, and interior drywall. For example, an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-b insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces (such as unconditioned crawlspaces, basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other'glazuig. Basement'doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slats:-Add an-additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3, 4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1a NOTES: . a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer'.in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall, floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- i less than ore equal to the U-value requirement 0.35 for doors). value of all windows or doors s q q ( ) e 43 `.. i , - - ' .......a P N a, lyw •• age f < f f � � 1 Project File No. 2 Location Date BY 3 Subject saMMAORY �. Checked BY 4 Based-on Revised BY 5 # ;........<............ .;.... .. .....:... -..;-. ... . . : s a . .. 7 s .. ... to .. ....;... .. .. . . 12 13 ? :..... .. 14 ............. ..<.......... .........>... ..>. /J ........:. ........ ..15 �1 16 17 !/ .......... .: ............. : 1s .....:.............. .. ...................°........................ ;...... . 19 ........:....... p� .....�'5........... ......:. . 20 21 jr �. : j :.... ., 23 �.:. f ............... 24 � .. 25 26 ... 27 28 29 .. 30 '�A p 31 .......:... 32 33 34 ......`............... _ 35 36 �. fJr�!._ � c.�l . .................. .. ............ .'....... 37 38 .... 39 40 - .. ... 41 _.....i.. ......... .. .. .. 42 . arr ..... .._.... ,.,.... i 43 ..._.. .. 44 �`5 ...... . ......:........:>..............<........:........„.... .............. .. ...:... .-;.... 46 o' ..........:........:........ .... .. .......:................:........:.... ..... .. 47 Mo.158f2�Q ......:.........................:.. .........................:.. ....... .. .. . <... 48 ...:......:.... ........:>....................... ..... .......................... .. .. kAI 49 s. i Page No. I Project D File No. 2 Location Date • e By 3 Subject Checke6 By 4 Based on Revised By 5 ......... . 6 Ir 7 8J. ;s 10 ix 11 _ 12 - 13 ... . y . 14 Y� ?; I 15 16 .......:.......... 17 1 . 18 19 .......: ............. 20 .. �✓ 2, c ' 22 23 24 25 1 _ 26 f 27 ................ . ._ . 2s -' 29 -- 30 ...... ._..--... 31 . ... 32 r 33 34 ./� 35 ... .. 36 i 37 38 .......... _ .... 39 40 4g' 41 ,�GP�� M4Sn\ 42 N DO ALD 43 ^. / QL —. : 44 .A Ne.D1 81R v .... 45 - �0 ......................... ..:.. ..... .- _ : f� .. 46 ....-..:.. : �.q` 47 ........................:..:. .. .. .. 48 Page No. a 1 Project File No. 2 Location'. ,9 Date By 3 Subject Checked.' By ' 4 Based on Revised By 5 6 is .. 7 i ... >.......:.... ::............ ......<..... ...... .....<. ... 8 9 fir•--- ;, _ 10 --: .- ._; ... . ' s , 12 .13 ..................................:................:. . .................... 14 15 ........_ ...;.. . .... .. 16 .. .. _............. .......<...............>...................... .......... . /l�Pv�P 17 18 - -- - 19 .... 20 ............ . ...21 ............- _.. .. ... 22 ... _. _ .. �., 23 24 �. 25 26 27 - .,.._ ..... .. 28 29 30 jr 31 __.. ..... 32 ... _ 33 34 . 35 36 A/ 37 38 // z 39 40 41 42 F M4�s 43 ONAID 9�yG .. as _ O T. . . 7 45 p No OLD 12 0 ............... . . : ................ .... & - 46 ................... ... .......... ........ P� �C'1STE� .. 47 48 :........:.......:.......:............. ....:... 49 .. .. . Page No. �. 1 Project f File No. 2 Location ,! 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(!Sour rw) --_ , a.+...Cwr►a 1 �.'h. � ie''At 9'_ i sa►.IP"Mot- i VMP— Km.t Ir Nwt—r h! sow ,L i �: Assessor's office(1st Floor): Assessor's map and lot number 1t~M MUST Q 11 Board of Health(3rd floor): / pp� eW �� Sewage Permit numberb I OV T INCOPAPUM Z BAHJ97ADLL i Engineering Department(3rd floor): House number ra= 1bso•Definitive Plan Approved by Planning Board 19 im �o Mar a APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR -4 APPLICATION FOR PERMIT TO �� 1 � `�✓� � `� �� TYPE OF CONSTRUCTION �l.�Q"TJ� '_�e_PrOk6 19 e— TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location I(1043 'AA 1M 4�;T ' Proposed Use V �A VMS Zoning District ` Fire District Name of Ownerlo ,Jopw Address tbA,6 IK41 ju S�- MA Name of Builder �a 1' � i� 1.i�[ Address 'Far Name of Architect "C Address Number of Rooms Foundation Exterior Wk-,6_ C am^ S%1%�M Roofing T` Floors Tt L / � eo Interior D. LW\ Heating k r A Plumbing Fireplace � Approximate Cost �® co� `--� Area Diagram of Lot and Building with Dimensions �t/fit X�Q` ��- � Fee / Lv`3 1� r OCCUPANCY PER MI REO IRED FOR'N&DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barprea above construction. Name Constthe, 0 7 GOLDBERG, DONALD & JOAN xg No 33194 Permit For BUILD ADDTT 1 oN Single Family Dwell ; nq JF Location 1643 Main Street _ - ' Cotuit Owner Donald & Joan Gnl d3 d-rcr _ Type of Construction Frame- Plot Lot w Permit Granted September 8 19 89 ' Date of Inspection 19 (_ Date Comple ed 19 r I ei4 _ CPC.a it Ni �YP �. ti • + w �.. 1 4 t Assessor's office (1st floor): Q '77 — (jC > tNE Assessor's map and lot number .......................... ................. SE r C SYSTM"us��� at • P..°�` TO�f Board of Health (3�d floor): 4 Sewage 'Permit number ....... ,Engineering Departme.�.�t (3r oor): vv �/ ;_:- t N d4 �;( D g;j� �o t639. House number . Q. ................. J ... Wl fGtJ1.slTiGtVS. 0 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 BARNFSTABLE BUILDING °INSPECTOR APPLICATION FOR ;PERMIT TO....:...... �.� ..:............ d r� TYPE' OF CONSTRUCTION ...:: -tR 1M. ......... ...:..... .:: ............ ............. .19 TO THE INSPECTOR OF-BUILDINGS; The undersi ned hereby opplies'for a` permit according'to the following information: Location' . ...........!V\ ... ...`........CcP U.:�:T ' .A...... ... .............. Proposed :Use ...........7r,><L ......... . ...................'.. ....... 41 Zoning District Fire.District .......1_© ............ Name.of Owner e .h.:... . .. .....Address ....... ......:. �"I t \?..................... Name of Builder G' .. . .. ...........Address YA • Name of Architect .......................:................................'.....:....Address ...............:...............:....................................... :..... Number of Rooms ........ 361c `� v .. ...............•........::.,..........".....Foundation ..............:......� : .:..�0.!�..A. Exier ior. .........................:....:................:....: Roofing '........ Floors .. ......... Interior r.......................... Heating Plumbing Fireplace .........................................................Approximate Cost .................. Area 1 0....5. � ............... Diagram of Lot and Building' with Dimensions Fee terry 1 M �'0 S OCCUPANCY PERMITS REQUIRED FOR NEW'DWELLINGS I hereby 'agree to conform to all. the Rules and Regulations oFtnn f Barnstable regarding the above construction. 'Nam Conrvisor's License :O )..3` �. ' GOLDBERG, DONALD } • No s'31775 Permit for .Add Deck j ............. _ Sinle�, Famil. '...Dwelling............. ; ......... Location „l6'43.Ma•in••Streea�..... ' ....•....• v=` r I t Cotuit 1 - ................ w *; Donald Goldber -- j Owner ..... ..g. .... 1 Type of,?Construction Frame ..................................` ..f .. . ... � .......... , r f• ; 4_ 1 P16t .x . ... ..... t Lotw ................ ......... �. Permit Gran ed ..Apri1...6 ' ....... 1:9 88 Date of Inspe'diori ...... .. ..... ...19 H Di&e;;Comp_.ted .............. .......� ......:.......19C. IE cc Ntl L r i Assessor's office(1 st Floor): j' ,-7 � �� �00� SEPTIC SYSTEM MUST BE Assessor's map and lot number Y� S� fig t Pic �`• ConservationINSTALLED IN COMPLIANC(4th Floor): - �� — —� � I,A �q WITH TITLES Board of Health(3rd floor): a ' ,r p_ E�a IRONMENTAL COOS seXISTLBLZ . Sewage Permit number G l 0 rua TOWN Engineering Department(3rd floor): OU � House number r rrr Definitive Plan Approved by Planning Board. 19 APPLICATIONS PROCESSED 8:30-9:36 A.M.'and 1:00-2:00 P.M.only TOWN OF - BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ,�lV � Z11�( v�(M (3 VLn L&LO�W TYPE OF CONSTRUCTION cs0� - 5 l 19 — TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location '(o 4?� 61 Q �� ;f M Proposed Use Zoning District K- Fire District Name of Owner �y`�1G�C� 1�be �� Address k(,-L -3 rn 01W3 S T • COT U CT Name of Builder �I--1 V✓` Address SS V J( 1?� Name of Q'4 'I Address Number of Rooms MA1Y• �<94 Foundation ���5`1—I� G e Exterior I�Z �� ?� C 5�® S Roofing Z � / 112�tCDX -Sn�LIR Z�— S��i�4� Floors C }� LV lh`d Interior—`', —L*-kWCXM )RAt Heating El�C �L PlumbingT6P U�fri3v ,\� Fireplace Approximate Cost -zs b0C Area Diagram of Lot and Building with Dimensions Fee 4 f 0 V�_ v t 4- MW I IUkg a 36 . l6o`_fi 4� + V OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 4 Affa. I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above const ction. Name Construction Si ipervisor's License v .r GOLDBERG, DONALD No Permit For BUILD SECOND '-,STORY, SINGLE FAMILY DWELLING ^ ,.Location 1643• Main St, Cotuit fit Owner Daniel Goldberg , Type of Construction Plot Lot Permit Granted June 23 , 1994 Date of Inspection: Frame /i/51 19 _ Insulation oaf 19 Fireplace 19 `• Date Completed 19 , . tw r" ro "s " F . E F t_ ailir " n Assessors map and lot number ...... '... �................ SEPTIC SYSTEM MUST THE roe` Sewage Permit number ........ .........��...'--..t.:... .�,�....�.`� 3NSTALLE® IN C®MPLI r t� WITH TITLE 5 t BAU'STADLE. House number ���3.'......ry.l .1.1N...S.r...........<...... .. ..... �Ni/IR®I1lNIEHTAL CODE b 9. TOWN REGULATIONS a MO a TOWN OF BARNSTABLE BUILDING .'I,HSPECTOR APPLICATION FOR PERMIT TO ...!.>Q.�..�1 ... dg�/�Q�, Z ,,,ter r CMS 1!; .. . TYPE OF CONSTRUCTION ........N ......... . ................................................................... ............ .`..........................19.M TO THE INSPECTOR OF BUILDINGS: The undersigned/(h((ereby applies Qf�orr a permit according to the following information: Location .....`. ...k ............. ..i.?..........................................� � � .............TV\�............................................... Proposed Use ............. �...... G4 ..................... ............... Zoning District ................... ...................................................Fire District ...................t,.r .l.. ............................... Name of Owner ...... �?.� ... ..........Address ....����§. rP �� � 4 .. ...................... . U ............... Name of Builderd.. `-�°rCX�� ......Address 2� f� ........... . .. �... Name of Architect ................Address Number of Rooms ...z...............:..........................................Foundation .. }'L..�`�Tl ........ ..�............................................. Exterior ....................................................................................Roofing ..... 5. ? .... ...................................................... Floors `�.�!�+.44' fW !.Interior .. �+1� ................................ ........... . . ... ........ (9 �..........f�. �S i_ �4'�y-�-...................4T . ......... Beating .... .... . Plumbing Fireplace ... „/0.!.Aj.e....................................................Approximate. Cost .. t,.®� .............................................. Definitive Plan Approved by Planning Board ________________________________19________. 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 n nstable regarding the above construction. Name ............... ................................................... Construction Supervisor's License 3.................... GOLDBERG, DONALD A=17-3-001 2912...6 Permit for Add dormer to. NO ........... ... .................................... 2nd floor of single fam. dwell ............................................................................... "-k Location ............................................................Main St ree t. Cot Ui t ............................................................................... Owner ......Do.n.ald. Goldberg .................... L Type of Construction ...........f rame ............................... ........ .........:.......... • Plot ...*........................ Lot ................................ Permit Granted ....Aipr.i I...2................?1986 Date of Inspection ........... .........19 Date,Completed ........ ...... ......19 7y1 i f Assessor's map and lot*`number ...... . ..... �� f = SIHE Sewage Permit numbern..''z..l..... �p Z BARNSTADLL i House number`.... y 3,........19%.).)...IST............::..... ' 90o M6 9 • �0 YPY a` TOWN, OF BARNSTABLE BUILDING INSPECTOR APPLICATION' FOR PERMIT TO .... 4��. e... ;i�jr�np, .. 1wi ....�- '.l�'�.1:..........:.. TYPE OF,`CONSTRUCTION ....... ...... ! . .:..................................................................... .......... ..........................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: r Location ..... .1 ...!. .............. ..l.t..'. � ..... ............. Ut�.,............... ............................................... Proposed Use ...:. _�2 4�1�1 . '� G4 . Zoning District.. ................. ........... ./...................................Fire District .................... :,7............................ Y Name of Owner .? !\ `. ......4; Sal , .`�?. '. . Address ....�.�Aar�.......y!!.`.''.A.«..���....................................... Name of Builder C3.. � ...... !'f<-n ...... n . ..........Address .r�.. ..�C�f..,{.. . ... �, ................ .. sal: S Nameof Architect ...............................................:..................Address .................................................................................... Number of Rooms :.. ........Foundationce � `.................. i...................... .... ................... .: ....... Exieriom .<................................................:.................................Roofing ...... 5.?YNII: .,,.................. 4. ` ( + 4 Floors ` ...... interior . 11.. 41eJ .................................................... I Heating ......... O AA...............t..\,... ... .:..Plumbing ......: .. ..:..Y :rti�fi.►. ..........:..... :. a............_- RA Fireplace ........... .........I..........................Approximate Cost .. vtE .............................................. 4— Definitive,Plan Approved by Planning`-Board ______________________________19________. Area 2.4.4.a.-S .............. 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 o n o rnstable regarding the above construction. Name ............ .. .................................................. Construction Supervisor's License t�� GOLDBERG, DONALD A-17-3-001 2-9126 Add dormer to No ................. Permit for .................................... 2nd floor of single fam dwell ............................................................................... Location ....1643 Main..St..,....gpj�14it ........................ ........ .......... ............................................................................... Owner .........D.on.a.ld... ................... . .... .. .... Goldberg..... ....... .. Type of Construction ...............frame .............. .... .. .. .......... .................................................ke................... Plot ............................ Lot ................................ Permit Granted ........April "2 ...................1986 Date of Inspection.....................................19 Date Completed ............... ..................19 IcY,7 .a ::±-.._�j�,�.., .irrr. .:�' R�"au ar ;.� ,,,/;_.,r,s2 a+n r:rw x .,n. ., _�, r• ,. •..r Assessor's office (1st floor): Q/ '— Q G� i' -t ° YNE F T Assessor's map and lot number ............................................ � °�`♦ Board of Health (3rd floor): C WP o d Sewage Permit number. .......f z .. Z BAH39TGDLE, Engineering Department (3rd floor): �o Ne & (� e, House number r ...� , a .. ................. +� .}�{P....,: ... .1 O'EDYP.1 ,. 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 ......... e.......:........................................................... ..................................... TYPE OF CONSTRUCTION .... '� .ff'? ,......... ?!!f!. '............................................................................. ' ,....' n.......................19-� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... . „h1r >........... 11A1� ... ��.�........t' �� ..5..' .........M.A..................................................................... ProposedUsed <- .................................................................................................. .�- Zoning District ...... .�.'.. ........ ?6! .....(Sv! �Aa. ,' �........t1/I +s 1 �", C"cam '�a NA Name of Owner �.:..................................Address �;�::,... ... ...,..,.........................."1...... ............... r Name of Builder ,,.�� 1�,.. {�c,� t t. ,..; .,v,?.�'................Address 1':. ` '' .(- .,! :�1!!........ ...... �r1 . .IlkV'....... x.:. r Name of Architect ......................... ........................................Address .................................................................................... Number of Rooms ....................... ...........................................Foundation ....zg-�.".'K sir Exlerior ....................................................................................Roofing .................................................................................... Floors ..i..? ., ......�r'�. .......0. .Y,,.n, .�..�.�............................Interior ................................................................. Heating t g ........................................................Plumbin ............... .................. Fireplace ..................................................................................Approximate Cost �........... J.........�.................... ................... Area � Diagram of Lot and Building with Dimensions Fee ( ' r fn I L 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. �c 4 ~� hr W Name. .... .... ............................................ Construction Supervisor's License ANI. .......... GOLDBERG, DONALD A017-003-001 /�- 617 - 0c3 a1 No ...31775 Permit,for ..Add Deck . .................. Single Family Dwelling ......................................................................... Location 1643 Main Street .............................................. Cotuit ................................................................................ Owner ...Dona . ............ld.................Goldberg................................ Type of Construction ....Frame . ............................ ............................................................................... Plot ............................ Lot ................................ Permit Granted ......April 6 , 19 8 8 Date of Inspection ....................................19 Date Completed ......................................19 d ' - u. . t . ..• t4J • '��}.1,�I�y4,. f•... .'1�. '4.isH r ..tf .. . Assessor's office(1 st Floor): h Assessor's map and lot number (! d !� (' yo`YN E To` ° Board of Health(3rd floor): Sewage Permit number Z DA STADLL i Engineering Department(3rd floor): rasa House number --A �/ xi °o t679• \®�" Definitive,Plan Approved by Planning Board 19 ��raY a 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 ta����.r„� -�Of ~'(ATM'' TYPE OF CONSTRUCTION v�..IPtV�E 1 19e-os TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 1644-11 MAIM IST • (oikjA Proposed Use AAA. ° � \AAtW01 QDZ40V\ Zoning District Fire District Name of Ownerlwy;-A A jww 1 Address kS r4a$u 5�- - ,+ Name of Builder WSPX6nL. Address . 4 D ES ► Au e S. Ild6 h\o ri"� Name of Architect Address Number of Rooms Foundation * Exterior W\--� 62"� `•'�a�� Roofing ��'�-r Floors T1 L I— y S/s fD?c S QG Interior 7)r Heating � � V Plumbing Fireplace Approximate Cost coo . Area « C> 5 t Diagram of Lot and Building with Dimensions , i • t I OCCUPANCY PE MATS REQUIRED FOR NELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstabl regardin the above construction. Name - Construction Supervisor's License t a GOLDBERG, DONALD & JOAN A=017-Q03-001 017-COS-001 No 33194 Permit For Build Addition Single Family Dwelling Location. 1643 Main Street Cotuit Owner Donald & Joan Goldberg Type of Construction Frame Plot Lot Permit Granted September 8 , 19 89 Date of Inspection 19 Date Completed 19 i _4� > ... - ... ..... .. -- ..... ... ..... ........ .... ........... .........., .. .. .... ..... .. ... .. t ....... cr" WW ...._ ...... .. .. W a a `�W �l►J - J' ICGr�e� 0 0 0 _ . .. ............ ......... 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"---r-i— r I }• 1-#�-r t-r----1--r---^ I I t Page No. • tIll" CJZX GOLOBERG•ZOINO 6.ASSOCIATES,INC. / GEOTECHNiCAL•GEOHYDROLOGiCAL CONSULTANTS Project ,�,/,f��� 1-4, File No. 2 Location Date �Sw �''� By 3 Subject, Checked By 4 Based on Revised By s 7 a 9 P p 1 `L Cali _ l 7 L Ate. T _ �`-�-�"___..� -7- .....' .. 12 13 i y . -f 14 , 15 i: r 16 S j 17 , n _ 19 20 _.._. _ .......... z, _ 22 In 23 2425 ' ? G __ ��, :___ 2��,, ,mod T' ..... . 26 27 26 29 30 31 32 33 34 /, v 3s 36 37 - -- " 3639 i� r� 2 40 'Z . 41 �4u 42 s 3�� c Miss �,'- ?r a3 5 c� DON ALD._ yp. w X T, rn as Cl ..--GOLDBERG---'.. y 46 47 46 49 Page No. GOLOBERG•ZOINO&ASSOCIATES.INC. GZX GEOTECHNiCAL-GEOHYDROLOGiCAL CONSULTANTS Project File No. 2 Location Date By 3 Subject Checked By 4 Based on Revised By 5 s 9 10 13 _.._;.......... v ; �r 14 15 /?7 / - - L6 - _.. ... _ 18 r - -- - 19 20 2, i•'--� 22 23 _ I 24 25 26 27 2929 �. ;. 36 w. 3, k 32 ~~ 33 34 35 36 37 38 ;_. _ 39 9 , � 2/ _ - 4513.- 0- - 40 a, 43 44 OF 45 �6a DONAIb 47 v GOLDBERG _ .. O 49 f l�V d� y COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY ; OF ONE ASHBORTON PLACE MAS SAC'HUSETTS B.OSTON,MA 0m08' lic}e 5 LICENSE. :XPIRATION DATE C O RS T R. SUPERVISOR 0 4/23/19 96 EFFECTIVE DATE LIC-NO. IESTRICTIONS NONE .U6/30/1993 017310 JOHN F KLIM SS POWDER HILL RD �EIARNSTABLE MA 02630 PHOTO(BLASTING OPR ONLY) FEE: 100.00 NOT VALID UNTIL SIGNED BY LICENSEE i ND OFFICIALLY • HEIGHT: STAMPS TURE OF THE COMMISSIONER - THIS DOCUMENT MUST BE • CARRIEDON THE PERSON OF S TURE OF UGEN$ _ THE HOLDER WHEN EN- 0—,HERS-RIGHT THUMB PRINT GAGED IN THIS OCCUPATION. ' �e�omrnnaruicrzl!/r. ./Lfaasac%.raeCG HOME IMPROVEMENYCONTRACTOR Registration 102696 Type - PRIVATE CORPORATION ' d Expiration 07/02/94 Coy's Brook, Inc. John F. Kilo 24 Forsythe Ave ADMINISTRATOR South Yareouth MA 02664 i I r«� ..:.,._w.F __ .. .-:.-:-- .. .:•... .. _ .._ ,..�. -. ..,.-sex:a. ., - ,.,_� ar.c.�a �m..? n:.,�.t,iuypakcc-_-.zr.,c».r .w_....�i a..... L. CO MMONTWEALTH 4F MA$6ACHUSJTrS �^ `c DErA.IMENT OF LNDUST'RTAIi►ACCIDFTTTS ' 600 WASHINGTON STREET games Gariooei: BOSTON, MASSACHUSEM 02111 �prr:n:ssione: m WORKERS' COMPENSATION INSURANCE AFFIDAVIT;', ' gitxnsee/pertniaee) -_ with a principal place of business/residence at: (Gcy/StsuJZip) - do hereby eer*,under the pains and perWees of perjury,that: j] 1 am an employer providing the following workers'compensation coverage for my employes working on this job. Insurance Company Policy Numbs [ I am a sole and,have no one w proprietor oriung for me (] I am a sole proprietor,general contnaor or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation insurance politics: - Name of Contractor Insurance Company/Policy Numbs Name of Contractor Insurance Company/Policy Number Name of Contraeor Insurance Company/Policy Number Q 1 am a homeowner performing all the work myself. NOTE.Please be aware t5:t while homeowner:who employ persons to do maintcuanee.construction or repair work on a dwcliint of not more than t^rcc unit, in whicl tie hora w coacr aiso resides or on the Erouncs appurtenant thereto arc not venerally considered to be a;,•plovers under the workers' Corr-vc satioo Ace(Cl-C 152.sec 10)).application by a hotneowoer for a license or permit may evicc-�cc tic lcral sutus of a.n crt:ployer under the Corkers'Cor:,•pcnsation Act. coc%•Gc t:- :st:.cmca,will be forwa-ccc to ti:c r'xc- ,.. :l r ---:c^.t o1 lacers::i Accidents' Office: o. Insurancr for cpvcragc C~v :-e :S rcc ' ��c_ �;_ c c ui:cc t n6c coca_ .' 'ci. ,G:. :c=r.icac to vac impo"tson of mmiaa] pcnJ6c cons isc £a :ii.-c ei u. tc S i 500.00 :r.c�or irroruo: of era to one yc:.:a^.c c•-i Gca:iacs i� the form of a Stop boric Order:ne a fine of S 100.00 Sicncc this dad•of 23 c r. �:c.^sor, :rr.:1.:.3: Z'-4" r ^ir�.' 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