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Home My WebLink About0133 MARINER CIRCLE /� ",?jP- iAMK Cl Q Assessor's map and lot number .. tNE. .......... P�pf Tp�y Sewage Permit number Z 31A"STABLE, i House number ....................f..< ... ..................................... y Mash t63oo'tG 9 YP a\'� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ,.................................................................................................. TYPE OF CONSTRUCTION ....... f'> r? ,, G�-ss ... ��°J =ice ?"............................................. �/ S' 9 19................................................ ....... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followiin�ng�� information:Location ....................................... ��' �'a�� [ Cif irk /f,,7Y . .... !'� �... ........ ............. . ProposedUse ......D .... ..... ..............................................................j......................................... .I......................... Zoning District ..........1.............................................................Fire District Name of Owner ......................;.............."LC-LC?... !`..... .":'.....Address .................I ....... !... .. t .................. l Nameof Builder ...... ::�... :� ..`.......Address .................................................................................... Nameof Architect ..................................................................Address ....................,.,....�..........................i'�?.............................. rJ �� Number of Rooms ................... .....................:.................—.—Found `ation ....... ................../................................................... Exterior ..!..:..... ..........................:f...t.... V ...`:S:..<........Roofing ..... ...... ...................... 3.. 2 ......:.. `.:.`...... .. J ./J Floors .................f .......................Interior ................... .......;......................................................................... Heatingl... . ...... ...............................Plumbing ........................ ........................................................ Fireplace .....................!::.......... ........................ .............Approximate Cost . ,CrG' ......................................... �. 1�q-- .......................................... Definitive Plan Approved by Planning Board _ Area -----1 9==- Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH l � I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....................... .......... .!� lCj%:� THEO CONSTRUCTION / A=23-51 No 2.3.6.8.g.... Permit for One Story Single Family Dwelling............ Location Lot...#.4.....13.3...Mar.ixier...Circle Cotut................................................. Owner ...Theo ................. Type of Construction Fr.ame............................ ................................................................................ Plot ............................ Lot ................................ Permit Granted ...... a . ....................19 81 7. Date of Inspection . ..................................19 Date Completed ... ......... ......................19 PERMIT REFUSED ................................ ............................ 19 ............................................................................... Approved ................................................ 19 ............................................................................... ........................................................................ Assessor's map and lot number /Jf.....:....../.�.'.l.l.............. a THE �, SEPTIC SYSTEM MUST � Selwage Permit number Q..-..� �.......................`.-...:.... I�/IP T. NS ALLED IN CO I;o9A , ' f WITH TITLE 5 : BABHSTIIDLE. House number ......:............. .. .. :..:...... ; . ENVIRONMENTAL CODE 9 rb a NME A 9a�e ra MA =1 S�TXBe T►O S TOWN Of;/ BARN Y r BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO U.�...� .. ..... ...... TYPE OF. CONSTRUCTION ........� !rcr!�1.... ...�./��%J�' �"'�".�........................................ v //...... �1.................19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the, following in1forTaation: LocationG ®e '(�............ � 1..................................................... ..... /. /...... ProposedUse ..... ........................ ...........................................................................................................I.......................... ZoningDistrict ........... ......................................................Fire District ...... ............................................. Name of Owner � � "� 1 / Address ................S....... / ...................... .. ................... Name of Builder I/ Name of Architect ..................................................................Address ................. ........ � � Number of Rooms ......................................... .......................Foundation ... .' � ....... .................................... zz Exiei"ior L!.... ".`.'....C .................. ....... . Roofing ..... . .. '.`""f .. ....../.... .."I-7. Floors ...................................Interior ....1..................... ........ Heating .......... ................................. ........................Plumbing ...............J.. ....P1..-...................................................... V Fireplace .........Approximate Cost �� 000 r................../.../........ .......... . ... Definitive Plan Approved by Planning Board ___ _ _________0______19 4 " . Area .....//: zqt�...� ....... �O Diagram of Lot and Building with Dimensi s --� Fee .........�.................................... SUBJECT TO APPROVAL OF BOARD OF HEALTHQ I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardi g the above construction. Name . .. ............ ... .... ... ... ...... ....... ................... THEO CONSTRUCTION CO. ^m .��.�.��— r�,mv ,p, ..��..'��---.. Si —_D ___�-----_—.. . -- _. . � ~ ^ Location Lot �45 l33 /��le ----------''~—'—~— ................Cmtoit................................................. Owner ..Theo..�� Tl..C�Q°--.. Type ofConstruction ..FXAMe............................ , ' � ,^/ ��/' ---------------...----------.. P|ck ............................ Lot .----------. ' ' ^ May 7r� ` ' 81 �� —�----.�----.�lA �dtef . . oiion .....................................lg Date tell ' PERMIT REFUSEDtr . �� . — '' .' l�—'= ' '�— ----------� .. r�. �� —..��..u�.��.o^'��.---.—.-----....----.. ^ �. —... --.y—.�.. .......... ��~ .....�—.----- .— ..�— ' .--....s'...—�...,�--....----...---'-- .` - --------.---------...—.—.--~~. . � . ~ '� ' lA "pp ",=" — r------------- —'—^^~'----'r^`—'' ^ . . . ---~---`.�.. . U ' U / �• � � ;Y.•_ j �� ma`s .r s f i y f r J�i.: �� r r ;A � IA.:j,y� Qom► +n ' �y �.' < ',t �. ��`} �,,t �'�rt 9�i ;�i;� OT- 4 nx.,' s.. ,.r,. �• E o-"�. - s r f +• ri } 1w 1 y 39* V 'y ►2-T. 4 Z � � v -H - # L ip atq, FLAN SHOWla#G -i y FOUNDATION LOCATION RT rN GOTUJT� ASSACHUSETTS Tji T OWNED BY: SCALE • DATE: ------ NORMAN GROSSt#AN REGISTERED LAIVD SURVEYOR ➢ �� sl l HEREBY CERTIFY THAT THIS FOUNDATION IS LOCATED- ON PHE LOT AS SHOWN AND CONFORMS TO THE TOWN u# OF BARNSTABLE ZONING REGULATIONS REGARDING ) SETBACKS FROM STREET LINES AND LOT LINES 1 !i; J 1! � •.! .. �``.>'=,«•`"err ➢ v . NORIGAN GROSSMAN R.L.S. DATE r a ..;,4`i..A�,z`�Jv' + t! '+k�'.�' t syr��i''t� �E y •j �a• -`o,n�e ��1.�vt .��.,#;.�:#��z9�.r^^+-aft: .�a. ,�i,. ,-t . . ^:v' & �r _ � <``i` TOWN OF BARNSTABLE Permit No. -----------_--------------------- } Building Inspector cash -IPAUITAX • --------- -- sum —- �O 16)0. \� �°""` OCCUPANCY PERMIT Bond ------� / -�� "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ....................................................... 19......_ ............................................................................................................_._ Building Inspector Ertgineci-ing D.pt. (3rd floor) Map 01Z3 Parcel O' Permit# 112- House# Date Issued j f Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Vol oZ Conservation-Office(4th floor)'(8:30-9:30/1:00-2:00). � (y�� f '/ . - I% -_ SEPTIC SYSTE ST 'BE IN NCE Board 19 WITH -ENVIRONMEN R, AN® TOWN OF BARNSTABL]TOWN REC S Building Permit Application Project Street Address ��.� majrinloa�� Lo Village ,t ;:. Owner - d J� ��p LG i gg(&0 kddress ZP 7 /�'6� 56a6ld SI�-f�/�►'lo+,�-h Tel hone - Permit Request ' I`First Floor square feet Second Floor square feet - r Construction Type Estimated Project Cost $ ,. 1(50o p�' 1 Zoning District Flood Plain Water Protection f Lot Size Grandfathered ❑Yes ❑No 3 Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) �i Age of Existing Structure 15`14KI. 690 Historic House ❑Yes No On Old King's Highway ❑Yes No Basement Type: Full ❑Crawl ❑Walkout ❑Other 1 Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing�_ New Half: Existing New i No.of Bedrooms: Existing_Q_New _ Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: /j�Gas ❑Oil ❑Electric ❑Other ,. Central Air ❑Yes X"No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No i Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) !� Attached(size) ❑Barn(size) 1 ❑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 6 CUy`cu Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS 'PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3' -�� I�RK I E E FOLLOWING REASON(S) i FOR OFFICIAL USE ONLY ! PERMIT NO. DATE ISSUED t _ MAP/PARCEL NO: of T- t - ADDRESS �` I VILLAGE' OWNER DATE OF INSPECTION: FOUNDATION - FRAME INSULATION FIREPLACE ELECTRICALkk: RUGH FINAL PLUMBING,;�rl (2' R(ACC�H FINAL tc _ GAS: 6 I1JGH FINAL FINAL BUI> DIG �� a9" 9-2 _ r 0JER S.* 40 " fn , f DATE CLOSED-OUT ` ' .4 ' ASSOCIATION"N-,�NO. ' I IxLt IL � Thc Continotti 'ealth of Massachusetts r � `L� •t;t Department of Industrial Accidents A � Y i 1_ Office a f111=119211817S 600 IIkr hnirtoniStreet •` ': Boston.Alas. (12111 Workers' Compensation Insurance Affidavit PIease PRINTaebj� _- names �2� L4,-,-Q LA 10ft-P,Pt location- l:5 3 1'VtaY-1✓lam✓ 6Af I`E' city �� 1, / `. ahone g I am a homeowner performing all work myself. I am a sole proprietor and have no one working_ in any capacity I am an employer providing workers' compensation for my empiovees working on this job. enmmom• name: nddress• city Phone#- imurnnce co. Polio # I am a sole proprietor. general contractor, or homeowner(circle arc) and have hired the contractors listed below who have the following workers' compensation polices: comnanv nntne: address- cit.c phone#: insurnncc ro. nolic%.0 --.•_-.-.... .._ ._.�._.-..... �•c_-•iyW•— rr�:iv'.r•ir'._— — _� __ __ _— -.��'- _ - ..may'-�y._�." -.a-�-- conirmov nnmc: addresc- city- phone Of: incurrence co. policy# Attach additional sheet if neccssa'ry� -_ + --��- Y;L.;:`__ �"%r.' '^"`•'•• yam"- _�'`�� -' Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of 2 line up to S1.500.00 2n diur unc%cars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that n cop} of this statement mad be forrr•arded to the O1Ticc of investigations of the DIA for coverage verification. 1 do herehr certift•under the pains and penalties of perjure-that lire information provided above s true and correct. t_nature R� ''fDatc J7 _0 T Print name ISO bL�X� �,14U Lam► i JO A779-A Phone# official use unly do not write in this area to be completed by city or town oRcial Y• city or town: permit/license# nl3uildin,-Department C3Liccnsing hoard t 0 check if immediate response is required 0sclectmen's Office ►_ k 011c21th Department E F: contact person: phone#: rnOther. s: Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers* compensation for ti etnplo.-ees. As quoted from the all einploree is defined as every person in the service of ancither under ally ecntract of hire, express or implied. oral or written. ' An emplorer is defined as an individual. partnership, association. corporation or other legal entity.- or ally two or m 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 owner of a dwelling house haying not more than three apartments and who resides therein. or the occupant of the d,xciling house of another who employs persons to do maintenance , construction or repair work on such dwelling I or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio: MGL chapter 152 section 25 also states that even-state or local licensing agency small 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 pertormance of public work until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc supplying_ company names. address and phone numbers as all affidavits may be submitted to the Department of �ndustriai Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the cit, 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 requir to obtain a workers* compensation policy. please call the Department at the number listed below. Co- or'rowns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P' be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returner the Department by mail or FAX unless other arrangements have been made. Tile Office of Inyesti=ations would like to thank you in advance for you cooperation and should you have any questi, please do not hesitate to Live us a call. . The Department's address. telephone and fax number. The Commonwealth Of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 r.l.nnn 1?• (4-1-) '717_141'M nvt 3f16_ 409 or N7; °FTME T� saxivsTnai.e, The Town of Barnstable . • Department of Health Safety and Environmental Services iOrFc r�'t" _ 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 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: Ke-pa.* r 0L 'd=-Ic Est.Cost Address of Work: 133 rY)ar-in 19 - C1Crj:e 6'h.L i, Mq 1?11(a ,wiler's Name � b� X e n owtA �, jin''2_ Lew DAKA4 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 Date Owner's Name Y y - " TOWN OF BARNSTABLE ,BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION /Please print. f DATE1- JOB LOCATION Number Street address Section of town • "HOMEOWNER" p� - . .. .. . LD Xr�S-�-�rt� �01DAKA Yo- q86 sYA -6,6o6 , Name Home phone Work phone - - PRESENT MAILING ADDRESS /p 7 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, 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 Officia on a form accaptable to the Building Official, that he/she shall be responsibli for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes responsibility for compliance with the Sta- Building Code and other applicable codes, by-laws, 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 compl ith said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. q ,y ,RI r i y a HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix 0, Rules and Regulations for .licensing Construction' Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems,. particularly when ,the Home Owner hires unlicensed persons. In this case our, Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home 'Owner-' actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. 1 #47 \ � < ; , , / \ �1 STANDARD LEGEND / �/ / \ note not all symbols volt appem on a map 'y /% Nl--.:��\ \\ \ GO DECIDUOUS TREES LF COURSE AY ,. EDGE OF BRUSH ORCHARD OR NURSERY CONIFEROUS TREES \ � \ // �/ //:.\ \. -y� •.� .>��/ ../.._ ,\\ MARSH AREA \ 0 AC � \ V / A u .> / EDGE OF WATER \\ 64 DIRT Roao \ , 6 ❑�„�--DRIVEWAYS \ 1R� � AC F—PARKING LOT 3 / „ \ 1 PAVED ROAD // y\/ \� \'' � .�\ �.J �`"•/\ // ^�� DITCHES 046AC _ ! ! PATH/TRAIL C_, .\ \ \ :=." �/ �l //`•� �..� /.'� \\ # 5 // 7 PROPERTY LINES 67 / \\ 0.46. 0 / 1" Y / . \ \ / rE�LOT ACREAGE , 118 \ ,/ s'f� PARCEL NUMBER \ \�\ \� ' /%/ .\�\ \ \ if r �'�'` \! "' HOUSE NUMBER \\\ i-- 2 FOOT CONTOUR LINE f `` \f'f „r/• !�^ / F \ \� .. 10 FOOi CONTOUR LINE #145 9 X., SPOT ELEVATION / �` �\ / / \ ,// 1•� ---"-- STONEWALL /" FENCE' /✓y l RETAINING WALL RAIL ROAD TRACKS � 0 4 \ / �% \'1'- �. ,•\ - A�j'/ TELEPHONE POLE \ 6 .. �4 ,✓ ...\.� / /• ` .�ai\\ '\ �Y� /v / \ \\\ —� STONE JETTY SWIMMING POOL PORCH/DECK 33 ` ! I / ! 4 BUILDINGS/STRUCTURES DOCK/PIER/JETTY _ )--T ASSESSOR'S MAP BOUNDARY ' _.. \\\ 0.46,AC \ - SITE MAP #12�' = i 6803 T.O.B.GEOGRAPHIC INFORMATION SYSTEMS UNIT SCALE: in feet 0 30 60 / \ 1 INCH = 60 FEET i, ' s \ fllF:lnti Apn 9i,miit Na1E:TNEPARCELLINES ARE ONLY aRAPHI(REPRESENTA710NS OT PROPFAIY BOUNDARIES,iMEY ARE Nat TRUE l0UTI0tISanh B-3,91 VEGETATION,TOPOGRAPHY AND PLANIMETRIC DATA INTERPRETED \ 1 j / \\ FROM 1989 AERIAL OVERFLIGHTS,PHOTOGRAPHY AT I"=R00' MAPPED AT V—100'.PARCEL DATA DIGITIZED FROM I'=100' / ENGINEERING ASSESSORS MAPS 1995 TOWN OF BARNSTABLE BUDING PERMIT APPLICATION 7177 DARNSTABLE Map UZ� Parcel �-�� f;S A ; `xt Application # UI S ��.3� Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address /.3 3 AIArz w 2 l aCL E Village CO rLL I r Owner 001C1-4 /Lta �/�A'it ctd% Address /3.3 Cl2 Telephone Of 3.3 Permit Request AlEk/ kircHru•.l C.417o e-►ts — 11c a -13A-rHRoarh — FLdOMiM�, PIE PL✓ CeMeN A liV Q6 16U Square feet: 1 st floor: existing BjKproposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 20,OaC Construction Type 2e- /nc Lot Size zU C 06 .S'F Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure -3S Ves Historic House: ❑Yes XNo On Old King's Highway: ❑Yes N(No Basement Type: 21CFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing ON E, new Half: existing OME new Number of Bedrooms: 'mow O existing _new Total Room Count (not including baths): existing r U K new First Floor Room Count 9v(L Heat Type and Fuel: Gas ❑Oil 0 Electric ❑ Other Central Air: ❑Yes XNo Fireplaces: Existing W New Existing wood/coal stove: ❑Yes ANo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: 9existing ❑ 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name /r'ICHeL- rPA Telephone Number 0Z8��! 933 Address /3Z /h Aizi N ep_ C (2 c[ r License# /"A, Home Improvement Contractor# Email /W/CAS- ''nn, C_ YAMM Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE��-�`'� �!//� DATE �UGvr i 2c)Is— s y FOR OFFICIAL USE ONLY �f APPLICATION# DATE ISSUED MAP/PARCEL NO. 'i.. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH r FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' ••+v 'Depw*ne&OfImbutr al Aczideu& , WE=nflmverizgations 600 Warhingtan.Street Bestm HA 02M ' www.mdrsgmv/,a . Workers' Compensation Insm7ance Affidavit Bnalde&Contt a tDrsMecSricians/Plumbers AppEranf'Laformation Please Print Leeffi y' Name �1(;��: J.,• ��C�� Addmss: Ciiy/&a�: v r ',. �' Ph=#: - ,j j` Are You an employer?Checkt6 appropriate:bo:c Type of project(required):I.Q I am a emplopw wi h 4. El sin a general contractor and I employees(frII and/ part inne). * have hired the 6• El New coinsiractim 2.Q I an a sole propaefnr or partner: IMed on fM afiarhed sleet 7. ❑RMDde:Fhg sbip and have no employees Them sob- sue. S. I]Dmolfiion wm3dng for me in any capacity. employes end hrya [No workers'�•fiwo ,rr. Comp.loran u t 9. BmZdmg addrt�On ah 1 5. Q We area corporation and its I0.❑Electrical repairs or additions 3. I am ahainoawner doing anwadc_ officers have exercised Veit ILL]Plnmbicrgrepim or additions n�ysel£[NO wow'cam. of emmxptiompe rMGL �❑ f repairs insoramce req�ed.j t ,G 152,§,I(4),and we have no empIoyem LNo warkaa' I3.❑Offier CM33R insorMUceregohMJ] *Any sPplirmmtihat ebul�box#I ffistalso fII oatih��efionbcloa'shawmetb�wot�a'e�mP��P��Y�� t Homeawaeas who subm$$iis afbdav$ID�i�' gE�ep gn doing�II wnd�amd thm hae oaLvde ea�acboa Est sabmit nacw�adavrt IDdie�g sow " �cbeokl�hint must arched an eddmnmil abeetsbowmgihe mine af�e s¢5-ranhar�s�d sty whdha ur not$�se�titirs fiave , employers.If1he sub-mtd�a have ea�lopxs,the.9 mast pcavide tbe's t�da�a'cax�„FaIieY maabeC . I inn an ernpinyer•that is provi�ig x+orkers'corrrper�smion bzrru�uur far azy emplayee� $ela�p is the po&cy mid job site . informaffon, Insurance Company Name: Policy it or Self-ins.I ic. Job Site Address: MY/S�rJZtp: Affach a copy of the Workers'compensation policy declaration page(showaag t$e policy ammber and a on dzte). Fai]=to secote coverage as required tinder Section25A ofMGL c.152 can lead to the imposition of r,¢miQal pcna ties of a die np to$1,500.00 and/or one-year fiaprisan m mt as well as civil peaalfl=iu the fo=of a STOP WORK ORDER and a fine of'up to$250.00 a day against the violater- Be advised tfrat a copy of this statement map be fnrwaided to the Office of Investigations of lha DIA for mMminc-coverage velfficafion. I do hereby certify under the pans raid perraFtirs ofPerjMy fhat de irk formafioa provided above is frM&mid rnrrert gal /� y Pbnne ceS f/ [[Cal 7dal use only. Do not write in fhu m e%to be conpk fed by city or town vgklaL y or Town: oard ofHean 2 Bt¢1dmgDepazmen3.Citp/TaWat Clerk 4.$Iectrical7nspectnr 5.Plumbinghspector Other•tactPerson: Phone ' Information and Instructions Mftss m lusefts G&=zl Laws chapter M regoires all emlhloyers to Aran&Wod='CompCnSatMM far$heir C 1plC1Y= Pursaantin ibis statt;an.employre is teamed as R.every person in go services of der under any ca&act ofbae, ems or implied,oral or Wrhen:' - An a W[,,ya•is defined as can mc&vidoA partnership,associstiam,iaxporation or other legal eofdy,or any two or more of fine foregoing engaged in a joint and indndmg f m legal rqz=cotdim of a deceased employer,or'hie recesver•or trustee of an indvidnal,partuetship,association or oibc r Iegal eutty,employing employ=& However the owner of a dwelling house having not momm fhan three apartmeofs and who insides fbemmin,or the occupant of the - dweIImg house of another wbo employs persons to do inafitmenct,car asttuctinn or repair work on such dwelling house or an the grounds or building thereto shall not because of such employnne ut be deemed to be an employer." MOL chapter 152,§25C(6)also Sihdes that aeverystafe or local RceaSmg agencyshaIl withhoId the issuance or renewal of a license or permit to operate a bashess or to construct buildings iu the commonwealth for ahry, applicautw•ho has not produced acceptable evidence of cdmpBmce with the insurance.coverage requied." Additionally;MGL chapter 152, §25CC7)states-Teithm the�tqo: vealih nor sup of its political subdivisions shall _- enter into any contract for the perliminan=ofpublic woticuntil acceptable evidmim of complimme Vd&the incnrsrt=-. regtmeoieofs of this chapter ban beempresentrdto to contiasting anthoaiy." : APplimi s , Please fll oc± fhe workers'compensation affidavit campleWy,by checldng&e boxers fbat apply to your sidnation and,if necessary,supply sub-contr (s)name(s),address(es)sad phone m— a(s)alongwhhtheir crrii icate(s)of f' insurance. Limited.Liability Companies(LLC).or Lfinitod Liab>lity Partnerships(LLP)wi&no employees ofher.than the members or pmt=-s,are not rbqmrrd to catty Workers'cmmpensaton insurance. If an LLC or UP does have employees,a policy is reganrxi. Be advisedthdl his affidavkmaybe submitted to the Department of Industrial A.ccideais for confinmation offasmance coverage, Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for f e,permit or licm=is being rcgnesbuL not the Department of Indns-t dal Arxidents Should you have any questions regarding the law or if you are regained to obtain a woil=' compensation policy,please call the Depmtmmd at file number listed below. Self-insured companies should meter their self-insurance license number an the appropriate,line. City or Town Officials Please be sm a fiat the affidavit is c zopletm and primed legibly. The Department has provided a space at the bottom of the affidavit for you fo fir out in the event the Office of Investig�has to contact you regarding the applicant Please be sere to fill in the peunit/license mtmber Winch will be used as a reference number. In addition,an applicant that nmst submit le mmmicense lit aftons in ear,need only submit one affidavit indicafmg cmreut P aPP �5t 1�m Y policy infohmation(if nay)and under'Job Site Address'the applicant should writr"all locations is (city or " ed or marked the or town be provided to the town)."A copy�f feafiavttintlsas L��fi�illy car �3'. �Y �Y applicant as proof that a valid affidavit is on file for fie permits or licenses. A new affidavit must be filed out each year.Where a home owner or citizen is obtaining a I our=or permit not reed to any busmcss or commercial veudhne (Le. a dog license or pert to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations woald lilac to leek you na advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The De"Imenfs address,trlephome and fax number Depnilmnt of lid lAcoad.ents WE=O.f iv.vesttatioaas Bos m.MA 0�111 Ta#617-? -49W ckt 406 4r 1--&77-MASSAFE Fag#617 72'-7M Revised 42407g �IMME T Town of Barnstable Regulatory Services 9 MASS. g, Richard V.Scali,Director 6596 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.townbarnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 Property Owner Must Connpletel and Sign-This Sec one `.` If tiUsm" g A Builder\\ W � I, ,as Owner-of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. s _ (Address of Job) ''Pool fences and alarms are the responsibility of the appficant.,Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date . Q:F0RMS:0wNERPERMISSI0NP00LS Town of Barnstable Regulatory Services - �TKE roityM Richard V.ScaIi,Director ? . Building Division RaR .�R Tom Perry,Budding Commissioner MASS. z639. 1$$ 200 Main Street, Hyannis,MA 02601 QED www towa.barnstable.maus Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ry� •Pieasc Print DATE: JOB LocATrorL 13.7 M �Z N 2, C[rt.e bL G o TV I•f-- nnmber stow village -HOMEOVINHR": [e e- ,r 9z7 namc � �I home phone# work phone# CUP—RI NTMAILIlIGADDRESS: /7.7 /0,y14R/NGam. cityhown state rip 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. DEFMMON OR HOMEOWNER Persons)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 Buildiag,Official,that he/she shall be responsible for all such work performed under the buildt gpermit. (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 pro-:zdures and requirements and that he/she will comply with said procedures and requirements. Sigcature of Homcow�cr 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 109.1A-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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,RuIes&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 Iast 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'�WpFE ESIF0RMS1bm1dmg permit fomislEXPRESS.doc Revised 061313 • Page 1 of 1 r-roc HC 04 NEW (' 3/NeT5 I � 7 1 (z r►'� Zuo^0*— h-ftp://www.town.bamstable.ma.us/sketche s 15/12 7 3 13 13 pg 8/4/2015 ....... -- ---------------- - - - - — �! �.. - 1p Wj http:f/issgl2/intraneVpropdata/ParceiDetaii.aspx.?ID=1.273� — 4_w �F it x bBing la .. - .-. ..of J. � e.>, »...;,.. `. ;-. '� �' '•- - a;, "5.. r.a m xe; ua z�,4+4'�i";�, �'flffi;�tY.t, Y'.? � x; - ., „ c h:f, '4= " k .'*vp =t w -'�"s ,�:a '. -'e. 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Frontage I, � Sec —I Sec Road Frontage , ----__--+ -' 77 Fire Village ICOTUIT ( COTUIT District' -' Town sewer exists at this Road d978 --- address No I Index Asbuilt Septic Scan: Interactive 023051 1 .Map I ... -. 5 OWner LAQU IDARA,ROBERT&TRASK,KRISTINE E loSPARROW,iatICHELE L I Owner' Streetl 1133 MARINER CIRCLE I Street2' I City,COTUIT - I State Zi p'02635 Country14 J 46 Zoning � VghbdAcres USe jSingle Fa . . a1o5 _ W tocat rtranet 2. W ,r ... .:arcel Mam.S A licitOutlook.. � Ma M a.uteri P � " y G mj �fY FW +! . ,10:19 AMA it et1MG1'�.""`Pid