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HomeMy WebLinkAbout0030 QUEEN ANNE LANE �� �� ��N , �� �� �� i 0 �t Town of Barnstable *Permit#c-<L-1y Exp'r' 6 months from issue date R I Regulatory Services IN"AS& .Thomas F. Geiler, Director t6 9, fir J Building Division �~'OWN .OF'BARN'STABLE Tom Perry, CBO, Building Commissioner Q W" 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY . Not Valid without Red X-Press Imprint Map/parcel Number Property Address LtiL 'P� >�nn Z ,,� C VFW LX Residential Value of Work , y Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address wil i ,L, 00/IG Ann 0/1 Contractor's Name �� (� lC�'� J ( Telephone Number��� Zl z 90 d Home Improvement Contractor License#(if applicable) LjDs Construction Supervisor's License#(if applicable) �� ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# 1/t�C j �S i rj '7 y/02-,F Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of rood Re-side' - ❑ Replacement.Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement, ntracto cense& Construct Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\Express\EXPRESSPERMIT.DOC Revise06O4O9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' ' 600 Washington Street Boston, MA 02111 :• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone.#: Are you an employer? Check t e ppropriate box: Type of project(required): 1.0-*am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-tim.e).* have hired the sub-contractors 2.E] I am a sole proprietoror partner listed on the attached sheet. T. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no l employees. [No workers' 139,0ther S I d 4 comp.insurance required.] *My applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: l�� � ..�5 12-2 y 0 V Expiration Date: ( 2-01(D Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. Signature:r� Date: lie- Phone#: Lf Z-,dr— q Un Official use only. Do not write in this area,tb be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to brim leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of.Investigations 600 Washington Street Boston,MA 02111 TO. #617--727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gQv/dia 6 / 17 /09 2 : 09 : 26 PM 4170 2 03 /03 '4 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYY 6/17/2009 PRODUCER (508)540-2400 FAX: (508)289-4111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Murray & MacDonald Insurance services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 550 MacArthur Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Bourne MA 02532 INSURERS AFFORDING COVERAGE NAIC# INSURED :NSURER A:Quaker Special Risk Kendall & Welch Construction Inc NSURER B Safety Insurance 39454 874 Main Street NSURER c:Liberty Mutual Ins Corp PO BOX 490 ;NSURER D: Ostervl le MA 02655 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. INSR ADEYL POLICY EFFECTIVE POLICY EXPIRATIONW LTR RO TYPED NSU POLICY NUMBER DATE MMIDDIYYYY DATE MMlODIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50 00, A X CLAIMS MADE OCCUR HB10000343 - 6/15/2009. 6/15/2010 MED EXP(Anv one person) $ 5 00, PERSONAL&ADV INJURY $ 11000100, GENERAL AGGREGATE $ 2 000 0OI GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 1 00O 00, X POLICY PJE'O- CT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) B ALL OWNED AUTOS 5055064 6/15/2009 6/15/2010, BODILY INJURY $ 250,001 X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OV•MEDAUTOS - (Peraccident) $ 500,00( PROPERTY DAMAGE (Peraocident) $ 100,00( GARAGE LIABILITY __ AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AJTO ONLY: AGG $ EXCESS!UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 71 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION I WC STAT I- OTH- AND EMPLOYERS'LIABILITY Y/N TORY ITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 100,00( OFFICERWEMBER EXCLUDED` (Mandatory In NH) 131S354774028 6/15/2009 6/15/2010 E.L.DISEASE-EA EMPLOYE $ 100,00( it yes,descnbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,00( OTHER DESCRIPTION OF OPERATION 1 LOCATIONS/VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of. Barnstable DATE THEREOF,THE ISSUING INSURER PALL ENDEAVOR TO MAIL 10 DAYS WRITTEN Building Division NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 367 Main St. Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ f S Harrington, CIC/S1,1H ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved, INS025(200901) The ACORD name and logo are registered marks of ACORD 1777 I lla+>:ii 5uastt> - Dcit:irtattent of Publa> L Bmird of Building Re<guhttittat, :1n{l Jt:in{l:ir'07, P� Construction Supervisor License License: CS 70086 Restricted to: 00 ,Y DAMON L KENDALL 48 KOMPASS DR ' rw FALMOUTH, MA 02536 Emma xaJ"` Expiration: 11/21/2010 {'nnniiwi,wica Tr#: 6479 B®ar ® u� n e cla ns an ��� ar s One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home 1ng r®vement.Contractor Registration Registration: 128405 Type: Partnership Expiration: 4/5/2011 Tr# 282001 KENDALL & WELCH CONSTRUCTION DAMON KENDALL P.O. SOX 490 OSTERVILLE, MA 02655 Update Address and return card.Mark reason for change. Address ❑ Renewal Employment F7 Lost Card i-CA1 0 40M-08/08-OBSUFOAMCM08212008 92. -ell?II20i12� dy✓f/LSdd6 7.11GaiLi6 - �\ Board of Building Regulatio sand Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 128405 vj` Board of Building Regulations and Standards Expiration. ::4/5/2011 Tr# 282001 One Ashburton Place Rm 1301 Type: Partnership Boston,Ma.02108 KENDALL&WELCH CONSTRUCTION DAMON KENDALL 54 KOMPASS DR. FALMOUTH,MA 02536' Administrator blot valid without signature 14 RATE 1 BUILDING AND ZONING DEPARTMENT .. 59 TOWN HALL SQUARE, FALMOUTH,MA 02540 (508)495-7470 ^ FAX(508)548-4290 ELADIO R.GORE,C.B.O. COMMISSIONER Property Owner Affidavit Property owner must complete and sign this form if using an agent/builder Owner of the subject Property Owner(print) _ �7 property at A v t::�Il ,9'qut�- hereby roperty Location authorize f' ,e,4 ,-4,/ �/G.-.� to act on Agent/Builder/Tenant my behalf, in all matters relative to this building permit application. Signature of er I%te ` ` , y. ...' ri" n ....-.. sr � +ti'i.t.•y.� r +«.� .. ,ti".��' •ii:_.� ?•,". a;�} '?,.;,r.� ',J.-- ,�,.y: +. � '.:•.;t�... `r_ ,.. _ Assessor's ,map and lot. riumber .. �..... .....I 7l FT ",�'/rios�.t7G Sewage Permit number d aw- OFTHErO TOWN OF BARNSTABLE i BJRBSTADLE, i 16 BUILDING INSPECTOR 0 '0 M a' c. APPLICATION FOR PERMIT.TO ........................................- ` + ............ti`. ........ ..a:.......... `.`� ................................. TYPE OF CONSTRUCTION "t rn r ...................( . ?..... ......19. .. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .��s? .. ./`a.....r,/��;;fit/ M�9. �./ .........ChTU/T......................:........................................................... ... ....... Proposed Use .... .xit76sVc / �AN7iG.��................................ ...................................... CU?il� Cn TLC/7' Zoning District .................:.....................................................Fire District .............................................................................. Name of Owner .............Address el A,lIV 7, Z-si f"� G1//T/l .. �. .........' ............................................................ Name of Builder ..L7� i. ?..../ c. P< .!.N.......................Address ............`�.i -si �,A/1y1/��-11✓ .........................,................ ........................... Name of Architectk. ...' A/?�!1 ?�P1�..... Address .. �!Irv....S�/{ E7 s?'Fif'1l ,� ..........................:..................................... !pU/P�/7 ��r?,CR� Tti Number of Rooms .........Z�......................................................Foundation .............................................................................. Exterior ...�!. !o.....:5.iDiN. ..............................................Roofing .....4.<,a? ..? ......................................................... Floors G'Q.�f Interior ..... I Heating 47-" ......1-1,pT. .../l//. ?...........................Plumbing ....... 174T .......................................................... ....... ...... ... ..... d Fireplace .....................................................................Approximate Cost �u� ............. .................................................................... Definitive Plan Approved by Planning Board --------------------------------19________. Area ....../3r Z:k.- ................... Diagram of Lot and Building with Dimensions Fee ..................�- : SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name V„........................................ . ..................... r~ McGowan, David & Marie A=22~121 ' ~ 18819 l 1/2 story, m"�!.............. Permit for .................................... ' � single family dwelling —'^------~----------.--.---- Queen Anna Lane ^ Locationr - ------^'--'.--~--------'' ' Cotd1t .----------^--------.------- David &/ Marie McGowan Ovvner ---.----------.'-�.�---�.-- ^ ' ^ / / frame Type of Construction .......................................... . - . . _ -------- � � . . � renno G,umun - . Date of / � . -_- Complete_ ^ ' - P%ERtT REFUSED . . . . . . . / ^ ` _ . . 19 ` -- ^ - ' -- . ............r.. — ._ ---.- Approved _------- .................... lV _ � ' ° ^ - , - -------.---------....,---~.'--. . . . -----------------~... .................... fl SC FT AQ Yd i 8 / c aj y V ° boot j r,r T Pen 7 A C 20• - .'� 8 i/V _ _ �• PtA. `T{ + Yx$,: won � ff d INC y FO u/)Cf q . 7 Xr i' !J/�1 F�4. F'" }4; Y : �4�31� Mum; Y N.. .'r � t, ��weer fh s /o y + TWA- Y $o GEORGE _ y {�� : LAMIQS kY No. 22723 V ; avow Qlays� f F 5r ,.�# riz _ � c)�r.A � '� (' / / �� �� /'� �J Yak r�Jwt7�tJ'�/t_' L � �i?! �T ti» d. , ,�. d�N`/�� C I° �r,• /�1 a j J'&ev�"�*� Zt Tom k..;.[S �• <j•wti- t e� wy9 J ! Y ,W^ •!':• n"/' - _ _ Y La`s,{ Y'.,'NF'A PC^'Y.'1dR"s'yJ42`/ Y f tM' E,n ineering Dept.(3rd floor) Map Parcel 4W Permit# 9-'� co I House# 30 PJ.-1. Date Issued Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) 05< X—Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) 1 S PTIC SYSTEM MUST BE � -h c•hnp�A in Bldg IlO1ST�'i�.l.�.®I I�IPI.ii41`/`iE hilI De 19 ENVIR0 ®E AND ]V O � s 79 1A ilGS TOWN OFfBARNSTABLE ° Building Permit Application Project Street Address O r r r+ p / l�J 0 Village C/7 ),Let�t— Owner �r 1/7 w G-1 d r a cool Address 10 z t r t-r! cl Telephone y� "l2 LL 7 Permit Request 1-2 ' A First Floor square feet Second Floor square feet Construction Type Orr r/rfi d ✓t fi o✓� /U.,);,J1 L)eeJ Estimated Project Cost $ ZY, 77,°6' Zoning,District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yeses j fNo On Old King's Highway ❑Yes 00 Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other /, "& ,,Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) �f Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Tdtal Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) c2z G n r a �Ta�j ❑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 �/t/ S 4z/ Telephone Number Address S2 r Z ,3 /2�1/ License# D/ 04. Q� C y% Home Improvement Contractor# 1�2 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 ESULTING FROM THIS PROJECT WILL BE TAKEN TO 7' SIGNATURE , 4 DATE �97 BUILDING PE IT DENIED FOR THE FOLLOWING REASON(S) i r / n 1 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED `' � �• � ,.`� r' -, MAP/PARCEL NO: P ADDRESS = = VILLAGE `O,WNER DATE OF INSPECTION: FOUNDATION FRAME ,y INSULATION' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:' RO:. GH FINAL GAS: v' -1 ROUGH FINAL FINAL BUILDi � " i DATE CLOSED <1. ASSOCIATION K� !1 Builder Home owner Tyler S.Walker Mr. Larry Ladd Coad Fbo Qpartment A thru Z Home Improvement 30 Queen Ann ave. ED 32 Shields Rd. Cotuit Ma. 02635 12" Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map# 022 Parcel# 121 12" 1 ROW lic. # 019380cow " reg. # 106956 �'�eve11 ` --- dge board 2 x 12 kd . ----1/2"CDX Roof sheathing 1�* -----------2 x 6 kd Collar ties 5'1"long 6)p t., '• ---2 x 12 kd Roof rafters at 16"o/c R: 2 x 12 kd Ridge board&Rafters 4 N i.. • ________ 4 kd at 16"oR Wall fiarning a� O ooB o •�p9 <- -- ------- ---T111 aiding 5/8" 1/2" DXR fshe g ttob lti r o10� 00 " Cn ,A dbl.2 x 12 kd head dbl.2 x 12 kd door headers 8'6"long dbl.2 x 12 kd door headers 8'6"long Transam windows O Trarisam���rrrwindows C2 x4 In posts 7x8' a oorT Tx 8'r�oor Cal Cn Scree eBle way with na 'lng a TT T NFoundation 813" 813" �T T N Foundation 1°� Concrete footing T 16' 24' TT 214" Front wall view 8"thick foundation walls 12'10" 21'8" Builder Home owner Tyler S. Walker Mr. Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. ,2. 32 Shields Rd. Cotuit Ma. 02635 Pith Mashpee Ma. 02649 20,515 sq.ft. lot size ---Ridge vent --- Ridge board 2 x 12 kd 12„ 1-508-477-1533 Map # 022 Parcel# 121 O -----1/2"CDXRoofsheathing lic. #019380 reg. # 106956 <- --------2 x 6 kd Collar ties 5'1"long <-- -2 x 12 kd Roof rafters at 16"o/c N ------- 2 x 4 kd at 16"o/c Wall framing 2 x 12 kd Ridge board&Rafters W C)l <----- ------- ---Tll I sidin 5/8" 2"CD roofieathir G O Q t b.�Ol 0 O9t3 tt 0o Ul gkJ eta q Y L� dbl.2 x 12 kd head <---dbl.2 x 12 kd header Qo Screci way with thedral iling a x 4 r posts C2 [LLLJ T � � NT T rn Foundation Foundation N - H Concrete footing - T 24' 16' 21411 Back wall view 8"thick foundation walls 12'10" 21'8" 24' 1' 26' Builder Tyler S. Walker A thru Z Home Improvement 32 Shields Rd. Mashpee Ma. 02649 < --.1/2"-DXF ofshe g 1-508-477-1533 -Ridg ent <-- idg boazd x 12 lic. # 019380 12" reg. # 106956 <_--- 2 kd of ra m at 1 "o/c i itch N O 12" 00 Home owner it UZ4 1 kd Beam l2long � o Mr. Larry Laddo 30 Queen Ann ave. dbl.2 x 12 kd head � Cotuit Ma. 02635 O 20,515 sq.ft. lot size <---------2 x 4 kd at 16"o/c all fuming Map # 022 Parcel # 121 <-------------------T111 Si 5/8" TT Foundation 0) = 24' `T Left side view 24' ge ven Builder Tyler S. Walker A thru Z Home Improvement 32 Shields Rd. -1/2" XRo sheat ng - Mashpee Ma. 02649 . ----2 12 kd oof r ecs at 6"o% 1-508-477-1533 12" lic. # 019380 Pitch - reg. # 106956 N 12" 0 6 Home owner o Mr. Larry Ladd -th. dbl.2 x 12 kd Header dbl.2 x 12 kd header 3 0 Queen Ann ave. o Cotuit Ma. 02635 <---------2 x 4 kd at 16"o/c Wall fiwrtir g 4�6 20,515 sq.ft. lot size <-----------------Tllt Siding 5/8 Map # 022 Parcel # 121 — — 4' 4' TT ---- Finished Garage floor height - rn Foundation ai - T 24' Right side view 12' N Screen Breezeway. ❑c--12"x 12"footing for tally post ,A 12' 4"thick Slab floor with wire N 24'x 24'Two car Garage CO 4" Thick floor with wire 16' _ Garage door garage door t All 819" �111Oil 81911 t tt 24' Builder Home owner Tyler S. Walker Mr. Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map # 022 Parcel# 121 lic. # 019380 reg. # 106956 Door o 0 v ' 6 12' a N " Saeen Door c E U c q� ---Lally Post 3 - Q N 12' a 0 x I a Saeen Door I I 16' Screen breezeway _ 4"Thick slab floor with wire I, $1 911 �124'i 81911 I 24' x 24' Two car Garag(Wall Framing layout Builder Home owner Tyler S. Walker Mr. Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map # 022 Parcel# 121 lic. #019380 reg. # 106956 T -----Ridge board 2 x 12 kd <---.-1/2"CDX Roof sh tithing Builder 11� 12' ------------2 x kd Coll.ti.5T long Tyler S. Walker .......2 12 kd Roof raft at 16•o/c A thru Z Home Improvement 32 Shields Rd. Mashpee Ma. 02649 -----2 12 c Roofrtie at 6'o/ 1-508-477-1533 N N lie. #019380 � o � reg. # 106956 N Home owner Mr. Larry Ladd 1/2° DXRc fshm, ing 30 Queen Ann ave. Cotuit Ma. 02635 20,515 sq.ft. lot size Map#022 Parcel# 121 breezeway 16' 4tjicreen Thick slab floor with wire T 24' x 24' Two car Garag(Framing Collar tie and Rafter layout t Builder Home owner 24' Tyler S. Walker Mr. Larry Ladd r A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map # 022 Parcel # 121 lic. # 019380 reg. # 106956 12' N T4-"' reen breezeway �—12"x 12"footing for]aRy post s 12' " slab floor with wire ° N 24'x 24' Two car Garage CAS 4" Thick floor with wire co 16' _ Gamge door garage door tt $�9t� 1'101 8�9�� 1 11 r 24' Builder' Home owner Tyler S. Walker Mr.Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma.02649 20,515 sq.ft. lot size 1-508-477-1533 Map#022 Parcel# 121 lic.#019380 reg. # 106956 i 24' i .. 24' i 12' A S,� °`401 T TT 4%, Back wall view of Foundation 8"Thick OD nj T T TT Footing Footing T T T Right side wall view of Foundation 8"thick Footing 24' T 3'9" 8'1 TT Left side Foundation view 8"Thick Footing �T j 24' T J ° b�°O SI T T °" A°,Bb T —LT ITT Front wall view 8"thick foundation walls ni C--Ie footing - Footin Footing T 16' 24' 24 12'10 21'8„ Insulation & Fire code Sheet rock Door — 2' 3 -----9" Insulation in Ceiling N -----1/2" Insulation in wall N 12 g� N 3 <----5/8"'Fire Code Sheet Rock on wall o� - — — — - — - — - q I I I I Screen breezeway 4"Thick slab floor with wire L e oor garage door 8'9-- d1'10f- 8-9" 24' 24' x 24' Two car GarageWall Framing layout ; Builder Home owner Tyler S.Walker Mr.Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map#022 Parcel# 121 lic.#019380 reg. # 106956 a a o � Mr 0 1 00 1 1 TTTIa ...r ..... �.... qT� q•ql q•y. ---------------- 1.11H...1p wrr TT 1 L - TLL T T o T N TT —24 ..Garage Wd Femmelyo T •w�uw....w.rrtiu 1 � b..:.,n4, Insulation&Fire code Sheet rock 1 ---9'lervhtim m Celma ...in•2aeamaa o,»w �. T w v [ �....5n'Fke Cafe SCeG Rack an me0 f 24's24'Twaca Garage Frunne C.R.m WRaRala 2-24'T—Garage Wag F,.mg[W •.y.0 v2e4v ' Builder Home owner Tyler S. Walker Mr. Larry Ladd A thru Z Home Improvement 30 Queen Ann ave. 32 Shields Rd. Cotuit Ma. 02635 Mashpee Ma. 02649 20,515 sq.ft. lot size 1-508-477-1533 Map# 022 Parcel# 121. lic. #019380 reg. # 106956 12" Concrete Footing down to 48" below grade 48" plus Concrete walls 8" Thick with anchor bolts 4" Thick Concrete slab floor in both the Garage&Breezeway with wire Sill seal 2" x 6" Pressure Treated wall shoes 2"x 4" kd wall framing on the Garage at 16" O/C 4" x 4" &.2" x 4" pressure treated wall shoes and posts on the Breezeway 2" x 12" kd headers on all windows, doors and on the front and back of the Breezeway dbl 2" x 4" kd wall plates Thiple 2",x 12" kd girt in the center of the Garage 1 Lally post in the center of the girt 2" x 8" kd Ceiling joists at 16" O/C 12' long with joists hangers 1 4"x 6" kd Beam in the Breezeway 12' long 2" x 12" kd Ridge Boards 2" x 12" kd Roof Rafters on the Garage at 16" O/C span 11'6" 2" x 12" kd Roof Rafters on the Breezeway at 16" O/C 1/2" CDX plywood Roof sheathing T1 i 1 Siding on the Garage Tar paper on the Roof Vented Drip edge Ridge vent Architect 30 year roof shingles in weathered wood color 1/2" AC plywood on the soffit 2 Tx 8' Garage doors 2 Anderson 48" x 53" Casement windows 3 36" x 6'8" Stanley steel doors no glass 2 34" x 6'8" Wooden screen doors 9" Insulation in the ceiling on the Breezeway 31/2" Insulation in the garage wall at the Breezeway area 5/8" Fire Code sheet rock on the left Interior wall of the garage 1" x 5" and 1" x 6" Corner boards , windows and door trim to match the existing house V x 8" shiplap on the Breezeway ceiling Nylon screening on both the front and back of the Breezeway Alum. Gutters &down spouts on the front and back 1 Pull down stairway 28" x 55" for attic access 2 1/2 HP Garage door openers 2 Ceiling lights in the garage 2 Ceiling outlets in the garage 2 Outside lights 4 Switches to lights 8 Electric Wall outlets set to GFI 1 Electric fan outlet in the Breezeway Smoke Detector and heat sensors 1 i I -�,GARAGE PORCH 21. 30 77 LaT 9Z u �' LoT4 9! 40 r j. Pon ��'fC.. Fou.,cla�.o„ aiy/r ris .:�� 7`/,•r �o{.: �jccvr�li.�J to r ecjr fht. . oT ; • ce o;. Fa�r,.���,� /� 7j an, � r��t; CJc r fh • s /o f i.; Pj red o� GEORGE LAH10E5 No.22123 V TEa�p ti Sti�yti IS a ,e _V F ,y AAI ✓'rI 'Y�r _r ,l 1oltv.,l a . S c ! = .A. 4C.. v 9, /gild ere r c moo. �:._ J. .4.J/� :, �" r�. p. �' Tit�•�' /{ �TMe r� . . °: The Town of Barnstable &UD' �0� Department of Health Safety and Environmental Services E1 9.�. 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: /ill,) �Gra7L /Q4,i Est. Cost Address of Work: rrAf Owner's Name /" r#4 e Date of Permit Application: 7 /, Z,9 7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. 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 o er: Date o ractor Name Registration No. OR ___ narp Owner's Name anac l" . 1 �•�..Ste- . . . ' 't? ;� t-•-. �3- Depart111C111 Of 111dilstlialAccidents Offeffff Wes tlMoas �'" 6011 111a libigil,ll Street ',• ���-a�:,�• B„srrla.Atil�x U3111 Workers' Compensation Insurance ARdavit ArmlicariTinform titin• —" 1'Icnse I'RINT''1e:• (v , name � �✓ � a • cit %- aSft r� �. 0.2G i,�n•e y,7/� �� [� I am a homeown performing all work myself. I am a sole proprietor and have no one working in any capacity ... ....._-._�- t- -•--•— - I am an emplover providing workers compensation for my employees working on this job. cnntnatt name atitlrccc• city- nhnnc#• incnrancc cn. nolin•!1 I am s sole proprietor. general contractor. or homeowner(circle one)and have hired the contractors listed beiow who ra•, the following workers' compensation polices: cmm�nm• natnc� adtirccc� cin nhnnc 0• in-mranrr rn. _ _ nniict•tt .f- vim.. _ T.T... �_ - Jt•��.`�����7..TS�n.�.y.. •�.. �7.,,�.� —� .ti•...5.—.�..._. cmmninv natnr,. �t)tlrrcc• -irs• nhnnc#! ncurance cn Holier•a Utach additional sheet if neeeiiarv� .:.."-3•c •--., ...,:-:....a. -... _..,....__.......�. •. _.,.�.,.......a,._._,+s ... ._ :_ .. .:. aiiurr tit secure cos•emac:is required under ziccuon 3A of I►1GL 153 can lead to the imposition of entntnai pettsitia of a lineup to S1300.00 andior ne.cars'imprminment as ss•ell as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand tbat a op) of this,tatcmeut mat be furss•arded to the 01rcc of Investigations of the DIA for coverage verification. rlo herchr=70-under the ants a td penalties o r rI rt•that the infomarion prosvded above is true and ccoirreect =3ture Date 7//O A7 7 'Tint mane / y/r Y -5- �/t� .�X���� Phone* ,77—J-5 ofrcial toile unly do nut write in this area to be completed by city or town ofTciai T' cin•or tnss•n: lserntitAicense# rrtluilding Department (3Uccnsing Huard L. checi.if imtnediatc response is required QSeleetmen's 01licr ► • �1lnith Ucparnueat . contact person: phone#• r'►Uther�� Information and Instructions ` Massachusetts General Laws chapter 152 section '5 requires all employers to provide workers' cnmpcnsatit�i; emplo.•ecs. As quoted from the "law".an cnrplut ee is defined as every person in the service df another undo: contract of hire. ex ress or im lied. oral or written. ' P P An implorer is defrncd as an individual. partnership. association. corporation or other legal entity. or any two the forcuoim_enaa__td in a joint enterprise.and including die 1e' 1 representatives of a deceased employer. or receiver or trustee of an individual . partnership. association or other legal entity, employing employees. Ho« having not more than three apartments and who resides therein. or the occupant of ��• dwellinghay owner of a _ hrntsc ; r dwcllin_ house of another who employs persons to do maintenance, construction or repair work on such dti�c. or oft the grounds or building appurtenant thereto shall not because of such employment be deemed to be"an e. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuanc rerre�y:tl rrf:r license or hermit to operate a business or to construct buildings in the commonwealth for u. applicant who Itas not Produced acceptable evidence of compliance with the insurance coverage requires Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for th performance of public work until acceptable evidence of compliance with the insurance requirements of this ci: been presented to the contracting authority. Alipficants Please fill in the workers' compensation affidavit completely, by checking the boa that applies to your situatic 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 afTidati'it. T1 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 ifyou are re fo obtain a workers* compensation polio. please tali the Department at the number listed below. .. ..II.. I..• ..� . ..�.... ••• .. ... • .. • ..••�•_. ... •..p •. .•h Clty or towns Ple_­ze be sure that iite affidavit is complete and printed legibly. T1te Department has provided a space at the bo: the affidavit for you to J-111 out in the event the Office of Investigations has to contact you regarding the applican be sure to fill in the permit/license number which will be used as a reference number. Mie affidavits may be ref: 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 qL please do not hesitate to _=ive us a ,::I1. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents _.. office of lavesugations 600 Washington Street Boston,Ma. 02111 r r -4. it t T "'F_T7AQ ,�;. ;'� �v�set>•�ac�x��� t� �3`�6s�a'EE�iai��e �� F'aaviiinxeeanrlld�E';.�acoaaiusa�: ROME.lk"OVENENT CONTRACTOR Registratiorf 106956 RT T 0 VV U ETT YPe INDIVIDUAL tit ERVT tTCtV Epiratotr: 01! 619b; 1... fli f $�f3yyppgg t 4t.V girt lift. T y C u IftoA To' 00 31 Shields Road MWPO MA DUO �f" $,. � c ammrnxxafth;<(Yna.�aaClfil4{. °A$ i 3 Y 3fSt ttY R'9iS.L o.A . QtStT)(.tr�.Ta. 80 S s Q3 f.. 7CNt191£W »kd9 3sat ..r 4i::.. Y A Iis$fk#}' oily r:iive to false:a arrest e t as.0i !s cAose for remit;zaa s ��is s sasc f`l Permit# Engineering Dept. (3rd floor) Map D,. Parcel House# Date Issued /0 Fee - 2-57,rti OFJHE De f y Planning Boarcl . .... • BARNSTABLE, MASS for p�e� TOWN OF BARNSTABLE Building Permit Application ProjaSet )ress k , / r'rr, 4m o Village I!f4 U t- cr Owner enljr-rdl r° Y cfd d Address . }0 V >22 AII0 /C) /m t-,1'/�v4 Telephone 1-5-O - �. ® � 7 Permit Request A-Ad 1�r,,� t� 'd j�/., 171­16r,f to �ur�y Yent, 7 �7 J-4 Y r V Yy� & S YI r 4 r Y A Y T C� /TC� o ,./ ✓ /IJ✓t Y 1 First Floor square feet Second Floor square feet ,Construction Type R O Estimated Project Cost $ Y I-e7� Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family �d- Two Family ❑ Multi-Family(#units) Age of Existing Structure Y�r I Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Q*rage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use 14 Z f fpr.�II���rn -��f Builder Information Name Telephone Number 1 S'O e - y77-/.5,1 Address �,Z S,�X,� l�f rr�• License# �/�cs��>T /�h• Home Improvement Contractor# /D tC, 7-576 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 BETAKEN TO SIGNATURE c DATE BUILDING PER IT DENIED FOR THE FOLLOWING REASON(S) k FOR OFFICIAL USE ONLY �, PERNI�T NO. � � V 3:2/All - - DATEISSUED;; � , MAP/PARCEL NO: ADDRESS t VILLAGE OWNER fo t DATE ON: FOUNDATION x • FRAME INSULATION F FIREPLACE . ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i i ^ �^ ,r 40 � `..G.. �f5'.s iB.S \ i nj o, r r , � /BS Pay .a �� CI,�L= fir' �. .'•. ..- L :� fi��'.._ ._. Foy„�r �,A, �,'��,; r IN J. f LANIDE . 22723 pVa c'r e!7 l r,7,r7`;v Z c eC_\, �151.`, r As map and lot`number .... .... ....... 'Permit number ............................................................ S*Wage i QyO�THEtp�� s, TON OF BARNSTABLE LSYM MUST i BARNSTABLE i r r« t "' 11VSTAL ` yD0 MA39 �� t 'ITFI ,TL; COMPLIANCt' Q6 Y a,. B U I L D I:N G . INSPECT 0r�,,r coo '° s tAT� d MP rq .' "i •. GU E N 4� APPLICATION FOR PERMIT .TO . ...... .. ... ............... T TYPE OF CONSTRUCTION ...........:...... ................................................................................................ ....................J:N...KI .......19.7iS.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the follloowing information: Location ��(.. ../`..........0(�Cl t��/.Q1.7:�1.�<.. ! !I� .........CSt7'L!/.[..................................................................................... ProposedUse ....��ES/,{JcI�.!c ......... ..... ......................................................................... .......................... Zoning District .......Co7 // ..............................................Fire District .....COT/J/T Name of Owner .r,�.r9V/D.. ............Address ...:2L!/....�-!Ql.1V..�!:...... Name of Builder ..&vK1J.... .....................Address .....3.6. ..�..�41r1.....��...... ................. Name of Architect.�G�N/j!...�29.4!l1nP .................:.........:.Address .. �9tN�... T� E. ....... 5.!. /4.!..................... Number of Rooms .........jC.....................................................Foundation ...✓O rf.!f ......C�JI��/s'ET..-�......................... .. Exterior .... .?DD.....5/D//1/Er ...Roofing ..... 5 ''�i�.� T.... �Y�dJC�G ............................... ......................................................... Floors ........GAS ......................................................Interior ......4 fZ... ................................................. Fieatingtic:.... ......� ..........................Plumbing ....... ......................................................... Fireplace ........../......................................................................Approximate Cost ....... Definitive Plan Approved by Planning Board ---------19________. Area I .................. Diagram of Lot and Building with Dimensions . Fee .............. ..................... SUBJECT TO APPROVAL—OF BOARD OF HEALTH 40y(-1/1110 7�14hb I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ........... ...................................... McGowan, David & Marie 13B19 v- 1 1/2 story, ................. Permit`for. ................................... 1 .:nglet family..dwelling.................... , ..QueBn' Anne Lane :.......... Location ..... ...... .......... ^ ......................Cotuit........................................... �r t• J ,. �, Owner ...........David & Marie McGow an Type of Construction frame' ...........................................................7.... ... .......... Plot ...... ............... .. Lot .... ...irk99.............. November 17-, 76 •' Permit Granted .................... ......:............19 ri Date of Inspection ��26. 7 ............19 / Date Completed .7 Y . ...............�19 _ a PERMIT REFUSED ............................................................... 19 _ f f ................................................................................ ' ....................................... .......................................... ................................ ........................................................ ................. f r t Approved ............................................ 19 �, r • ......................................................... .............. ............................................................................... ; f The C(///////l//1N'ealth of Massachusetts Department of lndustria/,4ccidents ty 1 office ol%nvest/gaUons trrr '' ;; ;• r; 600 Washing-wit Street ' Boston, Alas& 02111 Workers' Compensation Insurance Affidavit ......__ .�•,f,"�r.. ....._..ter..._..�..... �._.�..�. .._. _.�. T+�Mf. .yOF•!•'••'I M�ny�Y�ar::.•�!..^','�"•.n•r.»+•.,•. _ _ nhcant information• Please PR1NTle�tb1v name: Ar a Id/r ;0 d�1 ) City Rhone# 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity %'1"K:'+7A^9*+oJ' "er _. 't'le °°r•."hA�. :•......:.:._ :.. _ ,:c ..,... !!'.� r7r.r!'! .'•e•w.r•.a:,e: ❑ 1 am an employer providing workers' compensation for my employees working -o�nn this job. J company name T��'� G /T®2�'J Y ,�7"A/B V rr+a�n T ///rJ �' 1�G/ ��-t✓ address: city: phone#• insurance co policy# , ...:.....�r,. -► •�!.,•-^^ee'>.•�.� rsw:u, .... ,........ .,„.:• .yam 1 am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: Rhone#• insurance co Policv# .'_ ._c _ ._. +r..7:• • rati_^-^.-r... ...... •' ;-c..._.nr ^�t .T7r.TR!;a'�-y.+CJ+:_7i."w.�, .r w.ua,..i�owiGi.�.+Y �� III company name address city phone#: insurance co nolicy# .Attach additional shcit if Recess •f- 'f"! t1"tl5:fy i� ui�irr�[=:._"..,-:.� •.v`.°``L ty. �� s. ~� Fuilurc to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Office of Investigations of the D1A for coverage verification. I do hereht ccrrifi•iiiider the pains aitd penalties of p jurt•that the information provided above is true and correct. JJ SiLmature < Date Print name_ �// t>/ Phone# L7 7—Z- s.. _ T official use univ do not write in this area to be completed by city or town oRcial + city or town: permit/license# r illuilding Department �Liccnsing Ilnard 13 check if immediate response is required Selectmen's Office Health Department contact person• phone#• MOther (revised 3l95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers compensation for their employees. As quoted from the"law", an emplgree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. • " An rmplt rer is defined as an individual, partnership, association. corporation or other legal entity, or any two or more of the foregoing engaged in a.joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildinbs in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the in 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. 1.:.; ..:... > ,,' .1 -a wl •;V: t ..lAst r.w•`"r •.L.:?i r^'. tr ... 3 .J 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. Tile affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. ..._..- ..T.. a.._liy>n>r.'�.:..:..'.T'__ _.".. •,.q�...s'.-:.a>...++.'y^iw'.—'wn.an'11�t`�-. .. 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 permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile 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 Investigations }N° 600 Washington Street Boston,Ma. 02111 _. fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 r: �r IHE The Town of Barnstable Department of Health Safety and Environmental Services 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 alongwith other requirements. TypeofWork: XrAdol1 Est.Cost y Y� Address of Work: _1�0 a U r z / l� y 4- r fi w Owner's Name / i' a Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name iP. '"�'4�i �k89YGi:EEi>.�6+�ro:FFPf�'s e?�s d>Et6.;t�."1•r.�fi4.>>.s�i'':• �: WE IMPROVEXENT CONTUCTU z Rtpstmfon 106156 f Rt R bf MUC SAFETT ; T qS�r 2: r a ff?� ;f s t f Tree INDIVIDUAL 3L�S!RYTx3t+II ITCUS:. t �� Expxra.tla� 01 8.14) S `: t 5A 7. trier S. N 1.ke:r a , C�A ad tr�E s 14tt Maspee MA 044 3g( :: t�kktkt�m�i:y.iltf,it 11aa.ox<t...... 1 :9 Zr�i'8 Y6tkky d3f�dt e ,, £...`➢.. 00 - hit p� - #arX eels t; lf! - 1 8 2 TORY Nut � w .. fell Ee to Bassett cjrrut edition of. ik 1�.CEflS� :flr r$VpCEf 14o fl tt. �S f eat:..