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0104 RALYN ROAD
/d�f ��z��v �oa� � � I - A iication ...... number PP. Fee $ullding inspectors initials. . ........16 t7ate Issued.. WOO arcei.. c�off WOO TOWN OF BARNSTABLE. EXPEDITED.PERMIT APPLICATION; T0 ROO /SIDING/WINDO SIDWRSrfEN STOVESAVEATHERz;!: 6n64 ?pip PROPFR'ITY INFORMATION MATIOl•T �S7' Address of Project: '0 4 NUMBER r GM VILLA r Owner's Name:o r Phone Number Email Address .1 Gcab CeII.Phone:Number. Project cost$ 10 Check one Residential v' Co�amerci I OWNER'S AUTHORISATION As owner of the above property I hereby authorize' to make application for a building penPi. in accorr3anr�e with 7$0 CMR. Owner Sinatm Date.. :. � i TYPE OF WORK Sitting 0 Windows(no header change)# 0 Boors(ao beader change)#' C31ns lati6n/'4'Veatheri tion 0 Roof(not,/applying more tl a► I layer df s ingles} Commerckd Doors require an inspector' revie#v Con Lion Debris-will be going to Certificate of occupancy with no construction(complete below) Occnpantlfsmily'relstionship or`business name ; x or Existing amnesty ap rien (attach it copy of retarded comprehensive pelt) CCU RAt"`MI2'S'INFOF RAT. TON Contractor's tiame Horne Improvement Contractors.Registration(if applicable)# (attach copy} Comstruction Supervisor's License (attach copy} Email of Contractor :Phone:numbe .' ALL PROPERTIES TNArW vE s"TRUCTukrs OVER 75.MRs OLD 0R I T HE SUS)EC7 PROPERTY iS. A 01tT" 01e 111VTO !t VAII AA1'1C'!'!°#&TA/Al:tJhC7"J'! #1" !l L�t7Ltll#!!#i:lttS�i#3 li`DCifAalfY tAAf G I+CCI+ is i .p APPLICATION NUMBER ... ...... �'�'olt• Tents ��1 Date Tent(s)will be erected _ Removed on number of tents total µ_ Does the tent lave sides!Yak Nam(If yes plese attach fluor plan with exits marki} Dimensions of each Tent, X Additional tent dimensions can be attached on a>separate piece of pvet Purpose of went Check one: this event is a: for profit non-profit event Check.one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location{s}:of each tent Fuel source being used LP tack 20;ibs.:ar Yes Now,if yes,a gas permits,reqWred Natural Gas Yes, if yes,a gas permit iS required: If -0od is being served at yvur evert please obtainia.Mealih OVarf0eid appio val pert the hours of$,00am A-30 airs or 3.3d pen4 3(lprrt. Corrxrnercial events may require Fare Doartme i apgrova� *WOODrcaA IRELLET STOVES Manufacturer# Model!I.DI, Fuel TYi ,... Testing Lab offsets from combustibles:front back' left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: IS Cell or Work number: Telephone Number � _ ? I`understand: y responsibilities under the irides arid;reguI bons for Licensed Construction Supervisor in accordance.with 780 CMR the Massachusetts State Building Code. .T understand the construction inspection'procedures;specific itnspeet3ans.and dtHcurncntattoai required °78D CMMR and t e� wad Signature, " " Date1C} APPLICANT'S SIGNATC,�RE Sgnat i' t T)ate:�ir7Gt All pe�rrmit appticadons subject to a building afciar's appe al pr�r to issuance. The Cvttt ttwerxl`tatt of4wachteeUx DeptXt`t1ttenl of Il'dustTW;AaWntS offilee<$,f Invrrsagadonr flStfdPtr211 Workers' Compensation Insurance davit: BuildeWCdntrnc,ton/.Elecfr eiais/f'l ,be lieuntstfortnaiion _ Plee.priu# ib Name( usa rgeraitoatflndividuai): Address Chi" 1State/Zi : Phone . Are y©u an enaployer7;Clteck the atpprapt'3ate box: T. o�:pro�ect{req�IrecT}: 1. 1 arcs cr» to er ;vitlt 4, C 1 tun a,general contmctoar and F p ,6. ` New cstztt onction, employees(full a Vor part4dme} have Hired:tha sib-conir�t ins; 1.0 I am a.sole pzopri r or. : Wed on:the attached:atteded:Shoet. Remodeling 'These sub-contrA�rs:have: Ship and httvtz no etnployocs $. [�.Ihmotitfon employees and have wormers' w for me to any capacity. t 0l�uiiding addidort,. [No waorkers'comb.insu ance comp,insur;uXT it 1, 5. We are a corporation and its 10.01lectricai repairs or additions ofrers have exercised their 11, Plumbing pairs. 3, £am a hotntvatvner wing all work' [�P1umb" re or additions myself;[No workers'co mp. rrghi of extnngdon pa MOL 12.[]Roof nance require> c, 152;§1(4),and we have no employees.[No workers' I,3 n QWer camp.insurance required] *Aasy applicutow chocks box#i mast a wfit outether section below stwwir4 thair wtrr '. tiota o3itiy tratioraa tion t HornWvvtacrs who submit dlis Affi6vit wicviftsthqart 40ins pit W k W tea him outside must'saabartit to 6i:*s in 10"S such 1C.oaktt auors tha chook this box aunt attatbed a 0datioW shoes showh s me nam of ft;saiti�attra MW stut+*hetber or not Wsu etwet vo e pioy , ►f ft&A-004 have eva P*CCS,.t64:y mug psavidt;thtf workers'coaasta.policy nuwber: I am an employer that Is providl W workers'cnnViatsadon Waranee for my einptopeex Btkw is:J*e policy and jnb s#aa Infer rufort In-surance,Company Name. policyor Wins.Lie. c irafton Date. job Site Address.. _ CitylStatelLip: Attack a-copy of the workers'compenss�on pulley declaratlotr page(sbowtng$ he policy ntttntier and expiratJo. elate). Failure to secure 00vMgeas tegttii eel antler Seption 25A of MGL c. 152 clan lead to the i mposidon::of crizttiriAl perlaw, es of fine up to$1,500.00 arid/or o�-yr r irnprisonm &well as civil p�alties is the.:f6rin of a S'T`C3P WORK:ORDER Ands.fine of up to$250.00 a day against the violator; Be advimi that a copy'ofthis tIntement may be,,forwva rd too the af f ict of. Investigations of the DIA for irts=nce coverage verificatiart 147 hereby under the d penalries ofperfury that the informadon proves above ft'trrxe and corecat. tr. t u e vu . A? t t >Irr tla s ,to fie cvrt feted by<c�'ar totott nJ�ataL Cityor.Tq per l ,ice ee Issuing Authority(eircie one): !,Board offfealth 2.Building Department 3,Cityn'own Clerk a.El triralI der 5:Numbing Inspector. . C'otttaet i'er�ln;:�, I'bone _. From- Town of Barnstable Town of Barnstable lnvoce 2020reQ4.0042031 Payment Conf rmtion . al-ea Apr 17, 202.0 at 9 36 PM :. : 'ccoli come-ast.net { Cheat- NICCOLI LORRAINE J TR Payment Confirmation `Thank you for your.payment to Town'Of Barnstable cCount Number :. :022 048. Your payment has been successful{y processed and.your account has been updated. _Invoice Numfaer You Will continue=to receive an email each time a bill is ready far<your . ;2020reQ4Q02t}31 review. This is an easy way to access;.review:and pay your bibs:; y y' Payrnet Amount ; If you haven't a{read one paperless, please consider helping the: environment, reducing your clutter and supporting .dur green;strategy $1178.04 by opting to move to paperiess bliling`in your next,briling;cycle. You will always have the option to print your bill directly from your ' e �` computer if you need it;for your records. PAYMENT To go paperless, log on to your account at 4t.P?/ i i rOLLQWDOR2arns and select paperless.options' : F�RC3CESSE.O482232 t. - under My Profile.Then check the Yes;,I warit,to go Paperless box and press update. If you have any questions regarding,your account, please email us at and include..your account number, first name and1ast name on the account: Town of BarnstableBuilding snx�srn$i Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Ga'�d Must be Kept., Mom. Posted Until Final Inspection Has Been Made �e`� Where a Certificate''of Occupancy is Requiretl,.such Building shall Not be Occupied untila Final Inspection has been made."' ermit Permit No. B-20-1403 Applicant Name: NICCOLI, LORRAINE J TR Approvals Date Issued: 06/04/2020 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/04/2020 Foundation: Location: 104 RALYN ROAD,COTUIT Map/Lot:_022-048 f__ Zoning District: RF Sheathing: Owner on Record: NICCOLI, LORRAINE J TR Contractor Name Framing: 1 Address: .30 CAPTAIN CARLSON WAY Contractor License: `' 2 WEST BRIDGEWATER, MA 02379 Est. Project Cost: $0.00 Chimney: Permit Fee: Description: siding $35.00 ' Fee Paid- $35.00 Insulation: Project Review Req: Date: 6/4/2020 Final: i Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. t ' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing ' 2.Sheathing Inspection Rough: j 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set fort_h in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: f 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: `"9s,- G- 'Ye, City/State/Zip: f W6,4C-- Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with / 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g• Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. Building addition [No workers' comp. insurance comp. insurance.: required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: Policy#or Self-ins.Lic.#: 1{V C� 7V V 7,Z-®O� Expiration Date: /' "' / ' / Job Site Address: / 0 7 /? ��t'/� ® , City/State/Zip: (�o�y z T �f3�/t-�I✓w��� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce nder the ains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: 2XV Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: BIKE, Town of Barnstable *Permit# r 6l ILd Expires 6 monthsfrom issue date Regulatory Services Fee BAaxsrABLE, MASS.1639. Richard V.Scali,Director �� �'FG MA'I A Building Division ®PRESS R6 Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 J U N 2 S 2016 www.town.barnstable.ma.us i OpUIV ®� ry 190, I Office: 508-862-4038 p1!'U l�l-5' '-j90-6 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY a. Not Valid without Red X-Press Imprint Map/parcel Number L Property Address 0 / � A F ❑Residential Value of Work$ d O 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /zE0 P.,Za/0r /o �p� y - ��,( /L Contractor's Name G�e GAD L Telephone Number 761- i? ( C Home Improvement Contractor License#(if applicable) Z O Email: 47,4 Tp Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ave Worker's Compensation Insurance Insurance Company Name R Workman's Comp:Policy# (.,7017�Z 0 1_ -7-0 o 0 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy oft a Home Improvement Contractors License&Construction Supervisors License is uired. SIGNATURE: �C C:\Users\Decollik\AppData\Local\Microsoft\ Bows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 S / v v.tC J w�y Ad �S ���r'�L� "14 C dew vvi t -1-.S ` fio 'C�iu�y —t-0 ������ S .5®4✓�� �lUt•� ��� /lL�a ��P/ice /2�f� of � �� 5 OF THE + BARMABM 9 ,m� Town of Barnstable 'O�Fc nna�" Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder 4 I ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by Us building permit application for: Q� (Adgress of Job) Signature of Ownek Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.outlook\2PIOIDHR\EXPRESS.doc Revised 040215 �SNE Town of Barnstable J` Regulatory Services * sa M LE, AS& = Richard V.Scali,Director >+ 16 3 9. 6 Building Division Tom Perry,Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-86274038k Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, o rro�h ,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: D (A dress of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature of Owner Signature o Applicant Print Name Print Name Date V/ze '��z��wazcoecc�(�c jaracicwelCi UU Office of Consumer Affairs&Business gulation t c ` HOME IMPROVEMENT CONTRACTORType- ::' tl Registration140290 Expiration 9129/2017 Private Corporation i PETER FOLEY INC i PETER FOLEY ;. 195.GRANGE PARK r T4DGEWATER,MA 02324 Undersecretary { License or registration valid for individul use only 1� before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature ` Massachusetts Department of Public Safety ` lug Board of Building Regulations and Standards License: CS-073877 Construction Supervisor Construction Supervisor PETER J FOLEY Restricted to: , 195 GRANGE PK i Unrestricted-Buildings of any use group which contain BRIDGEWATER MA 02324 less than 35,00.0 cubic feet(991 cubic meters)of enclosed space. Expiration: Commissioner Failure top ossess a current edition of the Massachusetts ' State Building Code is cause for revocaMon oASSfGOVIDPSthis license- DIPS Licensing information W visit: WW r ' _ JUn N V0 11:49am P0011001 ACC ;ERTIFICA`�'E^OF LIABILITY INSURANCE °ATE(MM,°°"YrY) `.�.� 06/29/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED,BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the-pollcy(leS)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsamenys►. PRODUCER CNAME- ONT Christina McGowan JOHN P. RUSSELL INSURANCE AGENCY INC. IPHONE &c,N 81 344.0098 ADDRESS:, Cmc owan " russeilins.com 65 PEARL ST. INSu S AFFORDING COVERAGE NAICA STOUGHTON MA 02072 INSURER A; AIM MUTUAL INS CO ` 33758 INSURED _._.... ... INSURER B: _ PETER FOLEY INC INst> Rc� PETER FOLEY INUURER0; 195 GRANGE PARK INSURER E BRIDGEWATER MA 02324 INSURERF: COVERAGES CERTIFICATE NUMBER: 65504 REVISION NUMBER: TI•IIS IS TO CL--RTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW.HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION!OF ANY CONTRACT OR OT'FIER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED 1-ISREIN IS SUBJECT TO ALL THE TERMS.. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE;BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE D POLICY NVMBER MM(DD Erf POLICY MlD Y F�(P LIMITS 1.T COMMERCIAL MERAL LIABILITY EACH OCCURRENCE' $ CLAIMS-MADE 0bCUR PREMISES Ea occurrence $ MED EXP(Airy mr ar.•=) $ N/A PERSONAL B ADV INJURY.' $ GFN'L AGGREGATE LIMIT APPLIES PER: , GfNERALAGGREGATE $. POLICY u tCT LOC PRODUCTS-COMPlCPACC $ OTHPR; $ - AUTOMOBILELIABIUTY CO eJ . $ (Pa a ANY AUTO BODILY INJURY(Per par..on) $ -- ALL OWNED SCHEDULED N/A BODILY INJURY(Per aw.ldant) S AUTOSNON-OWNED PROPERTY DAMAGE _ HIREDAU'fOS Por ON aeeidehlL $ UMaRELLA LIAR OUCUk _, EACH OCCURRENCE $ HEXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ ` DrD RETENTIONS WORKERS COMPENSATION - XI-STATUTE ERA AND EMPLOYERS'UABILtrY —_ Y/N ; ANIYPROPRIETORIPARTNERJF.XECU IVE ' E.L.EACH ACCIDENT $ 100.000' A OFFICERIMr�eHMEXCLUDED? NIA NIA NIA AWC40070176702016A J 01/01/2016 01/01/2017 — (Mandatory yy In NH) E.L.DISEASE•EA EMPLOYE $ 100,000 �R6IPION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VE141CLES(ACORD 101,Addldorul Ramark:Schedida,may bo alt2Ghed If mom spaao Is rbqulrbd) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This CertIRCSte of Insurance shows the policy In force on the date that this certificate was issued(unless the expirallon date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by aeeassing the Proof of Coverage-Coverage Verification Search tool at www.mass.govnwdlworkers-compensation/investigations/. 3 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED,IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable; 200 Main St AUTHORIZED REPRESeNTATIVE Hyannis MA 02601 Daniel M.Crq ey,CPCU,Vlre President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) Tha ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION p pp �Ma V Parcel y 1 Application Health Division Date Issued jol Conservation Division Application Fe " Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board oll�c: '5- Historic- OKH _ Preservation/ Hyannis Lrmit et Address / ��J 1 �y �/fJ/G� Vic!A1011 Addres .� O G' 6- - O �-uest �e C , e-` a Zy �G�OGPJS Square feet: 1 st floor: existingro osed 2nd floor: existing ro osed Total new p p -proposed g -4 .Zoning District r Flood Plain Groundwater Overlay. o r ' ct`C/'uatie d Construction Type Lot Size 44 a/2 So Grandfathered: ❑Yes ❑ No If yes, attach s@ n-orting dpcumE"gation. Dwelling Type: Single Family kr- Two Family ❑ Multi-Family (# units) Age of Existing Structure '36 Historic House: ❑Yes 2<o On Old King's Hi hway: d--Yes Basement Type: a-ru'll ❑ Crawl ❑Walkout ❑ Other po Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: 3 existing _new Total Room Count (not including baths): existing _ new First Floor Room Count Heat Type and Fuel: &-6'class ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ®'No Fireplaces: Existing J_New Existing wood/coal stove: ❑Yes )2 No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:0 existing ❑ new size _Shed:Aexisting ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes J4 No If yes, site plan review # Current Use.A!. +✓ _ ,/- Proposed Use APPLICANT INFORMATION AA (BUILDER OR HOMEOWNER) amez Telephone Number �� Address a &,V License # �v if Home Improvement Contractor# Worker's Compensation # LL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO GNAT DATE ( FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED F kt MAP/PARCEL NO. 2 ADDRESS VILLAGE f OWNER DATE OF INSPECTION: f, k.__FOUNDATION FRAME f INSULATION ti- FIREPLACE x ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL :4 GAS: ROUGH FINAL FINAL BUILDING r E DATE CLOSED OUT ASSOCIATION PLAN NO. f R i = The Commonwealth of Massachuseto Department of IndustiialAccidents - Office of Investigations y i 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ai3plitanAfformation Please Print Legibly Name usiness/Organiiation/IndividuaI): C < G A ass: ZA �'^ �J�✓e ��� ,�. t� �<3 3�� 1 /State/Zip Phone#:. zz —�� -(L.J� �--- Are you an employer? Check the appropriat�o Type of project(required): 1.❑ I am a employer with �45%% I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition. working.for me in any capacity. employees and have workers' 9.. ❑Building addition [No workers'comp. insurance comp. ins rra„ce.$ required.] 5. ❑ We are a corporation and its .10.❑Electrical.repairs or additions 3 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions self o workers' co right of exemption per MGL myself comp. 12.❑ Roof repairs in�urance requimd.]t C. 152, §1(4),and we have no : . employees. [No workers' 13.❑ Other . comp.insurance required.] *Any applicant that checks box P.must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:- Policy#or Self ins.Lic.#: Expiration Date: Sob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 dayagainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do i1treby.c under a pains and penalties o perjury tva)eformation provided abov is true and correct Si Date: one#: Official use only. Do not write in this area,'to 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: w. Phone#: Information and .Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract ofhire, 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. j . MGL chapter.152, §25C(6)also states that"every state or local Iicensing 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()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 checkingthe boxes that apply to your'situation and,if. necessary,supply sub-contractar(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 muaber listed below. Self-insured.companies should entertheir 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 perzpit/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. ' towel)."A copy of the-affidavit that has.been officially stamped or marked by the city or town may be provided to the' . . applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a-license or permit not related to any business or commercial venture (i.e. a dog license or permit to,burn leaves etc.)said person is NOT required to complete this affidavit. The Dffice of Investigations would lice to thank you in advance for your cooperation and should you have any questions;* please do not hesitate to give us a call. i The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA Q2111 TeL 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 evised 4-24-07 WWW.ma s.gov/dia ri �s T Town of Barnstable Regulatory Services f t BARI&MA„rR Thomas F.Geiler,Director mess. 16.39. a Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ��. Fax:•508-790-6230 HOMEOWNER LICENSE EXEMPTION r, Please Print D TB: d ©� \ J(:B LOCATIOTI: /U uummber Str=V village name home:&,,ne# work phone# MAILING ADDRESS: OA01,/1ek city/toWn state zip code The current exemption for"homeowners"was extended to include ownerowner-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 SUT)ervisor. DEF=ON OF 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 Building Official,that he/she shall be re�ansible for all such work performed under the buiidin�permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department inspection procedures and re ents and /she will comply with said procedures and e me, ts, t /,, a of H caner 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 performingwork for which a building pemut is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often 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 carmnunities require,as part of the permit application, ` that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by .� several towns. You may care t.ammd and adopt such a form/ceriification.for use in your community. Q-farms:homeexcmpt • r °FAT Town of Barnstable Regulatory Services aaAss Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main S annis MA 02601 �,H.Y www.town.barnsta6le.ma.us Dffice: 508-862-4038 Fax: 508-790-6230 Property Own Must Complete and Si This Section If Usi uilder as Ownet of the subject property hereby authorize to act on my behalf, m all matters relative to work autho e this building permit Zed ddress of Job) **Pool fences and a are the responsibility the applicant. Poolsare not to be filled or before fence is installed and all final inspections are performed and accepted. Signature of Ownet Signature of Applicant Print Name Print Name Date Q:FORM3:0WNMPE MISSI0NP00LS 62012 u , �,�y Toy o� At� � � CX,s MIA(&th 31 �8 /ve cy DIVISION / �iM//y lee om, :4"C:7 eed TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2-�- Parcel _ r°'k'�x „ Permit# Via`{r ;F;.., Health Division �� ZI 23 a3 �� ' TAP(Date Issued Cam-30'0- Conservation Division 23 3 Fps Application Fee Tax Collector ��L/ �� - - _ Permit Fee r Treasurer �� '/�/�/ ~�-`.;` SEPTIC SYSTEM MUST BE Planning Dept. II\STALLED IN COMPLIANCE WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANL Historic-OKH Preservation/Hyannis TOWN RECUUTIONS Project Street Address /0 Aj/ Village Co Tit i 7- Owner fto D C v�,t Address .24 A 'Telephone ro e^ 0792 9 Permit Request Ae"Ve A&PI,9CC-' `797-i ale 9 jp®S?"S P116 0e C-IFtv5 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family T Two Family ❑ Multi-Family(#units) r Age of Existing Structure Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes A0 No Basement Type: '8.Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing ,New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name 7i/( C Q 3 Telephone Number Address o? V License# 0 S-9 3_2�2 131'0 G Afi o"V/ /1) 09 Home Improvement Contractor# /ao2 0 l Worker's Compensation# WCC S'ov/ a y 4* O/ 0 0. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO OV��^r�1�cr �,`s�U a► 'A e Y ter- i1'l 14 SIGNATURE DATE 19 " y t FOR OFFICIAL USE ONLY 4 PERMIT NO. DATE ISSUED r ' MAP/PARCEL NO. ADDRESS VILLAGE OWNER l . r DATE OF INSPECTION: FOUNDATION - FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL. PLUMBING: ROUGH FINAL r , ' GAS: ROUGH} FINAL - FINAL BUILDING �,'lulb, ,Ua >„,� 3P r3 2 G:. ; : ,cNr To tfow� DATE CLOSED OUT ASSOCIATION PLAN NO#..� i '. I . �OF114E,p��Y Town of Barnstable Regulatory Services seaxsz U, ' Thomas F.Geiler,Director - MAss. 1659• A g Buildin Division pTfD�.� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508462-4038 Fax: 508-790-6230 I Permit no. t 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: All-ve oL dQP®l&- 35-X J 2 ®e Estimated Cost s o Address of Work: A Owner's Name: A',-e C �� Date of Application: e o3 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: .7.2 Date Contractor Name Registration No. OR r,�fa Owner's Name The Commonwealth of Massachusetts — Department of Industrial Accidents =_ Office 91laNS0811oos 600 Washington Street Ce, ? Boston,Mass. 02111 Workers Com ensation Insurance Affidavit 6.vs �, o sC- do name �f i �'9 k�/%�� � � � - location. y Lo 0,-^ie fA tee_ ci ry G y-�.v v hone ❑ I am a homeowner pmfOrming all work myself. ❑ I am a sole rietor and have no one workin in ca achy 1 er rovidin workers' compensation for my employees working on this I am an em P g ...................................:::.::.::::.::.::.::.... :.:::.::.:::.::::::::::.::.:.::.:::..:::. ::.:.::.:::::::::.::::.::::::::::::.:...:::.:.::.::v.:::.::rr}:::::::::::.::: '- c .. ..-. ....... ;•}:•}:ti4:•::•nv?:::;.v.v:.y::...........•.,.....•:•.::•...... .. .......;;........ ...........v::.:-.::?•}}}i:^}:^i:•i?}:^:•}:v. .;.:.};.`,-}v.v{;{S;{.}w:::::::v.;:y:::.}•;fiyti4;{.:{.}}:{.}v:r::::::::::....:.•v.. ... .... ...... ¢.. .. ............... .:•.................:•:::::...r............w..�.. ..................:.::v::.,:•:?i::•i}:?;•isjti:{:'ii:•}}::•}:v:C:•i'-}:•i:{•.:v:`::}?•:•r::•::{,.:i`.y:{•:•};•}:;:;{:• ..... ,::•:•: ..........: ..:...... •...;:::v.;,.•:.;...::.�:.v::n:i:{{ti%}ii:•i}:i•}:{•::;i4:•i;.}:?:.�i:ii:hi:C:{•}}::: :address + r"vla .. `... >'>: .......... . .. ... ... . .... .. ........:..:....:: ..� t:: :�... ::.:::;:.�:}:::::::::::.}' hone# Q ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation o.l.i..c..e..s.:... : : :: : : : : : : . . . : : . . .. . .. . ::.:::::.t,,..,..::..,•.t•,•r^•-tt•;,:;:.;:.}:.}} ... ............:::••::::•:::::.......:•:.vnv::nv .......:::::::::.:::^v:::::,•....• •w.w:.nv::.v•••.. .. -.. .... v::::•'%:::::::•:fi:•}:{•:fi}:?'i::>.?:iiiiii::•}}:;?{�:•}}:?i;;?;;L};?;�:;:j}}}:;{4::::::......................,.....:..:....... v:•.v ••,'Fi:i:jCjjT?ii:;::�::;i:;:;{':•,•,'•{t:;:iiii;+4i>};i:;:;5�j;}i}iriiiii::iYi:::iiii}:;Yijji;:i;:};:.}•::::;:v::::::nv.v::::::•}':::.:v: :v:.;?•}•::.v:;?:.i};:?v:•}:{}'.:::?•i'•:::: ............ r.,..ii:kisi{�i%}':`i;;;.µ{tin}}3:};;.}}}?::• ............ ... .:::::::.:.::::.....:..�..:......::•:v.v::i v::v:.v...........,....•,:::::}:4:•.ii;:;i:{{:•}:{{{{^: y:;:::.}}}ii}:?:.}•:ni::::::.i}}'::;G:4}'•:.i'vn.;. .. ..... ...t. ......... ....::.v:..f...v::....:v::::.v:::-}:r.}:•:L.}i:;::}:•}}}};};.;•}}:3:;4}:fin}:•}}:•}:v::::::::::......:iv:srr::v:::::w:}::::{•}ii}}4:v':;:.}•.}:,:n.........r:'::y:::::nv::::•....... .....^.r... .....n... ....................... ..............: �-: w.vx;;::::::::::•p•:.v:.,v...v:.{w:�?v:v:};..;,,. •:C:+::�:i{:};r:•:^:v• ..... ...................................,........................................... n..:........................................................... �:•i}?:':ijTi::}.v:::::::::nv:::::.:w.v:.v%:v:.:v:n...........,.... ..`.�,.-.:;.;.?,}:}:is ......... .......:....�.:.......:-.................��::::.:.i::::ii:vi}::::.{•.v:•};•:i:•:•:4:•}:{;4;n}:L•.}}}:•}:}.....,}::}:•i:::::?:'r{•}:•i+i:v:.v}i•}.vrr^:::.?;v}•..... .....................t....v:4:4i:?{;•:....................•:::.v:::.v::::::::•x:{;•S:v :}::n.••}};?L: ;;;.; r.•.v.,;'iti<tr}}}w;;..•• :t m.l:;:.. .1.. }. •}::::xv:: VE ii ////// .... .... ••}:::•}.r...... . }..........%.... ::<)'�"�:�:?': :C;ry;{:}:�'q:2�:{:v:Sri`;:•`.::'::}�::�i:;:::v:``?;::::::?.:>;::j::;:;i;�:�::;:;;:�?:;:`.�:�>:i:;Y:;::�:t:;�:;;:}:::: L{::`.}}::i:.}+t:;i:?•:::,;v`.;;;`.;:;;,>.•:•t.;;{+}t•:{i•:;`•:ii;{{{•:. :;Warne=.. .............:. •ate`es ...:.........::.:.:...::..:::::.:::::.�::.. ''e''fs '%` $? `? `' ' a �`� '' f ?ate#" ` `: ' in .,`��ib i.. ...............................:....................................... •}}tin;••%•.,. ... .... .^. ..... ....... v.v:?. ......................:..............v:{y:fi�v:;::::::v:::^vw:rrp•{: v,.,v.,,:::v... r......... ............. .......:.............. ... 7::w:::::..•.....i};.....:::.v:• ..... :...............•.v.v.:::.v.v::.v•:.,...., +y..;{};{.}v.n•...v...%;d:•. 7= ,:�;iii':L:i+::;:i:Jiii:?ii::}:;}:?Ji:3}:!•�:{;; �;:ir::::>:`• 2�:'�:: :•:::f::;:r::;i::%};:;:;::,,••::;}:;x:; :•:;•};:;•}':':'.:i:};:;t::;::-. Q u. gybe to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine np to S1,500.00 andlor one yeato secure coverage agas wen u dd penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand fhat a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties f perjury that the information provided above is true and correct Signature' Si7�— SO 9: S�U Print name J o S eoV A" 1)'?U& 'S Phone# official use only do not write in this area to be completed by city or town official dty or town: permit/license# ❑Building Department ❑Licensing Board ❑Selechnea'a Office ❑check if immediate response is required []Health Department contact person: phone#; ❑Other (revised 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. 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 P to s persons to do maintenance, construction or repair work on such dwelling house or on the grounds or to ent building ernding appurtenant thereto shall not because of such p ym 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 situationand 1 ' company names, address and phone numbers along with a certificate of insurance as all affidavits maybe supplying mP Y submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and a_ city or town that the application for the permit or license is date the affidavit. The affidavit should be returned to the being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retmmed to 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 Investloatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 �pF�HE toy, Town of Barnstable ~O M � Regulatory Services 9BAMSMLF,$ Thomas F.Geiler,Director �p 163q. ♦0 rEn 39 Building Division Tom Perry, Building Commissioner 200 Main Street, ,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I. co , as Owner of the subject property hereby authorize /�' �U '� S C a-J S to act on my,behalf,, in all matters relative to work authorized by this building permit application for: ,vim ko C07A T (Address of Job) Signature Owner ate Print Name Q:FORM&OWNERPERMISSION s . . ✓fie�anvnwoiuea� ct�./�aasac,�ivae Board of Building Regulations and Standards 4 HOMiE tMe.20VEMENT CONTRACTOR Reg�stratiors W?2039 � crrabfior 7k2{ 004 --A idual I I JOSEPH F.MULN�IS3( tOFt i •fit=� , , MIN MULLINS 24 LORRAI:NE AVE G BROCKTON,.MA 02301. Administrator ;;.� ��teFTD��a�,/�aaaucfuaeka BOARD OF MILMING REGULATIONS Lieen.se' NSTRUCTfON SUPERVISOR Number�CS 059322 - I Biir��da�te� 1���1�6 I �-----— E�epre04 Tr.no: 389.. Re trcted R. JOSEPH f MULLS �_ 24 LORRAINE BROCKTON, MA 0230I- Administrator PUS ��;/,.�� .-�• r. r" YC D e C!�% ''S o41 l� 0 6J/reo A lo O. f� Q1 Q �o T S t f �Pl Are SScnB/can IX. ' t b N' /b Tc" PAC r\ rN �a re�� �-- �� y / -0 a 7/ h f -- - BRUT AIOIIeW SCSWART! podtQe M it"o r..WALPMM T. MMGMI RAWMISAtEP TD LAI AUMBO T.M�CdOtl A BaN� - — - ---- - L domitm 017000 REVISED 811 QJ2ppg MOR G4GE INSPECTION PLAN l N SALYN ROAD, C4TUIT, AfA OLD Oy,,3r R ROAD 119.32 R�69.85 Lot #9 M0 AC CBW 4 PEA NEFEMINClO MAID Z11 355 s. t Patio � Lot 3a h OsCk � � Lot !O K L1�oa R`7 1 stry. fJ�JytwoY L 3.73" L�1I I. 1 4=500.00 ROAD ------�,�- CER"RCA1'r10N CII'f1iY TO 71fs AJbVtt AY1gp1Y1'.LtA1r1L AitO'!'N61�,Tfltt N'b(TltAlra,CIMIYAMY THAT Tla 1MA0f BIIp�gC,flll'ItL,AYL�t till L,IIO.tl/r;<N/Y l!r OD>MPLWv�B Mfie'tYB 40CALlAyIVlI�In•ut►4 R ilrvtcr wwsr R'1M8PR,�ImttIR,H R[iPtitT TO IJCItiRAI iBTML1t Rfgtt�A,RM�EClt>X)Ql AR1tIlM F PROM V MAMM XMV0 (UW f ACT=UUM MAW►I;MnAL LAW TITER vfl,CMI&PrEM 40A,49CTMft 7. FLOOD DC78AAfl'VA1YOJV Y 9C kA TUB I)W& Nr,'Mww mm nm NOR FALL,rmw A UWAL itgODN j—&kf AAA7NB Ab 1>fL. ti1D ON A MAI tIf COAOA .NIiY 02toopt rW I D AS 24WS C OATNo l/J/1998 SY atn MA"OKAL,FLthl l ipgURMRk FA00ltA1t OLb&a~lawt Bwsry aL,Jhm -us 2040#►d mftr d ON M LaftsoM,AM 0W," e�iMu1N ftb M"1"3-33 ?CM :mdL tq.atlnro Idle:/OO�pt 9 tit?NERItL NDflti. ,UR n iespnson pltn i rNt Mel ores w r np I,Ynefe of nBnwmtto m JM a Irlel a ear wIYM. Ne=n t v4m§K It CMMt b.mo f11 tJb0rllq aM eme(,Lplltt MNd, «a1111t w�bna� e a bipO MMr.TNf InM aN rnrrll Aeon M 1n to an COW(Wnw rlpnnllfon a "W 1•W J W to amor UNIONS.to ft 0mmwm6 one t"a/rq. fro om Ll fl rbly0r r emneul to db rnr Or1M/w k Y oet J�e.nere b M timaAl. Td whw;IL fooz G! '►mr oQE£Cca60oet: 'or Ytrd A3'kM t1w i 3o1S 9a-u; Woad Assessol's maps and lot number ..2-Z- 1,elg .0�' t yO*TH E y Sewage Permit number ..... IC SYSTEM MUST `O �... . 2.1./................. I SEPTIC INSTALLED IN COMPLIAN BARNSTABLE, • House number ......................................................................... WITH TITLE 5 °o 1639. 0� ENVIRONMENTAL 0®E AhlOjpYa� �r TOWN OF BA'RN,9qQvA@4y TIONS BUILDING., IRSPE'CTOR ... APPLICATION FOR PERMIT TO ..............(r4P..r4)�S'T !!�' . ........................................................................ TYPE OF CONSTRUCTION .............. . '.��.��,``S?�!Ll..f"P. .(.."` .. ..` ................... . .........................191a.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies forQp permit according to the following information: Location ...................-d-..........e....../ ./ N.....f d............(. � .(........................ ............................... ProposedUse .......5. ,.V f/........)' Ap ............................................................................................................................ ZoningDistrict ... ... ...............................................................Fire District .............................................................................. Name of Owner ... V..<. wi .4..........................Address Name of Builder C�7[1Q 4re.....0!U. ................Address .1A.......QIR-W �... ........... ! �..5 t Al p Address /.Name of 1 .....t�-°Q�' ...f/..� r ..............�.................................... Numberof Rooms ...... .....................................................Foundation ...� ..........,......................................... Exterior .k6©4C..�. �. ,.L ..........................................Roofing ......... .� Floors ......C.a .�� ..................................................Interior ........�l. - �7 m p-2 . ................................................................. Heating ....... 5 ......Plumbing .... f' Fireplace ....... ��t'..C. ....................A Approximate Cost ........... `............. p pp :.. O-�� Definitive Plan Approved by Planning Board ------__------------------------19________. Area .... �1§..1�......... 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 .. ....... . A... ........................................... .� FABBO, LUCY t G„ One 23121 Story.-, . a �-�-No ................. Permit.for t" ;jing ng le Family -Dwelli , ... ................... „ ,. � —�� Lot #9 104 Ralyn Rd �-� Loc,�tion ..................... ................... ................... Cotuit r �t. Owner Lucy Fabbo...................................... r �t { Type :of, Construction ......F.ra.......m.e........................... r_ r!` , WY 1 � Plot ........................ Lot ............................... .�' 1 r T ,Permit Granted ...Kay...18..................a:19 81 L; Date of Inspection .................. �C :19�� S ,,: Date Completed ........................1.a.-�te�Z19$/- Q A M n 'S' PERMIT REFUSED r 1z in .... :5.� . .......................... .......... . . ...........................f...... Y Ci ........... � :. er.......................... t.y� . .�............................. ........ :Approved ` �............................. �19 ............ ......:................................................... ............... ..`. ... ..... ./...................... "1 S� s Assessor's map and lot number C5- ........2-2 sTNE Sewage Permit number ..... ........................... BARNSTABLE, House number ...... ......................................I.............. MASIL 1639- mp"i Ar* TOWN OF. BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .............. ........................................... ........................ TYPE OF CONSTRUCTION .............. ..................... ........ .....................19K TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a .permitpccording to the following information: Location ............... . ............................................................... ....... .Cl.......A) ................................ ProposedUse ........ ...................................I..............................................................I......................... ZoningDistrict ........................................................................Fire District .............................................................................. . Name of Owner ...� .....F/,?-44a.........................Address .................................................................................... Name of Builder ..... . ................Address ow.A.Z.41m... Name of ............Address ... ........................................... Number of Rooms ......�...............................................I.....Foundation ...(-0 WCAQ-6 .................................................................. Exlerior ..........................................Roofing .........�n> 4�.-1,14....................................... 7- Floorsn ..................................................Interior .......... ....................................................................... Heating ..............................................................Plumbing .................................................................................. Fireplace ....... ..............I....................................................Approximate Cc;st ....... ......7............ .................... Definitive Plan Approved by Planning Board --------------------------------19--------- Area ................... 0 -:�Diagram of Lot and Building with Dimensions Fee e7�.......................... 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 .... . .......... ............................................. FABBO, LUCY No 23121 Permit for O.ne Stor .. ... Y................ Single FamilyDwellin ................................................................_q........... ` Location Lot #9 10 4 Ralyn,, Rpa .,,,,,,,, ..... ..... Cotuit F ............................................................................... Owner .,.,Lucy. Fabbo ............................................... Type of Construction ...Frame,,,,,,,,,,,,,,,,,,,,,,,,, .............................................. .............................. i Plot ............................ Lot ............................ Permit Granted .. �a..... y8 ..................19 81 Date of Inspection ....................................19 Date Completed ................. 19 PERMIT REFUSED .................................. ......................... 19 .................... .� F.... �. . ........... ' ................................................................................ ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... °``"`.'•e TOWN OF BARNSTABLE Permit No. -------.------ ------------------ I ,l„n� : Building Inspector •e Yua Cash O ------- OUR",1, / OCCUPANCY PERMIT Bond ----_--_-------`�la�/1S3 "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 - - I ti i,4rlNZ) •�R h ,. .. .. • - •. . •fig F _ CItTin THAT THE rOtl11ATICN. L€�T ����� OF :LA.�• . SIICIVPU ON '�H S PLAI% � ll r'�:S I l 'A rt ALL „ - . tlq . t i t A'�;ICUf » "r .. - t r — 6 -03 Z�, Town of Barnstable *Permit �pF aY,y Expires 6 months front issue date w Regulatory Services FeeIzib sniuvsrastE, r �• �' Thomas F.Geiler,Director �A 16g9• A�0 Building Division �/ Tom Perry, Building Commissioner X-PRESS PERMIT 200 Main Street, Hyannis,MA 02601 JUN 2 3 2003 Office: 508-862-4038 a Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL OW N OF BARNSTABLE Not Valid fvithout Red X-Press Imprint Map/parcel Number Property Address 7 P�Q CO Tl.! /7'' • Value of Work Q�Residential r Owner's Name&Address /o y A/✓ A L C a n4 i T �r Jajw Jj,.� C G1, �r Telephone Number sy �'' So 9— 50 .9 Contractor's Name � "� Home Improvement Contractor License#(if applicable) 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# /✓C e 500 Pemut Request(check box) Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maximum.44) ❑ Other(specify) KC PlA c P /I,.h h4-,P® " 5, 0)0, S d�v T *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature /� Q:Forms:e trg n_..:_...71•1 7 Ol11 _ �' T •' �� V/O�Y//rlt4'J2U/BGi.GCIG Q�✓I�LL/.QJCLCILC[06G[t� . \ Board of Building Regulations and Standards WOMIE tIMIp� V:EMENT CONTRACTOR Regtstnati �1�?2039 ,� Mpaoct 3T /2004 3 k ric ividual II JOSEPH F.MULCI` 0£1 9 24 LORRAIN!E AVE I BROCKTON,.MA 02301 Administrator i �/cel�ommzarzrar o�e- w6ad� rCr B'.QARD OF BUILDING REGULATIONS G License:" NSTRUCTI'ON SUPERVISOR a �. Number:'=M 059322 BirtEtdateMAN,1N6 --- ---- ft t 04 Tr.no: 389. ' Re d0 �y r JOSEPH F M:ULLUhS� \k; r/ 24 LORR{gINE AVE�M��t BROCKTON, MA 02301- Administrator