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11/02'94 17:02 'C8177277122 DEPT IN'D ACCID Zoo
T —r,. Coriunoc2cUeafili ol ��Wjac{Iusetf�
' �aParfinenl o�.,)'nc�friap,�lccic�enf�
600 Walqton..Shf l
James J.Campbell &3 On, //lamaga A 02f f 1 _
Commissioner
Workers' Compensation Insurance Affidavit
I
1 �
with a principal place of business at:
(QW/Stutizip)
do hereby certify under the pains and penalties of perjury, that:
0 1 am an employer providing workers' compensation coverage for my employees working on
this Job.
Insurance Company Policy Humber
O I am a'sole proprietor and have no one working for me in any capacity.
(} I am a sole proprietor, general contractor or 1onieowner e one) and have Eared the
contractors listed below who have the following wo ers' comrolpensation policies:
r
Contractor Insurance Co parry/Po[icy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I underst<nd th--t::copy of Leis s=tement will be fonrarded to the Office of Investigations of the DiA for coverage verification and that failure to secure
coverage as ree:ired under Section 25A of MGL 152 can lead to the imposition of criminal penalties consistine of 2 fine of up to s 1,500.00 and/or cr,--
years' impriscrment as well as civil penalties in the for:cf a STOP WORK O ER and a fine of S 100.00 a day against me.
Signed this day of 1,9 �1 S
A
Licensee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375
r TnT,7\T 07 RAATTQTART A RTTTT TTTTC -PFRMTT if _
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB. LOCATION /
Number Street address Section of town
"HOMEOWNER"
N e Home phone Work phone
PRESENT MAILING ADDRESS
City town State
Zip code
The current exemption for "homeowners" was extended to include owner-occupied
dwellings of six units or less and to allow such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor
DEFINITION OF HOMEOWNER:
Persons) who owns a parcel of land on which he/she resides or intends to re-
side, on which there is, or is intended to be, a one to six 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 acGeptable to the Building Official, that he/she shall be responsible
for all such work performed under the building
permit. (Section 109.1. 1)
The undersigned "homeowner" 'assumes'`.responsibility for compliance with the Stat
Building Code -and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town 'of
Barnstable Building Department minimum inspection procedures and requirements
and that he/she will mpl with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will- be -required
to comply. with State .Building Code Section 127:0;. Construction Control.
HOME OWNER'S EXEMPTION
f The code state that: "Any Home Owner performing work for which a building
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that:.if
Home Owner engages a person(s) for hire to do such work, that such Home Owner
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the responsibilities of a' supervisor (see Appendix Q, Rules and Regulations
for licensing Construction Supervisors, Section 2. 15) . This lack of iwarenes
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed_ Supervisor. The. Home "owner-'actin
as supervisor is
P ultimatel
y responsible.
To ensure that the Home Owner is fully aware of his/her responsibilitiesi. man
communities require, as part of the permit applicatio
n, tha
t the Home 'Owner
certify that he/she understands the responsibilities of a last page of this issue is a form currently usedbyseveralutowns. You may
care to amend and adopt such a form/certification for use in your community.
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The Town of Barnstable
MPMABM
�e� Department of Health Safety and Environmental Services
1659. � Building Division
367 Main Street,Hyannis MA 02601
Office: 509-790-6227 Ralph Cmssen
Fax: 508-775-3344 Building Commissioner
For office use only
Permit no.
Date
AFFIDAVIT
HOME EWPROVEMENT 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-ex=ng owner occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent
to such residence or building be done by registered contractors,with certain exceptions, along with other
requirements.
Type of Work: Est.Cost
Address of Work:
Owner.Name:T 12ey/
Date of Permit Application: &6 ',A�2
I hereby certifv 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
--�--�..-..r.--r ,..+....-.- ,...w.t,s_�,y......-...-�..^.i..._.,�,_,�..+r�.re-r."r�-- t.?�^�...•�sy-........v - •---...w..,..-..,..:��..-..,.%�....-..-r.«e••.... �^-�.r-r-.n ._ ...+.-...•�-.'^'^^'"•.'^'^^`l
Assessor's map and lot number ......................................::.. '
Sewage Permit number ................:...::".. �
FtNEr0�o TOWN OF BARNSTABLE
Z BAHH9TADLE, i
"6 9 BUILDING INSPECTOR
��YPY Or
y
APPLICATION FOR PERMIT TO ....... Z..... ' ............. ... ....... �... ...
TYPEOF CONSTRUCTION .....................................................................................................................................
........ .. ........... .............. 5s
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location9.... f/I1 .... ..... / '�r4'..i/ .L,�ir..................................................................................
ProposedUse ...�A' �` � ..................................................................................................................... .........
Zoning District ........... to...I..............................................Fire District . .............. ..... ...... :....... ............ ... ....
.. . .......
Name of Owner � !9.NP.. P�'i a33fii11/ ......Address �9 GSA/Z�4 E r
Name of Builder ...FRANA..... ..K04.... ry..................Address ./.............7............................. .
74,64.
Nameof Architect ..............14.0.,W.......................................Address .................................................................
T(..4��1.r.........................................Foundation .G�'. 11r...FdG T .( -
Number of Rooms .......... ...........
(f`A.A4.�z- C
.Exterior ......... . ..�.."..................................................Roofing ...........��..��....r...........................................................
Floors ..................1!.O� Y.....................................................Interior ...........ly.!0*. .........................................................
Heating ............../Vm/ .......................................................Plumbing .........�4.1�/r�..........................................................
...................Approximate Cost f iN d 0.0
Fireplace "�(.O..1lr/.,f%.................................... ...... ... ............j!..........................................
Definitive Plan Approved by Planning Board -------------------_-----------19________ . Area 3 Z: ..........................
Q d
Diagram of Lot and Building with Dimensions
Fee :..............--'......................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
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TW-5 sl-K��rG I g
To 8r
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ell
Lit
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
`G.. ,
Name ....... .................. ...................... ,.r......................
Dromiu, Armand
\
i -
No —l7S5l.. Permit for ....
a��..�m..���a��— |
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......................
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Location ........ -
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..........................^=wter.^+.J.^P.--.__----_. .
Ovvhe, ...............4kxman6.l):rQPAA-------.
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Type of Construction ...........fz=m------..
--------.--.---------------'
Plot ............................ Lot ___________
. -
Permit Granted -- '9—./--.lg 75
`
Date of Inspection ~ --]V
^ ^
7 .- -'
Dote Completed ..�----]A
�
1
'
PERMIT REFUSED
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^—_--.—~-------------------
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.------------^.—..----.-----�..
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----------------^—^''..—^---'z�'
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Approved ............................................. lV
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----------'----------'—^'—^'^—'
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` - P'^X. .-, __+t•wVy_.+.:'_ ..r'*ti..: s i�A"t��._lYti: :/"" ..... ,..•'�.... .a.✓�a".1 .. .. .,^"", _ '�'A,.+ 'sue,... 4-w+ . _.
Assessor's map and lot number ........ ....`. ....................
Sewage Permit number "``� '� ` � '°"' . �................ . . .. .v�..............
��QyOFTHE'TQ�y.� TOWN OF BARNSTABLE
BABBSTABLE, i ;
Mb 9 BUILD INSPECTOR
APPLICATION FOR PERMIT TO ....................:............:................: :.......................�.
�' / . ............ .................
TYPEOF CONSTRUCTION .....................................................................................................................................
......... t�'-Y)... ............19........
TO THE INSPECTOR OF BUILDINGS:The undersigned hereby applies for a permit according to the following information:
Location .. ca ��' G"� �? -'... tr1/►�{ r f h,�' :. �a.f.::. :.......
ProposedUse .... .., . ^..'... .......................................................................
Zoning District .... ..... District s
......
f4 f+' A r'v'! �1i dUI ' C n/!�S'
Nameof Owner ............�........�......................�............:Address ...:...........:�.................:.................:. `^
t lIC .)" Cal ' vnr u�.� .r.!vS s I �` 7 l
Name of Builder .............:....�........,.............................................Address .....!':.................
Name of Architect ......................................Address .....................
Number of Rooms AfoA/ "
..................................................................Foundation
...........................................................
Exierior .........5��-A.A...A.�r''� Roofing �y o �//�
...................................................... .......................:::-..........................................................
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Floors ..0�(.;_.....................................................Interior ............. '!? /� ........................................................
......................
Heating ......... ....... _ ............................................
A-�h� - I - - � . - I ;4.. :.P:lumbing: - 41-4
Fireplace nn! ost ........ �.. �.......Approximate C .... ...........................................
Definitive Plan Approved by Planning Board _______________________________19________. Area ...... .. .�. .........................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
To R F i ` 1 _
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q,r
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..
.......... ...:.....t... � '........................
Drouin, Armand 571-
No ....L7.551.. Permit for .......add...tQ................
...g,,ax.age............... .. .....
Location .....................................
Centerville
...................................................
Armand Drouin//
Owner ............................................
Type of Construction ........f.r.a.w.....................
................................................... ............................
Plot ............................. Lot ..............................
Permit Granted .......Jan/ary...9..............19 75
...............
Date of Inspection ....../..........................19
Date Completed .......19....................... .
P RMIT REFUSED
................................................................ 19
..................... .........................................................
................... ............................................................
................ .......... ...................................................
............. ............................... .. .............................
Approved ......................................(PT 19
. . ....
........................................................................
...............................................................................
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�. TOWN OF BARNSTABLE
rb BUILDING PERMIT
PARCEL ID 251 055 GEOBASE ID 16137
ADDRESS 36 CENTER LANE PHONE
Cbnterville ZIP
LOT 4 BLOCK LOT SIZE .._ j
DBA . DEVELOPMENT.1 DISTRICT CO
I i
PERMIT •6642 DESCRIPTION REFOOY 16 SQ_FT. 1`
PERMIT TYPE BROOF TITLE BUILDING PERMIT R' OFING
- Department of Health, Safety
CONTRACTORS: PROPERTY OWNER and Environmental Services
ARCHITECTS:
TOTA� FEES: $80.00 THE -
BOND 1 $.00 Ox
CONSTRUCTION COSTS $2,040.00
I
750 ROOFING AND SIDING 1 PRIVATE ;)*) kry +
+ HARNSTABLE. • I
MASS.
OWNER DROUIN, HELEN T
ADDRESS 39 CENTER LANE #
0
CENTERV I LLE MA BUILD °'�9 DIV N
r i
DATE ISSUED 06/2.1/1995 EXPIRATION DATE BY ,�(/
DIVISION APPROVALS FOR
CERTIFICATE OF'OCCUPANCY
TO BE'SIGNED BY EACH DIVISION HEAD UPON COMPLETION
BUILDING:`.• h DATE:
t COMMENTS: +
r
M PLUMBING!' DATE:
COMMENTS:
ELECTRICAL: DATE:
COMMENTS:
GAS: DATE:
COMMENTS:
CONSERVATION: DATE:
COMMENTS:
OKH: DATE:
COMMENTS:
HISTORIC: DATE:
COMMENTS:
FIRE DEPT.: DATE:
COMMENTS:.
OTHER: DATE:
p
COMMENTS: t
TURN THIS IN TO THE BUILDING COMMISSIONER AFTER ALL SIGN-OFFS ARK
COMPLETED.A CERTIFICATE OF OCCUPANCY WILL BE ISSUED AT THAT TIME.
^ TOWN OF BARNSTABLE
BUILDING PERMIT
ARCEL ID 251 055 GEOBASE ID .16137
ADI
RESS -:.36• 'CEAIT R LANE PHONE
",Cc'i�tervi e ZIP.
LOT, t�: BLOCK LOT SIZE
DBA DEVELOPMENT, DISTRICT CO
PERMIT =''�6642 DESCRIPTION REFOOF� 16 SQ.FT.
PERMIT TYPE BROOF TITLE BUILDING PERMIT ROOFING
wt . Department of Health, Safety
[ CONTRACTORS': PROPERTY OWNER and Environmental Services
iARCHTT,E.CTS:
,.TOTAL FEES� - $60.00 Tkf
! BOND $.00 _ O�
CONSTRU.PTIOAT COSTS $2;040.00 Qr
750 ROOFING AND SIDING 1 PRIVATE 4) E>EIu►RN} STABLE,
MASS. �►
I. OWNER. SItOUIN, HELEN T l i6g9.
ADDRESS : " 39 CENTER LANE E�
I. ICENTERVILLE MA �� .
'F BUIL DIV I N.
HATE ISSUED 06/21/1995 EXPIRATION DATE BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST.BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF,PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS
PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED,ON JOB AND WHERE APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR
2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU-
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH-
3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS.
4.FINAL INSPECTION BEFORE OCCUPANCY.
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
I
II
2 2 2
I
I
3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
2 BOARD OF HEALTH
OTHER: SITE PLAN REVIEW APPROVAL.
WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS
THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX- CARD CAN BE ARRANGED FOR BY
VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE. TION. 508-790-6227
BUILDING
PERMIT
��
sessor's Office(lst floor) Map =a5 Lot =N Permit# ._�co#ol-,- if
Conservation Office(4th floor) ?
Date Issued -=�v�, -02/ s
Board of Health(3rd floor)(8:30-9:30/1:00,-2:00) - Fee- DO
engineering Dept. (3rd.floor) House#1
Planning"Dept.(1st floor/School Admin.Bldg.)
BARNSTABLE,
Definitive Pla � ed.by Planning Board 19 a
fDlM��
TOWN OF;BARNSTABLE
3 6 Building Permit Application
Project Street Bess _r r&nte,r' C-. m,
Village a±i�c&/i^��-�
Owner Address
Telephone
Permit Request
Total 1 Story Area(include 1 story-garages&decks) square feet
r
Total 2 Story Area(total of 1st&2nd stories) square feet
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered?
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Commercial Residential
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure Basement Type: Finished
Historic House Unfinished
Old King's Highway
Number of Baths No.of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached. Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
Name Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATU DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. #6642
DATE ISSUED June 21, 1995
MAP/PARCEL NO. 251.055
ADDRESS, 36 Center Lane VILLAGE Osterville, MA
OWNER Helen T. Drouin t:,•
DATE OF INSPECTION:
i
FOUNDATION 1
FRAME
INSULATION -
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ;; '. ROUGH FINAL
FINAL BiJING
,
DATE CLOSED OUT
ASSOCIATION PLAN NO.