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Permit +' Wu here a Certificate''of Occupancy'is Required;ssuch.Building shall Not be Occupied until a FinaLlnspectio�n h,been made Permit NO. B-16-535 Applicant Name: Map/Lot: 226-125 Date Issued: 03/29/2016 Current Use: 1010 Zoning District: RB Permit Type: Shed-Residential-200 sf and under Expiration Date: 09/29/2016 Contractor Name: Location: 73 CENTERVILLE AVENUE,CENTERVILLE Est Project Cost: $0.00 Contractor License: Owner on Record: PETRUTIS,REGINA Permit Fee , g, $35.00 , Address: 73 CENTERVILLE AVE Fee Paid '`;$35t00 �' _ CENTERVILLE, MA 02632 Date. - 3„/29/2016 Description: install a 8x16 shed J Project Review Req : � � �� � � :� � ``U " Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this Perm ii is commenced witkin 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. 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 work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work'' ,rr 1.Foundation or Footing 2.Sheathing Inspection 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 , t 5.Prior to Covering Structural Members(Frame Inspection) r` 6.Insulation 7.Final Inspection before Occupancy P P Y Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards_are the property of the APPLICANT-ISSUED RECIPIENT �J Town of Barnstable' / o� 'awti Regulatory Services, 3123i/C o � . Richard V.Scali,Director * MASS. �` Building Division /Uo Ft— i63q. �0 i°rEo �s p` Tom Perry,Building Commissioner - 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 PERMIT# FEE: $35.00 SHED REGISTRATION eUk RESIDENTLAL ONLY 200 square feet or less. /y )' .T qR p8 �4VO)C:,e ?016 qp. • Location of shed(address) Village "�Sjge P�rwS E _ Property owner's name Telephone number 47) Size of Shed Map/Parcel# Sign ape Date • Hyannis Main Street Waterfront Historic District? 1 V Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. , THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:040914 II - �-k s EL 1 0.4o (b i p )REP ARED FOR ERT/F/ED PL O T PLAN u g�- 'X CA TION: 'CAL-E: i--=zo DA'TE ' .J- 4 ?£F£R£NCE: LOT . L. C. P. FL O0D ZONEp� / H£R£BY CERTIFY THAT THE BOIL DING MOWN ON THIS PLAN /S LOCATED ON THE /gip RGE Gn " ROUND AS SHOWN HEREON . ow. �R. r'r' g��i t 27807 to y a�J 1 G 11,040 o .0 p PREPARED FOR- Assam• Or- 0651E�VlLU' 0-7:Ci CER TIF/ED PL 0 T PL AN ' LOCATION SCALE I''= LO' DATE 3- 4 -a0 REFERENCE: LOT P. B. 0 P. Z,S_ r L. C. P. � p FLOOD ZONE G/ RGE I HEREBY CERTIFY THAT THE BUIL DING { °s SHOWN ON THIS PLAN IS LOCATED ON THE �1 ' GROUND AS SHOWN HEREON . GIG aQ �M S,� o � LOW & WEL L ER, !NC. 7I4 MAIN STREET YARMOUTH, MASS. DA T£ - - c. Ks N or' offioe;'(1st floor):. i Assessor's map:,and lot number ....a....:........� .. ...... ` SEPTIC SYSTEM MUSTS pf THE TOE` Board of Health (3rd floor): o� � TALLE® 1N C®INP`'IA o" ` Sewage Permit number m............. .:.1. ,` i �� i BAB39f4DLE, ITH TITLE 5 . Engineering Department (3rd.floor): 1 ; pappaa //��ppp�nge� ee��pp C �i� roes � 19RONME®iI AL CODE Op �63q: 9p House number ' TOWN REGULATIONS APPLICATIONS PROCESSED 8:30`-9.30 'A.M 'and{ 1:00-2 OOP P.M. onlyl TOWN . OF ZARNSTAB•LE BUILDING,: INSPECTOR ; e r I APPLICATION -FOR PERMIT TO .......... Y..4.2. st? ,.....C !�C�..:.. av�: .� TYPE OF CONSTRUCTION .... .` ........!V�ad... 1►► :...:.......... TO THE INSPECTOR OF. BUILDINGS: The undersigned hereby applies for permit according to the following information: Location '......... .�1....4t hi2Y D 9:.Pe—' ...:.:`�U'� .......w.....�ly w1►�i?......� f l. ... ..`.......................................... . Proposed Use .............:..... �` = 3�? ` ... ......A .4�......:. .......CC,.......... ...................... r Zoning .District • ~.Fire District .......... ..•..•....... a �} l ...�"LY:. . �V° .41 � .� ................Address •......... W. y h�► ��oJ1 Name of Owner �:......�:'.:.....:..... ... .. .. U Name of Builder .......................................... .........................Address ` Nameof-Architect ..................." ................:.:................:...Address .....::..:...,...................................................................... a F� .................. Number of Rooms ............ .. :."`"..................... Foundation Q�c� V e Exterior .......... �'.�."..i.i................... .......................................Roofin /��,�a• c«l. h�!1 1Y,5 9 ..... ......F. . Floors ....:........C!%cY�� ......S�SD�....................................Interior ........................_.... ....................................................... ` r Heating g • Fireplace ...........Approximate Cost ............IAy Rq................................... Definitive Plan Approved by Planning Board _--------------------------_'____19-------- , Area ........ ............................. Diagram :of Lot and Building with, Dimensions / Fee ..........✓...® t i......................... _ SUBJECT TO APPROVAL OF 'BOARD, OF HEALTH L �e. E N' -f P—V t LL€• ' 14 V '4 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS r ; - I hereby agree to conform to all the Rules and Regulations of the T n of Barnsto -re rdin the ab ve construction. l Name ...... ..... .......................................................... Construction Supervisor's License JTIS, A. t N9; 30521.,jPermit for ..BREEZEWAY & GARAGE L Single Family Dwelling r- ' U' v- Location 7.3 Centerville Avenue _ W. Y - ..:'.w.o..:..v.- ...... ................. + • ._ it " ten-. - .. OwnerF A:-. Petrut..s Type of Construction Frame.............. ..... _ z :P...... ........................................................ 4 7 Plot ... ........ .... Lot- ............... t ' - Marc 1 7 ' F Permit Granted ...........................................' 19 B { Date of Inspection'......7 .....19 yDate Completed ...... ... ......... .....19 'i ',�T i• f ` , 'A.d.J• e •, r ; I. , � �.. ill ' i r. ' `. a S zj , Assessor's offioe.(lst floor): �' A sessor's map and lot number ............. . .......... ........ F THE T Board of Health (3rd floor): Sewage Permit number .... ...r. ...1..( Z 11aB319TnnLE, S Engineering Department (3rd floor): 'oo rb q, Housenumber ........................................................................ APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..............�Y..? E?�.�.....c h�I.....,�.y� ..:................................................. 1(V.Qod... ...��,e. TYPE OF CONSTRUCTION ........................ ( .............................................................................. ----........�?!�.vc , �.�.............197:. TO THE INSPECTOR OF BUILDINGS: li far a permit according to the following information: The undersigned hereby applies o g 9 Y PP P 9 ^� hi�Yu►'lle- 40* `N. Ny���;� ���� Mom - Location ...........1..........:.....>............................................. ... ..... .... ........ ... ................................................. t I Proposed Use ................... Y 71Jn? .v........av,8.........Q''........ �........`�J � c� e'aZoning District ......................................Fire District .............................................................................. Name of Owner ►.�j.MVS.'..�.?. �2 � i�. ...............Address ...........1�....15�� 4�Y Ii.II v- ..A ve- .....W.'.NYr:hhv 114- Name of Builder .Address Nameof Architect ......................-":......................................Address ......................................................j............................... Number of Rooms ..................--"".......................................Foundation .............I—)OQ........�bhCYe ............................. Exterior ............!.'.t.'.�.11..........................................................Roofing .............''lisp, ,: �l!•........��.�i'��e�. Floors �'�hr"Y.Q. c...... l g:.......................:............Int erior .................................................................................... Heating ..............................................Plumbing ......................'- ....................................................... OU Fireplace -..--...........................................Approximate Cost ............ '....,.........................I....................... Definitive Plan Approved by Planning Board _______________________________19________ . Area ......... .!. '....................... Diagram of Lot and Building with Dimensions Fee ........ f -C .�. SUBJECT TO APPROVAL OF BOARD OF HEALTH r Hovs cb 141 + �. � OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ,r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable ereggarding�the ab�ve construction. i Name . 'Lrgc Construction Supervisor's License ..................... J 1 PETRUTIS, A. • A=226-125 30521 BREEZEWAY &GARAGE No ................. Permit for .................................... Single Family- Dwelling .......................................................................... Location ....73 Centerville Avenue . .............. ...:... .............. ............... .... rt A. Owner Petrutis ............................................. Type of Construction .............Frame............................. ............................................................................... I Plot ............................ Lot ................................ March 17, 87 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 f / I � E . BUILDER INFORMATION Name / bt �� .S Telephone Number SVF-- 12S—' 3 91 7 Address �� C�E'WOIP ,4? 11 y A License# !� Cr U n4-S /"' 7 Home Improvement Contractor# e, f Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO i SIGNATURE V DATE L9 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map y Parcel / Permit# ��'�3 Health Division , -7 ' (3 D4 7 -'t.-9 Date Issued $1584 d DL en Conservation Division j - 'i , Application Fee Tax Collector Permit Fee ,Si q 9 Treasurer D f IST LLEI)IN c; PLL PlanningP Dept. TIT�.E 5. NP Date Definitive Plan Approved by Planning Board E RONMENTAL�®0�3 - foWm REGUL Historic-OKH Preservation/Hyannis . Project Street Address Cw T a L)i 11z 4c l� Village Owner �'Y1 r 5 _�O at an p -TIK' "ris Address -7 C_�,t1T_V U l 1(-� _ Telephone 5,60 -7 75- 3q 91, Permit RequestTc� Car.► ctcr �-r�►vaom R0Dt-0UY\1 �ea1�eaN °�Xtant46 htous_ Phlo , (gw-n&e-° C pleas-p- S* plrw Square feet: 1 st floor: existing- 1 y proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: Cl Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family B�'_ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes @-No— On Old King's Highway: ❑Yes srN Basement Type: Mull ❑Crawl ❑Walkout ❑Other Basement Finished Area .ft.(sq ) Basement Unfinished Area(sq.ft) 1 Number of Baths: Full: existing' f new Half:existing new Number of Bedrooms: existing 'new Total Room Count(not including baths): existing new ' First Floor Room Count S Heat Type and Fuel: 316as ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New. Existing wood/coal stove: ❑Yes B-Nb Detached garage:❑existing ❑new size Pool:O existing 0 new size Barn:0 existing 0 new size Attached garage: xisting 0 new size Shed:❑existing rO new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 0 Yes ❑No If yes,site plan review# ` Current Use Proposed 'Use p w BUILDER INFORMATION c�nrlp Telephone Number S - b ��"'NameE en � Address t K JIMn2�- �1��1� " License# 0 -s(,65 rt fflffi-SrniwS.. ktk n1►.3, V 03.&45 Home Improvement Contractor# 1245io g ' Worker's Compensation d-7 P J Q 8 760_�(447 9-64) . ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO _'RAkk(Sta- bI-P P. S pos r1l ,.i SIGNATURE- DATE Ca > FOR OFFICIAL USE ONLY _ - r -r PERMIT NO. DATE ISSUED j MAP/PARCEL NO. t ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: I0/1q/64 FOUNDATION rr FRAME IV INSULATION �� Z .. et o/ s. ®`c✓ C FIREPLACE ELECTRICAL: ROUGH FINAL — PLUMBING: ROUGH FINAL F . GAS: ROUGH FINAL - FINAL BUILDING = -- f f , DATE CLOSED OUT _ ASSOCIATION PLAN NO. r 3 f °pIME r Town of Barnstable y Regulatory Services BAMSTABM Thomas F.Geiler,Director i639• Alf MA'1 A Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 I NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR'S , owner of property located at hereby certify that et, is no longer Construction �. 3 Supervisor listed on the application for the project under construction as authorized by 3 building permit# , issued on 2000a� 1 I understand that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. t f ROPERTY OWNER DA E q/forms/newcontr reference R-5 780 CMR rev:080102 i The Commonwealth of Massachusetts Department of Industrial Accidents 600 TYashineton Street Boston,Mass. 02111 WorkersIC om ensation Insurance Affidavit-General Businesses name address 73 Ct?h��r«G(� /V O-er ai P q 14!/LLc�DYP� state: !"`Ifi" zip: 02,(�7a phone# S-Vg.- -77�-3 9 work site location(full address): Ct - ❑ I am a sole proprietor and have no one Business Type; ❑Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑g ce❑ Sales(including Real Estate,Autos etc.) ❑I am an em loyer with em loyees(full& art tw/roime . Other I am an employer providing workers' compensation for my employees working on this job. com anv name city phone#::. ohc. .# :..; . u I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: com..:en addressd.::•: city insurance co. _.. . .. ... • ollev:# ..: address city . .... .. .... : phone#ic insurance co.:.:: .:..: , .,: ....••..., Fallure 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 WORK ORDER and a fine of$100.00.a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIAfor coverage verification. I do hereby certify er thepains an o penal 'es perju that.the information provided above is true and correct �iC�-. Signature - Date Print name Phone# x ON e official use only do not write in this area to be completed by city or town offlclal �. rK city or town: permit/license# ❑Building Department K ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department , ON contactperson• phone#; ❑Other -iw,y (rzvaed Sept 2003) , 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 irrTlied, 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 o=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 binding appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance 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 amidavit. The affidavit should be returned to the city or town that the application for the perrnit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law" or if you are requirec to obtain a workers' compensation policy,please call the Department at the number listedbelow. 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 perrrrit/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. 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 Once of Imstgauens 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 ext.406 L �oFIME� Town of Barnstable ti 0* Regulatory Services sn MASS. Thomas F.Geiler,Director 9�A i 9. `�$' jF1639. A Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,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: L �� ( Estimated Cost �� 5 — Address of Work: 73 Owner's Name: g—T l e" Date of 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. OIt Date Own s Name Q:forms:homeaf6dav Town of Barnstable o� Regulatory Services Thomas F.Geiler,Director s659. �� Building Division o �s 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 Please Print DATE- —,-.2- 7 Y JOB LOCATION: 23 0,-_1&7a number street Page "HOMBowNEx k 9 Cr l V A .5-0f- 7 2L 3�7 name home phone# work'phone# CURRENT MAILING ADDRESS: G�. c/6? 1444sP0A 02�_� city/to state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)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 responsible for all such work performed under the building_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 minimum inspection procedures and requirements and that he/she will comply with said procedures and tequir nts. � _ i Signatur f Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-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 communities 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 amend and adopt such a form/certification for use in your community. Q:forms:homeexempt OF THE ram, Town of Barnstable Regulatory Services BAMSTABLE, Thomas F.Geiler,Director tab q 0 �� 9�Al39. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,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: PArh WjoAA I A 0 yaciKI Estimated Cost !(0©. Address of Work: 7 7) j lT-ew ltLe Owner's Name: Mvs GIN,A P-2k UT1 tS Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: 6-- 1 U- 04-, R c e t�A i 245�6 Date Contractor Name Registration No.- OR Date Owner's Name Q:forms:homeaffidav f ' -4- The Commonwealth of Massachusetts Department of Industrial Accidents" 600 Washington Street Boston,Mass. 02111 . Workers', Com ensation.Insurance Affidavit-General Businesses ' Y'!%l//L/u�/L/U/L//���y�/�/��`fG%%///G_GO���//��0������///�0���'°..• �'� f � �������0�//O//G���D/���////�///_�/O/���//��0����i,%//��0 ��.sg� 3.�a1.J •w�• >'>i''i.n.• ot.rr.a,�r'a•sy,,,. .. - "<'^ � �•.i: � „$t:.3idS1 name L�/�n► Wd..l Yl �•fr'�14� .. •• . S_ j _. • ,r- address' � �� ��Vtil h-21- F-p►��- •. .. city 14 lx� yn 1 I I state: Ya' zip: Q 9-6 4 S' • yhone work site location(full addressl ❑ I am.a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/BaAatYng Establishment working in any capacity. ❑Office El Wei(mcluding.Real Estate,Autos etc.)' I am an em to er with ern to ees full& art time).. ❑Other am an em ploy er p rovidig n workers' compensation for my employees working on this job.. _ . �.. +J. eaaress� �'$'77-77. I. -. . ..,+I ,t:• �q;�''.t ,. y W.Y'1 1.ram.i �,':' phoide#:' + lJ:�Li cl 131�J ' Ju MINOR .insiirance.co'' .•t -� �i' ' ' , I am a sole proprietor and have hired the independent contractors listed below who have t} e following workers' compensation polices: coin`an 'n'ame ;.s. �dressi. Did i i — i�' P one, . — -- .. insurance co. :> 'safe: COIII•9It. II _ - a cl eY': im ,::. insurance�co:•�°: Failure to secure coverage as required under Section 25A of MGL 152-can lead to:the imposition of criminalpenalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of is STOP WORK ORDER and a fine of$100.00 a day against in% I understand that$ copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification I do hereb ertify nder .e pa' nd penalties of perjury that the information provided above is true and correct Si�aa Gc.�t� DateV. Print name G Phone# a� 4�4 official use only do not write In this area to be completed by city or town official city or town: - permit/License# []Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office Health Department contact person• phone#; ❑Other (revised Sept 2M3) Information and Instructions Massachusetts General Laws c4pter152 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 defiled as an individual,partnership, association,corporation or other legal entity, or any two or mare of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased,employer, or the receiver or partnership, association or other legal entity, employing employees. However the o wner of a trustee of an individual, dwelling house having,'not-more.than three apartments and who resides therein, or the.occupant:of the dwelling house of s ersons to do.maintenance, construction or repair work on such dwelling house or on the grounds or to . another who employs.P . ereto shall not because of such.employment.be deemed to be an employ bang appurtenant th er. :. 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.coirimonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the cone ionwealth nor any.of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements.of this chapter have been presented to the contracting . authority. Applicants Please fill in the workers'compensation affidavit completely,by checking the box that applies to your situation . Please p g supply company name, address and hone numbers along with a certificate of insurance as all affidavits may be submitted to the Department-of Industrial Accidents for confirmation of insurance coverage. Also'be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding:the"law"or if you are required to obtain a:workers' compensation policy,please call the Department at the number liste 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 a affidavit for you.to fill out in the event the Officc 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 unless other arrangements have been made. the Department b}�,mail or FAX 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. is address,telephone and fax number: The D artrnen • ep . The Commonwealth Of Massachusetts- Department of Industrial Accidents Dino of Wesugoons 600 Washington Street Boston,Ma. 02111 fag#: (617)727-7749 phone#: (617) 727-4900 ext.406 M CMR,AppdWk j Table JS.Llb(continued) prescriptive Packages for One and Two-Family Residential Buildings Hated with Fossil Fuels MAXIMUM MINIMUM Glaring Glazing Ceiling Wall Floor Basement Slab Heating/Cooling Area'('/o) U-value R-valtw' R vaiue4 R value] Wall Perimeter Equipment Efficiency' Package I I R value° R-value' 5701 to 6500 Hating Degree Days' Q 12% 0.40 38 13 19 10 6 Normal R 12% 0.52 30 19 19 10 6 Normal S 12% 0.50 38 13 19 10 6 85 AFUE T 15% 0.36 38 13 25 NIA NIA Normal U 15% 0.46 38 19 19 10 6 Normal V 15% 0.44 38 13 25 N/A NIA 85 AFUE W 15% 0.52 30 19 19 10 6 85 AFUE X 13% 032 38 13 23 NIA N/A Normal Y 18% OA2 38 19 25 NIA NIA Normal Z 19% 0.42 38 13 19 10 6 90 AFUE AA 18% 0.50 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: `7 5 Ce L112 kJLI LP I� Lk ST r�bvKI 1.s �QJ-1— , ►m ►q 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: Z Sc� 3. SQUARE FOOTAGE OF ALL GLAZING: I U 4. %GLAZING AREA(#3 DIVIDED BY#2): ( •. ' 5. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: ` NO: q-forms-f980303a 780 CMR Appendix J Footnotes to Table J$.2.1b: ' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area, expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 fe of decorative glass may be excluded from a building design with 300 ft of glazing area. Z After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with I the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding,structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. S The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned bi cements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. " If the building utilizes electric resistance heating use compliance approach 3,4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a NOTES: a Glazing areas and U-values are maximum acceptable levels. Insulation R values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J 1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation p P levels the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). i 43 RESIDENTIAL BUILDING PERWHT FEES A PLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE Fpbyl $® square feet x$96/sq.foot= -x _ plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0031= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit; square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 _ Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee projcost Town of Barnstable o� Regulatory Services .�� Thomas F.Geller,Director v� %W. a,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 . www.town.b arnstable.ma,us Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property 13 to act on my behalf, hereby orize in an matters relative to work authorized by this building permit application for; G' Uy �1 � (Address of Job) 1 0 D to Signatur f Owner �0-k q-I Print Name r..cns�t„tc�[1wNERPFRMISSION . To- . �s OI a VJ'l1 Remo �a RAM �amvin°'uae t T�IO:NS _. a OF 8UILD6NG SUPER ISOR BOARD ONSTRUCTION Licenser 023665 �i gum'' _ 06 Tr.no.. 24547 M1 ' G x R / O-NAL H ��j` �' 1as TIMBER 1 NL���48 Commissioner MARSTONS M►' i r t t / { 226 ,r t t / t \ 071,9, f f 32 f w l ol ... # 73 ` 1 ....._._................ `t - ......._......_. .....- .. i � � t8 ❑ 8 8 3 c:\conservation.dgn 7/12/2004 3:41:27 PM The Town of Barnstable SARrMA.0 Department of Health Safety and Errvironmental Services MARS. ,a Building Division 367 Main Street,Hyannis,MA 02601 508.8624038 ;. 508.790.6130 PLAN RIEVIEw Owner: PtA r''N%S Map/Parcel: Z-" �? Project Address: 7 3 C e!tk-C- ' twt Builder: r• e 0.� The following items were noted on reviewing: i/ 'fib. �s�i 3olE,e9= fr, bot o bo ►TS i Iock (S" (yt, 3 -i. ` o�s'T� ? Went ► U fie i e w rvQ C JC' 3/ � . 6 UU'e-V S erK-lam hY4� tgG 2 n -i AAica CXGt.c-0! S v �GU KL l G t1141- i i i h(UW Reviewed by: Date: 712.E)O y - -Ext STI h1 C• C+A-}-IR U-2 1 — ' 1 n.r i I i III ti ,_ I j i , PRa2GSeQ Flwr Plrmm -�Rc po SE0 i RU oseo Arhioom Aoaiii.G1_- _._ s 71 faN'fC V Ifl .SN� F2ouT._y1GW: _ r /1 CGQ SS TO Chl9W1 1 nhOL(r l- 44LSy*N4& Lu,km OW U- 4iA I 1 v S AID r IOUIIiyt .—t,bm R,;c2 UaNr y My �ouwnnr,tt- Artlacln<o T70 w( Mrs Fnuunnnr,N balls MLK. IS" I__p r I .. EYIST•I P16 f�InII� (Zl L•U-�IV.T. _ ce hs 16^02. W'COX PI Road' Rn><�t�� ".:..: •6�' - Zx I:o QAQ Imo'-I -,iiI ilOt I II ct0 ✓ r� s(i iq it it f2 COK.P . wail X i II II. I! p II ��" - 2.C6 Ylea7z••• r ( I I II K4 JFlcLc SLUD II i II ' II X - C�.SrI �1- 'W AII.Is.I tAl '- � .I II- / 1 ,.'+ .. - FK CTIN6 E•{OLIS - , fl-h r3LC - II: 4 r• 6 QTic I II I� i� -II - >•� .•.` 2X4 ZuNtts- JV I F Rig"i UP IT I r: .... T � .' :•' by - PER C � ,�KNQ wt1oN ViN'I Z �: I • 1 I • t : ct If t tA(A?'EIC'PR�-As opE if Fz�Sr`tnt� { I-4(,t.�e.�'t�u�Yo � �� • u �— •.. 55 -1 ct(oN.. - - t pp I�e.a Nlq l $.P--Tt.4Tl.F._ .. I cruel. v4^-ram• a-a=� Gross SecriON sipr, few PFONr View I Engineering Dept.(3rd floor) Map )i Parcel , �°�� Permit# ON �- H f- #• 1.5 Date Issued Board of Health(.3rd floor)(8:15 -9:30/1:00-4:30) Fee S-. C7 Conservation Office(4ih floor)(8:30-9:30/1:00-2:00) Planning-De (1st floor/School Admin. Bldg.) �1 De ' v n Approved by Planning Board 19 _ RNSTABLE ` MASS ` TOWN OF BARNSTABLE Building Permit Application Project Street Address � Village '#XA AJ/V l S ?O 117 - Owner 1+2— F-b IVS 43 TR L, T jS Address b 7 z Telephone —7 7E-- 3 2 e Z Permit Request a First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ �, 4 ov Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family #.units Y( ) Age of Existing Structure (/ 'Mc, Historic House ❑Yes to On Old King's Highway ❑Yes �o Basement Type: L ull ❑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 Garage: ❑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 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 SIGNATURE DATE BUILDING PERMI ENIED FOR RTTHE OWING REASON(S). F FOR OFFICIAL USE ONLY PERMIT NO. - 1 DATE'ISSUED y. ..:. MAP/PARCEL NO: _ - • R . •mot`' 'ADDRESS 7 VILLAGE' 6 ! W OWNER , DATE OF INSPECTION:, t FOUNDATION • FRAME INSULATION FIREPLACE 4 ELECTRICAL: ROUGH FINAL " PLUMBING: ROUGH FINAL' GAS: ROUGH FINAL - ir FINAL,BUILDING _� r1 CU/1 DATE CLOSED OUT ASSOCIATION PLAN NO. a t TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE 7 —( 6 JOB. LOCATION 73 . d" 6 e V t L L e_ 4"V GU- ��i�l r►�l� D�2 7— Number Street address Section of town "HOMEOWNER" h L , S ?&Tipp U %GS 7 7S - 32P ' .. Name Home phone Work phone - PRESENT MAILING ADDRESS 0 /-a,c 30 7 '" • tv-A41 MnI S 0'�-7' 02,67.72- City/town I State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Officia- on a form acce-ptable 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 i dution procedures and requirements and that he/she will compl with said p o res 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 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 Owne: 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 awarene; 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� actir. as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/Ater responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. r r _ ......... �_ The Commonwealth of Massachusetts -. .. Department of Industrial Accidents Office 011=95#9 bons h - -- 600 Washington Street ��+i Boston,Mass. 02111 Workers Com ensation Insurance Affidavit name: lea, 'v` location l EU/73 t�o d Q ar`— _ ,Q city (f C( 3-dL // O hone# '7 , kr I am a homeowner performirit all work myself. ❑ I am a sole proprietor and have no one working in any capacity /////////%%/// %/ %/%%// ///%/e /p//%/%//%////%/%%///%/%/////%%/%/%/ ❑ I am an employer providing workers' compensation for my employees working on this job. com nnv name- address: city phone#: insurance co. olicv# //%////// / //////%/// ❑ I 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. dtv phone#: Insurance co. olicv# cam anv name: address- phone phone#: polity# Insurance co. FaIIure to secure coverage�required under Section ISA of�1GL 152 can lead to the imposition of criminal penaides of a fate up to 51,500.00 and/or one years'imptiaonment as well e'civil pensides in the form of a STOP WORK ORDER and a ijne of 5100.00 s day against me. I understand that a copy of tab statemenemay be fotwsrded to the Ofitce of Invesdgadotu of the DIA for coverage veriIIcadon. 1 do hereby certify der the pains and en a'es/of perjury that the information provided above is truo and co)rrrect 114 Date 7 —/(� Signature /��+ /V- �+7 p Print name 7< < / �G/ /l � Phone# <rs omcial use only do not write in this area to be completed by city or town official city or town permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Se lth De a Mee alth Department contact person: phone#; ❑Other (mined 9/95 P)A) ` �i _ J v L 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 comrac of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association. corporation or other tives of a deceased emploal entity' or yer, or the receiver the foregoing engaged in a joint enterpnse, any two or more of d including the legal representatives 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 hemployer.dwelling ll ouse or on the grounds o: building appurtenant thereto shall not because of such employment b deemed to be . MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha- not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be 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.a.se call the Department at questions regarding fisted below. w"or if you are required to obtain a workers' comp P pgl City or Towns rinted legibly. The Department has provided a space at the bottom of the Please be sure that the affidavit is complete and p 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. 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 { OMce of InvesdUatlons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 t - ' i The Town of Barnstable KM tee$ Department of Health Safety and EnvironmentalServices 11"9-o� Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosson Office: 509-790.6227 Building Commission: Fax: 508-790-6730 For otTtce use only Permit no. Date AFFIDAVIT, HOME IMPROVEMENT'CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, aite=dons, renovation, repair, modernization- conversion, improvement, removal, demolition, or construction of as 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. �q a Type of Worst: Re-p IAC e �o�►►� Jk-.� L Est.Cost����a Address of Work: 3 L°�/�� Gt1_ Owner's Name-4 LAIL6?I-,—' (0 — q Date of Permit Application 7 r I hereby certify that: Registration is not required for the following reasons): Work excluded by law Job under S1.000. Building not owner-occupied +/Owner pulling own permit Notice is hereby given that: OWNERS .PULLING THM OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FORI AOG'RAM OR LE HOME GUARANTY FUND UNDER MGL 142A PROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION SIGNED UNDER PENALTIES OF PER=Y I hereby apply for a.permit as the agent of the owner. 4 Contractor Name Registration No. Date OR r Owner's Name Date r