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a v . TOWN.OF BARNSTABLE BUILDING PERMIT APPLICATION
✓Map P rcel QQ _ Permit# � 79 (4
ealth Division Date Issued 3 0
P' 53 -
onservatjon Division 0 �q �� Fee L3�
ez`C`oflector T,
`reasurer *113 SUPTIC SYSm'Et 3 �1� USE
aiag-9ept. INSTALLED IN CONgF'LIANCE
. . ._ �fl.ITI.1 TITLE 5 •
_ and
E&�VIR�t� EN�'AL CC C- AND
Project Street Address ,/0 A14L Mze l7 GQ24Y
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Village C,�ti T_t(,b— U.V
Owner 11"A 1_A_4_Ntt/5 Address' e9 l i214S6 c SE
Telephone - '
Permit Request U I krq L . S br, Jr.
Square feet: 1 st floor: existing proposed 2nd floor:.existin.g proposed Total new
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑.No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑,Yes JX No On Old King's Highway:. ❑Yes No,
Basement Type: ❑Full ❑Crawl Cl 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: U 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 0 ,
Commercial ❑Yes. ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name FIZA-TC- k So,tiJ ill c , Telephone Number 75/ ) 3 - `(I:q
Address 5 u)AL Po c-E- S License# C S 033206
LALLCONSTR
0 er;J am Home Improvement Contractor# / 11°Q are 3n Worker's Compensation# /� / � � o D— o
UCTION Rr,s DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �1�`('r4�c1 -t , oU0-`(
TURE,-e.,, i�`� Ag
DATE 3
t
FOR OFFICIAL USE ONLY
PERMIT NO.
# DATE ISSUED ► f g
MAP/PARCEL NO.
ADDRESS t• t• tip" � ± ' _ , � l t: '• - [ ` '
F n- VILLAGE t
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME t .^ •
INSULATION
FIREPLACE - x
ELECTRICAL: . ROUGH. " .. FINAL ,
PLUMBING:• ROUGH FINAL
GAS: ROUGH FINAL' -
FINAL BUILDING;};;
r^ r w
DATE CLOSED,OUT_ 1
ASSOCIATION-PLAN NO. t '
_ f
S
Wausau Insurance Companies
Nationwide Insurance Enterprise
PO BOX 8062 WAUSAU,WI 54102-8062 18M732.732/
I
PRATT & SON, INC .
165 WALPOLE ST
DOVER MA 02030
JULY 01, 1998
Policy Number 1519-00-089595
Policy Period JULY 02, 1998 to JULY 02, 1999
Billing Basis ANNUALLY
Here is your Workers Compensation Policy providing coverage for the year and billing basis shown above.
If your policy is issued on other than an annual basis, we will send payroll report forms which you must complete and
return to this office with payment within 15 days from the end of the report period to keep your insurance in force.
Remember to apply any applicable Pool surcharge, experience or merit rating modification factor when calculating these
reports. Your deposit premium will be applied to your final audit.
If the deposit premium you sent differs from the deposit premium shown on this policy, you must pay any additional
amount due within 30 days from the invoice date. We will apply overpayments to your account or refund them.
If your policy is annual, the balance is due within 30 days from the invoice date unless payment terms are available per
state guidelines.
Wausau Insurance Companies accepts certificates of insurance issued by agents on the ACORD certificate form. If you
have an agent, please see them for your certificate needs. The agent will send a copy of certificates they issue to you and
to us. if you do not have an agent, please let us know when you need certificates issued.
If you have operations in Minnesota requiring certificates of insurance, please contact us directly. Minnesota law does
not permit agents to issue certificates.
Enclosure
TL1001
(06-28-96)
- :_ The Commonwealth of Massachusetts
•�-- � -:.:.:
• _-- =� Department of Industrial Accidents
A, ..'.:
:: . -=-� ONCe nfiasestigsOffs
600 Washington Street
Boston,Mass.' 02111
Workers' Comjiensation Insurance davit
�/�///% '
''�",'ii"can"f�mfa"r "r ✓//%//%//%�///.%!%%!%%/////%�!//%%',
name: P 2&-Tir— + o
location L,1� -_l2b' (i/ y f
city VIA 4- hone#
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
�am an employer providing workers' compensation for my employees working on this job.
compnnv name:
(��i4 Sowryc_
address: i to (.a j At, L
irn-
Citv: D U C-0, M 4�' phone Cz e&yy
insurance cn. l,(J�US� nniicv# `J { q o 0'- Cie 9S- Sr
ioa�oi��a�iiiio�oa/aoa�ai��a�ioaiiaiiiiiiaiiia��riaii���iioaa�aia�oa�a��ai�aaoiiaiiiaiioai�/l
-
El I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
the follo%%ing workers* compensation polices:
comnany name:
address: :..:;::•:
city phone ......
......::....:....
msurnnce co.
comnanv name: _ :::.: .... :.,....
address:
city- phone
I
::.:...::..:.. :.
insurance co. oli
//O%%�%///%/�/%��////�%%�� / // // / / // ////G///%//r.
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S 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 S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verincation.
r do herebv certify under the pains and penalties of perjury that the information provided above it tru/p and correct
Siena nue Date
Print name ST y rim L . P" Phone'# 7 ff� 3�1P ` l
ofIlciai use only do not write in this area to be completed by city or town olIIciai
city or town: permit/llcense f# ❑Buildi
❑LicenLD
❑check if immediate response is required ❑Select❑Healt
contact person: phone#; ❑Other
(rrmw*93 P1A1
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 cone-.::-.
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 receive: c:
trustee of an individual, partnership, association or other legal entity, emplovu' employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renews:
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 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. 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.
FOR
,
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 rctianed is
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
0MC6 of 18 sugatlons _
600 Washington Street
Boston;Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 eat. 406, 409 or 375
The Town of Barnstable
• enBKer�,e, II
Department of Health Safety and Environmental Services-
� � Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038
Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
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: -P(yJ(0 Estimated Cost oZ0 '
Address of Work: /0 PIL Y Q b I A q CEO rr- )i L L.
Owner's Name: LIP Ib A- AIDS
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
oJob Under S1,000
Building not owner-occupied
❑Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
(�D0
Date Contractor Name Registration No.
OR
Date Owner's Name
q:fortm:Affidav
Wausau Insurance Companies
Nationwide Insurance Enterprise
Po BOX em WAUSAU,WI 54402-SM (W732-7324
PRATT & SON, INC.
165 WALPOLE ST
DOVER MA 02030
JULY 01, 1998
Policy Number 1519-00-089595
Policy Period JULY 02, 1998 to JULY 02, 1999
Billing Basis ANNUALLY
f -
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✓die>�www.cen/G(yf uaasaa�uaeifG ✓/ie i�a»r.�nay,�uea�i �`f'lauac�u..ell�
HOME IMPROVEMENT CONTRACTOR DEPARTMENT OF PUBLIC SAFETY
Registration 1000/6 CONSTRUCTION SUPERVISOR LICENSE
Type - PRIVATE CORPORATION NwDer: Expires:
PRATT i SON, INC. Restricted To: 11
Steven L. Pratt
`o Walpole St STEVEN L PRATT
AOMIMSTAATOR Dover MA 02030 "' ' 28 AUDUBON OR
WALPOLE, NA 12181
II
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TOWN OF BARNSTABLE a Permit No. 28323
1 Bum"x i Building Inspector cash
OCCUPANCY PERMIT- Bond ------_`____1����
r F "
Issiied to James K. Smith Address
Lot 2. 10 Haivard Way. Cen.te� 11e
Wiring Inspector . Inspection date "`_.
Plumbing Inspecjtor Inspection date
i
+ Gas Inspector 0 Inspection date !".
Engineering Department Inspection date/, {
Board of Health • 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
` ...................................................... 191fi
% B�ilding Inspector
Dam _
Assessor's map,and lot number .......:....:......... c
r- SEPTIC-IC Sys b Egli"���a �tNE to��
�-'is ^^ '- ALL IN C o�
Sewage Permit- number .......................... ... ...J INSTALLED OMPLIA
ED
" MUSTAM
•
I� TITLE � L B LE,
House number .........: . . .�....:.... . ..:.... j, EMVII$ONIir�E /'p{ a F.
5 k,
MENTAL CODE 2639.
REGULATION� n war a.
TOWN OF BARNSTABLE ,
BUILDING 1k8PECT011 s'
APPLICATION FOR PERMIT TO ....::.......................................:�. . .................. .... ... '......................:..........
..............TYPE OF CONSTRUCTION....:......... ./... :"R�.." ......4-;?'14�i,....r..... ........................................
t ..........A,,, `. :191�7
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby,applies f r•a permit according to the following information:
Location ... ...... ............ ...t............ `�..... .........................................
Proposed Use .......... . .. .............. ............. ............. ......... ............................
.... .. ... . . ..
Zoning District ........ ......... ,
....:....... .. .. ...... .. . ... .... ...:............Fire.District ........ ........ . .. .. ......
4 '
Address .......... ...... .......
Name of Owner :..... .. .. . ....� . ................ ................................... ..
Name of Builder ..../..`.:.. ... . . ................Address ..... ......................... ,
Name of Archite ....:........Address ...............:
Number of Rooms Foundation ... :a.:. ...
................�f............... .... .. .. .......
041
Exlerior ... .. ... .. ...... :......:.........Roofing ::..
Floors .............. ...............:.............Interior ............. :.......... ... . ..... .............. ........
f
.............Plumbin .....................
Heating ......s.. g ...... . ..... .... ............................
Fireplace ...........Approximate. Cost
.................................................
Definitive Plan Approved by Planning Board --------------19 Area /�1!: � ..
Diagram of Lot and Building with Dimensions Fee .... . ..� _ .......
......... -
SUBJECT TO APPROVAL OF BOARD OF HEALTH
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ', .
hereby agree to conform to all the Rules and Regulations of the Town of. Barnstable regarding`the above
construction. `
Jam'
Name . 4.r?r9.../..`...:'
1
Const ion Su e`rvisor's License/ / �v
p .........i, ..... ............
�► SYEIY ,K7, JAMES K.
No ..28323.:.. Permit for,..One„StorY...............
:....S z�g7.s=..Famil'y.. ......................
Location ....Lat..2.......If)...Ralyar.d..-Way............ a �* • '^,�s'� ��.
C.antexviIZjQt......... � h
Owner - Jams ...K.....Sul7,tk�................ ........... L '
',� _ v
Type of Construction :....Exams........................... -. / ;� y •�' ..j� j�' � if)
........................... ..........................................
Plot ..........: Lot ................................ -
' +J
t August 14, 85 t
Permit Granted 19
......................................
j r
Date of Inspection ft 19
Date Completed `31.....>' .... 19.� �' -
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