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M1 - /... F , , , ,r F T y1. �a ,., �, eve 0 1. a t -a .. s - , � , :� � If' , ,'' . ,� ,� , � � ,: % ,� I , I , � � _�, "jij 6�41- ' ...r _ s+ , - ___- _. _ - Town of Barnstable �t Regulatory Services Thomas F.Geiler,Director w :ALMszABIX. ; Building Division Thomas Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 September 1, 2011 Ms. Jeanne Aylward 217 Horseshoe Lane Centerville, MA 02632 Dear Ms. Alyward, This is in regards to a porch which is being constructed next to your house. I am assuming that your request is in referenced to 227 Horseshoe Lane. This received a variance from the Zoning Board of Appeals. This variance was never appealed rp operly so the permit and variance are in effect. Sincerely, Thomas Perry, CBO Building Commissioner c/o IYD �`r�s BEES. 1;,�.Al 91Y o�l ` /�/Se SyDG � �l�J✓��My{lOd1E� w , :X Ce#tm✓ire, Ah LAW- aG3 ongoing necessary to make an,appointment with the establishment is not open during normal wo call 862=4644 between (8:00 - 9:30 a.m. or inspection. Enclosed is a food permit application form. # . along with the required payment on'or befor Barnstable, addressed to the Public Healtl ;MA 02601. Upon satisfactory compliance a two current ServSafd`Certificates, you will I ;. permit(s),for calendar year 2005 -'Failure to renew permit on or before January ;of,$10.0A late charge. ' If you should"have any questions, please fee `: • office at•86 =4644. -� � .� N 890 45'35"E S 89*JO'20'E ' 29.9!' 49.50 _ - — — — — — c _ °q `a PROPOSED WIDE b L.O T 26: PORCH 11.600 •/- S.F. �i O cn Q - .- #2217 1 GAR . o. Z ZONE RC SETBACKS FRONT - 20 S �3-55 / J S/DE 1 D. REAR /0' [� l HEREBY CERTIFY: THAT - `� OF THE DWELLING DEPICTED ON THIS >' � ti PLOT PLAN PLAN WAS LOCATED ON THE-GROUND A a� IN BY SURVEY ON FEB /6j .2011 AND o WHtT19VC� No.29869 BARNS'TABLE. MA EXISTS AS SHOWN AS OF THE DATE s o OF LOCATION_ . p`ssf� STE@��JQ,�a SCALE: I.'-20 FEB. 189 201I REV/SED FEB. 21 2011 THIS PLAN IS FOR PLOT PLAN /c� EAGLE "SURVEY I NG , : I NC PURPOSES ONLY AND NOT FOR 5��'`v!/` " 923 Route BA RECORDING, -DEED DESCRIPTIONS Yomiouthport, MA. 02675 OR ESTABLISHING PROPERTY LINES.3 ``' �� (m) 362-8132 (508) +432-5= THIS"PLAN IS :VO/D`!F NOTmomm ; STAMPED AND SIGNED /N RED, 0 : l0 20 40 PROJECT NO. 141/-0/l ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ace pp Z Parcel I Application # 160 �o Health Division Date Issued 1 Z 9) 1 Conservation Division Application Fee Planning Dept. Permit Fee .� Date Definitive Plan Approved by Planning Board Ok /12,S1G! Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner n J� L 20-k ROW De-1 1-aVddress /02� Telephon r �� 7 _ k ) , pp -- Permit Request A'Al Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ._, Construction Type ` Z' 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 JNo On Old King's Highway: ❑Yes ❑ No Basement Type: Wull ❑ 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 7. Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: Ll Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing 0 new sizeco t Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: t:, Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use ��rP_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name i- a A--r1M_5 Telephone Number - "7 ?�%✓`� U Address D c�I License # /(�gI Home Improvement Contractor# Z Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY _ APPLICATION# I� ~ DATE ISSUED MAP/PARCEL NO. '. ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: -- tt x FOUNDATION Sarres co • FRAME INSULATION I FIREPLACE =R ELECTRICAL: ROUGH FINAL k. 4 PLUMBING: ROUGH FINAL GAS: ROUGH `FINAL ' FINAL BUILDING DATE CLOSED OUT 't ASSOCIATION PLAN NO. i t k' P. 1 Communication Result Report ( Mar. 14. 2011 3:23PM ) 2) Date/Time : Mar, 14. 2011 3: 15PM File Page No. Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 4869 Memory TX 95087881813 P. 5 E-3) 3) P. 1-5 Reason for error E. 1) Hang up or 1 i n e fail E. 2) Busy E. 3). No answer E. 4) No facsimile connection E. 5) Exceeded max. E—mai.l size O - �— .. .. _... ...�- 32'O - .. • 4'437Rs+7 C' 4' 23'9•W 4" 4. . oZot7 1 aVsesl.e tia..� j C1917 zu.fl� afdt, i 1 u �'�' o"f-)(Ty7� zd,� 1�� }�rr.2s .a►Z S/Mpe- € 1 Lt4 26 77 j),82�,,,p w/aYz"ND* O!k- D� c�� P Lf p6t 2 2 7reg+rsL� Fry s. Cl M"AgS CLJTNLO o Wo.34774 s STRUCTURAL \ � �1SUty N p ERck� ?v5r I y l T �fflc 1 7%z 141, G 1 32'-0" �----- a t I � i i i i coco L)o �? f —6'-4„ _ 8,_2 _ 3, 1„ —3'-3" ----8'10" -- ,=2;4' . to �.... .-. . f-0" . cn o " 4'-3"Rai! 4" 4- '23'-9"Rai! 4" 4� 1 ��\ a _6'4"--- x 6'-8" X-O"x 4'-8" 3%T x 4'-9" 3'-0"z 4'-8" Y-T x 4'(r .m n - Oo � J 0 4" 4'-X Rail 4" 4" 23'-9"Rail 4" 4- I l�asrse sA,,e 4 an-e_ LO.. ojYNF, Town of Barnstable j � Regulatory Services" �Ba M�irsssL� Thomas P. Geiler, Director % 1639. Buildin 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 FLAN REVIEW Owner: Ko.Yv% aw s t Map/parcel: ,,LO d$o Project Address s2�-'7 es Lh Builder: The following items Were noted on reviewing: hrs �w, s .. Reviewed by: Date: �IZa�ll` Q:Forms.:Plnrvw The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations ,r 600 Washington Street a Ito Boston, MA 021-IL www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual):_K7i— L Addresst City/State/Zip: LGr i)` R f/e° d A Phone #: OR ?S L/S�a Are you an,employer?Check the appropriate box: Type of project(required): 1.❑ I am a em to er with 4. ❑ 1 am a general contractor and I P Y 6. ❑•New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. Remodeling r partner- ""�. am a sole. ro rietor o artn 2. ❑ I P P P ship and have no employees These sub-contractors have 8. Ej Demolition working for me in any capacity. workers' comp.'insurance. 9. ❑ Building addition [No workers' comp, insurance 5. POJWe are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box,niust attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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: Job Site Address: City/State/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 certify under the pains and penalties of perjury that the information provided above is true and correct—_, Signature• C �— Date: I—aO �. 1 Phone#: FOth&�� only. Do not write in this area,to be completed by city or town official n:. Permit/License# Authority(circle one): Health 2. Building Department 3. City/Town Clerk 4..Rlectrical Inspector 5. Plumbing Inspector rson: Phone#: Information and Instructions Massachusetts General Laws chapter 152.requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance;construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely;by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is.complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of.Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant . that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the,city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said.person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us.a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 .Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia License or registration valid for individul use only before the expiration date. If found return.to: y Office of.Consume'r Affairs and Business.Reg'ulation 10 Park Plaza-Suite 5170 Boston,MA 02116 L Not valid without signature L,"II:U UtiCnt fit rtltlltl: JHICtl, . ✓�ze �arrvnuyaureal o�/l/la�aaclucael7a 31. Board of Building Regulations and Standards Office of Consumer Affairs&B stness Regulation i HOME IMPROVEMENT CONTRACTOR Construction Supervisor License F Registration �,-102227 Type: j' License: CS 16981 Expiration 7/1/2012 DBA Restricted to: 00------------------- eg ` D LAS L.WILLIAMS CUSTOM+BUILDING k DOUGLAS L 'WILLIAMS SR .Y, + PO BOX 1069 ,0.a Douglas Williams ��`k CENTERVILLE, MA 02632 222 PINE ST n CENTERVILLE, MA\02632 :4 Undersecretary Expiration: 3/7/2012 ('unuuissiuncr .Tr#: 19320 Igo . Williams Custom Buil,dingCo. P.O..Box 1069, Centerville, Massachusetts, 02632-1069 508--775-1.500 fax 508-775-1501 e-mail homebuilda@-comcast.net iAr w .ca-pgcodhol3iebullder.com �r . t__/�C?���'•` '�... j9i�' y✓s ........of.. ...... Town of... �.7e7 t../%........ . ..... ........ state of Phone .. 4..b'r. :7 ::����`I� .':. . give permission to Doug Williams. Custom Building Co., Box 1069, Centerville, Mass.�02632 to apply for a building Permit For work at 227 Horseshoe Lane Centerville, Mass.. I L r r - . _. K 3. t Y '. ,,. '... , --'�;- ,4 " - ;;;- i�"_!". :.�.%. .:i,.,':,,� � - — s v c _ x } s - �� s - T _ � . w z r r t f »vPswa 0 " gip, — 4, � . s �.. �' '�t 1 � k �.L,.i � ti .*"* k { .h s,�, Sri,...{ ..r a W` 3 - .'r f` ,, '+'`=T p� �.. A `, �' a r v �''�' ..mow ' 3 +'T P 3 k+ gip. 'sy k. 1 _ i q �T7*�,�� V.^J�'M'ff J� S''' " 'Iqt4�_qq MU411 _' _-, - a1�- , �� , I I I � 9 "I'M ,1--11-r- ..i v.r k,;, -.,'?�''.I* 111 1 Z. W'. �-�.' � ,11-111.A `�� W �3r rya r ��Jy +*° I -# y y .1 . - v �'. �7 � � _�� - f `.�^� � -� -�; � x, . "s' d� :Y ;siR', ram,-x '*` 11 - � 4y � " ¢ 9 .x� s.. . ... h .9 9abi'_J it w. w .. ' .. gip. .ZEt R <JF": w '_P o HAROLD A. DONAHOE JR. REGISTERED PROFESSIONAL LAND SURVEYOR 18 NICHOLAS RD.— BRAINTREE, MA. 02184 Dale : (617) 843-0905 Job No. Land in 61q o,,1ST/a/3C owner(s) A). Title Reference Registry Disirict :�LfPJI/�i3Ct= L d T Z�o A = I I ( ooSFt IJ -4227 . IN- ' a i r o. 06) SCALE--1 FOR MIORTGAGEPURAOSES ONU`7No1 to be used fo determine properlp lines or to consfnW fences,Or/ondscapidy,etc. 1 C£RTi FY THAT THE BUILDINGS ARE LOCATED AS R SHOWN, AND CONFORMED TO THE ZONING IN EFFECT WHEN CONSTRUCTED EXCEPT AS NOTED. Sµ THE PROPERTYa LIES IN e��t!` of Mtr�'cyG ZONE AS SHOWN ON THE NATIONAL 8 /ONRHOEB "' FLOOD INSURANCE MAP. Ifa19419 « (4 S0"E�� L•d E18199L909 !�smojwo)j eigga0 dOl:Zl, 11 OZ Uef I M k - a 77777 WC nv Sri x 40 s" b o t r f 3 i e afi to €� 4 I �'� ',=�s #' `. +.Ai. .,. ', . g yam, y s rri w 44, - - k g. Sill "51" �"ttY t 5 ice' FX g ' :. 0 r • ..:. _ _ .. y ' - -i - - % - - y . ::. g P = 1 ,?' _ - F7,,- s b '& 4 . % I!.,-�----,��,,,,- - - �� r h -� �:e' d - �£+ t. by-rY.. 'il _ 1. a* ,y. �,. !T' Pam-- { BE " 4 -*x i€ `t' r }* E x - ,• ' � � y s� . '7*", , , -',- - - ,I.,, � -Xr."T I.t-�4 - .-,, , . �, - ,.�!, - �V i !� V- ,V - fe- - - .-;�." 113, It � - it,4".A -� � 1, O ,.� 1-1 I "'.,. ., ", � , w -3 � . , I, -, , % , 4 � .., " ,-,,,,,,��-,�, A i. YY S'Ydf .Xr -Lo.& ^4 .-r„ts 4'4 ik dS ,g r ks w�v- '�^� e' -y a_ u — . .11� , , w - - ,—, - ��.. k -a? t ,.r.N' a y., xr _ sH F:r�s i11 re-�a^.: r°xs r xs & u r hr tom. { a r a= .. .. . . ., .. x. r ` pa4 Z�a;� f \A of PA AS,, y �ti o mICHELE CUDILO U NO.34774 STRUCTURAL Iz Eli, I{ ' �i it it f:It it 1—� -s 4"D/A 29Y � c� ' 2.✓fir ����; ryP) r cot oFIHE Town of Barnstable Per # pExpires 6 mo,:lrs jror 'sue date - Regulatory Services Fee BARNSTABLE, + 9cbA 639' Thomas F. Geiler,.Director l A Foy AhJ Building Division 1 �/ Tom Perry,,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstab16.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY *��l.-�S� Not Valid witboui Red X-Press Imprint T Map/parcel Number Z0 Property Address 4,7i C 26- j J . esidential _Value of Work ,# L`,l� r�' Minimum fee.of$35.00 for work under$6000.00 Owner's Name &Ad es (���,��rciid� Contractor's Name cl U-),f Ct ✓ ✓,/ ✓S ( 4",/ ,ilf r . Telephone Number ljG�s Home Improvement Contractor License#(if applicable) .102, Construction Supervisor's License#(if applicable) e ❑Workman's Compensation Insurance Check one: IA '91', am a sole proprietor_ c ❑ I am the Homeowner. ! OVVIN OF BARNS l ABLE . ❑ I have Worker's Compensation Insurance, Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction.debris will be taken to ❑ Re-roof(not stripping.. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value �,�,Z (maximum.44)#of windows 7 *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 of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: 1 Q:\WPFILESTORMS\building permit formsIEXPRESS.doC 5 �i Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ttii t, 600 Washington Street Boston, MA 02111 ` { www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Y , Name (Business/Organization/Individual) �JJtt �1� CE6747-f �`� e,-� Address: City/State/Zip: Ile - - Phone#: �4 -'�r ':%�`�rJ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. Ellam a general contractor and I * have hired the sub-contractors 6. _�New construction employees(full and/or part-time). 2.kip m a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'. comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.�Electrical repairs or additions 3.0 I am a homeowner doing all work .~ right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12,Ej Roof repairs insurance required.] t employees.{No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#l 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 their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. N. i` Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Tc� Date:, /-Ji Phone#: j 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#: S y ' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service.of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state'or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states."Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy isTequired. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia IVlassachusetts- Department of Public Safety _ p , f po�nm�.uuea,�C� p�./�aaaac�Zuaella 4 Board of Buiidin!g,>Re!gulations and Standards � I .� Office�Con umerAffairs&Bdsiness Regulation Construction Supervisor License _ HOME IMPROVEMENT CONTRACTOR License: CS 16981 I - Registration .r�102227 Type: j I Restri.Fted to: ,00 .�l ���>`� ,� Expiration: 7/1/2012' DBA D LAS L.WILLIAMS GIJSTOMBUILDING j Z, DOUGLAS L WILLIAMS SR r +� = i ' PO BOX 1069 CENTERVILLE, MA 02632 ` " Douglas.,Williams 222 PINE ST. CENTERVILLE,MA 02632 - 'f Undersecretary Expiration: 3/7/2012 (lrnui�isiuncr Tr#:'19320 e _ License-or registration valid for individ'ul use only ` " before the expiration date. If found return to; I Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170' Boston,MA 02116 tg Not valid'without signature 1 x , e Doug- Illia s Cus- tom BuildingCo. P.O. Box 1069, C-enterville, Massachusetts, 02632-1069 508-775-1500 fax 508-775-1503 e-maii honAebuilda on cast_net w w ,.caecodhomebuilder.com Town of... T ....................state of.../lI.Z........ ... ... Phone 1... d.b'!. .7.�:: 'y ��......... give permission to :Doug Williams Custom Building Co., Box 1069. Centerville, Mass. 02632 to apply for a building Permit For work at 227 Horseshoe Lane, Centerville.,Mass.. .... 12/29/2010 �oFTHE.. TOWN OF BARNSTABLE BAHHSTOHLS, i 9� 0 p9a\ , BUILDING INSPECTOR t APPLICATION FOR PERMIT TO .................. .c.. .. ..................................................................... „ r TYPE OF CONSTRUCTION ................ ........... .................................................. ................. . . ...... . ...19..�� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... .�j........ � 4. ��:•e....... iC�"/J.� � P Proposed Use ..............: I.. ,�... ..............................................................................................................:.......... ......................Fire District ........... Zoning District ............................................. ................................................................... (Cedar Acres Reatty Trust Name of Owner ........................24.GreatPandJXVA............:....Address Add. ......... ...............................::........................................ South Yarmouth, Mass. a Nameof Builder ._ •: �•° ��`Zg•jc• ...Address .......................................................................:............ Name of Architect ............. Address ............., ..............`............................... e Number of Rooms ............ .. „�1 ........................................Foundation .,...... ................................ Apr: Exterior ... . .. :... ....Roofing ....... . Floors ................. .e ................................................Interior ...........4.. \\'' ...................... . / / Y Heating ........... C` 4....... `c ....#.................Plumbing .........................lF. :...... .... .. . ................. Fireplace . . . . ............................................Approximate Cost ...................../ -..&Q..�............... Difinitive Plan Approve by Planning Board ________________________--_-___19 . Q o e Diagram of Lot and Building with Dimensions C 10 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ? 4 4�' Name Cedar Acres Realty Trust DEC311970 No ....131 Permit for .....one story, single family! dwelling.......................... Horseshoe Iane Location ................................................................ Centerville ............................................................................... Owner .........Cedar....Acres. ...Realty. . ...Trust........... ........ . ...... . .... .......... 3 Type of Construction ..................frame........................ ................................................................................ Plot ............................ Lot .........#26................ r Permit Granted ....... 19 70 Date of Inspection e�A'�...e>k.......'S4.......19 76 Date Completed I PERMIT REFUSED ................................................................ 19 « S ....................................... .................................... - - .................................................... ............................................................................... . ............................................................................... F E f Approved ............................................................................... (� ...............................................................................