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!t•1��t
Engineering Dept. (3rd floor) Map Parcel Permit#
House# � Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30.)1 X` /-.L-F-9 7 Fee I dA,
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) �1
Planning Dept.(1st floor/School Admin. Bldg.) �t►�rq
Definitive Plan Approved by Planning Board 19 SET
INSTALLE 6 IANCL
TOWN OF BARNSTABT a WIT
'LtNVIRONMENTAL CODE AND
�& Building Permit Application TOWIV.REGULATIONS
Project Street Address 1:7 ►Gl n L.
Village I� fi
► ��� KYl cx o
Owner Address w f
Telephone
Permit Request &e Asck � P'`fit, p
}
First Floor_ _ 0 square feet Second Floor square feet
Construction Type
Estimated Project Cost $ 0 60
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure 30 Historic House ❑Yes JJ-Ro On Old King's Highway ❑Yes o
r "' went Type: &/Full ❑Crawl ❑Walkout ❑Other
)
Basement Finisleo Area�,�sq.ft.) Basement Unfinished Area(sq.ft �5!S O
Number of Baths: Full: ls�Xisting�_ New Half: Existing New
No. of Bedrooms:. Existing \ New
Total Room Count(not including b f s): Existing _New. First Floor Room Count
Heat Type and Fuel: f�Gas ❑Oil LAElectric ❑Other 10,
Central Air ❑Yes $f No Fireplaces: Exis g _New Existing wood/coal stove ❑Yes b No
Garage: ❑Detached(size) ther Detached Structures: ❑Pool(size)
r
❑Attached(size) ❑Barn(size)
2None ❑Shed(size)
❑Other(size) �I
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes (INo If yes, site plan review#
Current Use �,� Proposed Us
Builder Information
Name '--' P ►�P Telephone imber C�� �() 2 !'7 _
Address'p;t)e Bh4 PO Y-e,I1�g icense# 0 L J C -
4) 0._x {, Home Improve 'ent Contractor#
Worker's Compe sati.,n#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUIL T)SHOWING EXISTING,AS WELL-AS"-1
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS ROJEC"T WILL BE TAKEN TO
Ck
SIGNATURE DATE
DATE I
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
ti , .
i
FOR OFFICIAL USE ONLY r' ,
t -
PERMIT NO.
DATE ISSUED '
MAP/PARCEL NO. ,' +
•� i
ADDRESS s VILLAGE
OWNER ( {
DATE OF INSPECTION:
FOUNDATION �J
FRAME
INSULATION
FIREPLACE ,
ELECTRICAL: ROUGH FINAL
PLUMBING: E3UGH FINAL
E �
`' 'J FINAL
GAS: RO;UGI-C«� °`'
FINAL BUILDING
DATE CLOSED OUT .
ASSOCIATION PLAN NO.
r
� 1
a
°F VAE l
ti
The Town of Barnstable
f�naxsrns[.E. = '
9� � Department of Health Safety and Environmental Services
ArEDMA'�A Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
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.
0 Type of Work: Est.Costj) 0
Address of Work: ncA C, A.
Owner's Name My-y- aa, yrir s LL�2
Date of Permit Application: L J.A21 Qn
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:
1 /2t7 h ez,bd14 11761 d
Date Contractor Name Registration No.
OR
Date Owner's Name
L I
"-' The Coninronwealth of.4fascac•husetts
Dt.partnunt ojltrtlrtstrial.9ccrdurts
6 OlficeofinvesMatians
., ' 1 - •� - Street
I
.•.\_! tillfl N usher„tun t
�• ': Boston, 111u.vs. 02111
` Workers' Compensation Insurance Affidavit
Ahplic•int information• Please PRINT'lebi�lv
name
location•
cite Phone#
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
• .�^-r+ �� ,..-ac+..Ar-.a+.�R.s-ss'p.•^� ,;:r.s±r^.e�°• n*�I.'el^�w ...+,.wg+�rs,«..*.•..._. s+.�+•....A n+.,...^ro.r•_._±...r.�.__.... _.. .,.,
1 am an emplover providing workers' compensation for my employees working on this job.
coninanN, name:
address 1v---a-- '—ram—�—j�
city: ��Qi-� t���c> bp' ` i��rA phone#• 1S®IQ�
r—
insurance co. W' ofic y# Cs
1 am a sole proprietor, general contractor, or homeowner(circle otte) and have hired the contractors listed below who have
the following workers' compensation polices:
company n•ttne•
address:
cite: phone#:
insurance co Policy#
. ._ • �i.::.y� .a\�Y^. .�..�.Y..^..:', ....._..'=•• �T'_. �. �=�ti4 iT'�l�yl._.'ra1,• .i/....- .y.��'..� ..._
_..__.^ ..... ..._._..�...�.._..... _�.1..+r�L.�r.._.w_.w_.J...is.►lr.r....'i�]i.ai.w.Irrr.,. _ L _ - _�. ,..��..s .._�.L'...�:tWai`a. Lr�..+:
company nine
address:
rite: phone#•
insurance co nolic}•#
:Attach additional sheet if necessary
F:lilurc to secure coverage as required under Section 25A of n1GL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andior
one years' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement mac be forwarded to the Office of Investigations of the D1A for coverage verification.
I(Io herebr certify under the pains and penalties of perjun•that the information provided above is true an correct
Signature A iuR.�n �� ,�,Ii>\ Date
Print name P lCc Phone#
rT YWL'(Y!
llcoi�
r to�cn; permidliccnsc# I—tt3uilding llcpartmcnt �'-^
C]Liccnsing Board
C]check if immediate response is required ❑Selectmen's Office f..
011calth Department
contact person: phone#. t"tOther y:
N
1«nised 3;11;11JAI
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their
employees. As quoted from the "law an en►ploree is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An entjyl►►rer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the forc�_oin�� en��a�sed 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
dwellim, house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or oil the �-Trounds 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 of-
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.
Additionallv. 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 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.
Cite• or owns - - -
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 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.
�....y,v.-e*..•--...: . . .__.,.�.,.v:..,... .--•.r....sr•.-r-r^r_...,.....x...-...,e,,...--.:,....',7..,fix.n ...o+: ...T.sw,yr...:<,wew�..+.._n7.w•e..-,+ *Tnn�+-.r•r•�ra.rr4z.rr•r.• ^..,-•.•n�•w....n....-:�.+r�i
The Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 «'ashington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
'
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✓fie V/antarzoouueal/� o�✓ �awac�zudeltt
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Nuaber� '- w . Expires:
Rest tted.40.. `00
'STEVEN'L HELLOR "
PO,BOB 334
yT,W -%'Yi'BARNSTABLE, HA 02668
r
PM�ROIfEII CONTRACTOR:f
P DMA
94ERC i►Al b / :BO 334 �
��`4'"Y r RNSTABLE� R2668
''ADM' F
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