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Engineering Dept. (3rd floor) Map a O B Parcel . tYS " Permit#
House# `. ; Date Issu 0Z o
Board of Health(3rd floor)(8:15 -9:30/1:00-43fl) `Zf zxa�e
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) -V&X A' y STEM mu r'SE
Planning INSTALLED I PLIANDE
WIT
Board 19 ENVIR®NM E.AND
Q TOWN TOWN OF�BARNSTABLE.
` Building Permit Application
Project Street Address ''S a Qj ft�tGi,7- S�
Villages err /lam �
Owner lJ�� a r iR ' r" /t d Address F14V I� /erh 1-- e Pr i?9SG✓dd a` TX,
Telephone 2-6j Z
Permit Request
i
First Floor square feet Second Floor square feet
.Construction Type '
Estimated Project Cost $ ��(,, "a,
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Ei" Two Family ❑ Multi-Family(#units)
Age of Existing Structure 00 rs. Historic House ❑Yes a Flo On Old King's Highway ❑Yes ❑No
Basement Type: ErFull ❑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 h�
Total Room Count(not including baths): Existing e New First Floor Room Count �f
Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes 31 o Fireplaces: Existing =New Existing wood/coal stove ❑Yes io
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 A%G�/ V. �)Alvwtl Telephone Number SA6- -773"' 3 7e) 8
Address/Of 1:6V Ses�pp Za License#
Home Improvement Contractor# /1,2 f 77
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 PERMIT DENIE FOR THE FOLLOWING REASON(S)
�7a//ems ;
F �
FOR OFFICIAL USE ONLY
r •O
PERMIT NO.
DATE ISSUED ► w
MAP/PARCEL NO.
ADDRESS VILLAGE, ; - i f
OWNER '
DATE OF--INSPECTION.
FOUNDATION _ --
FRAME
INSULATION < r
FIREPLACE T '
d ELECTRICAL:t ROUGH FINAL
` PLUMBING:,-) ROUGH FINAL
GAS: rw ROUGH s FINAL
FINAL BUILDING :=
DATE CLOSED O.UT
r `ASSOCIATION PLAN NO. 4 ;
Z
Y s
The Town of Barnstable
• fABNsrAa� •
9 sARG- � Department of Health Safety and Environmental Services
659. Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227
Fax: 508-790-6230 Building Commissione
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.
Est. Cost
Type of Work: C AV
( �'�liYCvGs t:
Address of Work: 3>'2 Owner's Name4 Fa `r ` '
Date of Permit Application:
t hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job 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:
a� d a
D to VContractor ame Registration No.
OR
Date Owner's Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office o11aVe5tigZ&9flS
_9 600 Washington Street
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name ILI,I't��l V fp
location ✓a 0 Sf
city shone# 7) 7
❑ I am a homeowner performing all work myself.
[✓ I am a sole pro rietor and have no one working in anv capacity
////////%/%%%%//////%/%/%/////%%////%%//%%%%%%%%%%%%%%////////////%//%%////////////////%%%%%�%%��%%////////////..%,i
❑ I am an employer providing workers' compensation for my employees working on this job.
com any name:
address:
...
city phone#
insurance co. Rolicv#
%////771,///%/////%/
❑ am a sole proprietor general contractor. or homeowner(circle one) and have hired the contractors listed below who
ha .
the following workers' compensation polices:
company name: AI'C,hA •e J. c .y!Fit 2/0
address S ! )rSe S� d e /�n
city
phone#
in9arnnce ca. ! /1 Gt
/rnnc / %/////////////%/
cam any name.
address:
h.- ;. . one#.
city:
ii #
insurance co. - o cv
/
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 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OfIlce of Investigations of the DIA for coverage verification.
I do hereby eerti y under the pains and penalties of perjury that the information provided above is true and correct nl
Signature Date
Print name / f/� e- J /t`/� 2 ,9 Phone# IL-_ 370 0
omcw 1Se only do not write in this area to be completed by city or town official �
dry or town:— petmititicense# ❑Building Department
❑Licensing Board
❑Selectmen's OMce
❑check if immediate response is required.. (]l3eslth Department
contact person:
phone#; ❑Other
(roved 9/95 PJA)
v
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 cpn=
of hire, express or implied, oral or written.
An Yo ernP t er is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
rise and including e th legal representatives of a deceased employer, or the receiver
the foregoing engaged in a joint enterprise, g P
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 c
building appurtenant thereto shall not because of such employmentbe deemed to be an employer.
p yer.
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. Should you have any questions regarding the"law"or if yoi
are required to obtain a workers' compensation policy,please call the Department at the number listed 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 th.
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 peimit/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
Office of Investigations
600 Washington Street ,
Boston, Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 eat. 406, 409 or 375
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