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Home My WebLink About0715 OLD STAGE ROAD y ` Town of Barnstable *Permit#&_414 S �s op xvires 6 months from Issue date Regulatory Services , Fee �,6 *63 Thomas F.Geilerj Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 MAY 2 7 ''I r Office: 508-862-403 8 TO 2��5 Fax; 508-790-6230 ��O'er EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ST�BCF Not Valid wfthout Red X-Press ImimW Map/parcel Number � ? Property Address Residential Value of Work 30 / U Minimum fee of•$25.00 for work under$6000.00 Owner's Name&Address h �✓ t'4""' e A. Contractor's Name 7,. xT e- oL f c, Telephone Number Home Improvement Contractor License#(if applicable) �� o� l�s Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance C 1 .am a [g I am a sole proprietor ❑ I am the Homeowner ,. ❑ I have Worker's Comp ation Insurance Z-dle Insurance Company Name {� W orkman's Comp.Policy# C -3 /...S ,-o ZAf C Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will betaken to, OdRe-roof(not stripping. Going over l existing layers.of roof) ❑ Re-side . Replacement Windows. U-Value (mmimnm.44) *Where required: Issuance of this Permit does not exempt compliance with other town departramt regulations.i.e.Historic,Conservation,etc. ***Note: Property Owner must sip Property Owner Letter of Permission. 7v t Contractors License is required. Signature QTorms-apmtrg 6 Revisc063004 The Commonwealth of Massachusetts Department of Industrial Accidents -_ Office of Investigations ' 600 Washington Street, 7`h Floor — Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:� Buildin;/Plumbing/Electrical Contractors''� l.Ya•�.TrS S `��"x !.P... '4 ip�1:R'" �.�el :��VS +EPipn•. •..,:max l.:, - > name: re- address: -t Ic cit ✓ L state: 21 </ JJ bone# C work site location full address): ❑ I am a homeowner performing all work myself. oject Type: ❑New Construction ]Remodel ❑ I am a sole proprietor and have no one working in any capacity. M Q Buildin Addition :'il"14;.x;5;C,�o't "`!'i�:.;YtY;.:�:`<x;.,:�y"�.1;. ,.. 3#4v�e.: if•. ..a. ... ."�-':... ._,. .ci... .. .. .t:.u'� :..:� ..:.., '..:.,,..n ...,. '%�:Y=.•.•'.,L`,c�t,;��..;,..: ... .a..;..�.� =FS}a.¢-fTaB'.�"!'1�.:"r'rp..`:j'i."'°ib.^•;t,•; I am an employer provi -n//g workers' compensation for my employees working on this job. company name: •L T t'l' address:' - %�C 7 C /cif c city: C) ll✓e nbone#• �. C � � :3 Q insurance co. ::-�:i•.�.w.. ado ..c:'+e+.�ea.rp '�.,�.' :.'. 'Y a` :� -?S ti= .:i,:; - D��:�.a,,.,;:!� ��`'//_ - s>.m3 av au.,,..�7t Fwn6.w7.�.`d4iu.°'.'k'c=:4T.'pw,".t.•,F'+i..>_�au� ':'t�„i.^'.t ,. rG�e+'ka:... .;5/�'y!^i,;�.. � „ •.. ..•; �,,;y ...,.�,: _ :. t�<'i.Fa`�'S:*.: •m�•.i.i:ry�:x'cM.rar.:a'tw:.:•��.i7`.�'i�:i:e:'�du: `:�5 ❑ 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: - city: phone#: insurance co. policv# company name: address• city: phone# . insurance co policy# ttaa dditio'naCsheeti aoece sa �, 4 � ,. r� �!.�F n.-r w;r• oaR w' •� �� ;w _.�. _ ._.,1:.._...3. .�Yer�.�$` q.+�:xw .:o�'�'ail'�.Y� .&�� '� +.`�r.:«:�r�i'�"fib'.--.�,w�++�,.�{!a��„,,..,r.,..a� ,� Failure 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 maybe forwarded to the Office of Tnvestigations of the DIA for coverage verification. I do hereby certify under p ' s and na s a perjury that the information provided above is true and corre t Signature Date / � .a 7 OS Print name '�-� e- d 4 P a `� Phone# C 21> > official use only do not write in this area to be completed by city or town official city or town: permittlicense# ❑Building Department ❑check if immediate response is required ❑Licensing Board ❑Selectmen s Office contact person: phone#; ❑Health Department❑Other (revised SepL 2003) f it Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provid- workers' compensation for their employees: As quoted from the"law", an employee is defined as every person in th service of another under,any contract of hire,express orunplied, oral or written. ti An employer is defined as an individual,partnership, association,corporation or ther legal entity,or any two or more of the foregoing engaged m a jo nt`enterprise, and including the legal representativ s of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,emplong employees. However the owner of a dwelling house having not more than three apartment's and who resides therei ,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair wor on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment bed /emed to be an employer. P✓IGL chapter 152 section 25 also�ateMhat every state or local licensi g agency shall withhold the issuance or renewal of a license or permit too erate a business or to construct uildings in the commonwealth for any applicant who has not produced ac table evidence of compliance with the insurance coverage required. Additionally,neither the commonweal or any of its political subdivisions shall enter into any contract for the performance of public work until acceptab 'evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. .t -`°4' rx, t,: , •p. .1;. -r(tY ;ev' , :ss�,:e .,�., ^3:"}t,�i9!-' d:1u'�`,','SV.M1o�.4�,.�t:i`'�;�-::,;_',•. >: `'' .,, y `*` :'•f.' i';` : .k'. ,w'a-f`,rr.. :;:+� + a.= n..a. 'o- :. S..i'i:r' s "•';' �t`t:�';.._,.'' '' .~�:... ,s•.;:. t _ ...:_: �,'�. .-w .. k -?..,•'r.?'.:n:w`tfi�`'��v.'�"'`•`- .#•?' � .aJj�';�t u ,s.: �di: r;�}i51F�u � ..'Ft 'a4 ��'�.i r.ii%rltf�: mod:;�%:'.i�''i:?'.;x i`uit?i::ir„ Applicants �. Please fill in the workers' compensation affidavit comple e� py checking the box that applies to your situation. Please supply company name, address and phone numbers along wi`tla certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirm on 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,pease call thepartment at the number listed below. ,.-. v.n, «,�.. rt�,.: x�a'sgrL•n':;,"'Zfnd:Tl. �` .`:�;.?�- .�" ,. �;;��y a,3''9E: +dl�. �.�;�. '?'"i.iD':��' e i.pfity s9�5 ••:Ir'.",• $;.`.xr. *� -...,p' :kr ..'�css,,,t'» .rFt -`°: ';''r!k'�- :r.;;.: �,r,..,,t-kt ,�s•.•3Ri4.rt"=`'... *.' ^rwj: v -A �f, '..i, '� 4,'�Y ,;.J.:n�;• �.lr..,r,?w� .,.+:. f!'p'q�.''�.j;{r,-rt,d'+. vc �..'„+:- �rS?.4. y;y. y ��..., zJ-'i3`;:.t.;.�•.:.,;•,,� -.n,,r.F^..�f,','_hr �: 'iN:�'wn:iw �. .t '� .,4 ,�t,•.� i3a'y'rK"''4�4 '.-"'r'['�'•ii+•v'4L,�tN"'�4'w.Y:}�f�it �•l':'�e( +.4 ^tiT1�+��'i��'s;r�:$.9..tLa, ,..7v1.C>� :.:8....-r:. ..�tvwn..3.u'.t-,.:f:^t.,:. '.�r•.F.Xe''f:'u,�i.;Cr��i'J'.t:,k=.{Gf::,9 City or Towns Please be sure that the affidavit is complete and printed legib d ly. The Department\ha 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. Th.a affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. i. 5 The Office of Investigations would like to thank you in advan�{e foryou cooperation and should you have any questions, please do not hesitate to give us a call. a:r w.i: r-•,F--r — :F :u:: w�t^'`?'.e:- :`}rL.:�:2 - �� 'i/.::. or r;. o y:,y,q^r':r(.:.TG .�, 't,..- _Yl�:�a. .�5. hrti�• rxl::6.:.i4i.a.i:5`.G�:ia�:i��l?:�+,A"...:�nY:'':��:.h.:J�.:!� � rA<'+'.P,.: .�i - "{{ad tt�'<,'b"_^sS�,,.`fr„'�;.ar.p:.w: ,..it�ax �&$�:.'�:�,`�rt�1r"'�ti '�'. :'.a,;:'�•>:6?:r..9r.. - .,•'� .r .,r,:�:: :i,.r..,..:...... .�a:::.� .'t rd''. m_.+;.. tifr.I. d1�k,. ,1'"r Rl' r'.,a::;d'.. ;!+b..;r.',t of .-,r'._ q,.s;.•r.� '"Jtr: .e a':r..t.:4.,e, ';r: J:fr.'*' ce'�:11?�ta; ,=.5:':y„S.C a':.^'1 ;a• iSu �'� ,m°ti?..e�; r :xr�.�l'e•+., n.r&3' s *F_'r''+ 2 ' .� is' !4E:.r..ee::fy_ ,at..sr,,..•., �3.ti84im.,,,,r -,F�. �..� i''2•i'.-�C:. ,., The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,71h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 :of Barnstable Op�E laY,y - ...• Regulatory Services TJaoma :Geiler,.Director: �� 9. �••� Building-Division TomPerry; Building Commissioner ' • 200 Main Street, 11anatsy ,MA 02601 - .�.town.barnstable;ma.us Fax: 508-790-6230 ' office: 508-862-403 8 Property Owner Must Complete and Sign This Section If Using ABuilder C � ,as Owner of the subject property b authorize : $ to act on mybehalf, hereby in all matters relative to work authorized by this binding permit application for, ( dress of job) g'4tore of Owner Date C C a h6� Print Na= , J //��,j * As ssor's° ma and lot number ....f•.../••�•�• 177.3••.•• k �/ `�' p SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE ^ Se�wagef!rmit number ...'...................................... ............... WITH ARTICLE 11 STATE " UNITARY CODE AND TOWN THEtO _4 TOWN O F BA MY— ° ls 4. �� Z BASB4TODLE; i C: t= ' " 39 D`UILDINGINSPECTOR ' Gp ;r639 \00 t r x �'PMAY a' ash APPLICATION FOR PERMIT TO .............................................. ........................................................................... ....... ......................................................... TYPE OF CONSTRUCTION .. .... �- ................. ..........2 ...19 .SQ TO—THE INSPECTOR OF BUILDINGS: The und�rsig.n.e.d ereby applies for a permit accor 'ng to the followi information: Location . . . ...........�....7........ ... :: .:. .. . ..........:.. ....................... .:.............................. r - Proposed, Use ....,��............................for. ................................ ZoningDistrict .................................... .................................Fire District .......... .................................................................. Name of Owner ...: . .......2 :.:............Address ........... .............. C- ..... ....... Nameof ............Builder .................�..............................Address ............................................:. ....................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .. �...................................:......Foundation .............................................................................. ................... Roofing ' Exierior ........ .. .. ................. ..: ....................................... f. '.............................................:.. ......... ��7� Floors ........:.............................................................................Interior .Y-� .... . ........................................' Heating ' Plumbing �/ g ............... ..........................�............. ......... ................................. . . ... . Fireplace ..... ....:...........:.................. ........................................Approximate Cost ...... Z 4�� Definitive Plan Approved by Planning Board -------------------_---- -------19________. Area .�JY.. - ..:......... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH a I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardi the above construction. Name .. ........ ..................................... Small, Alan ,,V.. A 18441 one story, No .................. Permit..for .................................... single family dwelling . .. ............. '0-1-d",*'S'*t'*a**g'**e* *Road*' L6catiq0 '.1............................................................... Centerville ............................................................................... Alan E. Small Owner'%........................................................... r. Type of Construction ......................frame "..................... ............ Plot ......................... .. Lot ..........#7...................... June 8 76 Permit Granted ....... -Date of Inspection �IA.� l......19 Date Completed ....../ 6 ...........19 PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... . ............................................................................... • ............................................................................... Approved ............................................... 19 ............................................................................... ............................................................................... /oo -o O a o � h G � /OO•DD l-OC ATE v�J CE�T'E2✓,c-u�, /� f Y �07- a7 P� `1 >v- 2'l2 PA&e. ' KIyL- f EJC. SND iN.c/ NE�Eo.�1 C-oA.)1-o'JNS To Tc/E CECr IS"r"Ei2t L A Wb 7 rl c1 .to,15 zo v. lA �� 7 �,� o sr� ✓ M A c,S i zorE 5A/A4 ��T1T10►Jt=fL