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HomeMy WebLinkAbout0028 SHUBAEL GORHAM ROAD r (u i r' t* �c,�sp.'T'tG TAt•ak.. - �1c.�.r t=;:� °!� r.�;� r-..�.L. `� f � �POSAL P1T_- (JSE f 1�<•�o G,Ci.t_• �. '`.. SUP-K/ALL-A2EA = i`7U S.1='. _ 1 �Ca`1* ILk 8cr-ro�vt ,nea= sr-. TC>TA L T7 ES!Gtl = �2r-�• G,•'P.Z�. Q r�'- �`'`"'t-�,, 'MTA L Pr= 1CDL&TIOQ Ok'CE : tt! 2 �t1� UR �SS. "` + ,'401eT r X-A k Z ear, - z ► lei Tor >^"w c tao.o -1. Jf ems-.3'�.�7'. �. •cam p. ti ir, .ruc � LohiN 17 �- , � toe<> ilN' y1 'Z t /� t��' l! IWV aN. FtT WITN A WA514MV STow1t ay --- �"�t � tJ o �.c ta>~�•- L bGh,T i v t..j ��,+i-�„'ti.r,� :-.i.�� ; J� - r- 4 ( cGtZ-rtV:.{ TI-4,n,T T14c ;-n +JGAT1n1~t ,clawt.l Pt_b,t 1-lt`y,t�i�l.1 Gta4lt�l �(S W IT Z j'►-tic": �jt i7 L!►J� AWZ:> 'S4Tk'?ACN 1'C-CJJ1��-Mi-.E.1rw Gi= T !-tCr 't.•'.rT 'TOWS cam" , Q�•l�,Th _ FL CHAT �r.� i� 7 `� �-' t.�n-� -1-�-,�• tZc-.GtSTL'-2Ga tJ�ti:C� �vl`�t Yet•:: tJa�,e-t vt-4 A+.t � ttdS�"�'.Jr✓ttl.l� jtJi:�tt��' �� 7'+-tC, c�i=G=-�i_:("�.c !ttc.t.sl.z� 1S.S-�tTl_1 �'tS.F--! s t.f:�r tw,t"_ lJ->C_t'� (v t�t- �'�'_t:,,L(t ••I i-- 1_G t" t_s t t��;:> --- -— �_ t . :r oF� r Town of Barnstable *Permit#o)Gr(ae/ Expires 6 months from issue date Regulatory Services Fee ��, + RA STABLE, + .7 MASS.69 Thomas F. Geller,Director pTED�►r°, Q I 1�l0�1i Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 _ www.town.bamstabld.ma.us Office: 508-862-4038 Fax: 508-790-6230 - EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / Not Ilid withoui Red X-Press imprint Map/parcel Number Property Address 9 CP /-1"b?j f�e� (Residential Value of Work _/XrCl o, C1 0 Minimum fee of S35.00 for work under S6000.00 Owner's Name &Address _eo i5 cw_4 A1411 A l Contractor's Name (rIG = ` d U'��/�,t/ Telephone Number 5-6 Home Improvement Contractor License#(if applicable) `/ A Construction Supervisor's License#(if applicable) 0,5 C) ❑Workman's Compensation Insurance . ' Check one: N O L/ ❑ I am a sole proprietor 2011 ❑ I am the Homeowner [f I have Worker's Compensation Insurance [-�� '� r.8'�11;1�iS AB Insurance Company Name Zv k'�C'r/ 40- ,ti"l('4'0 Ir,11A ve' ) A( f 10 Workman's Comp. Policy# Z-�C�1� - S13 J,S� -g Copy of Insurance Compliance Certificate must accompany each permit. Permit Request check box dRe-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 +@E (maximum .44)#of windows *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: `jam Q:IWPFILES\FORMS\building permit forms\EXPRESS.doc y Revised 070110 0 The Commonwealth of Massachusetts } Department of Industrial Accidents xl. Office of Investigations % 600 Washington Street e r k Boston, MA 02111 {- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly . Name (Business/Orgariization/Individual): � 6� 01 .gf Address:. �-Ca 1/c -71K A,4;t/ 65"' City/State/Zip: Ynt Ati'Ll's W%l_A 6-d-6 G) Phone #: cS • Are ou an employer?Check the appropriate box: Type of project(required): 1.Z 1 am a employer with 1 4. ❑ I am a general contractor and I 6: ❑New construction employees(full and/or part-time).*.., have hued the sub-contractors 2. El am a sole proprietor or partner listed on the attached sheet. # 7. ❑'Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. 91 ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical'repair5 or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs . insurance required.]t employees. [No workers' 13.0 Other 11 ' comp. insurance required.] *Any applicant that checks box#1 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 is providing workers'compensation insurance for my employees. Below is the policy and job site. information. Insurance Company Name: Policy#or Self-ins.Lie.#: to 7:13-03 9—P7y� `�'1' Expiration Date:, t� 0 /Y Job Site Address: 9;5-- Sdt'(s.i4 94414.c) City/State/Zip:(' ,/Zf �i ji� �6�- d 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. . r I do hereby certify under the pai and penalties of perjury that the information provided above.is true and correct a, Si attire: 4�i' G ' icy. Dater Phone#: IT 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#: ` . 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, constriction 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 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'02I I I Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www-mass.gov/dia Towns of Barnstable ` Regulatory Services p ores Thomas F. Geiler,Director �`IED }�� Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section if Using A Builder I, 561 ✓f AV , as droner of th.e subject.property, herebauthozize y 'of 1(�4 �, �'b�-y �. to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Ownd nate 0- 414�1J . " • Print Name _ • r If Property Owner is applying forpemait please complete.the Homeowners License Exemption Form on .the reverse side. TFiE Town of Barnstable ywP�� Tp�� - Regulato-ry Services sAxrisrAsrF Thomas F. Geiler,Director 1639. ,a�w Building Division PrEo�{ Tom Perry, Building Commissioner 200.M2iTSireet-Hyannis,MA.02601 www.town-barristable-ma.us Offi6e: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print r DATE: JOB LOCATION: _ number street village 'HOMEOWNER"-. name home hone work hone# n p p CURRENT MAILING ADDRESS: cityhown state rip code Tkte current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER . Persons)who owns a parcel of land on which he/she resides or intends to reside, an whichArre is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a bomcmmer. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, That belshe shall be respozisible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifes that,he/she.understands the Town of Barnstable Building Department es an requirements and that he/she.will comply with said rocedw-cs and ,,,;,,,i„�inspection procedures d equir mp y p requirements. Signature of Homeowner Approval of Building.Official Note: Thrce-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION .The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section_(Secd n 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a peson(s)for hire to do such work-~that sur h Homeovmcr shall act as supavisor." Many homeowners who use this exemption arc unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awwrriess hften results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To cnsurr that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homwwncr certify that hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a.form eurrrntly used by several towns. You may care t amend and adopt such a formlacrti6eation for use in your eorrimunity. r NOTICE N NOTICE W TO a TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21, 22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6ZZUB-4395P74-9-11 ) 10-01 -11 TO 10-01 -12 POLICY NUMBER EFFECTIVE DATES DOWLING & ONEIL INS PO BOX 1990 HYANNI S MA 026016990 NAME OF INSURANCE AGENT ADDRESS PHONE# o� CAUTHEN, BILLY E 86 BETH LANE HYANNIS MA 02601 "= EMPLOYER ADDRESS r- v J,_ EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE m- MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services a_ provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •� connected to the work related requiring g P injury. In cases re hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 005887 W20PIG02 TO BE POSTED BY EMPLOYER j A Nlassachust is - Dcp:u-tntcnt of Public SafetN Board of Building Rclgulations and Standards i' Construction Supervisor License License: CS 9975 BILLY E CAUTHEN 86 BETH LN }: . HYANNIS, MA 02601 ^ Expiration: 8/13/2013 (ommissinncr Tr# '1683 - ' - pJN�azr�^tE.arorG+.a�:?r�r3,r�t,At�a3.x�r.�nr,7,ar!�i�:: Office�t�o sum°-.e7lR .rs`R'c`$�ine�"s�gu VCA HOME IMPROVEMENT CONTRACTOR Registration 116609 Typ#:Expiration: 6/29%2012 IndividuaF UTHEN,; ^ 4 BILLY CAUTHEN, = , k 86'BETH LANE HYANNIS, MA 02601 i Undersecretary IVIasS;tchusetts - Department of Public SafetN Board of Building Regulations and Standards i Construction Supervisor License License: CS 9975 is ; BILLY E CTHEN AU 86 BETH LN 4 P HYANNIS, MA 02601 Expiration: 8/13/2013 ('unmiisviuncr Tr#: 1683 License or registration valid for individul use only before the expiration date. If found return to: Office.of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 'It Y I - � ti of valid without signature h„ - - J T 1 Ws map and- lot,number .....r..��."..�3 ...:.......� �F?NEtO SEPTIC SYSTEM MUST BE �a Sewage Permit number ................ ........................... INSTALLED IN COMPLIANCkt ry WITH ARTICLE II STATE I MAMSTODLE. : House number ...............................................c r m"8, SANITARY CODE AND TOWN co t639. ♦� r `-' REGULATIONS., TOWN 'OF SARNSTABLE BUILDING -,11,SPECTOR APPLICATION FOR PERMIT TO ... TYPEOF CONSTRUCTION ... .. ...... .. ................................................................:............................................ ........... ...... ��'y�Ls......�.........19?..� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... ....2....s.................................................................................................................................................... ProposedUse .. ....;......?.. .�.-'{.:G. ..................................................................................................................................:..... ZoningDistrict ........... ........................... ...............................Fire District .............................................................................. Name of OwnerKte��?.. ....... .......................Address ........gj!e... ... .k. ........ ...........:.................. Name of Builder ....Address Nameof Architect ..................................................................Address ...................................�.. ............................................ '� C'u%Gl/��' Number of Roo s ......l..........................................................Foundation .. lf.�:............................................................. Exterior ....... ................ .A.....................................................Roofing .... ..... ............................................ Floors �G...........................:..........................................Interior ....:../.... ...t'iG � ....................................... Heating ...Z�7.n../!.... n................................................Plumbing .. ,.._.................................................................. Fireplace ..:. � L�r✓��! .... . ..........................................Approximate Cost ....0 .................................... Definitive Plan Approved by anning Board _____________________-_-_______19________. Area .Z ................ ............... Diagram of Lot and Building with Dimensions Fee ......: .. ................ 00 SUBJECT TO APPROVAL OF BOARD OF HEALTH ��� YX I hereby agree to conform to all the Rules and Regulations of the Town of BarnstabLr ,arding the above construction. Nam -............. .. ........r.......... ........................................ � � . . � � . . Small, Alan E. .---..�z����.. . ���.----- 28 Road Location ---.�������..�������`-------. ^ .--.-..—. ��—~--------- Owner —'.. AQau�..E~.. ______'___. Type ofEGnxtrucdon .............f���\�------. ^ -----~--------------------.. ^ � Plot ............................ Lot ---Jt2Q5.............. � � � � March l 79 Permit Granted --------_----]V Date of Inspection lq � �m °"'e Completed � . . . � ^ - � PERMIT REFUSED v � ' . . /__--..._-----..—.-------. lQ � ^ � ~ ..----.--.------.._.---... ....... ' � /,—'-----^^^^—'^^'--------~'----' ' ' ° . . —.-.—.~..-----^.—.—...--..—.---.—. � � � � ^ / .......... . . � Approved ` - ---------------- lV ` ' . '..—.—....�--------.--.---~—.---.. . � ° � ^ � Assessor's map and lot number .c;....1... .....,.... .'r.. �°- E TO Sewage Permit number ............:.... ........................... L BABBSTABLE, House number ........ ................................................ 90 MAO& p 1639. \0� �fp YPY f►• TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO j ` TYPE OF CONSTRUCTION ..............:.z : !"�1.....f.........19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......`.� ...... ... . ............................................................................................I............ .......................... ProposedUse .. ' a` .: ............................................................................................................................................ Zoning District ........................................ ..............................Fire District Name of Owner ...................... ......... ............Address ........; /�� ....A�'? ?T .... ............................... Name of Builder .........................Address Nameof Architect ..................................................................Address ...................................... ............................................. Number of Rooms ...... ........................................................Foundation ..C... ....C:.............................................................. , ,� �Exterior .'.......�.?.. .....................................................Roofing ....._.,............,..,............................................................... Floors ...............................................................Interior �-? a I���=- " ........... .......................................................... Heating .....�......... ......":..r.................................................Plumbing .... ................................................................... Fireplace ....� {, .....;?....... ...... ...........................................Approximate Cost ..: .:: ': ..................................... ;f.; Definitive Plan Approved by Planning Board ----------------------_---------19________, Area .�::-3 2........................... t � 0 Diagram of Lot and Building with Dimensions Fee ................'".".'�"�».................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 goo 1J , r 1 I hereby agree to- conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. 'Z Q, Name .................................................................................. Sri;,- Small, Alan E. '°A=171-138 t No . Permit for .........one story single family d ling Location ........28 Shubael Go ham Road ........................................... Centerville A •....m� Owner .......... lan E 11........................... Type of Construction ...,frame ............................................ ................................ i Plot ............................ Lot ..... 8 Permit Granted .......March 1 19 79 Date of Inspection ....................................19 Date Completed ............................19 PERMIT REFU ED ..... .. .19..... .�. ...........fic.......... . .....�. ......................... . ................................................ ............................................................................... . ............................................................................... Approved ................................................ 19 i . ............................................................................... 3n,t it V SE t C-cxCa IGIAIL. _ '7i5PtxA,t.� PIT - l._.7r.►s✓ 4 ocher C-�.�.L. � � � � a � ' J t��ulls<t..L Atzt:.-A. � C�C� s.t=. _ - •, ��,,�,w f,.,.���T"/y {t-JC.>' J 1+ 1C '�,.c�„ z �"?r7 C�.F,•'.D. K: F �T'� y`. 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Ins �, Inspector e■n.a Cash ] fi N. _ � �v1f61 �0■pY � OCCUPANCY PERMIT. Bona "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Alan E. Sell Address Centerville lot #285 28 Shubael Gort-wam Rcgd, Centerville Wiring Inspector + Inspection date, f Plumbing mspectwl '`�, Inspection date Gas Inspector f 1� .�� Inspection date Engineering Department f , 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.' . ...................... �_........_...._....�, 1977r .................�f...Building ...Inspector .... ._...._...