Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0152 SKUNKNET ROAD
1 9 ° i S I Town of Rarnetahlp *DL/ 0 V � V L (i Inc i t1 1 K1 AA"%," /ir I ermita Regulatory Services F 6monthsjr�rr issue date MAC. S PERMIT Richard V.Sea}i Director 1659. 1L- -3 d 2015 Building Division t+ ~AB� inPerry,CBO,Building Commissioner I0(� 200 Main Street,Hyannis,MA 02601 "www.tuwu.uai ustauic.uia.iis Office: 508-862-4038. Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY r^ r� Not Valid withmit Red X-Pren Imprmt Map/parcel Number l ! W p / Property Address l s �- Sl,k-4 x.f c [j Residential Value of Work$ 55 1rS& . ao Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,/1, A u011y Contractor's Name I��,�C'{��� f Telephone Number -2dd ?0 Home Improvement Contractor License#(if applicable) / Email: Construction Supervisor's License#(if applicable) tWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner 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(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over 1 existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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. I � SIGNATURE: C:\Users\Decollik\APPData\Local\mictosotl\Windows\Tcmpotwy Internet Files\Content.Out]ook\2PIO I DIMEXPRESS.doc Revised 040215 L 9 •Mar� s,�' Town of Barnstable �r Regulatory Services: Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 ° www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Oumer M»ct Complete and Sign This Section If Using A Builder r I' as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: ( 5 2 S�b� �✓��'� C--en-(Pout'q f (Address of Job) ila0LUM of v W ncr Dati: 1 LlllL 1V0.1111. ' If Property Owner'is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PTOIDHR\EXPRESS.doc Revised 040215 ; 0 7'fae Commonwealth of-Ma.ssachassetts Depardnent of Inds.-soiad Accidence O, We of Investigations 600 Washington,Street Boston,JV 02112 wrt►ty.rnasgnv/dia Workers Compeusal on IJ12i.aranee Amdavvi BadersJCnntractoYsElectriciaiiiii/ m6ers: APP item Inforinat i Freese:Print .,eea`ialy Name(Busioett?anizati eiy:: Fc�� �► Address: CitylSlei i�VU ct� Prone # Are you an employer?Check the appropriate box. T of project r tre I am a eatesal cottractor and I }' F f ( . J.E I azu s employer with ❑ g 6. ❑New t nsctioii. employees(full andlor part=timej.s have hired the sub-contractors: I M a sole Proprietor ar part s- tisbed ore the atta d sheet. a ] shave no employees: smb-coe&artars Lave 8. ❑ mo iikio for me in employees shave vrarlcers 9. ❑B,�ildirsg addition` [lsro�vorlrs'comp:insurance cow:in cuaa I 5- ❑ 4Ue are a corporation anti its 10.❑Electrical repairs ccadditions 3 ❑ l am a homeowner:doing all reoe k zeffs: l�aasi exercised their 12_❑�lambing repairs or additidin myself.[No ivorlaers' right of e�ao�ption per lVfGL 12.❑Rioof repans ins mace d :l c_152,§1(4 and we have no required-] a3 Q O.dser employees [No worl�ers comp:iaseuamce required_ *Any appkcm that cheers boz#1 also Maw the section below stewing cheer wmke s':con�aeim policy iafbMudan- HUMWWRM vrho sabmit this atifidavit JR&tatFng whey ate doing'an xai}and then hire outs] a as wntcmrs—st anbmit a new aSidavk indicath*s®rh: EContaactorsthat deck this bM,nit attached sn additiaaal sheet ahostieg the is M of&e Seb_contea=is Md SMe whethea Cff net tBose ea:xties have.. wpmYees. If the cub-couftacis hwe ems;they mutt pmvi&tau waikeW comp.policy numbe. d firs an erupioJW that is pr in Vor s'coemerasvrd"ins7aad"Ce for'rrry eepioyeft Behr is at8 pridii*�raad}aab s inf 7. 0nna&n; Ias�aace Comparsyl�iame: C�f� Policy 4, or Self Frxpiration Bate_ Job Site Address: : f�Z Sf` G':n�l : �c� City/Statel?ap rltt�cls a copy of the workers'csiapt=nsaiEior,yolicy 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 criminalpenalties of a fineUp to$2,St10.t1tI andr'or aue-y r it so ,as watt asciwil penalties in le fog of a STOP WORK GIRDER and a�e of up to$25©_�?a day against the violator::Be advised drat a copy of this scat eat�y be fof*Wded ti►the Office of Iflvestigations of Ilse DIA:Eor insurance coverage verification. I do fsereby a rk nnde r the pains a►�d pnnabies mf perjury that the information prot�zM above is tnie and correct: — Bate_ 2 S6 ep rciol an on Yd Dri t¢a¢tvrtte in tfi�area,to bg camplelerl by,epy or roses o�iceaC C9tyor:Town Permitucense# �� Issuin�'Aathorty(circle ones:, 1.I3aarxi of$e tit 2.Boildireg;Depar ent 3.City,+'Town Citric 4:Electrical l�nspeetor 5 Plumbing]tn ector 6:CTther Cip ontset:'personi Phone!i: ,`6 f CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD.^IVYVI CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHYS UPON THE .CERTIFICATE/ HOLDER. THIS JIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE ':COVERAGE AFFORDED BY THE POLICIES .,LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ,% IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the olic the terms and conditions of the policy, P y(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to , certain policies may require an endorsement. A statement on I this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ( PRODUCER ' SCHLEGEL INSURANCE BROKERS INC NAME: PAUL SCHLEGEL PHONE 34 MAIN STREET -- (AC,NO,EYI); 08-771-838= IC, 508-771-0663 EMAILIA _Nol. �NCE@GMAIL SCHLEGELINS A - WEST YARMOUTH MA 02673 ADDRESS: - U .COMINSURE - -........R(Sl AFFORDING COVERAGE NAIi C S —----- ____ INSURER A:COLONY INSURANCE Timothy Keating Dba Keating Construction INSURER e:CNA - - INSURER C: 7 -- ----59 Lower Brook Road E South Yarmouth, MA 02664 INSURER --- ----------__—.____ 1 COVERAGES- INSURERF -- --' CERTIFICATE NUMBER: Tal IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSUREDS NIA<ODNAB BVERFOR IFI} POLICY NL:II:A'fEU. NOTWITIiSTANDING ANY REpUIREMENT, . TERM OR CONDITION OF ANY 1 CER?IFICAfG MAY BE ISSUED OR MAY PERTAIN, T I CUNTRAf,T OR QTHER DOCUMENT WITH RESPECT 10 HE NSURANCE AFFORDCU BY THE POLICIES DESCRIBED HEREIN IS SUBJECT' TO AI:I. iFI `IT(N.T11i, F:CUJ,S!ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSl1RANCE INSR NND POLICY NUMBER POLICY EFF —pOUCY EXP�'—'-=---- ' A ;GENERAL LIABILITY (MM/DD/VYYVI IMM/DD/YYY1•)GL3594908 LIMITS -------- 03/20/2014 03/20/2015'EACH _}[ i COMMERCIAL 6ENER.AL LIABILITY .i S 1,OQQ,Q _ DO r--- 03/20/201 03/20/20161 PREMISES(ea occurrence) s f 500,000 1 _ . CLAIM, MADE I•- J OCCUR ., - I MED EXP(Any one person) I g 5,Q Q 0- .i PERSONALBADV INJURY E 1'000,.QQQ -FJL AGGkFGA TE LIMIT APPLIES PER I j- GENERAL AGGREGATE 5 2,000,000 I I PJEPCOTT —_ - I _— APRODUCTSCOMPOGG _ � 2,_000_000pOLICI LOC y AUTOMOeit.E LIABILITY AN'AUTO I I. .(Ea accident) �S ALL OWNED SCHEDULED I I I BODILY INJURY(Per person) E - AUTOS 'PUTOS __•___r NON-OWNED I .I BODILY INJURY(Per accident) 5 !'IIREU AUTOS AUTOSL.._. -JSROP RE TY OA'MAGE (Per accident) E I I UUMBRELLALIAB S OCCUR {EXCESS LIAR I EACH OCCURRENCE I S CLAIMS-MADE '' _AGGREGATE DEO� RETENTION E ,i s ---___ B WORKERS COMPENSATION ---- -_--_ ----- " AND EMPLOYERS'LIABILITY i 0224N37-2-10! 03/09/201403/09/2015 WC A U. OTH. =Nr PROPRIFTORIPART.NERIEXFCUTIVE �Y I-N T TORY UMI?S ER • .;!'ICERIMEMBER EXCLUDED' I y I I NIA I03/09/2015 03/09/2016 E.L.EACH ACCIDENT Mandawry in NH) L-J S 100,000 I1 yes desrnbe antler I I E.L.DISEASE EA EMPLOYEES 100,000 DESCRIPTION OF OPERATIONS below I _ ! E.L.DISEASE•POLICY LIM17 j S SOO,OOO UESCHIp TION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,if more space is required) I - TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPESNATION POLICY CERTIFICATE HOLDER " CANCELLATION r- ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV 1988-2010 ACORD ACORD 25(2010I05) CORPORATION. All rights reserved. The ACORD name and logo are registered marks of A 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlYY)'Y) 03/12/2015, /CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS %rTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE (COVERAGE AFFORDED BY THE POLICIES BLOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. CONTRACT BETWEEN THE ISSUING INSURER S I ) AUTHORIZED IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the j the terms and conditions of the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to policy, certain policies may require an endorsement. A statement on:this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER SCHLEGEL INSURANCE BROKERS INC 7NA",ME: PAUL SCHLEGFli NE 39 MAZN STREET c,No;Ezp: 508-771-83$lI FAX508-771-0663 A -- IAiC,Nl_WEST YARMOUTH MA 02673SCHLEGELINSiTE2ANCE@C>kFtIL.COM .INSURER(S)AFFDRDING COVERAGENAIL A INSIIHED ___._ URERA:COLONY INSURANCE ------ �----- Timothy Keating Dba Keating Construction INSURER B:CNA -----'------{------ .____ _._ 54 Lower Brook Road INSURER C: ---- -` INSURER D: INSURER South Yarmouth, MA 02669 INSURER F: ------------i- _--.._---__...COVERAGES CERTIFICATE NUMBER; THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED DE LOW HAVE BEEN ISSUED T REVISION NUMBER: NC:II"AT[U. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY O THE INSURED NAMED ABOVE F I rfI TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THEN PO ICIESRACT RDESCRIBED HEREIN IS SUBJECT RTOHALL L�rHE TFHrt;! FXCLUSIONS AND CONDII IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OTHER DOCUMENT WITH RESPECT TO WHICH THIS INSR - LTR TYPE OF INSURANCE INSR WVD _ POLICY NUMBER POLICY EFF P--- OLICY EXP--T� A : GF_NERAL LIABILITY IMM/DD/YYYYI WMIDD/YYYY) i LIMITS ---- - GL3594908 03/20/201403/20/2015 EACH OCCURRENCE X I COMMERCIAL GENERAL LIABILITY 103/20/201 03/20/2016 s 1,000,0p0 — CLAIMS.MADE )OCCUR PREMISES(Ea occurrence) $ 500,000 i MED EXP(Any_ one person $ 5,000 -_ --_-__ ---_-- I PERSONAL&ACV INJURY _--- 000 �__EN L.AGGREGA r GENERALAGGREGATE E LIMIT APPLIES PER I 2,QQQ QDQ POLICY I7 JECT LOC PRODUCTS-COMP/OP AGG 2,000,000 AUTOMOBILE LIABILITY I I ----' A'JY AU'F-0 (Ea accident) S j ALL OWNED j .1 SCHEDULED I BODILY INJURY person) $AUTOS AUTOS I HIRED AUTOS I NON-OWNED UTO WNED BODILY INJURY(Per accident) $ I - � 1 (Per accident) IS -I UMBRELLA LIAR --- OCCUR I EXCESS LIAR CIJaIM^sMADE EACH OCCURRENCE S DED RETENTION $ AGGREGATE -�-�-- '-- -�-- -- B j WORKERS COMPENSATION -_-------------- 10224N37-2-10 AND EMPLOYERS'LIABILITY 03/09/2014 03/09/2015 WC STA U- ,ANY PROURIE TORIPART'JER/EXFCUTIVE YIN TORY LIMITS OTH- J GF!�!CERrMEMBER EXCLUDED' � NIA _ � I03/09/ ER ZO1S 03/09/2016 -�-------- IMandalorp in NH) E.L.EACH ACCIDENT S 100,000 i II yes aescr!be under DESC.P.IPTION OF OPERATIONS below i I I E.L.DISEASE-EA EMPLOYEE S 100,000 _ F----- —.-__. E.L.DISEASE-POLICY LIMIT �s 500,000 I i I - IDESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,it more space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPESNATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV 'ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of A O j 960za1,/90 uollejldx �auolsslwwoo 3. ,..�� c e ON I. I _ 9. ZO .1P'W ginomle 3 A9 no S 1PBM K9.[a bo-I o01. + bS o-ASS 3 •asu aal-I _ j tille►�ads�osr:vadnS noq�njts " spjepuelS Pue su01leln6a8 6ulplln8 3o uoO Uo3'_ Alales 31Ignd to luawijedao- s4asn43esseW o� Licensear registration valid for,individul use only Office f Consumer &osmess Rem before the expiration date. If found,return to. HUME IMPROVEMENT CONTRACTOR Office of Consumer.Affairs and Business Regulation Registration ,.,,*143053 Type: Pl 9d�te19Q Expiration( 6/14/2016 DBA 1S�Paf r Boston,MA 02116_ - n KE ING CONST.I TIMOTHY KEATING`� s • 54 LOWER BROOK RD �TM gx��o� SO.YARMOUTH, MA 026641 Undersecretary J Not valid without signature a s MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION ' Two Center Plaza Boston,Massachusetts 02108-1904 (617)`723-3800 Ma Onlv(800)392.6108, FAX(800)851-8424 31712015 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.313 CENTERVILLE BUILDING DEPT 200 MAIN ST HYANNIS MA 02601 Re: Insured: LISA APREA Property Address: 152 SKUNKNET=RD,CENTERVILLE, MA 02632-7120;F. - Policy Number: 0782494 _ 1V Type Loss: Collapse:All Other Causes of Collapse Date of Loss: 02/09/2015 Claim Number: 333600 Claim has been made involving.loss,damage or destruction of the above captioned property,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable, If any notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate, please direct it to the attention of the writer and include a reference-to the'captioned insured,location, policy number,date of loss and claim or file number. r' MPIUA Claims Division CMA00021 * , 1 � s4 -7 . � Y a 0 TOWN OF BARNSTABLE BUILDING�PERMIT APPLICATION Map /7J Co�� P TOWN F BARH^Tk&� # �" 6�� Health Division — � 2ap7 BAR -4 AM IQat%sued Conservation DivisionS� v� Fee 79 P• Tax Collector,;? Treasurer ll ll [IiVI ION Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address /SZ- S L0N -We7— -9:1--> C<iJ+t--W'LL 9 Village..- mil= Owner Sfim U e L— J54 EAa�`� P R A Address �����'�^'�NETS C�n►�r�V/LL�Mel o a.l, Telephone $ — 77/—,9a y7 Permit Request vv c c. ©s`,v G t S /ry C, D c ►c . ,� tea�� �, ` �.►-. � sue . i"/� i L— Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new \, Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family kf Two Family Cl Multi-Family(#units) Age of Existing Structure e3&-_ yR 5 Historic House: ❑Yes VNo On Old King's Highway: ❑Yes XNo Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) ° Basement Unfinished Area(sq.ft) Number of Baths: Full: existing z new Half: existing new Number of Bedrooms: existing 2 new Total Room Count(not including baths): existing y new o First Floor Room Count IY ' Heat Type and Fuel: ❑Gas Oil ❑ Electric ❑Other Central Air: ❑Yes tkNo Fireplaces: Existing U New Existing wood/coal stove: ❑Yes 14No Detached garage: ❑existing view �size Pool: ❑existing ❑new size Barn: ❑existing ❑new size Attached garage:Xexisting ❑new size Shed:Cl existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 4 No If yes, site plan review# - Current Use Proposed Use BUILDER INFORMATION Name wN C t Telephone Number Address �—u�y License# C e�✓-r��.v JL<g P1,N a Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEUTO SIGNATURE,, DATE 3` `7''� k FOR OFFICIAL USE ONLY PERMIT NO. , DATE ISSUED , MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION r FIREPLACE 3 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE"CLOSED OUT ASSOCIATION PLAN NO. RESIDENTIAL: SHEDS - POOLS —DECKS-OPEN PORCHES- GAZEBOS DETACHED GARAGES FEE VALUE WORKSHEET ACCESSORY STRUCTURES >120 sq.ft. (Sheds,detached garages,gazebos,etc.) >120 sf-500 sf $35.00 $ >500 sf-750 sf 50.00 $ >750 sf- 1000 sf 75.00 $ >1000 sf- 1500 sf 100.00 $ >1500 sf—USE NEW BUILDING PERMIT APPLICATION DECKS x$30.00= $ (Number) PORCHES / x$30.00= $ (Number) IN GROUND SWIMMING POOL $60.00 $ ABOVE GROUND SWIMMING POOL $25.00 $ RELOCATION/MOVING $150.00 $ (Plus above fee if applicable) PERMIT FEE $ Q:forms:dkcost eff:082301 of Ina F, ' table : . .. The Town of Barns . �sxsrnatE � g Regulatory Services rf1659. o Nv►� Thomas F Geiler, Director Building Division Peter F. DiMatteo,Building Commissioner 367 Main Street,Hyannis MA 02601 . f ce: 508-862-4038 Fax: 508-790-6230 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. Type of Work: /CL Estimated Cost Address of Work: �✓Z /e'��T AAZ- n Owner's Name: Sono(Ufi- T �� 4",itiv - ,r PPC Date of Application: 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 1&0"6r 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. Date Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Massachusetts M - — Department of Industdal Accidents ....office ollarestiollooas 600.Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: _I , A PR i= location: if 2- S kuiv k U,e*--r cif, L-(-f Hbo ` ;z1�3 2—: flhan� MU am a homeowner performing all work myself . f� ❑. I am a sole 'etor and have no one.worldn m' achy //%//-----����� •�" for worinn on'oa this'o an I workers' b. I am mp ogees �g g ...: .....r............t .,...............t-....:.:...r...n.... ..n%............::....n.........................................r.......,..............t........:......-,.....t..n::.::n}•n•::^•:fin.:,}..} ::: .::::.{.:t::i}}}:.;:-:::::.}{.... .n.::.--.. ::::,'.:.::::..:..: ::::::.:::.::::::.i:.:;;.}::t::.}>:>;:;;?: ...ear::.......:._ }:.}}:.}:.};:;::::. ::..:^.;<:;::}}.::....::.::n.::::.}:.:;:;}'..:}::n:.:::::i:: {•}:.>:;.:::. ....:...............•r.ear::::::::::::.,::•:.:..:.2..,..n•:.::::.:�::.,......-....:.............-,.:..:.t.::::::..:...r:.:..::::.:._::::::.::.� :-::::r::::..�t,.::}:.::.i:.%.}:.::.;'.}:;:^'<:,{.:.��-:::.}}:.i}}:: .......:.:.:.::.::n....-....n.. ...........................................-.... .......-..:-....... ,..n. .....-.:.. - ..................J....;..-...t,;.J....:........r.v...,................:..:::.:---......:....::..-,.....:...:::::::.v:::n::•:.:,-:: :::,•::n•::::%•::: ,...-........r.....:::?n•.}:.%•.•:•i:}:r.v}::::::::...L.................._..-......n..:.:.. .comaamr.}name::........................ .r..................................... .............. .................................................................................::. •'S?tip:;:}::•:%•}}:}:•.{.;.t•:.}:•:?-::::.. :.r:....:.... ;'it:;};:;�:ti::t:i':ii;:?;ti�::ti:`.:;'tt.:-'•i'i}'.::jt::Ri:j:::.}:;':;;`>:,:`;:;:}:i:. :iilL4:?{:;:ti;:j;::is}r::•}::j?jy .:::i::i':3:':itiS:r Si:{::':::}ri! }}}`}}:i•}:•:i:•}:•%4:•:{4%:^}:^:{?'?if{:n}}t:::?v?•}}Y:•}'C}}:h} .n............• ^•x:::x." n•:::{{:.;}•.}v.r.;.v......}r'.v.;::•:::::::::::.v:::?:.v:.v:•::.}•::•.v.v::::::::.v. my}.:-'• {..{•}:: ..K4:{?•}:•i}w:x::::ii;{{:r,^ ..a:!:}.jv{.}:?:^:::•.:..:%(:{}' ::��?:S:vr1:;:ji;'•••':;�:;j?v}. -aitdres " ::::::.:: L•::.:::..t•:::::....:..::...:.�:•:{t.. ,.,..:::..:.: t•::;4:•:•::•::.-::::::::::.�,:.....::.:;.;:•.�::.;:•::;?•:t•ii:•:ti:•::.::?•}}}}•r;;;}:<;•: ':i} .... .n.. .............. r::::::•i:-i>}i>}:.>i:;}:•i}}>;.;.�{:;:•:::::.:::S:tiJ'::::::%:}:=:-:{•}:•}}•::{.:�::. ...:.n......t......t....... t... .t•:.. ::':ti;i'::,�i>ti:�'iiiti}Si}::�ii:?:$'-':i;::-:i:..............^•..�}ii::ii"i: ,1� `}(._ }'ti:%:ir:4:4i;; ::i:L•v.?::i:::J::}':•:v}::;i•:?•}}:G{:•}::4}}�ii:?:i-}}}}}}:•}i:}:vi}}:•%•}:ice:?•}}}:•}}}:'•}:''•'':::'?:i:}'.t:}i::;:{:j; :;:;:j�:;i:;v: .r'::::::iii:::`iii::i:•'..}::i::::}'ti:^ti:;i,:•-::i:?:?;`:}}: ....... t/l�:�,r•:�::;$:;r>:�#:�:<r:>::t::=:"•:z•`%; �r:::::::#:•}i:::?•s::}t:::;•}::;5::}:::::`:;::::rr}"g:?::%:r:?:r:•::%�}:•:L:•::•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 policesr ...... ......:...........r::.vn..:•^•-...:.... ..... r.....s........... ..... L:::..::atv, ......-%L:x.....wn-.;x:xrxvrrrx{x•::w:•.vn•w:•.}s•.Lwv:•::A•.vn:::v. .n..n.v.........-..v::•^........................ }�.v:.v:•::...........•....n.....{•:::•}:{ti•:;v:::;:_}:?{{_}:v..........v................. '•.. ..} .r .......:.::::::v:•Yiv:v:v?:v;?w:::r.4::,::.....{w::::::r:.v:•::::::::::::::::.:.�i,?.:.r:::::::::v::.•:.v::::.vn:nv:::v::•:w.v::.vvv:.v::.:{•}:}:t:ti?:?v:;•i}}:•}:•}}:4}i}}}}}}:vv:{.},:}w: ....::. ........................ ....:....n......r............}.n•:::.............r....................-..............._..................r....r..................................... .............r•.:::::: ...;•>;•}}}:?t:::.;?•'.•.?;w:•i}:?}.yi:;•�;:: ....... x:nvnv.v::::::::{:.:•:{•:...rv:::;..•vvv:.v::.vv..... r..::.v::::•.v:.. ............,.•::{.:%{{{•:ti•}'4:;•:r{-.:v,;::n,}:{{+' ....::.Y;•:4:.:�:?•,J}}.4:.v:nv}::'; r::.w:::nv.v::.:vv. •v:w:::v::::•• r ... ::<?:i}' r.:>+}:•:::.::•• ....,........,rn•{.v• fiti::::?;:::::tit: .}•:::: -•:vv•}::•.v:;..,n.....¢n:v.:. ...:..............t.............••:.v.v:::.v:nay.v..n....:;{v:•v.v::•:r.x::::n:•::.nv..:.v;}i:?•}.•5:.:.. ... ........... .v. - •.:::v:•}:{::.. ..7....,t ..%...:....:::...........:;.... .,}.. ::•:Inv ::fin:}::r•.v. ::::.v::.::....:...... ..:-..-.-......••.'.•. ... tLt t:,.?`:::.:t•:t .tr,•:ai;?;.>}:J;::{•}•;:.t•}}-::,.:-,.:}iti:y,.... ..t.:::.:,v.-:•.v:.{:y.;•;},:::.}::... r::n•::.•...,•:::.:v.:v:-::::•:n•:::.,•:::.:::.......... .....:....LL..{...L .. {nn....:�.{.v.n.7.....-.,,......r...... ,-:::{•:{•}.v:n:•:....t........r.............n,....rt•::::.t•::r:::::::.v:::.:v::.v•:::^•:.v::;•::::::::: ....7r... }%Oi:;•}}v.}7}}:}Y::'r:r?:?i>•:{:r ?.}\r{Jt'i•vY•i:•}}':•}}+}}:•%:.v:,...-{n}}n:v-v::::v::.v:.v:•:v•.v::v:{{::;n"•}}.:..::..:.........v:::.v::•}'•}ti•;,}:8}..;.:.....:v. vnx:w.::::::::::v w:•i}v:::: Y.iv.:v:•.:.... .v...r..r..n..ry.............r..:.{:•.:.:..n,.n ns..v.n, ...r..........vn.vn....r$.L•}:'4}}:vv:}:J}'•}:i•}}:4%v::.{v '-.......v:r.:•::,-•,.,... v-• w..-:_ '::nrnv:.v!•i:}•'Si.;i.{ .:v:}::fin,--.?..:::. .................../......}•::w:.r......-................4....r.......................-.n.-.........:..r.-_-..:...:::L:in:v::v. ............x::}::^:..v:.::n..n•::w:::;•: •:.{w%' 4-....: ........v.................. n......-v:»:v.v;�•;rv::w:x::•:x::}N}:.vv:::v:::v:x:•.vv:::.v::::::nvxv...................x:::w::�}::..vr. ............ ......?...... ....... ..._......:.....r.�-::^-... •::::...r,.n{:.. .n. .....r..:x..n n.........L. .....:•nfi•:n-::•-n•::fin,::•:�:;.:::..;•:.;}• ..........,.}:•:•i::.:.:n•:n:•. ...............................................r.:.r.•:}::::......,.:...............n:•.....:.....:....:...:.:r.::::::.:.:.�..............,;,,. ........... LL•:::.�:.�:.:�:.}:.:w:.�:•}:•}:•n�:r:-r:.....n.......�:•.:,:.:::. ..........................................ai}}}•••,•;i}:;;<•:;.}••}••}>}ii:}:}:}:ter:�}:}•:::.};:.......:.•,�:.;:'::'::::::::•:.: ................_.. r:::::::::.�:::•.�:::.�:.�:+::::.:J:::}i••:{.......�......:...............:.::..r:•:4}.::,.:::..:. r.:;.:?n::�}i:.;i;:.;:•:::n•:::.t•:rr.:t•::•>}::::.,-..}}}}iti::;;::;:; .. ...............t..........::........,.}..r. -.. ....{.t:..n........ .:..,....t•::.v..n....t.........,r.:.::.::}..,;.}}}}:•}:;:f:%tr:::i}:•%{•}:.};r.::,;;::'t:•::•-}}::.......r.::.•:}:r... :rr:}::...:.ti.::••:..:... , r.....::::e:'t} .....v:-- ^' ....-.....-v::.v:::::::n::•::::?.}:•:•::{:::{;•}:•}:+.•�:^i%•"r.•:.::.:r.•%rr ri.v•:%?•-•:!::•:..-.-,. ::, ?�. ':J};{•jQi{i:};.{v:: ..... .::irr.t;;J:••}}:.�r.::.,,n•.,-:::::r.•:n:,:f•::?r ... ..... .::?..,,:...--r.-:.�%.:......::,•. ••:•:::;n•-.,,-. .:.., ::::::::n::v:;;?....... ..x..r::.vf•}:::•%•:::.vnh::}:.•r:ear.-::::.n::.vv:nvv:{4}}.?irfw:::}::^J:•::--:v.::T:.:r.. ......}......:....... .:w:r.nr\x.. {..n.n,....{..nw .v.4 .rwP.w.n' ............:. .-.......,c•:::}:>:•}i}:•}:•:r:r:•::•:.n•::.�.:r.:;•'t::?^}}:a}•r..}:r.}r,.t?+:;-r::::�:?:;;•r::::.:::..:.....:.:::. n.:::::::•.:..t•r.:::::.�:-y:»:::;.>:::..:r:}::.:�}•::.:}:•:�:•}.{•. :........ r...: ...:.. ,?:.:n•.•.�::•.........r...........r.x•::::..:.:..........:• ...::•:::::lit::::,• yti;..::.,•ri••{,}.,•::•::.,•: t-:-{cr:: ?..�::.:.>... •::--:.�....................r..r.......... ... -:>:ran:....%n:•:}:.,••:d:.+•::.t•}•::.�.,:•::..... .....:: •v:Fn•�w:. :•:a•}:,{.:.v:.4::::v. �;•,.r}:::::.v:v:r:}:r.;i?. :.h...{:....:i•'r,'.}iv?::vi}:4::::iv:�::{4}. .._;.... • ::.v:::::.v::;•i:;•}:•}:•}:•}::ni}:v.........n..^:J.....................nn..n....v...n:x.:...-..n........... .-.... n.,.; ............. ...v....--.. r.......r..........n.....................................:::w:::?':;??•}ii+:•i:•i}:w.:v.v:w:::.v:.v: ............n.........:i:•.,.r}.{•nnv:^vr:.v...•...:nt�.x...vv..v:xv:.:V{w.v:::}.titiiti�{:i::: '� r::,•......-....fn........v.t.....}....n........................\..........,.........-...v. hV{�C.7/I.........................r......\v.........-.......-..........n..n.........y ........:-v:•:::::::::::::::::::::::::::v{:?::F:%:ii:��:r:::::..:/....:•r::,:v:•:•:rx....::.::v.............n•.v:::.v::::n:::.v::........•;.r v v::.v w:.v.......:::r::.v:.:w.r.•nv}'•}}::::... Jr:•>iT .......... ....................... .. .. ., .... :.:...n..-• .. t ....... ..........-..-...............vnv::•:.:.r.n,{....L...........................n......v::•:h:•?•{4}::.•..>.':{istiY::;:;%:t:i{£}tii;:i�,ii{';•i>:ttix:'r .:....:•v w................n...r...}.:::•.vr.•. •n.x..nvr yrn..........:.J.r.:�r;r..... n.................. ,..........._.....:...\.......... rn.r. ..h.N....x.{........ to L::••:•...................v.v::•......... ....r.............:•::.•::rvv:•:v:^:,{•.v7::�•x::}}t•:•:nv:••.,,4::n,..:.vv r.;:};.ir.::.wn}:}::ii:}:;:?iiY.�i:•? trr:n v: :rvw:x^:r:x.»w:::•.vn..tr....... ...... n...;f{.vr.:4:4.r:fr t. v n... n......v-,....... v.....v.n........n..................•:.n..v.'4 vw:x;ax::..^,.r,.{ti!•:{{•}•:?{•:v\'•'.:i$:>•}:::•'::::{•}}r:r,L.?:vw::n�in vv.}':•i't..\�};{{:{.,+.wv}iJ.:.....n.:......... r....... i..v.. yy ....................n....:•:::.•lw::n.-n. .. :}. ....-..: :. ...v.../.............n.........-.....:•-•:.v.vr.x.v ..v........v .t.........., -: •.::!;..y }}%v.:::•::n. nV..:.+A ...r�s':}•f ..4.A.. .,•}}. ...r-•:.r:.t............a............t,.%..n.:..,..n...,.,LL .r:r.-:}:i;:.;;•:�.. }.r n.a.„ r.F.,.,^ n::•i%t:.%;.:{•:{•; r:x:::::..........n....vw.v.:v::.-x�.••:%..fin.}.•::}:ni•arn..n.nv:::'v:w.v•:x:::rx.rvvL,rn. ....n.a.v....{}.. .r fin, nnL. ... r w... :::.... %{•} .........A:•.v.vnv:::?r i................4-..\ v...v J........-...-......,.....t..r.......... ... :.•::-:xw::•.v:v::w:.:v+:r.%v.v:::::::}; ..... ..........a..::.:..........:hr^}};:;:}v{.i:-:::}}}}:r-. .. .. r•:Y:••v::v.va• ....... ...:........ ..........r-----.....:..r.:.:..:.n.........:. :.:.,-.:;.;:?J:•:^::?-.�::}. ..{?.,•::n:.t r::.. :::•,• r..r-.};::.%r•:-:{....}r ::t•........:.�•:............:........::::. :......,...t ,.....,.......t...a...t ...-....... ,-....,,..t..{..n.:. •rrtn .r .. ........::::..:.�:.}'::::::::rj}};}i}i}??fi::ti:}i:;:•}:.}}}}}:{':::.v::::r::.v:::::::..................::::n�:.�:. : :.;.::::::.:�:::::::.:::::::::::r.x::n:;.v..:::.: v.;..}r. .:•. by ii:....v:rw::.,, .....::::::::w.v-,y?:ni::{::••r.•n•.v:•... ._.-........,....:::::::::}:?ii... ....-........-w.iY•:{-:•}r•'•}}::v4}••.vv...:...-.v:•nvv::.w::r:.r.•}.•:r•:•::}n}i.:i?�i:::•::i•v+• ..}n.n-.. ..... ........r.....r. ..n:..:.n............. ....::•v.v.4}}::x:nv::.v::::}:.w::Y:x:::n:•.v::r....r...n:rv:::::•.•rvw:}n:i•:v.:::v:x-,..n•v.v;..::{.v:w•,v..._...v. .rt?-%i}'•}%,4:.,-w.v:r.}}J}•:{;.i}: . ............::x:;•...........-:.-n.., ...nn.::nvv:.x}.v:•::?w v:.:......;.}.:...;8.... n.....x.Y.:-..... .n..n. .....:r... .......}r.. .. .... .........:}'-:••:::w:::::.v:::::n:.:w:v:•:•:.:.v:nv!:v:'ti;4":}.•:.. r•:4::::...:...v.:.•. r\,{...}}}:•}}W'v'?-.-.}},........v.....r.-:.. ...n:..x......v.{...r...-:......r........:r. ..n.....r..r....A......., :• .........ear.........:....4' v.r_n.....t. .... .. Jn.::}:-$'•::{:.?}}}'.{?}•.�}:• ...................... ... ......... .................... ...v.............,....-\n -....... ..:........•:::::........n..n.-...n.-v.--...:.n::?.{:•.:?J::.}:•}}} -.....::.n,:t•:•:rr:}'•:;•}:r{v.A•..n..:rv:}4?:?vrir.•,,v.. ....n..........:.::•:•..r.:/.........v.-n v.....:...r.-.,-.. .....r.........n........rr.r.........r....... ........r..... ..........}... n.^..... .:n r.....v r.n;...;?.....r....r,........ ................. . x.... ....n.......r-n....{.... ...ti t ...: .......-..... .....;..;..::::::::::{;4 w.v:n...., .....x. t ....v.. r...r..:.}.:.,•. n:.-.. .....n........ry• :niS,:},4r.:`:4;ti:•{:h{::y is ......-.....:-:•w::......«.....-.-.n..,.r.:::r.:.v::;;r...r,;r.{,.:._.q..x.............?%w;:}:.:..v......-...:..r............n eat.......vn.{.t... ..v{...... ......r:::v:.vn n•..,,:n?{4:nv?:•.x:•::::r.%n{::?{:}:^{ry:}ti>-nvn r.......r...... .....................,.-'v::::a...... .w:::..:n.....nv:.vv:::n?•:nv:.......................v....-..............-;•:}v•.w:::.w:rv...t.....r,. ..../..n.........:................ ..._i F.... v..{ ... n.nv.•:}::::?vX•}:{•.�'•} .... -... :.....v:}:?•:v.r:x:::w::w::r.v::::•:.w:::::::.;.•..•nnw::::::::::::x{:::x:}:4}riw::vY4x::::::.vr}}r:}:t;:.}:: ,... •v}:v:.`rx::r:•:•:}'-.v:.....,}iv: t.4 mvn.•w:;r:r..A.a...,..h......-..,..;}.:..}Ysiv}::::f}�{';v'}t}C;,nrv.Yr�\•...,t ,::Qw.v:.•v.•m:::1:::..-:.v. .s.\}..:::::::nv .r.{.....}..;...{.}.....:... n.f•..:.•.::•....C:..'•::'\':. xQmQany'nam .: ..:...........n- r::rx{r .......-...... . 'r vrLYr:', h•... '•tvi•})C}ti:itiY:i' ::r�:•.:'?•'r{:L::•'::'•'r�?:::titi':.>.L:��i:•`:i?:•::$}{::ii v:::4:}:J:rt;�::j�`.`-:ri.:{C}:,?}in.,.n•.:{•i^'�:w:•::;:;i};is•-n;i{:}M1{::-::titiSt::':$in•.v:: w,Kv. ......r.v:.v::::::::^v^:w:::::::....:....................v......n:v}:v:;.n....n.............w:•.:••::::::n::v:. :.v::::rv:xv:::::::r::::::::.w::::•}:4:xrv'r•'v:};}}{.}}vr.w:.}'x? : ?4:•}}ti:ti4:w:w:::::r.:::::n::v:::.iY{{{•} ............................ .............-....: ..r.................-.....-....................... ...........:.-:.:..,................,w::::r ...r...... ,.vvn:.:.•v:nv}:�?v:...r..Jb`..•i<.{\+wn w....,+...w•..... '��SS::>:::::::''%`:>:�:}:':;?+:;:t:;•:ti::i::::':'??::ti-:2:+i-'�:�+:2�:::<:::::C•.'•.:<::::.'•yj:>s>?r.;.;:;{::':ist.�:::%<:::i::j::`;:;';;:•,::i:::y':!'}::ii:i::i;:;:�:}}:'::;•-:ii<::::�i:�:�:�i':;:::2:''��'•!:�:::2:;�:?{:;:;:i�:;:;i};{.':;%:v<:'''•.'•i::{:;:•;:::::{:,:':}:•}ii}:-y:{.:{t{•;•}:•%•}%?{;n}::�;;?}}:}>{:: .:...... .._........,,,•.}:•}'?r.yv}}}:,w:::::{{•}:.--.n.......-.n....................r....... •v:,}}}'•:i?•'}at}:{4}}v:vv.4ni{i'i'.:::::::•:ji:::i}::}{{:::i::iiiii:}.�v.�}i:}}:•}::;•i.}vy:::};}ni'^'•i':r;'::j:?}: t..r v:•}:�t..v...t. .r•:••::.. ....n:•.ni';:%::.}}•.vn•...x.v... :•:v::::::.:v:::::::nv::::::.:.v:n..,:,?•:rx:::}::i}}%•};:;.:?t{}.v:}'i?i}%{4'r.•}:v:•....:.:.-..}:::::::•.................................:.v::•x: •r.:::.;;...}..}:•}}} .:...............:::nv:::::n:•..:.r.:vx. .tea..... ,...................n...•,.:^.::::--.:;.ti.n..•::�.:v-....n :.......r:::::,vr.rn...:::::::.•r{•:::v}::w::.:.:.........n....r.x:••:.w.vnv}:}•:::r. .v:::::::::•:::.:....................:•..nL s. n.v..................v....:....v::•:x...........................r...r-.....f..n..•w.vnn::.v;....; r...r.. ....n.n....n.. .. ti+.:}. .}?,.fin;,, ,....:::.v;...... .-......-n......................... .........r.-......................}......-.-.+....-....................................v..--....-. .v....,....x.r........ ...}r..r:xv:}:::::•:xv:::::::.....rn...........nv}:::x::::n{:::::. vnv::::.i}'•}:•}:L:L}•--...' x.v:::n:rv:::v;ti -:.v::::Lv:v:::::xhJ.rw::::v:}:m:•:•v- ................... .}}}}:;•i:•}::v•::•......................-•:•:v.....vti:-w:::::::::::v::i;�:•}}%?.%-+:v;?�i}}}}}`}:�:'-i}:B:G........ rw::}.iw:+:: ....:'v:n-. n.v,::}::?{-::L:}}•.v:::i-}}}vr�:; ..................:^::r..... ..-..:..... .. nr..v:ivm:::.:vn.r.:::nvv.�•}:::::.,•::::eat•:::.-....-.......n.........v...n...........r....n........ ,....... v.:.. tn..v.v •»r.'.-'� x'•.r:v.r.....".....n...,....v:-: .:.. ............... ............r.....?r:::.::,rr.r.r..............r.....-:::::n•.v::n•:.,•:.t......-....n...._.. ..............:•........ \..........r..x::.x..r.a:;r:•:i:,t-:r•.:_.,r:�:%}:..}•.,;.-:•::: .^}},••}'i;^:::::}hw::.v nv:..c..-..;n......t:•.w:::}}:rr':::-}:•`:-:?::.}:{�:Y:ry:.............................. :.::::v::.r:::::::.•?n.yri:i}%4}}} ............r . ..... .-....,.........................t•.......-}x4:{{4..:::•. ..........:r:..:::}}:•:{.;•::•.}}}:.{;:•::.:,?:::.t:w<a%�:}%•:;4}�{:{.;:::•%L:�:-::}%.}i::«_=«:{.:.s......:::. ,v.................. .............. .......nv::::x:::..r..........................................,.;;....-nv:v;{,......-.....ear,.;;...n..•v:::::v;... t...... m.,. .. ••nvv:::::::.�}:::v••v.•ri:::{??ear:• ..v...r.v..:::......... ..-........ .. ••-•:v:::••n:n}i .. ::\v. rh.:.Y.ti:i.:}:?;rji:<:•}:na''krr' :!::tiff:? r]ti7:::':'n`}' :....Y..•:?^i':}:r•}:•$:?>•':}}}:.:x: .4:..:-.::.?ryr::v:::•%%:{f{f•:4:{.i�+:...:::•.v.i;{:;:}$4::::4h:n- vv:}?:::i•.�i:J'S: ... r .. .. •:••: r:•.:::�•::: ............:}::::::...:::.:v::•-:•}:::•.ir:::-.t•:.:..... .t,+:::n•.,:•. r'%?.yti:{•: ,}+.. rkk'•}�:}�:<i::! .ri-{v{.... t...r. ......... .•v. ...-..x.n...n...............v.:v:nv:x..........{F•.•{ri':t:{>.•ti•}•:s r::-:::::x..r::::::n: ..:::v:nv:.+.•:h•`nvvv.v:.n..v.A. .......nvv•r.{v......w:./.:. ..rn...v;y:•ri•::vv......-..fin...n.............. .....r ..................,r, .. .. }::• v,%'�T:::iw:'Jiv7'is��•l�r ....n...........:...• ................ ...... ... ......... ....n.,.r.....:. .::.:w:Yn....- .......... } ..•w:;....,.. .... ..........::.w ... ...:v•::• :+":+r:+•�•.,•'��':itnitinv��ti.;.-,..; .}...;}:!::ij: ..................:.:. ...........::}hk{�:n:r•.vv}la4n:rr{,v-O.:w:};{,L,t.nv::::nvnv-v.{rvtiv 7v..........m{nv:r.._...:G...ai[J..:v.....}, ...... n..(. v::?>.{•S.{•: v .•}.{:ir.!•:.v:.,...:. .......::!•.......-....n... ..... ........r...................n....:....t•:::.-....:•::::•:.:::::•::::.�::.�:-:::::::r:::.. ;•:::::.::,.:-•.C.,..�......-... n,L::LS:::r::Jr•:n?.}:}:.,{..:v}.Jan.. ' Fame to secure Coverage as tegaircd mtider Seetlon 2SA o a fine up,to s1,MMOO and/or =a yenta'impiiaonmeat as well as dvfi penalties in the form of a STOP WORK ORDER and a flue of 3100.00 a day against am I understand 69 a .COPY.of this statement may be forwarded to the Office of Investigations of the DIA for(overage vertfieatiion. I do hereby certify the pains mid penalties of p that the infonna don provided above is tnu mid correct s --� Date 3_y — © — official we only do not write is this area to be completed by city or tawa official city or town: permtfllieense# ❑BuMI g Department ❑Lkenzin;Board ❑cbecieif tunuedtaie response is required ❑Selectmen's OMce ❑Halth Departzu contact person:• phone#; ❑Other_ (nriwd 9N3 PIA) 1 1 11 1 1 1 1 1 1 1 1 • • • • �• t •111 /• - • J 1/ / •�1U1�• �1 • • r / 1 .1 • 1• •�1 011 •�1 • •1•ll / .19 • n•e/ �• • • / w• • • • 11 • �11 • �• 11 • /1 �/•/ �1 / .11• 11 • •1 H - • • 1 1•• U • 1/••1 1 1• •« .1■ •11 • • •�1 •R :1.1.1 • :•1rN • • • =•1 • 1• 1• 1 11 • 1 • sefspilwad• J• 1 • •/a i1HA .0 1 • • ..`I • • 8.64 • •• :1111• • •-1 •11 • • • 11 1.1 -6 • •" •u • • M• •11 o • 1 1 •• to • • • • •1• /1 V • U• • • •• •• .11 11 /•••/ • 1 1 1• •SKI • 1 • �111u • 14 �1 eJ 1 •�..11 �• t• / .11 �•r1N • -1 / • �1 • •11 • Y.I/w /1 .1 : 1 I 1 1 Y 1 1 1 1 / 1 1 1 1 / 1 r 1 ' 1 1 • 11 1 I r • 1 yll 1 1 1 1 • I r 1 • 1 � 1 1 1 11 11 1 1 • 1 1 : 1 • 1 1 • • . 1 1 1 • • • 1 - 1 1 1 11 • 1VP1 11 1 • 1 I • w1 •• 1• •11 1 • 1�11•••.1 /• 110••1• • 1 1 1• 1 • IA •• 1• W. •• y ♦11 y• 1 .•Ilr�. 1.1 • .II r•1/1■ M • /1 ••w • ogle I 1 • I 1 • •'• ., 1.1• • Y • •w1 •1 r•1.1I• 1 r ' 11• /1 11 •• lotr -• 1/1 -to -•11l • 1.1 1 .I• e.w 1 1 -•/1 •1• •• 1 :MjNjjjj���jj����jjjj������jjjj///��j���/jjjjj��jjjjjjjjjj����/�jjjjj/�jjjjj��j�/�jj�j����/ ill 11 11 • t. r•H11•r• .1• •1• . tt • . 1 M•1/11• �• / ' • .•11 • // ••► /1 .1 .1•• • • U y111 keels1/ J• • • 1• • •Ilu• .11 I r1 w • •1 wl .1/• • 1 •11 II Ir• ••d•. •11 • /1 •'.� •l• M:11 • 11 11 .1• •• 1 i/ • IA 11 • 11 1• �• • / • ••1 .••1 •1 / U• •• « •-•uA 111 ••I I I11•U .1• •II •1 11 Ito-1• Itq to 1 -1 1 1 t/ • - 1 1 • 1 • • •1•••�• f• •1 MI y •I • •'1 /1 .I /1 .1• • ✓.1• •Ir •1 •1 •�1.111/ •1 rw• 1 . �• w 1�;IW7 1 /1 , • .• •1/�•11 • 1•11 ■• M •w11A 11 • 1 •• I .1• • I I w • •II .••r1 • u • u • • �• 1 • ►• • • 1 •'. 11 ' •U�� •'•N11••+1/.'✓-I• •1• •• • r � r= 1 •1 � �• 1.1�•11 .1 •1 rural •�• 1�• • • • it 1 1 1 • 11 11 •1 •1 it • ' 1 r•11IU �•1 .11 1 1 UII�e -••1 • 1 , • II•-•11 1 • • 1�• • -1 /1 • • 1 •IU • / " • i •1y • • �1 • 1/ 11 •l •••rl /1 / i/ r • 1 ' w • ••:u •i• 1 I• r•111Y. M •• 1 .••Y. •IN • /1 - • 1 •r,111 -� /1 • :11 11 1/ •L1.1.11 rw• 11.111 •.. ••1 • ( • �• .+1-1 .H• •11111 •w 1 tt • IA 11 • ••••1�• 1 •- •11-•/1 • • Ir •1 111 •/1-/ . .1• • w1•••11•. 1 - •►�•1 •I✓. • it • 1 w • ••:u m • 1 • u .n . • u • • -u .• • s 1 .••• •.1 .0 •n . 1 • 1 • • • • . .n • 1 w ••/ 0-3 j�j jjSON�j��j��Mj��j�j���/ • •11�111 •• w`1. 1 0 •Ole .11 • /s•' •1 I•e ••rl 1 1 11 1 1 1 1 1 • 1 1 I 1 1 1 1 1 1 1 1 1 ` I I • 1 1 1 1 1 1 1 / I11 1 ' II II 11 1 1 Z x„� 6 i✓ /� c�►��� J�,Q J Ito 14 CA V l � cl Qr j Fl 1 IFT-11 IN _ { �, . r .�. ��W • ,...�� X T 1 k N �f 11i , 1 I ' � d w Cho `�' ' "f�f.�" A►� S-rigid. .�"��.. r : t` fi i P e 0 o J 1 e 1 C- EIS'Ste' ��S rerS w -- r 0 r .. ...e. ��.,,..�.,..» .�,,..,..... �....,.,......�......,�..,.,........:..,. �. kIKE NP �� The Town of Bar. BMWSrABLE, . astable Regulatory Services s6g9, ,e MAy p Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner 200 Main Street,Hyannis MA 02601 . ce: 508=862-4038 Pax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: y- D JOBLOCATIONJ 7 {euly/f^N c j r'h� �`et7T�P�UlG(,` y!� " �/OR,��9 el"z number street village "H0MEOWNER":1S/V1y0,6' , name / home phone# work phone# CURRENT MAILING ADDRESS: S VjV k Aj -r a21,.E2, city/town state zip code The 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 Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there 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 homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible 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"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said proce s and requirements. Signature of Homeowner Approval of Building Official Note: Three-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(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often 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 ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part.of the permit . application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:F0RMS:EXEM1`TN 1371-k--�10 J t e,r41^ �. T v l e- f -p c z r 70 �, ator1� 1/ x P` ® A e- j Ir Of- r5 vo a to ICNO -> 7 { . 0 ;,s r� �:� i f14 P`0rl U rr, r i. �� 5 fft5 ��� � COPLOT 14 IO� 169 O N fUc4% 1pgo�bSLO �Ge oS4'4# 2x� LOT 15 4'V 17,003 sq.ft± rr�+ 0.39 Acres �1 CONCRETE FOUNDATION TF m 53.V ' O O S CdPT� N LOT 16 JOB # 96-251 CERTIFIED PL 0 T PLAN LOCATION SKUNKNET ROAD CENTERVILLE MA SCALE 1 = 30' ' DATE AUGUST 20, 1997 PREPARED FOR: REFERENCE: LOT 15 PB 224 PG 127 CHAMPION BUILDERS 'INC. I HEREBY .CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. y OF MAJJ� on SOB-3eY-�a{� of ARNE 4yc H.r� 5oe aa2-4eeo �OlI7! capetweel'11tg, iaC. 4 o 26348 Q M7 A) z, 90 CIVIL ENGINEERS 1E 939DATE LAND SURVEYORS -- --- ----- — --_ q T[ —————— A main D L st yormouth, ma 02675 A TE REG. VEYOR TOWN OF.BARNSTABLE BUILDING PERMIT APPLICATION Map / �% 'Parcel o OQ-�- i Permit# 4 r� Health Division O'— v' 1 Date Issued Conservation Division Fee Tax Collector' F Treasurer - ,' S,EP u IC SYSTEM MIST BE DC-) INSTALLED IN COMPLIANCE Planning Dept. -WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND T®'u'4 REGULAT*'ilS Historic-OKH Preservation/Hyannis Project Street Address l .�� -S'D�V��aC'� Village _C---e✓_1,_A �1 1(-L C M _, Owner S/9 at')a, F C�1�'002 P�C�! Address s,;Z X",6 /Z Telephone a 8 -77/ ,5- r: Permit Request Square feet: 1st floor: existing 0-49 proposed 2nd floor: existing proposed Total new Valuation 7 ® � G ' a Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Qwelling Type: Single Family �k Two Family ❑ Multi-Family(#units) Age of Existing Structure 3 y2s Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No easement Type: '(Full ❑Crawl ❑Walkout ❑Other lka Basement Finished Area(sq.ft.) N�&.?cz Basement Unfinished Area(sq.ft) /Z- 8k 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 Central Air: ❑Yes 16 No Fireplaces: Existing 0 New Existing wood/coal stove: ❑Yes U(No S Detached garage:❑existing ❑new size Pool:Cl existing ❑new size Barn:❑existing ❑new size Attached garage:)�existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name J11" 0Q Telephone Number 9--27K Address /7'001 License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU �- DATE i FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS t VILLAGE OWNER DATE OF INSPECTION - - FOUNDATION FRAME 1 • INSULATION FIREPLACE " ELECTRICAL: ROUGH FINAL S f „ PLUMBING: ROUGH FINAL GAS: ROUGH FINAL z FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. # r r °F IKE 1'4 . . ° The Town of Barnstable • BARNSTABLE. M $ Regulatory Services q'ATEo;9. Thomas F. Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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. Type of Work: �k/.S f fRc�GT/'`-9 Cam Estimated Cost ' Address of Work: /3 �' �S�'`>Alk—vt> Owner's Name: Date of Application: 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 [ROwner 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: Date Contractor Name Registration No. ORS Date ner's Nam q:forms:Affidav The Commonwealth of Massachusetts - -_ Department of Industrial Accidents Office 81108508 ions 600 Washington Street Boston,Mass. 02111 WorkersIC om ensation Insurance Affidavit name S/V b-t c.-P�Ft— Peg —coy location: l S�Z, S k-v�(_ L ci G lJl G.G �'� l� D hone# I am a homeowner performing all work myself ❑ I am a sole r netor and have no one workin in capacity p Iaman em toy er providing workers' compensation for my employees working on this job. W. com"an -name: - ' ,.: iatldress. < crtwX. phone# ali #: insurance co. ❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have workers' coin ensation polices: the following P....... :::: ::::.:::::::::;.:.::::::::::.::.:::::::.:::.::::..::::::.::.:::::::.:::.:.::::::,:::::::.;:.;;:.;: ...... .;...:..:.. aom an name: - addresst x. <a <r a ri one;# :.............. f•..•...,::•. ansnranee:ca t►6cv# .:.......:...:..... Vt c anv.narne.: ht►ne#c ....:... c Zii11ra11Ce'COS;' ; Fafimre 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 may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby:7dorthe pains and pee of p that the information provided above is true and correct Signature Date `7 f Print name Phone# %"5"�' g"77'C 2�`I 2121111 official use only do not write in this area to be completed by city or town official city or town permit/license# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other 0evned 9/95 PJA) 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 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 section 25 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,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 you 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 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/li ei number which will be used as a reference number. The affidavits may be retmmjid 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. jj���/jj��jjjjjjj����j/j/�jjj�j�jj����%7,�J %%/j.��/%� 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 ext. 406, 409 or 375 LOT 14 I Tgo�bs`p O 5 4. N OO 4 f tl' ,2 X.0 pv?G56ft F=Tg-l-Wc0 LOT 15 ►� 17,003 aq.ft± rri + 0.39 Acres CONCRETE FOUNDATION TF 53.1' • O O O y .S'CdP7,r C O Nlif 8O,8t _ I 7;70 36, LOT ,16 JOB # 96-251 CER TIFIED ' A-0 T PLAN V LOCATION SKUNKNET ROAD CENTERVILLE, MA SCALE 1" 30' DATE AUGUST 20, 1997 PREPARED FOR 'REFERENCE: LOT '15 PB 224 PC 127 CHAMPION B UIL.DERS INC. HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. `,N OF Mqf, ott SOB-set-464t �`�� ARNE te m 508 3B2-PBBO �� H. G✓' I � � down capeerir lac. .� o 26348 e AJ Zt M 7 9p • _ CIVIL E IN NaEER8 -- �(' ---�----- IERE � LAND SURVEYORS --- 939 main at. yarmouth, ma 02675 DATE REG. VEYOR s GF ZME STAB The Town of Barnstable 9�A ��� Regulatory Services. 39. tEn Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: j U I V r /V G I �I JOB LOCATION: / ,6 S" � U Iq K I 1 (S 7- number street r street G 'jviilllagle .,HOMEOWNER": (5� l"I V CL T RP/�E � ,� � 0 / 1 ` — ?,/ name home phone# work phone# 7�I CURRENT MAILING ADDRESS: / h U! ` ' ` city/town state zip code The 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 Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there 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 homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible 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"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said proce res and require. Sign.ure of Homeowner Approval of Building Official Note: Three-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(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor`(see.:..,_. _ Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often 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 ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMPTN rYtCK `y t ` wr Engineering Dept. 3rd oor Map /']'f Parcel .. cpe)1S � Permit# Date Iss House# . S �3 d 96 ,� o Board of Health(3rd� or)(8:15 - 9:30/1:00-�ib' ���- .""Xg Fee pr � t Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) L ('1 �o a - Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SYSTE E TALLER IN C E Definitive PIP roved by Planning Board 19 WPM ENVIRONMENTA Aar 01 TOWN OYBARNSTABh&N REGU Building Permit Application Project Street Address d 1,��. JL-0 tv k M E"T f�D ' t Village G c�i E(.Z 1//1,�F �l� 012 v Owner S A �U E I_, .7' �I d a Address .'/vd.S/ev N(�.+�+�� C�;ZRVILLC��d Z6 � 2 Telephone %-a 0' a - -77 Permit Request 2 40A p/ �'/q �Z l� c_� t -First Floor 7.57� square feet Second Floor square feet Construction Type Y f�f 'S - � X C Estimated Project Cost $ ® , C, Z Zoning District Flood Plain Water Protection Lot Size / S / Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 11'04 7-6 ` Historic House ❑Yes XJ$To On Old King's Highway ❑Yes KNo Basement Type: OFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) c "� Basement Unfinished Area(sq.ft) l.2 3 Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing 2,xg 1W New �- Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas >(Oil ❑Electric ❑Other Central Air ❑Yes JxNo Fireplaces: Existing New d Existing wood/coal stove ❑Yes Wo 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 g.No If yes, site plan review# Current Use �I V-L.L/u C_ Proposed Use i,,-/�-_I-L� Builder Information Name 0-&V-njeJL Telephone Number Address License# Home Improvement Contractor# 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 — LUI I G PERMIT EI�D F TfIE FOLLOWING REASON(S) r FOR OFFICIAL USE ONLY ��b t PERMIT NO. '' r •^ . - _ . DATE ISSUED MAP/PARCEL NO. , ADDRESS VILLAGE' w OWNER DATE OV INSPECTION: + FOUNDATION ,. F FRAME _ V -;�w-e_ �s►�C� 04 '�LV _. INSULATION FIREPLACE = - - fft ELECTRICAL: OROUG. FINALcr + r t PLUMBING: L-R-@UG FINAL'. + GAS: >- 1 m FINAL - - ca FINAL BUILDINIR { _ 5 is ► C� _ w. DATE CLOSED OUT nI w i ASSOCIATION PLAN NO. f , LOT 14 COP -- 76g 71, 10 ly r- 54.4' v o LOT 15 +� 17,003 sq.flf rr�'V N 0.39 Acres CONCRETE FOUNDATION TF - 53.1' e3 v p O O O N 808,� l 7p 36, LOT 16 JOB # 96-251 CER TIFIED PL O T PLAN LOCATION : SKUNKNET ROAD CENTERVILLE, MA SCALE : 1" = 30' DATE AUGUST 20, 1997 PREPARED FOR: REFERENCE: LOT 15 PB 224 PG 127 CHAMPION BUILDERS INC. I HEREBY CERTIFY THAT THE STRUCTURE SHOWN .ON THIS PLAN IS LOCATED ON THE OF MAJIy GROUND AS SHOWN HEREON. ARNE �y OR 308-362-4541 G✓ fox 506 302-OW 3s H. c do1►a cape a#&eering, inc. Aq-1 r, 90 26348JCIVIL ENGINEERS ----- — --- lA►��J ------ LAND SURVEYORS 939 main sL )armouth, ma 02675 DATE REG. VEYOR CF THE � , The Town of Barnstable • wexsTasze. • 9� ' AM 6 �m�' Department of Health Safety and Environmental Services A'Eo " 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 I > 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. �1 �ype of Work:(. �22�d Est. Cost Q OP-" �. /Address of Work: %,5 S�val� N 5 — �� C� 'tP l/jGc,� fI C�� � Z_ /Owner's Name —� ,,-Gate of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law I 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: Date Contractor Name Registration No. OR Date Owner's Name The CottttttonMealth of:1fassachusettt; i �•�..: Department of laditstrial Accidents Officeallnyestlgatlons 600 1114s6in;;ton Street ' Boston.Alaxs. 03111 Workers' ComPensntion Insurance Afridavit al�jlirint information•, — Please('RINT Z-jjjY •__�- _ , v name S)Lo4 l 4 'Ri4 /lac�tion•��Z' Or I am a homeowner performing all work myself. [I 1 am a sole proprietor and have no one workina in any capacity CI I am an emplover providing workers' compensation for my employees working on this job. enntnarn• name* address- CON- nhonc fi• insur-ince cn. Holier# I I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who na% the following workers' compensation polices: comn:tm- nime- addresc• cin phone�• incurnncr rn nnliev M comnins nimr- address- cite- phone fit• insurance co,_ pplicr tl Attach additional sheet ifnrcessarv �. �r..�:�.'.. �:'c:..y.._ _.... .;.�. _ '...,.rr.7 7+-�L+.. +.ter.y: a+.... .�.•,, _."•.�.�'��� Failure to secure cos•craec as required under Section_5A of 111GL 152 can iead to the imposition of criminal penalties of a line up to 51.500.110 andiur une years'imprisonment:t.%%Cil IS cis ii penalties in the form of a STOP NrORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement mas be forwarded to the Office of investigations of the D1A for coverage verification. 1 do herchr cerrift tuf r the pains and penalties of per' n•that the information provided above is true and correct. Si^_aature Date / Print name SA g(g(G) �� �f R,�p Pfione>* 31--7/ 1— ' official use uMr do not write in this area to be completed by city or town CIM621 T+ citr or tntsn• permit/license Department ( C31-icensing Board (:check if imtnediate.respunse is required ❑ Selectmen's Ufface ►- (:]ticalth Department contact pcnnn: phone tt• Mther F. information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers* evillpensatian for employees. As quoted from the "IZINC. an empluree is defined as every person in the service of :11lother under any contract of hire, express or implied. oral or written. An cmpinrer is defined as an individual. partnership, association. corporation or other legal entity•, or any two or m: the foregoing enuagcd 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 owner of a dwelling hcYuse 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 wort: on such dwelling i or on the :_rounds or buiiding appurtenant thereto shall not because of such employment be deemed to be an empioy MGL chapter 152 section =5 also states that every state or local licensing agency shall ithhold the issuance or rencival of a license or permit to operate a business or to construct buildings in the commonn•ealth for anN applicant who has 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 wort: until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authority. Applicants Please fill in tite 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 recuirc w compensation policy. lease call the Department at the number listed below. to obtain a workers- cot P P P City or l O�rns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to J-111 out in the event the Office of Investigations has to contact you regarding the applicant. P' be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retume: tfie 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 questic please do not hesitate to :give us a cc11. . 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 L: (617) 727-4900 eat. 406, 409 or 375 • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Pease print. DATE _ . . JOB LOCATION C' �<E` (LC 1SJ 0;?_C,3 y Number Street address Section of town "0OWNER" '7 R 3-o R-- �7/?s ,7 �s-7 7 9"D Name Home phone Work phone . - PRESENT MAILING ADDRESS - A4.fi _ City town State Zip code The current exemption for "homeowners" was extended to include owner-occuc_ dwellings of six units or less and to allow such homeowners to engage an is dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person (sj who owns a parcel of land on which he/she resides or intends to r side, on which there is, or is intended to be, a one or two family dwellinc attached or detached structures accessory to such use and/or farm structure: A person who constructs more than one home in a two-year period shall not bE considered a homeowner. Such "homeowner" shall submit to the Building Of`4 ' on a form acceptable to the Building Official, that he/she shall be resnons: for all such work performed under the building permit. (Section 109 . 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the Building Code and other applicable codes, by-laws, rules and regulations. he undersigned homeowner" certifies that he/she understands .the Town of arnstable Building Department minimum inspection procedures and requiremient nd that he/she will comply wi h said procedures and requirements. 7 IOMEOWNER'S SIGNATURE ,PPROVAL OF BUILDING OFFICIAL `ate: Three family dwellings 35 , 000 cubic feet, or larger, will be required "o comply with State Building Code Section 127. 01 Construction Control. HOME OWNER'S EXEMPTION e The code state that: "Any Home Owner performing work for which" l�'building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that it Home Owner engages a persons) for hire to do such work, that such Home Own shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations fo= . licensing Construction' Supervisors, Section 2. 15) . This lack of awarenE often results in serious problems, particularly when the Home Owner hires ;unlicensed persons. In this case our Board cannot proceed against the ::nlicensed person as it would with licensed Supervisor. • The Rome "dwner act: as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her- responsibilities, me communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On th Last page of this issue is a form currently used by several towns. - You may .,are to amend and adopt such a form/certification for use in your community. yj Z 940WINAIL /sz Sk�ar� GZo i1 A /I Afif2AAP nn fl n A ,41 . 10 e-j WALL iC IL fi v Aa)A-TiDAl vt�i4LL • B;OffcMEAtr PUbR .4nm Tfflck 'the o� n of Barnstable ci2r�s-s -s�cria �1 r As��i�r \ �� �{vv� 5/�itiGLC_ E/z-S 0� /s"��'- FELT 09PE2 uc u� Ko off" P� Y G \�_ tG � T x15r/NG Ce-6 .TorST 4. -a te . wIto DoW, �PEFL .JbiST IYANGE -S HE:-QPr-RS (-rYP ): ,[X16T!IV G rrJlaC ro BE RE/>lovED- 11"cmlt®4r--,o'0 5 ElITH14 PL YW 00 D FL o 02 F.. T s t4-L . ,� _ � � � �� �<< �.�6« �.��«�v�moo• y _ 97,11ZVIM, t 4. �a Y� .fin .l i• 1 t g TOWN OF BARNSTABLE + CERTIFICATE OF OCCUPANCY PARCEL ID 171 005 GEOBASE ID 9855 . ADDRESS 152 SKUNKNET ROAD PHONE CENTERVILLE ZIP - LOT 15 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT. CO PERMIT 26499 DESCRIPTION SINGLE FAMILY DWELLING (PMT_#18801) PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety , ARCHITECTS-, and Environmental Services TOTAL FEES: BOND $.00- O�Tt1E 1q�_ CONSTRUCTION COSTS $.00 "�•� 756 CERTIFICATE OF OCCUPANCY * + * 1ARN3TABLE, MASS. 1639. �Ep 6 t. BUILDING DIVISION DATE ISSUED 10/22/1997 EXPIRATION DATE BY �y�",�� r �- TOWN OF BARNSTABLE BUILDING PERMIT PARCEL ID 171 005 GEOBASE ID 9855 ADDRESS 152 SKPNKNET ROAD - PHONE' Center-4ille ZIP' - $flow.. L0IT6 15 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CO •`j'" 'wf, PER11IT 18801 DESCRIPTION SINGLE FAMILY DWELLING (SEW.PMT.#96-53�iI.iiz-1. PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT TRACTORS- a)ACEY , Mrlk%1T Department of Health, S' BI1TECT5: and Environmental Service L FEEd, $241.43 TNE: �..,, $.00 'TRUCTION COSTS $77,880.00 1f-%1,0 i SINGLE: FAM HOME DETACHED 1 PRIVATE P ABLE, •' �,,� ' eR BRI GSS, DANA S TR •... ' '�5 BARBARA W BARNARD TRUST �? 29 WHEELER RD BUILD G DI SIQN r .t'y MARSTON S MILLS MA e<• BY X iJ �,_,_ .Mp DATE ISSUED 10/24/1996 EXPIRATION DATE }P �.; MIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTVT- ., MENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STR&f:bA" ' h�4!E��A dRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE Or fi4 ` 17R�c�, OES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. d M FOUR CALL INSPECTIONS REQUIRED APPROVED PLANS MUST BE RETAINED ON JOB AND ' LL CONSTRUCTION WORK: WHERE APPLICABLE, SEPARI` NDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED R TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND ME DY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. CATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. L INSPECTION BEFORE OCCUPANCY. 011 ILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVA etta l' c� �•c e. � crier r.�� s / lt Ln 9 7 /iOiw'ZZ-vye7 i A((5 rce e- See-Na^--j �(, cue. •vim e,� 1 HEATING INSPECTION APPROVALS NGI EKING DEPA TMENT` `�f q. 2 BOARD OF HEALTH 1p�22 Q7�,p rf 7 _- SITE PLAN REVIEW APPROVAL , WORK SHALL NOT PROCEED UtfilL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. . ,ak�� • . � 1, : �'' r �4����y �� ' s,•; ` { • • • • y, Vic. ` +f �� ��• 'MIT� ° Y �y, �. �n- I ' � � ,•. '� 1 _® -r>.►�-ram-- -' _ -. <- "R"w,..r"_ - <..f s `'` ,...p�`.p. :.. ., .�.� ..• TOWN OF BARNSTABLE v, - BUILDING PERMIT PARCEL ID 171 005 GEOBASE ID 9855 ADDRESS 152 SKUNKNET ROAD - PHONE' Centerville ZIP' LOT 15 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CCJ PERMIT 188PI DESCRIPTION SINGLE FAMILY DWELLING {SEW.:EMT.#96-53 PERMIt TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT �I TRACTORS DACEY 4 MATT Department of Health,-Safey t 'IIITECTS= and Environmental Servil' L FEES: $241.43 Ox $.00 ! 4 .-TRUCfTI.ON COSTS $77,880.a0 101 SINGLE` FAM HOME DETACHED . 1 PRIMATE P1639. oo� BRICaSS, DANA S. TR.. � �A E ' . S BARBARA W BARNARD TRUST D IN1�y 29 WHEELER RD BUILW.tiG DI SIGN MARSTONS MILLS . MA . BY y "DATE IS90ED 10/24/1996 EXPIRATION DATE a IS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,-ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY EN ROACFIMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREF TOR, 'AL`(Yti',,Gf1ADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT.OF PUBLIC WORKS.THE ISSUANCE O° ;''IS WgE_,P vI1w OES NOT RELEASE THE APPLICANT FROM,THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. y "INI A M OF FOUR CALL INSPECTIONS REQUIRED L CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND k, THIS CARD KEPT POSTED UNTIL FINAL INSPECTION WHERE APPLICABLE, SEPAR I NDATIONS OR FOOTINGS PERMITS ARE REQUIRED ?,+ R TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND Mf' 1DYTO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. JLATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. r !-&L INSPECTION BEFORE OCCUPANCY. ILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVk Tw S� 2 c 2"�.�=���e-•Cam / t: 1 HEATING INSPECTION APPROVALS ENGI ERING DEPA TMENT 4 � I 2 BOARD OF HEALTH tR. - SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED U IL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRAGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. r F • • c Y f 11 I 71 • i. ,C]ti (� yf �, � Q r +r • - g�� f-s�1.7G ♦ � Y" S+ /k� � t. ,♦ � r w \ 'j• 41 +f 4 �-� b •� �V.•yS F �j +�r r . s � .. � Engineering Dept. (3rd floor) Map 171Parcel "r "J Permit# House#- SoZ/KJf Date Issued e a o,Z"[ - 1 1O Board of Health(3rd floor)(8:15 - 9:30/1:00-4:30) fa , flee _ ®;7 . Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SYS`T'E E greetAddress Approved by Planning Board A 10 le 6 19 WSTALLED IN STABLEWITH Ti , E TOWN OF NMENTA Building Permit Application LoTT \5 ; it 1 S Z S Ko N KtV Et p_oA Village C_E_N1TE:QV IL L.5 Owner CNA,nAPAbt� IN L . t Address 3CYJ OA - S I„*Ss,, P1rZ1N1RP,0Y1E� M� Telephone `5O18 BIBS G(o 4-6 Permit Request -TO C,oN\STR v C-T A ip A M 1 L_�1 First Floor gl(o _ square feet Second Floor (o OCD square feet Construction Type Woo t-0 1�:RA d\AC Estimated Project Cost $ 1 Z, g80 Zoning District PIC; Flood Plain N U Water Protection Lot Size S,F. Grandfathered ❑Yes ❑No Dwelling Type: Single Family 2 Two Family ❑ Multi-Family(#units) Age of Existing Structure f-1 Historic House ❑Yes ❑No On Old King's Highway ❑Yes 0"NNo Basement Type: &rfull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 0 Basement Unfinished Area(sq.ft) (o Number of Baths: Full: Existing New�_ Half: Existing New No. of Bedrooms: Existing New _:�) Total Room Count(not including baths): Existing New G First Floor Room Count 3 Heat Type and Fuel: fr Gas ❑*Oil ❑Electric ❑Other Central Air ❑Yes EJNo Fireplaces: Existing New 1 Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) f Attached(size) k A-i x ZZ 1 (fLnvg?E-) ❑Barn(size) Cl 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 1\A-TTl'EW T. DAC.;-=\/ Telephone Number 5O8 Address C,%AAMp 1 Oty R,ylt A , i NC_ • License# CS Oq-GC>ZO �00 OAS ST,. S v tTE 1 S Home Improvement Contractor# 1 U t 9 20 P EMP) KE . Yin a 02359 Worker's Compensation# C4-1 o 1 Z'l q 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 SOUP<� SIGNATURE DATE A ov a<JST' "2_-1,' 19,Ca BUILDING PERMIT DENIED F4 THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED _ T MAP/PARCEL NO. ADDRESS VILLAGE } OWNER DATE OF INSPECTION: FOUNDATION } �1/Q? FRAME N INSULATION // Q FIREPLACE. ELECTRICAL: ROUGH FINAL PLUMBING: „ >ROUGH FINAL GAS: ?ROUGH FINAL _ FINAL BUILDING,^=- O 2 2 Qplo - DATE CLOSED OUT ' ASSOCIATION PLAN NO. �oFTMe� The Town of Barnstable ELAMSTABM 9� ' � Department of Health Safety and Environmental Services ArFDMA'�A Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner October 24, 1996 a Re: 142,152, 162& 172 Skunknet Road,Centerville,MA Map/parcel numbers 171/004,005,006&007 TO,WHOM IT MAY CONCERN: This letter will verify that,in accordance with our meeting on October 22, 1996,You have agreed to do the following as a condition of all building permits being released after foundation permits: 1. Upgrade the section of Skunknet Road in front of your lots 16 feet wide with six inch dense graded stone and two inches of 3/4 inch crushed stone on top. 2. In addition, if the water main is not in front of your lots,it has to be extended. Sincerely, Ralph M.Crossen Building Commissioner RMC/km .-.•- •. •- C-.-..r.'r,-.ti.F r, �..��__...,..- - ..r �, r"....t•.�. ,,.. .' a'r-+.- „..... ..s,....rv. w-_- ......... "+1.,, r-.. _.•.f_^''".r.•- _._.,. `..i .mow-�-- `�iHETq;_O� The Town of Barnstable BARE. Department of,Health Safety and Environmental Services MASS. r634• ,e� QED MAC s Building Division ' 367 Main Street,Hyannis,MA 02601 Office: 508'-790-6227 Ralph Crossen Fax: 508;790-6230 Building Commissioner 4 �- Inspection Correction Notice Type of Inspection Yp P Location Permit Number f Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting;" R'7 ' r ~Ft Ow. v c. ' s,A ( iz kk!4q. (z- \ S-e,- •3 � c l- S -T S�e �;A, ILL U 4",)—1 -"�_ t� 1�� h-� -2C-�C � �T �CL`'Tw7"'o- r��•• C/'4, �a�12,.1•� ' L a'R4-D 0 U e ez-, F, 1 (14 Please call: 508-790-6227 o re-inspection.Inspected by �. -- S pet 1q-ff Date r SINE , The Town of Barnstable • BARNSTARLE. • Department of Health Safety and Environmental Services MASS. Building Division04 - 367 Main Street,Hyannis,MA 02601 'Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner t Inspection Correction Notice Type of Inspection t� Location ` ` . `� �v tvA-i-e'i'' Permit Number Owner Builder C k-4 A r -J One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: 1 I 1 -e(,cQ z f >P/Z- k A J { t- o elf t;i)-,P J P-t a 4-0 o �. 011 457— r i l n a �tiQ —.. .J }�P/Z 64 Y 5 roll(�`` , 17-T cJ P v C 1 T 4 '4� ek C-7 -/C f<- A�Y (Z�'IQ(, 'r ti -, vim'., 3 GI t7 I Fr Please call: 508-790`6227(fo-`/f e-inspection. Inspected by -�-. Date � 'ti rO — 7 P i ate Time WHILE YOU WERE OUT M of Phone Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILLCALLAGAIN WANTS TO SEE YOU URGENT RETURNED YOUR CALL Mesea e I�� S Operator AMPAD 23-021-200 SETS EFFICIENCXe 23-421-400SETS CARBONLESS To � Date Time !A HILJ� E-YOU WE6�E OUT of �7 Phone Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CALLAGAIN WANTS TO SEE YOU URGENT RETURNED YOUR CALL Message v G Operator AMPAD 23-021-200 SETS EFFICIENCY® 23421-400 SETS CARBONLESS - :1 . AM AIN v 1' ` .+ vim. l�tl� � { i� � � ,� •.iY•' V' 77-6 Min M ! I a a ; M 1 3. T Ir O f ! 3�t t x7`7� Li.. t , 1' 1 ,]2 Y t� "3r��.� YS����'fz�Y`�'�!.l,r':RS'�t�[�"1i8,�'r,SHw�N d.i%S„lw..Y..�.�d.}:Yra�7.�'F+{t�.Y'�il�w.�.�.'�il�iti.�.N:..�'a�,�isi�{ 9:..,,AA��r•kti��X...?..� 3''.�. 4?'L.�i:. .. ��:�n' #4..�','f.:t�.t'�tttT!.{.,�,��..;�w��M.,:.�lo��.{�� r� %1 NT 1 - T VN ,0 a' 44n X. 4 07. OEPARIMENT OF PUBLIC SAFETY License: -;;.CONSTRUCTION SUPERVISOR Nusber'.: ...Expires aMA11HEY J. OACEY :PQ BOX`1558 aBO11AROS BAY, MA 02532 COMMISSIONER f USIRiCTIONS: 1G i 00 - None 1A - Masonry only lG - I & 2 Faoily Hoes I ' 1 ��-- The Commonwealth of Massachusetts €- _ Department of Industrial Accidents t1 xcee11n11affVZ OOs _ = 600 Washington Street Boston,Mass 02111 Workers'Compensation Insurance Affida At � - - name: locatio 7 1 - city �� ���, 1 ► Y� D S� phone# 417 U —3$00 I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name. address: city* _ phone#• insurance co. CIbWA IIJSU(1ANFLE CO policy C4-4P � 1Z-1� D I am a sole proprietor,general contractor,or homeowner(circle one)and have Ured the contractors listed below who have the following workers' compensation polices: company name: address: City: phone#• insurance co. polio!# - company name: address: city: phone#: insurance co. policy # tkttach additional sheet if neecii—a! _ ,; ,�;;d �"0c"�"�" '���'`-'�'R' � .- 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 S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine; :5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations or the DIA for coverage verification. I do hereby certlj- ar an penalties of perjury that the information provided above is true and correct Signature Date &U U (0 Print name NA HIE T. D hone# 1'-1 31-fp -N Oo official use only do not write in this area to be completed by city or town official ciry or town: permit/license# riBuilding Department pLicensing Board C)check if immediate response is required ❑Selectmen's Office E. oHealth Department contact person: phone#, rjOther (messed 3M PIA) OCT 18 '96 02:59FN 50877560c9 P.2 The Town LlRN3TABLE. of Barnstable 6� � Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office. 508-790-6227 Ralph Crossen Fax: 5OS-790-6230 r Building Commissioner I j A .. October 17, 1996 John W.Kenney,Attorney At Law 12 Center Place i 1550 Route 28 {' Ccntcrville,MA 02632 i f j Re: Lots 14,15, 16& 17 Skunknet Road,Centerville Map/parcels 171/004,005,006,007 (142,152, 162&172 Skunknet Road,Centerville) Dear Attorney Kenney: Thank you for your clarification of the beneficiaries on lots 14- 17 on Skunknet Road in Centerville. Based on this information,I believe the lots are buildable from a zoning standpoint, Sincerely, Ralph M. Crossen 13uilding.Commissioner RNIC/kn . LOT 14 -- O� 769.71, I C" N Cv V. o LOT 15 +� 17,003 sq.ftt rr� 0.39 Acres �l CONCRETE FOUNDATION TF = 53.1' O O O O N 770.36' LOT 16 JOB # 96-251 CER TIFIED PL 0 T PLAN '* 15a- LOCATION : SKUNKNET ROAD CENTERVILLE, MA SCALE : 1" = 30' DATE AUGUST 20, 1997 PREPARED FOR: REFERENCE: LOT 15 PB 224 PC 127 CHAMPION BUILDERS INC. I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. 0f M�s9 off 506-382-4541 mot A H E yGF fax 506 362-OW y S down cape 43&eerin{g, inc. 4 o 26348 e 9 z�A CNiL ENGINEERS M 7 p ----- — --- -- ------ raxn SURVEYORS DATE REG. Hai tam �939 main st. yomwA. ma 02675 VEYOR To Oats Time WHILE YOU ERE O Y M of 0,,k ✓7o--L j,Cf Phone Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU URGENT RETURNED YOURCALL _/ f Message Operator AMPAD 23-021-200 SETS �JL] EFFICIENCY® 23-421 400 SETS CARBONLESS Assessor's map and lot number : (�3 • �� f u�K 2-Y� U �G ' • °iTHET Sewage Permit number .........../j//.,!q ... �n<? . ..�•.,. y...•! ? �`` o� 33MUSTODLE. House number ...........A....................:................................. / s rasa 'FD MPY a' t TOWN OF BARNSTABLE BUILDING INSPECTOR 6 v (. lJ P(Y--f1 G 8 APPLICATION FOR PERMIT TO .....:......................................................................................................................:.. TYPE OF CONSTRUCTION ......��....1�.�?.�.......�.!. 6L:!..G.......4..!9 ....................................... ........., �.L.......3..�..........19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information- Location ... . .....YH. .s.?.L(�..... ... .!..... !J'LLB...... . r.'................:........:... ProposedUse ...........:...:A..i ... ..!12r.................................................................................................................................... Zoning District ........................................................................Fire District ...C...I,�NT a1/,G�c:.�...( ;.�.r>�: ��.Ltd........... Name of Owner o `S t< /!9 l Ju(rGa�L Address/Zn...PNgf 9. �l�e.�...!.,..N. -r eX Occe, ............ Name of Builder PA.e;KeA.a.....6, R t?.u....:...................Address (� ..%,�n v(�w f���r...�`'... 4e21V7,94It!...... Name of Architect�. a.�!.!^! s V`...G G.. 2 ST, /1! . ... ... �,�, .............. .......................Address ............................ .s.................................................... Number of Rooms .Foundation . "..° �.. Z . ....................l' Exterior ............... ..............................................Roofing .....jJ .f ..�.T.................................................... Floors .. ? !`'y ..Interior . G)... D Heating ..... ..`7...r`.. ... .. ........................................ Plumbing ......ti. .. ..................................................... Fireplace ....................... ..`...�.."..................................Approximate Cost .............�....................................................... Definitive Plan Approved by Planning Board __ `?"____�'L_____19_ _� . Area .... k...y .. Dia ram of Lot and Building with Dimension � g 5 Fee ........,�'.e...��................ SUBJECT TO APPROVAL OF BOARD OF HEALTH i r r I i hereby agree to conform to all the Rules and Reg.u_Lations of the Town of Barnstable regarding the above construction. . x _ Name .... !.......................... ............................... l � J DU%JGER, JOHN & MARY- �24`7- 8-4,D No .23345 Permit for B.u.i.l.d...G.ar.a.ge.... .. .... .. .... Single g Family Dwelling ...................................... .................;R... .....;........ 1-69-�ale Drive' Location .................................................................. Centerville ................................................................................ ,John -& Mary Owner ...........................P4 I Du ..........g ..........g .-.r.............. Type of Construction .................. ........................................................ .................... Plot ....................... y Lot ........................ i A'gust Permit Granted A August . .19 ..................... .......... ,(........................ 19 Date of Inspection .............. #Date Completed ...... ........ ...................19 PERMIT REFUS D ............................... . . ......... ................ 19 ......................................... ............................... ...... ........... ......................... .................................. ................. ......................... ..64a;; Approved ................................................ 19 .................. ............................................................. ................. ........................................................... Assessor's ma and lot number hod ���. �c6}�r (jaol�' ? 7� D�G S pf........ ......... F N E a << /L/I Er Sewage Permit number ..:.�/ ?..�....... ........ SEPTIC SYSTEM MUST ' House number .......... asasT,wr,E, ........................................................ . INSTALUD�IN COMPLIA MAGa 1639. m WITH TITLE 5 0 0,f, � TOWN OF BARN COO ODE eN,I;l BUILDING INSPECTOR APPLICATION FOR PERMIT TO ... �. .�?......�01Gz-A.6. ............................................................................ TYPE OF CONSTRUCTION ...... .........`! r4 0►�.4b`....�.�.i............................................................CrI6 ......... �..4. .....3..�..........19 !... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... ....� ....�.�.........�.�.)...... .....N...E-/�L/ C. ..!.a...�..�..................................................................... 10 Proposed Use ..............4? ! .1�..T"A.g.................................................................................................................................... Zoning District Fire District ... OS. Name of Owner 01 kt .S f>! ...��'..�uG-�-v Address ail, �+,E3 n� o�lt dILGb............. Name of Builder . ...CLa !)..... 3:P..y........................Address �.s...J—...�..�.....v..i..c..c..w.....I.Z..,.�.�...�``' gs��,✓.7���.. 0 H! .S D J G G �✓�1.�,,�ST. /U vJ T o..� r� Name of Architect .....n..................................2....�.........Address � �........:.� ' Number of Rooms ........................ ........................................Foundation �. 7r/ .... e F�.. ......................................................... .................. Exierior ...............� M M..............................................Roofing ....A.XAj-u4.A-.7.................. .................................. Floors ............ ....I...... ........ ......................Interior ... ............................................ Heating �J.. ....w..Lz..................................Plumbing . .,. .......A... . ..t........................................................ .... ... ... ... . ... .. Fireplace ............................. ...........`....................................Approximate Cost ................r....�... ...................................... Definitive Plan Approved by Planning Board ____ --------------19__ f. Area .... ....'.... J.S .. Diagram of Lot and Building with Dimensions Fee ........ ...7..�Q................ SUBJECT TO APPROVAL OF BOARD OF HEALTH O l /V v U� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... .................. DUGGER, JOHN & MARY 23345 N9 ................. Permit for ....build....Ga.r.aq.e. . .. .... .... .. .. ... .. Single Family .................................. .............. LL 'atio 16 'Thistle Drive ocation ............................................ .................... C n e � terville ............................................................ Owner ... ,/John & Mary D K ........................................ . ......... Type of. Construction ....Frame...... .. .. .... .. ..................................:........................... .................... ! f Plot ............................ Lot ....................... ......... 6 81 Permit Granted .....................Augus...t...... ....... 19 Date of"1nspection ......19 Date Completed ... .............. ...... ..195 PERMIT REFUSED .. ........ C.......................... . ... .. 46, z............................................ i7 .................. .................................... ....... ............................. ............ vu 0 ..................j ........................................................ App,6-ved 19........................................ ............................................................................... ................ ........... ................................................. Mom SEPTIC PROFILE TEST HOLE LOGS F T.O.F, AT EL _ (NOT TO 9CJ� - � fl.•-:r r-- ACCESS COVER TO WfTF�h OF FIN. GRADE ACCESS COVER (WATERTIGr4 ) TO ENGINEER: , r + f wrrHiN OF FIN. GRADE WINIMUM .75. OF COVER OVER PRECAST / r _ 2% SLOPE REQUIRED MR s'SrEM WITNESS --.-�� ���'����— ------ ------ -- — ---— — `j RUN PIPE LEVEL •- `, i.'t:. _��c-t —- DATE: _ ••� �.'�J� ---� �_-PROPOSED Sm,fJ (D�...__) ;� �� �F�JR FIRS 2' --_�""_`"" � .-.+.r--- � �� � .. _ 1 �_ � , c.A.t s�Eic — — T—�;''""T_' _ _ FERN . ATE " 1eI " TANK (kls2� �-a __ - V -� sh .s� c So%r 5._. ._ i CAS --- �_— SOILS P EL a' ( 4`� __ ►vim y _____,_ } SOtl � L><% SCOPE; ! 6' :RUSHED �,OhE OR 1AEC}i,W IG4_ _.._... .,.,..- DEPTH OF FLOW comPACT1oN. 11 5.221 1'21) , � _ -- TEE SIZES: U% SLOPE) .;x SLOPE, l'} { 7 L r; �_I)L C ti.1:Jr 0 i4il0 _ i IN LE? OEPTh 10 < + " LOCATION MAP " - "� ASSESSORS MAP 11 — PARCEEA C L = T?ON— (� S Ems,-.� 'ANC -AC;'��C '" t� �.�, _._ __i-_., c`0 ?ONE. 5 ,�s.� k3 �°�� ='' ~ti._>".,O BUILDING ONE: SE-BACKS' FRON i ? , � SIDE PLAIN PEFERE!NCE: 1 -" — ! ( � Iiew-v ,co 43,L' 40 _ a , �� iV _,o = _ _ • _.'`c�_:. � ` SE 'T'.�. DES E sPOSER -5 0 �`•c' j MUNICIPAL ''WATER IS �--"' iGN: Ct t� p 2 \` ------ --- I�t c, '; I DESit;�; F'_OW_ _.? gFrRCOMS `,O GPI} — _="<' 3P 3. MINIMUM r�1PE BITCH TO 3E ' '8' PER FOOT. I `� � a DESIGN LOADING -0R A_� � PRECAST UNITS T;r. 3E AASHC'-*; JC_;' . LPG t7ESiv!v �c^W PIPE TO BE MADE WATERTIGHT. p.�._..__.._ . .__ _._�,I -- - }' j`� .1 -ANK .' 3 GPD 4 ✓,� {,AL�ONS T f Tj it ^ C TLI _ c w �.; G �ONS T RU. +QN DETA„S 'v ,rr ACCORDANCE W1. . MASS. �F — ENVIRONMENTAL CODE 'ITLEgV SALLON SEPTIC TANK I - 7HIS PLAN 'S FOR PROPOSED WORK ONLY AND N 0 7 TO 8E 1 ti — fih�Veti- LEACIa1IVU: USED FOR LOT LINE C .,TAKING. _. _ _ ______. _ _ --�•� coo -.' _ ` 4LS+?� _-_�__ �i - 4 ~ a?S S PIPE FOR SEPTIC SYSTEM TC, SCH. 40-4 PVC, .r. '• - �. .. _ .._,�� — —..—..�.— V a v U' M .. L T ,�,y L. �,/R v ry ram' r I. 4i M~I_-._ a PONENT� N TC' aE BACKF! Eu ONL 0vi _�_. o oI '�` ` _ EALED wRHot L A/ ",` t ji ° - "_ " �aSb S'� GPr "vSPECTION B'v BCARO -OF "F_AL-;^ ANC P_RM'S$ION OPTAINEE --;ROM ROM BOARD OF EAR.i H- lkt f f v +S. ✓t � i �r7 e _ SITE E AND WAGE PLAINT OF 0 D E 1 <, c I IN THE TOWN OF: L c�T I Co BOARD OF HIALTH — ---- MA PREPARED FOR: �,��wl � ti � � ' ►`�►.�� .� �� '. �t APPROVED DATE ji_rt::74a +��..i-� pa.q,,.1 µ O 'i'is.r�•t r^ L , s F T ix:, f .It c�G. i ti G ice ► .© 00 - 2.0 � 6:�O F i rrrrn�� - ( i i�✓iL W 1 i `? ?. �'� lam+ i+A-"S ii. �-e' , - r SCALE: � "�:— _ D_1 ATE: _ I1�' 141tV! 'Q-,cam' to. zz _ 4t down cape engineering, Inc. AANE f CIVIL ENGINEERS GH. � LAND SURVEYORS aML PHONE 508-362-4541 MD. 30M 4' FAX 508-362-9880 �� 1 939 main st. yarmouth, ma AR JALA, bA TE JOB#