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Millis, �,p{ 2 ..,. , ,.. �• r n !'1 K �1 kS ,fl f-- ,i t a, }d�T4tt3ltdd,.�& t{Btnna� tyds;; a. a a, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION_ 2`old9 Map Parcel ® Application # � � Health Division ..Date Issued Conservation Division >Appl.catiori Fee p .:Permit Fee Planning'Dept. 6 ; .. F Date Definitive'Plan Approved by Planning Board Vim° Historic - OKH _ Preservation/ Hyannis Project Stree Address (45P� _ 6L Villa e Q f 9 Owner � SGLe,_. 1�- Address L►. �� Telephone 6 Permit Request ,1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District: Flood Plain Groundwater Overlay Project Valuation v UJ Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units) ' Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highw ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other_ 2� r 11 Basement Finished Area(sq.ft.) Basement Unfinished Area (se" ) ice, C Number of Baths: Full: existing new Half: existing --new F Number of Bedrooms: existing —new N r Total Room Count (not including baths): existing new First Floor R om Count n Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing 0 new size—Pool: ❑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 APPLICANT INFORMATION � (�b �` (BUILDER OR HOMEOWNER) ame n Tele h / / p o e Number � � Cu Address 4o Z �1��14 /` r1 e+ A4, License # J I Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 12-dlD 5SIGNATURE DATE f 3 FOR OFFICIAL USE ONLY °APPLICATION# DATE ISSUED ti MAP/PARCEL N0. --- J A ADDRESS VILLAGE s, OWNER DATE OF INSPECTION: r FOUNDATION p FRAME ` INSULATION FIREPLACE ELECTRICAL: ROUGH -`" _ FINAL PLUMBING: ROUGH FINAL GAS: ROUGH 'FINAL FINAL BUILDING DATE CLOSED OUT 4 , :' ASSOCIATION PLAN NO. i 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organization/Individual): (l Address: G� %y City/State/Zip: ( �'✓ �W�CR- Phone.#: 11_� 6 7—e-3 01— Are you an employer?Check the appropriate ox: Type of project(required): L❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction .2.❑ I am a sole proprietor or partner-' listed on the attached sheet. 7.. �Zemodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all,work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[:]Other comp.insurance required.] "Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy'of this statement may be forwarded to the Office of Investijzations of the D r insurance coverage verification. I do hereby ce • e the i s and pe t' of e ury that the information provided above i true and correct Sijznafore: Date. Phone#: Official use only. Do not write in this area,to be completed by city or town off1-cial, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons'to do maintenance,'construction or iepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." .� MGL chapter„152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . v enter into any contract for.the performance of public work until acceptable evidence of compliance azth the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."..A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: - The Cornmonwealth of Massachusetts_ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4.900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass-.gov/dia r Town of Barnstable Regulatory Services r r snat M111 a Thomas F.Geiler,Director �� Building Division QED MAy A . Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: (Q Z O c num er street village "HOMEOWNER": �i ���� '�"�- �• � � i name home phone# work phone# LCURRENT MAILING ADDRESS: 49 / Z 4 1_� 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. I !h-- '"� - k ,c - DEFINITION OF HOMEOWNERS -V 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 resoonslbie for'all such work'performed under the building permit. (Section}109.Ll) ., The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations, The undersigned_ "homeowner"ce that he/she understands the Town of Barnstable Building Department minim on ,cedure d q ements and that he/she wiiomply with said procedures and requ em Signature of Homeowner i 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:\WPFILES\FORMS\homeexempt.DOC ' �TNE Town of Barnstable Regulatory Services B"x AB& ewes. Thomas F.Geiler,Director 1 yq. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 � a Y Property Owiier Must ; Complete.and Sign This Section i k` If-Usina A Builder as Owner of the subject subj l property hereby authorize Fr r LC nd, ' o'�©Y'ee-1�' to act on my behalf, in all matters relative to work authonze �y this building permit application for. ,,/4"-/— Address of Job) Signature of Own �` ',Date 000"'�l I'ef Print N If Property Owner is applying for permit please complete the . j Homeowners License Exemption Form on the reverse side. Q:FO RM S:0 W N E RP ERM IS S ION Donna M Seviour,CIC,CISR SeniorAccount Executive � � F bryden & sullivan - insurance agency 88 Falmouth Road 485 Route 134,PO Box 1497 Hyannis,MA 02601 So.Dennis,MA 02660 Tel.(508)775-6060 Tel.(508)398-6060 Fax(508)790-1414 1_ Fax(508)394-2267 dseviour@brydenandsullivan.com / r . t MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL APPLICATION FOR WORKERS'COMPENSATION INSURANCE MAIL TO: The Workers'Compensation Rating&Inspection Bureau of Massachusetts P.O.Box 55005 Boston, MA 02205 (617) 439-9030 IMPORTANT: For assistance completing this application,refer to the Pool Procedures.for New Applications under Residual Market on the Bureau's website,www.wcribma.org. A separate application must be filed for each legal entity. This application must be typed or printed in ink and submitted in duplicate to the Bureau. Under no circumstance will coverage be assigned if: payment or required deposit does not accompany the application; the declination requirements are not met; there is a record of coverage in force for the entity making application; the applicant is in default of premium for prior workers'compensation coverage; or, the applicant has an auditor inspection from a prior workers'compensation policy that remains incomplete due to the applicant's failure to cooperate with the prior insurer. The earliest possible date coverage can be bound is at 12:01 A.M.the day after the application and required deposit are received in the office of the Bureau. The undersigned employer has failed to obtain workers'compensation and employers'liability insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Assigned_Risk Pool and expressly represents that such insurance is sought in good faith. Requested I. GENERAL INFORMATION � Effective Date: 1. Ericsson Torres •yome Improvemenet NAME OF EMPLOYER (Nan)e the sole proprietor,general partner(s)or trustee(s)along with the trade name of the business.) N qq []PENDING2. - FEDERAL EMPLOYERS IDENTI ICATION NUMBER (If pending,attach a copy of the IRS application.) 3. 16 Hoover Road West Yarmouth' MA 02673 508 360-9221 MAILING ADDRESS Number Street City State Zip Phone 4. same PRINCIPAL MA LOCATION Number Street City State Zip Phone 5. TOTAL NUMBER OF MA LOCATIONS 1 6. none 15 ADDITIONAL MA LOCATION Number' Street City State Zip Phone (If there is more than one additional MA location,attach a list of street addresses and phone numbers. Fully complete Section VI for each location.) 7. 16 Hoover.Road West Yarmouth MA 02673 508 360-9221 LOCATION OF RECORDS Number Street City State Zip Phone 8. LEGAL STATUS ® Sole Proprietor ❑ Partnership ❑ Corporation ❑ Trust ❑ Limited Partnership ❑ LLC ❑ LLP ❑ Other(explain) 11. ELIGIBILITY REQUIREMENTS To be eligible to obtain assigned risk coverage: • The employer's application for voluntary Massachusetts workers'compensation coverage must have been rejected by two(2)carriers licensed to write workers compensation in Massachusetts; • The employer must not be in default of premium for Massachusetts workers'compensation insurance; • The employer must have complied with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety of employees;and, The employer must not have an audit or inspection on a prior workers'compensation policy that remains incomplete due to the employer's failure to cooperate with the insurer, 1: List the names,representatives,date(s)of discussion,and phone numbers of two insurance companies licensed to write workers' compensation in Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must be an employee who has authority to bind coverage for the insurance company. A failure to reach such a representative cannot be construed as a refusal to write coverage. a National Grange Mutual Ruth MacMurray 800 258-5310 Norfolk&Dedham Nancy Bates. 800 688-1825 NOTE: If coverage was recently terminated or expired in either the voluntary or assigned risk market,you must attach a copy of the cancellation or nonrenewal notice. The reason for cancellation or nonrenewal must be indicated. If the coverage was in the voluntary market within the past sixty days,the cancellation or nonrenewal will serve as one of the two required declinations. Generally,coverage must be replaced in the voluntary market if voluntary coverage was cancelled or non-renewed at the employer's request. 2. Have you received any offers of voluntary coverage? ❑ YES ®NO If YES,attach the offer for coverage,including all multi-line,deductible,or retrospective rating terms. 3. Is there any unpaid workers'compensation premium due from you or any other commonly owned enterprise? ❑ YES ® NO If YES,provide the entity name,balance and policy number(s). If the premium is being disputed,attach an explanation for Bureau consideration. If an arrangement for payment has been made,attach a copy of the signed agreement. 4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy? ❑ YES ® NO If YES,provide the name of the carrier and the policy number. If the employer has scheduled an audit,provide the name and telephone number of a contact at the carrier. EFFECTIVE JANUARY 28,2008.(EDITION 01) V. BUSINESS OF EMPLOYER (continued) 5. Completely describe all operations of the employer. If there are multiple locations,provide a description for each. Completely describe any changes that have taken place in the last three years that might affect the classification of the operation. Residential carpentry dwellings,painting interior/exterior/wallboard VI. MASSACHUSETTS CLASSIFICATIONS,ESTIMATED EXPOSURE AND PREMIUM CALCULATIONS Attach the four most recently filed Form 941s or DIET Form 1s. Provide all information for each location by shift. 001 1 Carpentry 5645 0 0 7.50 0 001 1 Wallboard 5445 0 0 7.13 0 001 1 Painting 5474 0 0 5.01 0 MANUAL PREMIUM --- -----..._—..__...._..__._._.._......._............-....._......__.._..----............._........._.......................__ Employers Liability Limit Options(check one): * Waiver of Our Right To Recover From Others Charge ..................._..._.._....---- .._.._...__..............._....._......._.._......._..........._.............._.._._......._-........_..................................................I............. ® 100/100/500 no charge * Employers Liability Increased Limits Charge( ) ............................_..._................._........._......................._...----...._..._...._........__......................._...._.....-..........................__............._.._.........-. ❑ 1o0/100/1,000 .50% $75 minimum Deductible Credit( ) ......_..................-__...._.._...__._... --...._.................__.._...._....._........_...................----........_.._..._.........._....-........._.......... _ ❑ 500/500/500 1.00% $50 minimum Experience Rating( )or Merit Rating( ) ❑ 500/500/1,000 1.25% $75 minimum MCCPAP Adjustment( ) _................ - -.....__._._.._.._.._........_...._..........._........-...-..._........._.........._......_...._..._..._............._._......._.................................. ❑ 1,000/1,000/1,000 2.00% $75 minimum STANDARD PREMIUM __ ._............. ... ..._............ ............................._..................--............._..._........... ARAP * QLMP Adjustment( ) * Balance to Admiralty/FELA Minimum Premium * Loss Constant VII. DEPOSIT REQUIRED : Expense Constant ...._.........._......._._.._._._...._..._...------- --......_.................._.._....---.._._._..._._........ -------- 1. Installment Options(check one): ' Terrorism Premium(Total Payroll/100 x ) __._.._....._.__.........__............_.....--..............._....................__........._.__.._..._._...._.....-- Installment Required Total Deposit Additional * Balance to Total Policy Minimum.Premium Basis......._.................::-::Est,_Premium..:.:.......:.:......._Factor.............. ....._Pay.,ment§..:..... ❑ Annually > $0 100% none ** Former Self Insurers Insurance Charge ............._...._........_........._..............._._...__...._._..............................._............_..._......._...................o_....._._............._................._........_......:.. ❑ Semi-Annually > $5,000 75/0 one TOTAL ESTIMATED PREMIUM Soo ............................_....._....._.._......._....__.._.......--....__.........._...._._.__.._.........................._...._........._._..._o._._.........----..............._..................... * o ❑ /o three DIA Assessment Quarterly > $10,000 50 ( /o) ..............................................................__......_............_.........._......................................................._.......................................................................... . ❑ Monthly . > $25,000 25% nine TOTAL EST.PREMIUM AND DIA ASSESSMENT ................................................................_.........................._........._..........._..........................................._..._..................._.._. *** REQUIRED DEPOSIT 2. Enclosed is check number in the amount of $ Make the check payable to the Massachusetts Workers'Compensation Assigned Risk Pool(or"MWCARP"). 3. Any binding of coverage is conditional until the check has cleared. If the check is found to be non-negotiable,the check will be returned to the employer who will be given ten(10)days to provide the carrier with a bank check or money order for the full amount of the required deposit. Only if sufficient funds are received by the carrier on a timely basis,will coverage be effective as of the tentative binding date on the Notice of Assignment issued by the Bureau. 4. Is the premium being financed? ❑ YES Isessment O If YES, then 100%of the Total Est. Premium and must be sent with the.application along with a signed copy of the finance agreement. If applicable. Refer to the Pool Procedures for New Applications and to the Residual Market Premium Algorithm-Appendix F in the MA Manual for details. k Applies only to Former Self Insurers. Refer to the Pool Procedures for New Applications for details. »• Calculation of Required Deposit: (((Total Est.Premium+DIA)-(Expense Constant+Insurance Charge))x Deposit Factor)+(Expense Constant+Insurance Charge) EFFECTIVE JANUARY 28,2008-(EDITION 01) III. CORPORATE OFFICERS,SOLE PROPRIETORS,PARTNERS&MEMBERS If there are more than four Officers,Partners,or Members,attach a'list including the required information for each additional individual. For Sole Proprietors,Partners,LLC Members and LLP Partners: List the Names,Titles,Ownership and Duties of all Proprietors,Partners or Members,and indicate whether each is electing coverage. Sole Proprietors,Partners and Members are not covered unless they elect coverage. To elect coverage,a letter must be submitted on company letterhead in accordance with MA Regulation 452 CMR 8.07. Refer to the MA WC 8 EL Insurance Manual,to the Rates Page with Miscellaneous Values,for Sole Proprietors',Partners'and Members'Basis of Premium. In Section VI,include the Basis of Premium for all Sole Proprietors, Partners and Members electing coverage. For Corporations: List the Name,Title,Ownership,Duties and actual Salary of all officers listed in the Corporate Articles of Organization,and indicate whether each has chosen to exempt himself from coverage in accordance with MA Regulation 452 CMR 8.06. Corporate officers will be included unless a Form 153 has been submitted to and approved by the MA Department of Industrial Accidents. The stamped and approved Form 153 must be attached. Corporate officer salaries may be subject to payroll limitations;refer to the MA WC 8 EL Insurance Manual,Part One-Rule IX. In Section VI,include the salary,subject to the minimums and maximums,of all nonexempt corporate officers. s ,. , Ericsson Torres owner 100 Exempt IV. INSURANCE RECORD 1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? ❑ YES ® NO 2. If YES,complete the following for the most recent three years: ON SIN IN Enwe 3. If NO,complete: ❑ New Business ❑ Uninsured ❑ Self Insurance Group ❑ Self Insured ❑ Other(explain): 4. Was the applicant self-insured within the last twelve months,or was the applicant's expiring policy subject to the ❑YES NO Premium Determination Endorsement—Former Self Insurers—1? If YES,an audit must be completed before coverage can be bound. Refer to the Pool Procedures for New Applications for details. Former members of Self Insurance Groups are not subject to this endorsement.. If self insured within the last twelve months,provide the termination date: 5. Is the employer in bankruptcy? If YES,attach a copy of the approved bankruptcy filing. ❑ YES' NO 6. Does this entity or any other commonly owned entity have operations in states other than MA? ❑ YES NO If YES,attach a list of employer names,states,carriers and interstate or intrastate ID numbers. 7. Has there been a name change within the last five years? ❑ YES NO 8. Has there been a merger or consolidation within the last five years? ❑ YES NO 9. Has there been a'sale,transfer or conveyance of ownership interest within the last five years? ❑YES ® NO , 10. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they C took over within the last five years? ❑ YES NO 11. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? ❑ YES NO If the answer to 7,8,9,10 or 11 is YES,complete an ERM Form and attach it to this application. V. BUSINESS OF EMPLOYER 1. Does the employer provide temporary or leased employees to other businesses? ❑ YES XNO If YES,refer to the Pool Procedures for New Applications for instructions. 2. Does the employer lease employees or regularly have temporary employees supplied to them from another business? ❑ YES XNO If YES,refer to.the Pool Procedures for New Applications for instructions. 3. MA Law provides that the employer is liable for injury of employees of uninsured subcontractors. Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontracted labor will be utilized during the policy term? YES ElNO If YES,estimate payrolls made to subcontractors without certificates of insurance. $ Transfer this amount to Section VI and identify by classification of work performed. 4. Does the employer use independent contractors? YES, ❑ NO If YES,documentation must be maintained which supports that they are,in fact,independent contractors. If such documentation is not available,or if the designated carrier finds evidence of an employment relationship, then premium may be charged as if the individuals were employees. EFFECTIVE JANUARY 28,2008•(EDITION 01) Vill.APPLICANT'S AGREEMENT—PLEASE READ CAREFULLY By signing this application, I certify that: (i) I am the employer or have been authorized by the employer to complete this application on its behalf; (ii) I have read and understand the following statements to which I agree by signing this application;and (iii) All information provided in this application and on its attachments is true. Inconsideration of the issuance of a Notice of Assignment and subsequent policy of insurance,I hereby certify,under the pains and penalties of perjury,that: 1. I made a good faith effort,but failed to obtain coverage through the voluntary MA workers'compensation insurance market; 2. 1 am not knowingly in default of premium on any MA workers'compensation insurance policy; 3. 1 have complied and will continue to comply with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety of employees,including but not limited to: a. Allowing the carrier to make a careful inspection of my operation for the purpose of measuring the hazards,making recommendations for the health and safety of employees,and determining the rate or rates which are adequate and reasonable; b. Complying with the carriers'reasonable recommendations aimed at controlling or reducing the hazard(s)insured against; c. Keeping records of information needed to compute premium and providing the carrier with copies of those records when asked for them;and d. Fully cooperating with the carriers'attempts to conduct premium audits or inspections of the premises for loss control purposes. I understand that the ployer' ompliance with each of these certifi ns is material to the issuance of Assigned Risk Pool coverage. Business Name of Employer Date Sign itl (S le Proprietor,General Partner,Corporate Officer,Trustee or Member) NOTICE: This insurance is being provided through the ACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through the voluntary market. The employer's non-compliance with certifications 1,2 and 3(a—d)may,to the extent allowed by Massachusetts law, cause the carrier to initiate a mid-term cancellation. FRAUD NOTICE: Massachusetts General Law,Chapter 152,Section 14(3)provides: "(A)ny person who knowingly makes any false or misleading statement, representation or submission or knowingly assists,abets,solicits or conspires in the making of any false or misleading statement, representation or submission, or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment, coverage or other benefit for the purpose of obtaining or denying any payment, coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums ... shall be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars,or by both such fine and imprisonment." IX. AGENCY INFORMATION AND PRODUCER'S STATEMENT The producer hereby certifies,under the pains and penalties of perjury,that all information provided is true to the best of his/her knowledge and belief and that he/she made a good faith effort to place the coverage in the voluntary market as required by M.G.L.,c.1.52,Section 65A AGENCY Bryden and Sullivan Insurance Aagcy,lnc 042317371 Name(Printed) Agency Federal Identification Number ADDRESS 88 Falmouth Road H annis MA 02 508 775-60 Street City State Zip Code Telephone PRODUCER Donna M.Seviourt. 1780451 (Y] Name(Printed) ignatu Da Agency License Number MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL ADDITIONAL INSTRUCTIONS PLEASE READ CAREFULLY 1. Pool Procedures for New Applications and for Existing Policies can be found in the Residual Market area of the Bureau's website,www.wcdbma.org. 2. Applications will not be accepted by FAX machine. 3. An additional or replacement entity cannot be endorsed onto an existing assigned risk policy as a named insured unless an application and check are submitted and coverage is assigned by the Bureau. Refer to the Pool Procedures for New Applications for instructions. 4. The Pool is able to provide coverage only for MA employees. If an employer has operations in any state other than MA,or commences operations in such state after policy inception,application for coverage for those operations must be made to the appropriate Bureau or other agency administering the Residual Market in that state,K voluntary coverage is not available. 5. When a Pool policy has been cancelled twice by the insurer for nonpayment of premium,the employer will lose his payment plan,and payment in full of the remaining policy premium will be required as a condition of reinstatement. 6. When a Pool policy has been cancelled twice at the request of the employer,the producer of record or the finance company,the employer must reapply to the Pool for subsequent coverage after all outstanding balances have been paid. 7. Applications for joint ventures must include a copy of the joint venture agreement. 8. Payrolls and classifications are subject to review by Bureau Staff and may be changed. 9. The Waiver of Our Rights to Recover from Others Endorsement,WC000313,is available to employers who require the endorsement by contract. Refer to the Pool Procedures for New Applications for details. 10. Producers are not agents of.the MA Workers'Compensation Assigned Risk Pool and cannot issue Certificates of Insurance. 11. If you have any questions about the rules_governing the MA Workers'Compensation Assigned Risk Pool,refer to the Bureau's website, www.wcribma.org. If additional information is required,contact the Workers'Compensation Rating&Inspection Bureau of MA at (617)439-9030 or write to either P.O.Box 55005,Boston,MA 02205 or 101 Arch Street,Boston,MA 02110. EFFECTIVE JANUARY 28,2008•(EDITION 01) Ericsson Torres Casablanca Home improvement t''7 ''° 0 A R S`'TA 0 L.E West Yarmouth, MA 02673 209 MAY 27 P '3: 3 May 23, 2009 Jeffrey Lauzon V I i ON Building Inspector Town of Barnstable 200 Main Street Hyannis, MA 02601 RE: Project petition address: 628 Skunk neck Road Centerville, MA Dear Jeffrey Lauzon: I like to express my apology for overlooking such an important step of the building regulations. I assure you that in the past I have being very cautious about getting the necessary building permits and will be more in the future. This has been a very embarrassing situation yet a learning experience for my personal life and my small business. The customer have entrusted this project to me and has expectations to move in by the end of May. I have followed all the instructions you have given me in order to get the building permit. Therefore,please consider my petition to approve the permit request to get this project completed on time. I do not want to disappoint the customer by ruining their expectations. Again,thank you for bringing these matters to my attention. I understand this was my mistake and I am truly sorry. Thank you in advance for your consideration. Sincerely, -- "' Ericsson Torres Cell 508-360-9221 s � - o F T a 33 SLOES JZ(Y ,�J='cJN�4yECL f •• .oQ B�T� °y - 0l,< 7 all- t. Q Q Q�. rr11 ,2-4 t x 15 Fi s rouo . I r 03 FLoog- c�v- 154 4„ /121151 4„ 819 37„ 2„ 24 N tV I nirl_h IN O W27UF3-UTT W1830 W1230R CW2430L M CD 6 I--IGO _ M 00 _ M - B27 2FUF3.BU DWR 24.DISHW SB33 1B-TO BSS36L WD �t} f 4 12 2 3 36 32" 26 ., 52 211 2 � s All dimensions_size designations This is an original design and must Designed:4/15/2009 given are subject to verification on not be released or copied unless Printed:4/15/2009 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. 992 ee n 24 „ 2 „ 30 33ee N V_ 100 W3012� N CW2430L 1230L W3330 Ln ® MW.HOOD o CD C4 . QD QD O QD QD QD �J ti 1CO COLO _ Jam' 30-RANGEI1 B3 3 2FWT Iq BSS36L WD C'7 "I N, 36113 332 , 6.1 ee 48 2 ee All dimensions_size designations This is an original design and must Designed:4/15/200! given are subject to verification on not be released or copied unless Printed:4/1.5/2009 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. y - - 138" 36" 72 V 271 -a I0D N ILro- W3612X24 DP NF]InI W2730 BUT"UF� 00 — o e4— cOCID M M UT3624 X 84 4ROT m21, 33R-REF ti h L KDC36/33 � = � Fes . � B27 2FWT BUU � LLI N LO LJ 36 ' 36 3 27" CO B 21 3 n 6 7 1111 /1 Q 111 16 16 `'F�J 8 All dimensions_size designations This is an original design and must Designed:4/15/2005 given are subject to verification on not be released or copied unless Printed:4/15/2009 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. t x TPta5 . Tam 9. N S � �N Gk��,'• tip sit Too`• ,r cA It Q8 CormLP v®�- ate► 3� Town of Barnstable *Permit# 7 OFF Expires 6 months from issue date Regulatory Services Fee mess. $ Thomas F.Geiler,Director Building Division X-PRESS PERMIT Tom Perry, Building Commissioner 200 Main.Street, Hyannis,MA 02601 AUG 19 2004 PLE Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTA EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X Press Imprint Map/parcel Number 1,4 9,0 l Jra J )l 7ResidentialAddress Value of Work �p®•G Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ' Telephone Number / .0 —,:A 709 Contractor's Name Home Improvement Contractor License#(if applicable) ] Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one- sole proprietor I am the Homeowner I have Worker's Compensation Insuranceko co c Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. C=) co Permit Request(check box) rn ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑Y e Replacement Windows. U-Value .9®G'1*i0 (maximum.44) ,Where required: Issuance of this permit does not exempt compliance with other town departrnent regulations,i.e.Historic,Conservation,etc. ***Note: Property ow4q must sign Property Owner-Letter of Permission. H e Impr ent Contractors License is required. Signature l O:Farms:exo Map J(p G/ Parcel House# r 5�, Date Issued Board of Health(3rd floor)(8:15 =9:30/1:00-,40)r r Fee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) ✓1A Planning Dept. (1st floor/School Admin. Bldg.) THE Definitive Pla ved by Planning Board 19 RNSTABLE. ' TOWN OF BARNSTABLE, s Building•Permit Application eet Address Village e 0 _e IIA-- Gamm Owner ���1Vy � �Y�i(� Address i SG1�Yl Telephone �0 3 F " - -Permit Request • (l (�00 1� IC-A e ' 9610 `First Floor square feet Second Floor ' square feet Construction Type cpp Estimated Project Cost $ _ , o 0 c) Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Struct re �(� Historic House ❑Yes to On Old King's Highway ❑Yes Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing �_ New No.of Bedrooms: Existing-_New Total Room Count(noZas ng baths): Existing C P New First Floor Room Count Heat Type and Fuel: ❑Oil ❑Electric ❑Other Central Air ❑Yes Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) one ❑Shed(size) ®Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 21 o If yes, site plan review# Current Use Proposed Use Builder Information Name 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 4&JN DATE 19 J B PE . jT I FO E FOLLOWING REASON(S) :3,' l r , r FOR OFFICIAL USE ONLY c PERMIT NO. r DATE ISSUED MAP/PARCEL NO. } y . ADDRESS VILLAGE OWNER :' r � t '' :. - .. .. -' •,�, ,� ; DATE OF INSPECTION:` FOUNDATION r ! FRAME INSULATION `FIREPLACE ELECTRICAL: '• ROUGH - FINAL PLUMBING: ROUGH FINAL : f • i - < + GAS:, ROUGH v FINAL FINAL BUILDING - DATE CLOSED OUT ' {ASSOCIATION PLAN NO. F F f I h . The Town of Barnstable 9 �' Department of Health Safety and Environmental Services • g BuiIdin Division fo r� 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 509-790-6230 Building Commissione For office use only 'Permit no. I ' 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: �d Y Est.Cost N Pei Address of Work: Owner's Name Uh GIn ' Date pp t Permit A licaion: Da ' I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000. Building not owner-occupied wner 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 v is Name �� The Commonwealth of Massachusetts Department of Industrial Accidents " Office oflnresaffatfons t 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insu/rraance Affidavit �� rioirCr�/ ������������������������� �'',,,, �'Jri�iCn11' name �Ohly C�-/ ScO�M ^..7 location (0� O ������ C city � � 1 hone I am a homeowner performing all work myself. ❑ 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. oiicv# ❑ I am a sole proprietor, general contract r. or liomcowne (circle one) and have hired the contractors listed below who have the following workers' compensation polices: com nnv name: address: city phone#• nsurntice co. cam anv name: .:. :::. address: hone#: city: oiicv# insurance co Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal pet fides of a tine 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 tine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage veriticatiom 1 do herebv ce ify un t e pains an penalties of perjury that the information provided above is true and correct Date Sigltahue � Print name / official we only do not write in this area to be completed by city or town otllcial d or town permit/license is EC3H:ealth Department city ard once u required OMce ❑check if immediate reap q rtrnenicontact person• phonefi; � trevam 9.95 P1A) Information and Instructions 10/ 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 c 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 renews ,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 r 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 penmit/limnse number,which will be used as a reference number. The affidavits maybe retumed io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would-like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Ottice of Imlesdiatlons 600 Washington Street - ` Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE J 1 . JOB LOCATION �a� �C bl /7 ly-7 Number Street address Section of town HOMEOWNER" Name Home phone Work phone . - PRESENT MAILING ADDRESS 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. e DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, 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 responsibi for all such work performed under the buildinq permit. (Section 109.1. 1) The undersigned "homeowner" assumes responsibility for compliance with the Stp- Building Code and other applicable codes, by-laws, 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 ahZ' d pro edures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which d"'building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person(s) for hire to do such work, that such Home OwnE 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 for . 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 inlicensed- person as' it" would with licensed Supervisor. The Home "dwner acti as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/bier responsibilities, ma: communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. TOWN OF BARNSTABLE `y,.°� •o Permit No- ------------------------------- Building Inspector cash -------I------------ �°""",\ OCCUPANCY PERMIT — - Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ...................................................... 19..._. ...................................................................................................... ..... ._ Building Inspector fPssessor's map and lot number .../..L�.y�.'��.1../J.. :.1 '' i EmsJSewage Permit.,.number ........................ SEPTI C SYSTEM M A11 E • ::............ �.�2 8...................,........::.......:...... ' IN a House number STALLEY Ifi!`�OM0 L a H TITLE'6 ° Q yp-i"". y 3 TOWN OF BAR ` � � ? , k B U I L DPI H B I H SPEC:TeO R 3 Y: APPLICATION FOR ;PERMIT TO .... :Q.(ls.�ry� :. \� �.. TYPE OF CONSTRUCTION ................. ..................................................................... TO THE INSPECTOR OF.BUILDINGS: . t The undersigned hereby. applies rfor a permit according to the following information: Location .............\.. `.....\<.,......�a •.v k C1� .. ....... ............... ... vA`:�` ...... tProposed Use ..... ..�:(1.�,V- ........ . ................. ....................... Zoning District 1 J.�S�e,n �"�`�' : ..................Fire District ...........:...�5 ,( �ii�` .. ........... E ;, i Name of Owner ... te A d. ............................................ Name of Builder- . 'YlQ-�'... ..1�!.: : :�.. ...Address ............ ................................................... i Name of Architect ....:::.:..:................... ...............................Address ;1....:.;........ s Number �of Rooms .......Foundation Exierior �':..... ' ...S. R(/��n/{y1Y�Y_{: �..l1.Roofng. ........ .. t '......................:.:...:..:...... Floors ...� ......� A..........................................Interior ........................................................... Heating ` ... .................................................Plumbing ..............a........ � .......................... Fireplace ......Wulr..................................................................Approximate Cost ..... G 00.0............ ... ........ f ..... .... ... 5Y .. Definitive Plan Approved by Planning Board _____________________________19________. Area .. Diagram,.of.,Lot and-.Building--with Dimensions Fee �.� j f SUBJECT TO 'APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name C -.......!°...... ... `"^............................ o. S21ITH, JAZAIES K. 23 Two Sto?�Y No ......� Pq rnj t fo r ................... ............ It - Siingle Family. .............. ...... ..... Location Lot #18, 628 Skunknet Road ................................................................ C� ...............Centerville.................................... CN . ..... ....... ....... .. . .. 0 Owner James K. Smith ...a ...................................... Type of Construction Frame < . .......................................... (b ............................................................. ................... 'Plot ......................... Lot ................................ :Permit Granted ...J-.u.1.y....1.4...................19 81 Date of. Inspection ......................... 9 Date Completed ..... ......... .. 9,V PERMIT REFUSED n ............. ...... ..........?.......... -W q ........ 19 ... . .. plo,.. ........ ........................ ...... I ...... ..:7 C, '71................tl;�.-11,..�..,.:.... ........................................... V t, .............. ....I................................................. EF => .............. .................................................... Approve ............................................ 19 ................................................................................ ,Cd~ S Assessor's map and lot number ...,1�.x...............1.. ....�•.� �oFTHEtO� Sgwage Permit number ...!.. .. 3�. ..�,,.................:.... ro G 2 8 Z BARN TAX E, i HOUS@' number ............. ..........�u.......................................... 90 6 a e� 39• CFO MAY a' TOWN 'OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... �'�'n l,C� ......... r,)f? x ,l� ................................................... TYPEOF CONSTRUCTION ...................................................................................1... .............................................. ! ... .............19.( .� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... �.;� .....�.s�"?....... �.... �� n .................. ............. ............... .. .............. \�.................................. ProposedUse ..... ........... UyM� -al .............................................................................................................. Zoning District ....LA AXE'R)�3 6,9. '" ................Fire District n ',,,QS �C V e �' '� C..__ .� Name of Owner Ol..�:� ..... ...... '.!!`...............Address ............... r!F..�.5�...`..�.. ..................... ...... .��M O-� r Nameof Builder .... .......................................... ...Address ..................:..( ...�.. ... ...................... Nameof Architect'..................................................................Address .................................................................................... Number of Rooms .................... .........................................Foundation (/ !1 '.� .:,-an C.4!! c_. Exterior - ANA;CC'.......f.e.kD. ..... .�..�WRoofing ............ �. 1.t ............................................. Floors .............................Interior HeatingG; �f" .....................................................Plumbing ............. ...... ............................... Fireplace ...................Approximate Cost..:............................................................. .................................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name 1,�uvnj^........V...... ................ SMITH, JAMES K. =169-15-18 232)39 Two St Y No ................. Permit for .................. ................. Single..Family Dwell ' n ... ...... ............. ............. . . .....g............... LocationLQt... k B...5X .. X:D.Q.t...F, ..............C.en.terxil..e... ................................ Owner ....James.. . ...K m.ith............. .... .. .... ... .. ....... ............. Type of Construction ...Fame ................................................................................ Plot ............................ Lot ................................ rl - Permit Granted ..... ...............July 14, 81...................19 I Date of Inspection ...................................19 Date Completed .........19 PERMIT REFUSED ................................................................ 19 ........................................... ................................ .................................... .......................................... z ....... i.-Al.......I................... .. ................................ Approved ................................................ 19 ............................................................................... ............................................................................... 'UE SlL6I ! DATA � rv1�IGL6, G"AMIL`{ 3 BEDrZDotitS'� �DO • 'abb-I L:,f 1 LoW 3 3c 110 • &w S 'CIC -rA,,.1k m 330 x Iso y. • 45 we I , �. uSaC loon eo&L. 'I . I -roTAL. IC)mSt erw + dg2 4FIV o�A-n o Q QAT� (u Iti low. Or, ue �. 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