HomeMy WebLinkAbout0018 STAGE COACH ROAD 4.
�. . . .
t
�.. ,. ,.
i
u .:
n
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
3
Map f ? -zr Parcel Application # aal, o�
Health Division Date Issued 3
Conservation Division Application Fee S�
Planning Dept. Permit Fee Cow
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
Project Street Address b P f-F C 4c f RD
Village
Owner Address 4? r rog#
Telephone
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation..
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes No On Old King's hway: i9Yes3XNo
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
Number of Bedrooms: 3 existing _new --
Total Room Count (note including bath 3): existing new First Floor Room Count.
Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes X'No Fireplaces: Existing New Existing wood/coal stove: ❑Yes No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage:Xexisting ❑ 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 INF TION
{BUILDER O Hh6M]-bWNER)
Name %'1 / °'� Telephone Number
Address S 6'� �d��lT ��� License #
V11
l Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE h DATE 2S
J
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
F
Frfk?
f � `
,i ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
�LL1V
it,FOUNDATION, ?
FRAME
INSULATION
,r FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
F
,k DATE CLOSED OUT
k.
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street.
- Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
G
Address:
City/State/Zip: (JC �`�JirJ, 'hone#: 5��F ''V 30
Are you an employer?Check the appropriate box:
general contractor and I Type of project(required
1.El4.I am a employer with ❑ I am a g
employees (full and/or part-time).* have hired the sub-contractors 6. New construction D l)
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
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 X I am a homeowner doing all work officers have exercised their 11.❑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 13.El Other
.
employees. [No workers'
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.
lContractors 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.#: 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 up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the and p o e ' that the information provided above is true and correct
Si mature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
i
Issuing Authority(circle one):
i
1.Board of Health 2.Building Department 3.City/Town CIerk 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 repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter.152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 obtairi 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 permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
zHMET Town of Barnstable
Regulatory Services
B&ARNSMAEr,E, : Thomas F.Geiler,Director
1659.
s Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.toWn.b arnstable.ma.us
Office: 508-862-4038 Fax::508-790-6230
HOMEOWNER LICENSE EXEMPTION
gr Please Print
DATE:
JOB LOCATION: / + ✓5!� � �' ���,—'"��
number street village
"HOMEOWNER": �.
name p home phone# work phone#
CURRENT MAILING ADDRESS: 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.
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 r
"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 proce,pkues and ements and that he/she will comply with said procedures and
require
Signature er
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. c
Q:forms:homeexempt
f
Town of Barnstable
ti
Regulatory Services
nsass �, Thomas F.Geiler,Director
i639.ram" Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on ray behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOLS 6/2012
03/05/2012 04:51 5004200055 1 PAGE 02102
-MO R TGA G-Y I.,ZV,SP-EC TIO N RLAIV.
APPLICANT: LAWTON TOWN, CENTERVILLE
V �p
00
Cam _
OVERHANG
d -_-- --- -- _
-- -1------------
--
__==a DEC 0
r.
10'T 37 LOT 38
a
LOT 6DOYLE
�,
�r`d/3J} ///
FLOOD (PANEL: 250001 0015 C FLOOD ZONE: "C" DATE MAP REVISED: 3/1/12
1 NEREBY'CERTFY THAT 711M MORTOAGF INSPECTION PLAN HAS DEEN PRRPARFD FOR: DATE: 3/1/12 SCALE: 1" _ 30'
THE CAPE COD FIVE CENTS SAVINGS BANK CERT REF:172208 & 194034 PLAN REF: 37851-B (1)
THE LOCATION OF DIE DV.RLUNa SHOWN DOLS NOT FALL WTHIN A SPECIAL FLOOD HA7ARD ZONE•
PER TARRO INS"PECTICN THE l?UYR11NC APPPARS YO CONF'CRM TO TOR LWAL ZCNING NYLAWS IN I-�rF'ECT 1HE 9TRUC'TURES gHDWN ON THIS M1OMAM INSPECTOR PLAN ARE LDCA7M 9Y`YAP@ SUPV�Y
AT THE TIME Or CONSTRUCTION MTN REAPRGT TO H1A7c?NTA4 PIMCNSIONAL VTaAcK RpggjRNFNYS ONLY,NO INSTRUMENT SURVEY WAS PCRFORMEO AND LOCATIONS SHOINN ARE APPROXIMATE
OR IS VVPT FROM VIOLATION Et+CORCEMENT ACTION U14DER MA MAUI.LA"CHAPTER 49A AN INSTRUMENT SURVEY It NECESSARY FOR PRECISE DETERMINATION OF DNILDINC LOCATION.
SECTION 7. REFERENCE DEED SUBJECT TD AND WITH THE BENEFIT OF ALL RIGHTS,RIGHTS OF WAY AND ENCROACHMENTS, U ANY EXIST,EITHER WAY ACROSS PROPFRTY LINES, YANKEE LAND
EASEMENTS,RESERVATIONS AND RRgTRIGTTCN9 OF RECDRD,IF ANY TWERE SHAL,BE,AND IN"FAj SURVEY COMPANY INC.SHALL NOT RR WELD UARLE FOR DAMAGES RESULTING FROM ANY USF
AS THE SAME ARE OF LEM FORCE AND EFFECT, JOF TW17 PLAN FOR PURPOSES 0TWER THAN MOMAGE INrPECTION.
TELEPHONE: 501 42s—oo� YA.�V.�.EE LA.ATD -S"U.RVEY COMPANY INC
FAX: 508-420--555 119 ROUTE 149, Marstons Mills, MA 02648
yankeesurvey0comcast.net www.yankeesurvey.net 8184Br JM
n
b�
_
a..
_
G z: (�o Q -
o
cz
Y
R kon -
r0071 5 vivo- c(3
sP�
_ 2 2X_f
- f ?7
Ctl
STg��S
-IA - —
0
- sm
j
• ' t
1
j
I
�1���
L...X,ISTING IQ./41LING
CONT2ACToQ "IV INSTAL
RAIL]AIL �E`fAlL-:
(1) 6 A' 6 Te K6w D 6UL
- { 1 ` -ljX'l r•T ?eSTS � j I N � � � � t t ,
zxZ- J2ri_aAiVSTt_KS y �L�C. 1
a 1 ZKCn j 'PT T6G !RAIL
E AHacJ�'mrn l Thw C3olls' �� ` ILKISTiNG
1 ! 1 i � I hold 'dawn hmrdNrorc f I ' ! p
:ZX.aL£OGEIi-
• 71A
1, �E• n ATTAC11�0NT As
i h f i I � 1 ! zo,z zrtc.
ZXS ,SiMPsonJ IJasT �ANC2S
1'H iC�' PIT 1�os-rs j 6K& PT POSTS
li,(4 P.T.
t
I , 1 , I 1 J 4 i f , � i i 9t; F CeNcR6'4E � ! •
I j LS� IDE�VIE
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel `: U Application #
Health Division Date Issued
Conservation Division ► Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/Hyannis
Project Street Address f g S p (z)r
Village C—ein Cr w I ��
y I
Owner_ U,pQ1-0 Address_
Telephone
Permit Request ��.l S' �' vh\
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District _ Flood Plain Groundwater Overlay '
Project Valuation - Construction Type Sf P,dI
Lot Size Grandfathered: '❑Yes ❑'No 'If yes, attach supporting documentation.
Dwelling Type: Single Family a Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
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
Numbeir of Bedrooms: existing _new
Total Room Count (not including baths): existing v new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woad oal sto\iiE ❑ ❑ No
Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn ❑existing 4ine maize
`dry
Attac'ned garage: ❑ existing Li new size _Shed: ❑ existing ❑ Inew size _ Other: -:,:;g'i n11V M
Zoning Board of Appeals A��uthorization ❑ Appeal # Recorded ❑
'Commercial ❑Yes 0'No If yes, site plan review#
Current Use tee;ids,,..,(, Proposed Use
APPLICANT INFORMATION '
(BUILDER OR HOMEOWNER)
Name Telephone Number
Address Oct G4411License#
Home Improvement Contractor#
Worker's Compensation # '
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO)�
SIGNATURE DATE `
Ff:
j{
'. FOR OFFICIAL USE ONLY
t APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
r
ADDRESS VILLAGE
OWNER
4 r •
DATE OF INSPECTION:
.UNDATION
if
' FRAME
s
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
k'
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
Al FINAL BUILDING �s 113 l/3
tt
DATE CLOSED OUT
.4
k ASSOCIATION PLAN NO. �` —_
- The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ��� ���✓ (/�
Address: IT
City/State/Zip: CeN7tiOILL X-Z? Phone#: �O 0P-_,;U J/d-3 6'
Are you an employer?Check the appropriate b x: Type of project(required):
1.El 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. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working for me in any capacity. employees and have workers'
comp. insurance.:
9. ❑Building addition
[No workers comp. insurance p•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑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' 13ZrOther y,�Z 1"_RfVlf
comp.insurance required.] 6-g-VO�
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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.#: 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 up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unde a pains nd pe 1 ' of jury that the information provided abov _is tr a and correct.
Sip-nature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation-and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street.
Boston,MA 0211.1
Tel, #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
c�tcv GERTINUAIt: Ur UAMILi IT 1N*UPtANL+C nx' s 3 04 1
ONLY AND COS NO MMM UPON N THE CE MMATE
Durfee Saf f into& Io&. Agcy,Inc HOt, M THR CEIMFICAM OOES NOTANE.EMM OR
371 Second Street ALTM THE CDVgRAAE AFFOMW BY THE POLK=BELOW
Pall River Ka 02721
Phone:508-679-6496 MISURERS AFFORDING COVERAGE NAJC i
IR D: Limos Igtr�l ssr�rame�ers�
h��a�tinative Po�or1S 00Wmc
blvau QOrlando 0 77�t m�
iOURMW e
CbVERAGES
'ME POUCIP�oP Y�t7R11HCE YSLEO BELOW W WE BE�11�7®TO TIIE NIIY�ABOAI�Pm1 Tti�iDLGY�Rt�IDIDTCAT�.1ldiMrtlfrffiN1110�4
• ANY HEa17i1E�.TEAIL OA COi�DlTltAl OF ANYOONt>LACT OR 07MLEN 0CQ1M9f'f vri1M A> r T01NF�ITFgB 6liY►Y�1SStl1'a OA
YAY PEq^THE OISURA mApMAM BYTW PMXX Nt 0290FAW MOM 18 SLS=TC ALLTHETERM NANO C*ND f NM Of S"
POLOM AGNMATE UWrg$HDM WAY HAVE SM RMUM BY FA®MXAM
LammGupj ► Lam
LMOWT &M 4 i,00o 000
A x am.wEpcu%LavamALuA9uLry 9RA22442700• 03/29/13 03/29/16 PRL S :50,000
CUIp/SLMOE ®axon LsnexFwwwo 4 5,000
P&R9MKAADV@WfW 4 ILI 000 000
GENOMAt#GN8l ATE s 2 Ooo 000
EGOSfLA06AfiWTTsLuer/OPPL1�P�k PAODOcm-�'rO1eP/QDAw 42,000,000
FOLD LOG
AWA M
AL{,o1NNmM1To8 BMMY04A W 4
SCHMASAAUf08 WON"
MMAU70s
aoraosrr�ALlY'05 - a
t:.Agns6LJ11H8,Lrtt ALtTOONLY-EAA (i :
ANY AIAb 9►AGC 4
w A $
L7RYcss�LglBRFZ1.A LLABL1JrY tArx ooa s
WWR C]QA%G tAQO@ mutmm s
oeoucngLL� _ a
AND BLPLOEAL:MISM via
B OFPH F03Wem WC2-319-385929-033 04/09/13 04/09/14 9-L.m#zNAd=mW L? a 100000
twww„1t q,04 EL 00SfAM•1A M04a 100000
FOe�pansn��-bow EL.DWAN•mmy LAUr s 500000
omLan
o or o��a�l Lorr►TnNa t /�.ueoNS A�oeo BY��sveaw aaon�D�
i�sRT1FlCATE NOLDBi CANCGUAfM
• SMOULDAIKOFIIB;ABOYE085�PD �CANCgI� TIB:F]WIBl1TOdt+
WAY p .s �� 0117E T11 .7lIQ OARtASL��Ip�q YO MA0. �QAY'L:INRH'TE1!
NOTWETOTNE L10LMNAMMYOTHELEPT•evrFAAAML�lTODOSaM"L
: cry Hwy.'OWLWMW 00 M M00UMMY01FAW LW=TM4010MffSACBMOR
R�Rf1T11T111El.
W oham, MA 02571
t ,
ACORD 25 P0001) - 01 108 ACOAO CORPORATION.AN 0910 reserved.
The ACORD LI m and logo are ra&ered N4 of ACM
03/05/2012 04:51 5084200055 1 PAGE 02/02
MORTGAG-' JIV,S.PEC'TlON -.PLAN.
APPLICANT: LAWTON TOWN: CENTERVILLE
00 T
,10
�.$3 L,q
06 00'
O OVERHANG
-_ _--- -
DEC r 0� a DEL �L a
r3 'S'/"FA�DYN--.fit oee
_L T LOT 38
00" gF
LOT 6
OFZT
Vic)
t, 4` ,� b STEPHEN a ;•
.: 40 U J. -
�� DOY��L��E�� J1rf�h
•, `dam T v-559_ •. 19 f
' dl� v
FLOOD PANEL: 250001 0015 C FLOOD ZONE: "C" DATE MAP REVISED: 3/1/12
I REMY CMFY TWAT Ta MRRTCAE W E IW PLM M 9M PWARW M DATE: 3/1/12 SCALE: 1" = 31Y
TOE CAPE COD FIVE CENTS SAVINGS BANK CERT REM 172208 & 194934 PLAN REF: 32851-9 (1)
ItE LOCA-1 ON Of 7HE DWWjN0 MOWN p=NOT FALL W"A SPECM FLOOD HAZARD ZONE.
PER TAPED INSPM1,16M THE D* 1WC APPEARS 70 CMCM TC 7M LOCAL.WOO SYLAM IN SECT THE StROCTUM SHOWV ON 1HM MORTGAGE INSP TON PLAN ARE LOCATED NY TAPE SUMf_Y
AT THE TINE Of CONSTRUCTION"R GT TO MMONTAI PRAENSOIAL SEMACK R ttS ONLY.NO INSTRWAENT SURVEY WAS PEA AND L.00Al1ONS SHMN ARE APPROXIMATE
OR 14 HXEMPT FROM 40LATW ENFORCEPOIT ACTION UWER NA f4DUAL LA"tIiAFTr7t 4011 AN I-STRUMT SUM 13 NECESMY FOR FRWW DETERMINATION OF MUM LOCATIONS
$ECfIOP1 7.RWEkENCE DF1D SURJEOT TO AND MATH THE 8F91€FIT IF ALL iQL817S RIlA41S OF WAY AND ENCROADU NTS,IF ANY EXIST.ERHFR WAY ACRIM PROPOM UNM YANM LAND
MS SAME�OF tWAL Ff AND EFFECTOF t+lwtmRP ANY THEI:<SHMi AHD iN9�i1 OF INS PLAN FOR PURPOSES NOT
THAN NOMAM DWEL)TO ft€.�1L7INc FROM M11 USE
TELEPHONE; 50�-428-00 � Y TT' LAND SURVEY COMPANY. INC
FAX: 508--420--5553 119 ROUTE 149, Marstons Mills, MA 02648
yankeesurvey0camcast.net . www.yankeesurvey.net 818g8 JM
GATEWAY POOLS, INC.
2667 Cranberry Highway, Route 28
Wareham, MA 02571 '
774-678-0875
GatewayPoolsInc.com
SUB ITTED TO PHONE DATE
Yv To 0 -1 -
ADD ESS JOB NAME
JOB LOCATION
DATE OF PLANS - JOB PHONE
WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR
4 06A-n 1900 L l/v
�-,7-,d Z Z Al Z: 2 U A 2 �L2
` rA 4 m
O
J
0 1 11 9/ �/h fiz,p�0
WE PROPOSE HEREBY TO FURNISH MATERIAL AND LABOR-COMPLETE IN
ACCORDANCE WITH ABOVE SPECIFICATIONS,FFOOR�JTHCEE SUU'M OFF
7��/�� DOLLARS($
PAYMENTTO BE MADEAS FOLLOWS n /IJ D-k1.4X y iQ/ X&1�.1!�_
ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED. ALL WORK TO BE
COMPLETED IN A WORKMAN LIKE MANNER ACCORDING TO STANDARD AUTHORIZED
PRACTICES.ANY ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS SIGNATURE �--/INVOLVING EXTRA COSTS WILL BE EXECUTED ONLY UPON WRITTEN ORDERS,
AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE.ALL
AGREEMENTS CONTINGENT UPON STRIKES,ACCIDENTS OR DELAYS BEYOND NOTE:THIS PRL` OSAL MAY BE
OUR CONTROL.OWNER TO CARRY FIRE,TORNADO AND OTHER NECESSARY WITHDRAWN BY US IF NOT ACCEPTED WITHIN DAYS
INSURANCE. OUR WORKERS ARE FULLY COVERED BY WORKMEN'S
COMPENSATION INSURANCE. "
ACCEPTANCE OF PROPOSAL — THE ABOVE PRICES, SIGNATURE '
SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY AND ARE HEREBY
ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT ,
WILL BE MADE AS OUTLINED ABOVE.
C/� , - / SIGNATURE
DATEOFACCEPTANGE 7` cf
4s�'a
.Fawn UBarnstable
RegalatoryServices
Thomas F GE9er,Director
BII11dIIlg DI'ViS1on
Tom'Pe ij.3uildog Commissioner
.200 Main'Street, Hyanfiis,MA 02601
WWWAowri:ba rnst b1e,ma.us
Office: 508-862-403 8 Fax: .508-.790-6230
HOMEOWNER LICENSE EXEMPTION
DATE: /� /
3 PIease Print
JOB LOCATION: / V ��C� Ar, 1,1,eo a-�V/-,_?y
number street
n village
"HOMEOWNER":_ yam,'
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellinIs 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.
DEFWMON 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 Bamstable Building Department
minirnrrm inspection procedures and quirements and that he/she will comply with said procedures and
require .
SignatipeSf 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 super-visor."
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 lastpage of this issue is a form currently used by
several towns. You may care t amend and adopt such a fonn/certification for use in your community.
Q:forms:homeexempt
F '- •',.>+�_���.4s.�.��=J d._�Y9�AI'� � ,�[�;� (f Ya A,r}4 4. �np'.�d: 1� G��' �F GMS _ f�d'�hu����E f i,.��+ S�*�a•�{r,'A +�.tl� •' S..r� 4 .' } f<.=r .ar-' _
l�y:t .., -,fir. °8 �" ie F. •op'l,'" y. �4; ,y �a,Al
C A W
+-,.. 5wr'i 4.. '� `��^ �y� 'trip:{ �� ...� �i:1r�o- +`�� r�4y. � ,qr"fit" �tµ H'dd'+�Y i .��. "� ll '✓'f S�F,';�.'f,,p( �.. .,Yl,F+� 4. �'� �e,;y a;,�....�� r jj l
eZHEe7:rL.'N kJ •j t �., ink .� '• P.F .sf .A.kJ
,�$, , �F RTonof;$Barnsta�le�` -
r
{ �Re x� t to em�.ces �
. lMAS � Thomas F Geiler'Director
b g DTP1S1oi-
Tom+PertyBOdmg Commissioner
.200 Main Stree Hyannis,-MAi02601`
,x.
�rvv towribarnsiable maxs
�r
Office: 508486'2 9-038
Fax: 508=790-6230
Property Owner Must
` Complete and Sign This Section
If Using A.Builder
as Ownet of the subject property
hereby authorize to act on my behalf
in all rafters relative to work authorized by this budding permit
(Address of job)
Pool fences and alarms are the responsibility of the applicant. Pools
are not-to be filled-before fence is installed and pools are not to be
utilized until all final inspections are petformed and accepted.
Signature of Owner Signature of Applicant
Print Name Ptint Name
Date
Q:FORMS:OWXMERMISS101Q00LS
y yof7HETo�� TOWN' OF BA.R.NSTABLE
i 33ARISTAMLL • -
1M*MA BUILDING l INSPECTOR
'Fp MPY�'• •
APPLICATION FOR PERMIT TO .......................'a.:...........w.:..... ..:........ ?.............. ..............................
TYPE OF CONSTRUCTION .............. o ..... ......................
. � .............9(l..1`
JJ
l:i. ....... .19........
TO THE INSPECTOR OF BUILDINGS:
The undersig ereby applies fo a permit according to the f wing information:
Location .. rz ``^�,� ............ . . - tn �.... i ......................................... J. ...................................
Proposed Use .................
Zoning District ....... ..... ....... Fire District...... . .................. ........................... ....4.LA.
Name of Owner - - Address ../
Name of Builde 4--, «:a air: �p,�, :.'."`. Arc dress ��t . ... 07 �-
_ �« ..
Name of Architect ..... ...................... `. ..Address
. ........................................................
Number of Rooms ................. ...........................................Foundation ............... ...�-��� ,..:...............................
Exterior ......... ......11
'Roofing ...:...........
Floors .- . . ......................................................Interior ... ..... + . ...... .. ....... ..........................................
� `
Heating ...... ...... Plumbing
r...........r................................................... ........ -
Fireplace �i ....................................................Approximate Cost �i .......
��►0 S.
Definitive Plan Approved by Planning Board -----------_--____-----------19--------.
Diagram of Lot and Building with 'Dimens'ions Fr l is
SUBJECT TO APPROVAL OF BOARD OF HEALTH
P 30
ST B
SEPTIC SYST 4 com DANCE ,
STp1.LE0 IN STATE N
WITH A�TICI-E �I p ZOW
Sp,tAly RY coo AN �I` j
TIO�S'3� .Q �/
REGUTA ,�
�ate•
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardingthe above -
construction.
Name .. ... ... .. ....................... ........4...:....... . <..
[ ,
� Mahoney, �v�ox J. ~
! �
No -. Permit for --.-OnG,- ...StO.:17........
.........--~----.—.-.----.. .....................
�{} |
Location .u.�J_. .........................................3�mad
�
�
---------'-=���'====---------.
�
Owner �q�u�
� ------^----.���~��=�-----.. - ~
Type of Construction ----'Zra=.................
.....................—c^----'-------------
'
Plot ----.._--- Lot --'�-''�37---'
- 7 `
v .
. .
�� �'- -` - `~��
Permit Granted ---��'��------.�-lg
`
Date of | ...... . . 19
Completed
.
� . .
u�n: �pmp ,�p
� -
^ lV '
----------^''--------'.x
.-------~.---------'-------.
—_----.----.-------,---.�---
� .--------.-----.---.-^`.-.-..~._.
^ ..
-------.--.-.----.~--.-----.—.. � .
� -
. . .
. . -
A' rove6 ~--------------- lQ '
--------------------.-----..
' ^
-------`--------------.---.. : ^ `