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Date 19 _ Permit ti I =, zlto T1iAIlr�GzrFF' �D ` �,� "'n �� � �,,,�/, Building Location Owner's Name �(7 r[rt CIZgG///7 M&/tL [ P yL$�R?1/d,,L16 Type of Occupancy New - Renovation Replacement ' Plans Submitted. Yes` No N ¢ N W A Y Z T. VI Yf N 67 CC0 cc r = W W ¢ O U m r- 2 = O u < ¢ ¢ O O O C F < ¢ > < N ¢ W Z U W N W < ¢ o O f- _ W W N J < 2 ¢ cc ccW W Z < W J < C ~ ~ i V! m Z O ¢ 7.1 O 0 = j U C > G a M- O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3AD FLOOR 4TMFLOOR I STMFLOOR eTMFLOOR 7TMFLOOR 8TM FLOOR Installing Company Name SNQW's Pt.ITMRTNa & H ATTNr. Check one: Certificate Address P.0. BOX 39 Corporation W BARNSTABLE, MA 02668 -:3 Partnership Business Telephone 362-9111 Rj Firm/Co. Name of Licensed Plumber or Gas Fitter CHRTSTOPHER SNQW INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Xx No El If you have checked yam, please indicate the type coverage by checking the appropriate box. A liability insurance policy VC Other type of indemnity( Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner(] Agent S4gnature of Owner or Owner's Agent hereby certify that all of the details and information I have submitted(or entered)in above lication are true and accurate to the best of my knowledge and that all plumbing work and installations Wormed under the permit issu s applicatlo will be in complian it h all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen By T of License: Plumber n r cen or itter Title Gasfitter Master License Number 10705 G /Town Journeyman • e F l 4 A MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Punt or Type) AAA 1—" Mass. Date— 02 19 Q Y Permit # u Building Location Owner's Name 3`ii1 177b Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No FIXTURES z Z N N Z Y < N O Z ~ U W W Y J u1 > V < O (7 ¢ ¢ N Z N < ¢ Z< NO h z Z z UJO = N a F ¢ a Q d C 3 X CC Uj r< W ><< F<s N V1 z Y a ¢ ° X Wu 3 z O O LL O O Q 2 Z Q O J ¢ s O Q h- 3 SU8—BSMT. BASEMENT 1ST FLOOR 2N0 FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TM FLOOR 7TM FLOOR 8THFLOOR Installing Company Name SNOW'S PT.TTMRTNG & AF.ATTNr: Check one: Certificate Address P_0_ BOX 39 ❑ Corporation W. RARNISTART.E. MA 02668 ❑ Partnership Business Telephone 362-9111 C$ Firm/Co. Name of Licensed Plumber Christopher Snow INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2 No ❑ If you have checked Ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy E Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and informat!igna5ture ELTceftid or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and install r the permit issued for this application will n compliance with all pertinent provisions of the Massachusetts State Plr } GeneralLaws BY r Title City/ Type of License: Master IX Journeyman❑ APOF own I 10705 U NL License Number ` `� . v� 5�,. 5 �. " � � �'� �` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map NO Parcel � I�q. Permit# G0 310 .Health Division Date Issued I ! 2000 Conservation Division F a Fee Tax Collector Treasurer 00 ; Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Lt �� S Village �.E�t vw 1 Owner y o��p W t 6610 M3 TK\Wi ` Address Telephone Permit Request R-4,—' 9 33 S!JV ftk5 sa-4P d(� Evc, s i 1 0,J G tt tV.J R i_m�A S aNX <u k i-So% _ . fig/ �ei tJr, I�rP tjj, .. U�� 12 ��. S c IS Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation -f7W• Zoning District Flood Plain Groundwater Overlay 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 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 Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool: O existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zolhing Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name�J 4lrl fJ LPtV SAT`( Telephone Number U�s 4 � Q`j, a.. S3 Address ).Uy License# �. R—i kAA Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE (— �� `d D FOR OFFICIAL USE ONLY ` PERMIT NO. DATE ISSUED ` MAP/PARCEL NO. : ADDRESS '' `VILLAGE �- OWNER .v i < • - r DATE OF INSPECTION:_ FOUNDATION } FRAME - INSULATION x FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL _ s FINAL BUILDING DATE CLOSED OUT s ' ASSOCIATION PLAN NO. , i °FIKE A The Town of Barnstable * BARNSTABLE, • 9�A ��g 'Regulatory Services rEnN,prA Thomas F..Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 3..67 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date I AFFIDAVIT HOME IMPROVEMENT'CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: P 0 Estimated Cost Address of Work: Owner's Name: Date of Application: �X_ 0 I hereby certify that: n Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav O. }, 72. Po�n..nanu ealb�x a�✓ aaa./«aeQ2 - BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number..CS 076460 Expires 09116RO03 Tr.no: 76460 Restricted To. 00' JOHN R LAVERTY _ { PO BOX 20001 W HYANNISPORT, MA'02672 � :x' s . Administrator ` e A, THE COMMONWEALTH OF MASSACHUSETTS Board of Building Regulations and Standards Transaction No. ap One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Registration No. Application for Registration as a Home Improvement Contractor or Subcontractor Effective Dace MGL Chapter 142A, CMR 780-6 Expiration Date FOR OFFICE USE ONLY _ Date 1. Name J t7 k N 1�- LAJ rL Print the name of th'e1 individual or business applying for the registration(not both) G 2. Mailing Address �V t 1.1tJ k �k) (6 V ) 4gy = 6yq t<�. K.�d4��\5 P 2T State��zip, `7 Area Code&Telephone Number 3. City 4. Street Address(if different) n A- M prtN 1S7_61Wt Ur1 44A- DUTY Print street and Number(P.O.Boot not acceptable) CSry State tip 5. Applicant type: M1 Individual ❑ DBA ❑ Partnership ❑Trust ❑ Private Corporation ❑ Public Corporation ro (See instructions on back regarding enclosing a city or town registration under the DBA or."fictitious name"law-MGL c 110,ss 5&6) 6. (see instructions) 7. Number of Employees 8. Individual responsible for Home Improvement Contracts �y To o iA N Last Feat Mi 9. Title of individual responsible for Home Improvement Contracts 10. Does the applicant or responsible individual hold any other construction related state,city,town licenses or registrations? El ❑ If yes,complete the table below. Use additional paper if necessary. Yes No Type license or registration Issued By License or Expiration Name of license Holder registration number Date sees t1 t^ nF 0 4- .`b3 L40 11. List all partners,trustees,officers,directors and major owners(1011b or greater of ownership)of an applicant partnership or corporation below. Use additional paper if necessary.(See instructions on back) Check here if you wish to receive an application for additional ID cards for key persons.❑ Last First, Middle initial Title in Applicant Business %Owner Address 12. Is the applicant claiming exemption from the registration fee? (See the instructions on the back) ❑ If yes,include a copy of a current Construction Supervisor license or motor vehicle repair shop license or registration. Yes No 13. Registration fee enclosed.S Guaranty Fund fee enclosed.S p9 Include two separate certified checks or money orders -one marked"Registration Fee"; one marked "Guaranty Fund". ALL APPLICANTS MUST INCLUDE A GUARANTY FUND FEE EVEN IF EXEMPT FROM THE REGISTRATION FEE.See instructions on back for amount of fees. Make all certified checks or money orders payable to"Commonwealth of Massachusetts" Pursuant to Massachusetts General Laws Chapter 62C section 49A,I certify under the penalties of perjury that I, to my best knowledge and belief,have=an turns and paid all state taxes required under law. Signature of applicant or appli nt's represeritative Title held with applicant A false answer to any question in this application constitutes grounds for suspension or revocation of the applicant's registration. 3 The Commonwealth of Massachusetts Department of Industrial Accidents exce of/arestigat/oos 600 Washington Street �4 f Boston,Mass. 02111 / Workers' Co m ensation Insurance Affidavit name J to V. ,iL7 4 location C1tY IJ�C.t/�TfZ rUQ L UU, I phone -—/L f o ❑ I am a homeowner performing all work myself. ❑ I am a sole �prietor and have no one worl� in anv achy I am an employer providing workers' compensation for my employees working on this job. :::: :: ::::::::::::::: : >:>. a omaenv :::.::.l::::.:.: ;;;::.:.;:.:.::.:.:.::::..:::: .:.::.::::...::.:.::.:::::::::.. address : .. .. ......... ; :.::.. a phone# � :. ` inaurant :c0r> . . # 1 :; 1 "• 0iicv# ❑ I ,;gz: am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: name. ::.;. ;.: com s . �tddsess ............................................... ...........::::::•:,...:.:.:.� ........:•.:.h.............,n.......: wi 'Xxx :•::� vh i�— ::;}:;'>:;a::::`t':':>35::::j?{;?5:i::::::::::i::rv,;:;i:;:;:':5:>::isj::rii::vi:>::jy.:;:j;.`::;::yi�'�:- ..........::::::::::.............................................................................. ....... .........,.,::::::::::::..,.:::•::. .............. x. .................................................................................,..::::::::.,.::.,.......,:...,.,4... .... ..... ,:.+;•:::......,... lusarwrceco:�:;:«<.::,;;.;>:.;::::::::::...:::.::: . . ...::,....:,,..... ......... ..... opicv _.... ::::::: ::::: :::><::z?>:: `:; [3' ii?is2;:;iS::E:::i%•,•?::;g;:;:;::;:%;:;:;:: ::: E:;:E?%::::z;>::;:;z::;;:;:::: isa;:k <;.;:;;>:.;;:.; address. ; .:::::.::.:::: t�honefiE :::.....::. ..- �n�nraace oli twnow Failure to secuim coverage as required under section 25A of MGL 152 can lead to the impoaitioa of Criminal penalties of.a 6ne up to S1,S00.00 and/or ow years'imprisonment as wen as civil penalties in the form of a srop WORK ORDER and a Hue of 3100.00 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 verincatiom I do hereby certify under the pairs and penalties of perjury that the information provided above is true.mid correct Signature Date ��� ° ©d Print name �(�tE IJ LA\IFOa I Ph=# 6f �7-y" ���9 — oincial use only do not write in this area to be completed by city or town olflcial city or town: permiWcense# ❑Building Department ❑Licensing Board ❑cheekif immediate response is required ❑Healt.kch en's rtmce ❑Health Department contact person: phone#; Uaind 9195 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation_or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this:chapter have been presented to the contracting authority. , JApplicants �r. Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and ;Q�uPPIying camPany nmm,address and phone numbers along with a certificate of insurance as all affidavits maybe ",submitted to the Department of Industrial Accidents for confirmation of,nsumnce coverage. Also be sure to sign and f 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 peimit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been,made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Offlce of InvestlgNons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat 406, 409 or 375