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Etuptivs .L_E D 7)214.6
RE-ROOFING/RESIDING/WINDOWS (COMMERCIAL)
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❑ If located in OKH or Hyannis Historic District- Certificate of Appropriateness
. required unless same color/same materials specified on application
. ❑ Map/parceI number •
Approval Sign-offs from:
❑ Tax Collector
i ❑ Treasurer •
❑ #of squares of shingles or square footage of roof or sidewall to be shingled/sided
Sec' stripping old shingles or going over old roof • •
❑ Specify PP g g
.
If going over
[—how many roof layers existing now
❑what size are rafters? What is span?
n Owner's name& address
n Project valuation must be entered
n Builders Information
n Signature
n Workman's Compensation Insurance Affidavit State form must be completed and a copy of
Insurance Compliance Certificate must be submitted.
❑ A copy of the Construction Supervisor license is required. Effective March 1,2009
❑Check expiration
date,no restrictions
❑ Permit fee$160.00 •
•
❑ Property Owner must sign Property Owner Letter of Permission.
•
Projects requiring the use of a crane must complete the forms issued by the Aeronautics Commission
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q-forms/bldgpermil5/permitchcckIis>s •
rev,070610 •
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,
254 NSA BLE �fMap Parcel 004 J�, , €� r Application# TI0- a01 /
__T6 ,;;I ? E l iQ: 06 '
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. DIVISION Permit Fee ��Q0 - 00
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Pro'e�"�ct�St et=Address=, ? SS ..:7://4(e)er,1601e,,e. /9,4
1 (Villaa ff cL/t/I/f f
Ouuh la N 'f Address 9 f✓, „tie, %- /i/cie��'
i .-", o � S
Te�°ep�F�arae � � f /6
Perfnit-Request (00 f'?9 Y ,�/�G�ft
Pr' /
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Pr6 eet V atio�►' fr7C: Construction Type-�� �
4
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: ❑ 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
(BUILDER OR HOMEOWNER) ��
tiSEme0 .-1i4fr riefr' e , Telephone-Nur�ber'
Ad es ip,,,7 S W s ii- Lic CS. - 0 D AY ”
Home Improvement Contractor# / Y.57/057
EC it if i- (�/ 6e7(Jfc,e aj1'411 Worker's Compensation # 6 /M 06 r,�.5�`
A L7C_ON:ST_ ''CTION'DEB'RiS RESULTING FROM THIS PROJECT WILL BE TA N TO
Ni o ffiC-2-/er Ve/7 /
CSIGNAi TORE DATE- 7/20/A
` a FOR OFFICIAL USE ONLY
'APPLICATION #
bATE ISSUED
MAP/ PARCEL NO.
• ADDRESS VILLAGE
OWNER_.
DATE OF INSPECTION: •
FOUNDATION •
FRAME -
INSULATION •
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
r .
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
•
°+. r, Y e
A* ` TOWN OF BARNSTABLEBUILDING PERMIT APPLICATION ,
f tail.)
ia
Map` 2 -ri Parcel . 6- I1 I „ ).';' , i `Application # --- '& - tD
1-7 k . .•Health Division ' j Date Issued
Conservation Division Application Fee
Planning Dept. , f° '\;4•l j '' '' ..ti , Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
f( 4
Project Street'Address � R -s••S �� 1 ^' .
Village a C1/'°/f'-14:r.r ,*,/ _. `
i '' . .`t'j" ,' ' C ° , ; ..
r :�;,, ..�.�}'�'. ,,.�„ � fir'" �� a w/ v,,fr!'
Owner o/t,:°j 1fr17t °>•ir . � '+ ' Address (�' SJ _.� e. �%�, C'Q��
Telephone S O S 7 /6 f' `z*' 'Jr
Permit Request ' 4 )O 1I9' 3/ D(/`
r,t -. Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation X S- Type'
1Cr Construction Ty r" f
EPars 7 ,
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 U No On_Old King's Highway: U Yes ❑ No
\/ r ".. 1 i r'jk"'`,,..P IT ire S i,•i
Basement Type: ❑ Full ❑ C a I' O�Walkout ❑Other 1
Basement Finished Area(sq.ft.) 1 r ''"- j Basement Unfinished Area (sq.ft) ).. ! ,
' ,cam ,. 0,, 4 a. 4VHalf:
fNumber of Baths: Full: existig L- 1 l, `new.}'r,4'!. ✓.i Y existing - ..' .di. new71-
.,-, i ,,,cs,r,, _,.'/'r,//
Number of Bedrooms: existing _new /i
Total Room Count (not including baths): existing i-m iv"‘ '- -=new t � `�A t Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other .2 /' f.- ///0--
z
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑;new" size `Pool:0.•existing ❑ new size _ Barn: ❑ existing ❑ new size_
(r
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
k
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) .
Name /2 if` `)/ /( Telephone Number gr.? 7,.. .4)
SAACO f_.�/ License' - ps
Address /) ) j" � # ( .S - v D sy -:7 LHome Improvement Contractor# / Y1(
Email le /1 r/1g `ce/1/l G �j14 /eWorker's Compensation # 6 // a �GU /33-,e
ALL CONST CTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO .
H , i FIA-2-i ei' Ve /7 /ter
SIGNATURE i:. ��'� DATE //42e /A .
f F mil' f ' t _
FOR OFFICIAL USE ONLY
'APPLICATION #
BATE ISSUED
MAP/ PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
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.The Commonwealth ofifassachrisetts .
Deparbitent ofinclushial Accidents'
-,.
II -
1, • Office of Investigatienzs
600 Washington Street
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Boston,MA 02111
-----,. .
. , www.tnass..govidia
Workers' Compensation.Insurance Affidavit Bthiders/ContractorsiElectricians/Pimnbers
Applicant Information Please Print Leafy
• Ight—fgaLsia=tOrganintionanividEd): e A--y?evt 6-1*7..?? 4°taDCY
Add—Tail I OA sheeV,5 A
0-0 yy
• cityisiateizip: 13a ip if tee , , 1 pho._,,,: w 7 0 (9-0 -
Are you an enrployer?Clueckthe appropriate bor Type of project(required):
I.XI am a employer with 4. 0 I aro a general contractor and I
employees gull andfor part-time).*
2.0 I am.a sole proprietor Or partner-
is,
ship and have no employees. .
-wailing for me in any capacity
11•To workers'comp.insurance
required.]
, 3.0 Lam,.a homeowner d.oing all work
nrywl f {No-workers'comp_ have hiredthe sub-contractors
listed on:the attached sheet.
These sob-cnrorac-tors have
employees and have workers'
comp.insurance-1 •
5. El We are a corporation and its
officers have fywcreised their 6_ O New constructica.
7. 0 Remodeling
a 0 Demolition
MD Electrical reixtirs or additions
ILO Plunibingrepairs or additims
right of exemption per MGL g. El- Bilildi. lig additi°11
12.VI ' •afrepairs .
c.152,§I(4),andwe have no /
insurance required.]i •
employees.[No workers' 11 A Other
comp.insurance required.]
*Any apprirort ffist theclabax O.nu m,1 also en out the section.below showing their'armlets'compensation pacy information_
i Eametywners•who submit Ibis.affidavit intrxxling they are doing allwock api theo.bire=tide contoacturs=est sahmit a near affidavit indiczting sack
rCantactors that eil Pek tide box must attached att additional/sheet shotting the nese of the sub-contractors.and state whether or not those entities lane
empkyen.If the sob-contitctots have employees,they mustplovitle their workers comp.policy number_
. .I am an employer that is providing workers'co riTensation insurance for my sir EA;pees. Below is file policy and job site
infirmation.
Insurance Company Name: is Tailc/ets- • .
• -Poficy ff or Self-ins.lie..44.
6 g U d6136-Exphation Date: P3A
Job Site Addresw C S-9 .1.A1 riWee VCity/Stateirrp:. Iyalfr5/1,
Attach a copy of the workers'compensation.pollcy declaration page(showing the policy nu .r ands expirAon date).
Failure to secure coverage as requiredunder Section.25A of MGL c_152 can lead to the imposition of criminal penalties of a
fine up to$1,500..0G and/or one-year imprisonment,as well as civil penalties:in the form of a STOP WORK ORDERand a fine •
of up to$250.00 a day against the violatur. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the MA for insurance coverage verification. •
• . . . . . . .
I do hereby certify ander the w;4 s crnd penalties ofper jury that-the info maim provided above Is true and carre
Oisnah-----/P 1.111°."—r q3at" VA)C.) 0-' •
c-P h
,
Official use only. Do not writs in this urea,to be completed by tity artown offidoL ,
City or TONSIL: • PermitiLicense ii . .
Issuing Authority(circle one):
L Board.of Health 2.Building Department 3.City-frown Clerk 4-Electrical Inspector S.Plumbing Inspeztar
6.Other
Contact Person: Phone#:
_____________ __ _ ___ . . . — -
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o formation and It ctions
Massachusetts General Laws rh arfer 152 requires all employers to provide workers'compensation for their empIoyees.
this s&n rrr.,an.etzpIoyee is defined every person in the service of another under any contract ofhae, .
express or implied oral or-eaten_"
An_employer is defined as"an individual,partnership,association,corporation or other legal ra ft i ty,or any two or more
of the foregoing engaged in.a*oint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individnal,partnership,association or other legal entity,employing employees. However the
owner of a dwelling home baying not more than tine apartments and who resides therein,or the occupant ofthe -
clw tiling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds orbutgrinng apputtenantthereto Shia 1notbecanse of such employment be deemed to be an employer."
MEC chapter 152,§25C(6)also s14es that"every'state or local lir&nring agency shall withhold the issuance or s
renewal of a license or permit to operate a business or to co for any
nstruct buildings in the commonwealth
applicant who has not produced acceptable evidence of compliance with the Insurance.coverage required." ,
Adriiti onafy,MGZ chapter 152,§25C(7)states'Neither the commonwealth nor ally of its political subdivisions shall
enter into any contract for theperfo�ance ofpnblicwort[u acceptable evidence of compli7cewit _the instslce.
reciuirenients of th;c chapter have Been.presentF-i to the contracting anthozity." .
Applicants
• Please El oil the workers'compensation afl davit complctcly,by checking the boxes That apply to your situation and,if
necessary,supply sub-contractor(s)name(s), addresses)and phonem1mher(s)along willt.their cm.Liflcate(s)of
insurance. Limited ted Liability Companies(LLC)or Limited Liabiity Parfneiships(LLP) witli no employees other than the ,
' members or partners,are not required to carry workers'compensation ins-mance. Bran LLC'or LLP does have
. employees,apolicy is required. Be advisedli,atThis affidavit maybe submiffedto the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date tlse afi-rdavit. The affidavit should .
be returned to the city or town that the application for the permit or lirin se is being requested,,not the Department of
I dns rial Accidents. Shouldyon have any questions regarding the law or ifyou are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insinnce license member on the appropriate line.
City or Town Ofadals
Please be sat c that the affidavit is complete and printed legibly. The Depar(ment has provided a space at the bottom
• of the affidavit for you to fill out in the event the Office oflnvestigations has to contact youregarding the appliranfi
Please be sure to ifitinthe permicense m .ber which will be used as arefrc taco number. In addition,an applicant
flat must snbmt multiple pennitJIirrtn.Se applications in any given.year,need only sabmit one affidavit indirat;ng t.uncut
policy inform-afloat.(if necessary)and under"lob Site Ad&ress"the applicant should write"all locations m (city or
town)."A copy of-he-affdavittitathas been officially s[died ormarkedbytithe city of town may be provided to the -
appIir-Rai=as proof That a valid affidavit is on file for<Cupuic permits or licenses_ Anew affidavit must be filled.obt es rTi
year.Where a home owner or citizen is obtaining'license or pe mitnot related to any,business or commercial ventxn e
(Le.a dog license or permit to burn leaves etc.)said.person.is NOT re:Fi ed.to complete this affidavit .
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The Office of Investigations would like to tit auk you in advance for your cooperation and should you have any questions, .
• please do not hesitate to givens a call .
The Department's address,telephone and fax number: . .
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The Ca �r onwea of Massachu tGs - - '
,. Deg' cut offrid ial.AoDiclan fiS
OfU ce d Ige 'gat oR. .
65f1 Waslzi Q..&re t .v...
BostoIAE 11F .
M.I.#617-Thi 49Q t 406 or 1-•g77 Zvi A STAFF •
Fax 617 727 7749
Revised4-24-07 wWWrrIas5 g.ovtdra. .
&THE ros. Town of Barnstable
• Regulatory Services
Richard V.Scali,Director
Building Division
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, , as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
•
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant Pools
are not to be filled or utili7ed 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