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++nn��nn�� nn nnII AA L�
TOWN IDBA�RISAt" li`BILDlN PERMIT APPLICATION '
Map a vi Parcel 0 3 , Application# 240156 661D
Health Division Date Issued l Z`�3 :/5-- -
,,
Conservation Division 9290Application Fee 50.0
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board /01"
Historic - OKH / _ Preservation / Hyannis
Project Street Address 3 01-4 AAPtk/ 4 1
Village ScrtAic1-4.6 k Owner 1)066.A.a 1 OAN4t AO% 5dI Address P*0 1,e Y TY G ,
Telephone 5.d g'' 4 Z k' 33 1 5
Permit Request t pkc,..,11 (a) Clip t a. # t.c ,4 w s` ( frt.ittwi ).
a ik KL t1'UtNI '1' ^i -kk eN 611 C ►�!'5 l oc-c_. 1 ka 5.{t� 4,/ �..r 1 1 l
1 i
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new —0
Zoning District - I Jrpod Plain Groundwater Overlay
Project Valuation ._r.1. :i��� Construction TypeN. 2''
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units)
Age of Existing Structure i 3', 1 Historic House: 04 ❑ No On Old King's Highway: IR4s ❑ No
Basement Type: 'Full ®'Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) —0 "' 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: U 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 IN
(BUILDER 0 HOMEOWNE
Name nn {� A► I �� 41,f " 33l7
¢v�,d� % • ,"V�5.J t ) ' Telephone Number
Address 3011f Arkt& 94' License #
13 /M Ll,t C i A" V'c D A T ° Home Improvement Contractor#
Email 1'1'�UaJokpprtkott � �MCaZ 4`►t'�-�' Worker's Compensation #
ALL CONSTRUCTON DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 1.1' Z 2 (. l-.)
---: :.: ' ----
FOR OFFICIAL USE ONLY
. *
,
''L)' APPLICATION #
,.. • -. .
. ... -_
.1.! . ....-
I DATE ISSUED
! . •.: .... _ -
: ')
! • MAP/PARCEL NO. .
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, . . 1.....,......_ -..-... 1-
i • • I 14. .• i •:',.
ADDRESS
VILLAGE
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.,.
.., . .-
1. OWNER ...
- ---, , . •,!.
...•." .. i t : _...
, —---,
I f DATE OF INSPECTION:
.., - .
,. ._,.
, _
.1! FOUNDATION --. -.' •
FRAME
. .
cy
!, INSULATION .
. '
..! _
..!‘
-
C FIREPLAE ..
., •
!„- . - . .
—...ft • . .,
ELECTRICAL: ROUGH FINAL
__...„
!!, PLUMBING: ROUGH ' FINAL ..,...- '
' )
GAS: • ROUGH ' FINAL . .
,••.! .• _
. FINAL BUILDING t ,.. • .-.,
i••,,
,.. - ..
,... ,
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•-z -)'
DATE CLOSED OUT - i i
.-
(
ASSOCIATION PLAN NO. ,...._ : • ,_
, . .
,
.. .
.!
i. .
_ _
•
-` The Commonwealth of Massachusetts
.., ,._ Department of Industrial Accidents
"�- 9 Office of Investigations
'3 -Y — MO Washington Street
Boston ?CIA 0211
.1
www.masLgov/dia
Workers' Compensation Insurance Affidavit Bmlders/ContractorslEIectricians/Plumbers .
Applicant Information Please Print Legibly
Name(BessiOrganizationirndividual)_ 1),,k(A, f— M A 41 l
Address: 10 ` kt P4dAJti r .�
city/state/zip_ 6rA 5 LaA42_ Phone: 1 6�, 21C-- 3 t
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑I am a general contractor and I
employees(full andfor part-time).* have hired the sub-contractors
6. 111 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ']Remodeling
shipand have no employees. These sub-contractors have
8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance$ 9. [11 Building addition
equired.] 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' right of exemption per MGL
comp.. 12.❑Roof repairs
insurance required.]a C.152,§1(4),and we have no 13.0
3❑Other
employees.[No workers'
comp_insurance required.]
'Any applicant:that checks box l oast also fill outthe section below showing their workers'compensation policy information_
lromeowaers who submit this affidavit indicating they are doing all wow 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 bare
employees. lithe sub-contactors have employees,they must provide their workers'comp.policy number.
I ant 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 pt'naltihs of a
fine up to$1,500:00 andfor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fuse
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 pains and penalties ofperjuly that the information provided above is n:e an correct
"--r..? e</-
Sitmature: Date: 2,
r
Phone#: 6 — '128-, 33 [
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/L tense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
_ 6
Information and Instructions ..
Massachusetts General L&.ws chapter 152 requires all employers to provide workers'compensation for their employees.
ParsTan t o this statute,an eaplaye.e is defined as."_.every person in the service of another under any contract of hire,
express or implied,oral or written." - ,
" legalen ortwo or more
ociafi corporation or other entity, any
'r}rTa arCn ass on,
defined as an indivr ersh�, rP
An e,�loyer Ls1,P
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 dweTTrrig 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 maintenancc,construction or repair work on such dwelling house
or on the grduuds or building appurtenant thereto shall not because of such employment be deemed to be an employer?'
MGL chapte0 152,§25C(6),also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or pern.itto 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 or any of its political subdivisions shall
enter into any coltract for the perfOrmance ofpublic work until acceptable evit ence of compliance with.the insurance._
remnrements of this chapter have been present-A to the contracting arrfhority." -
Applicants \
Please out the wo ers'compensation arTdavit completely,ompletely,by ch the boxes that apply to your situation and,if
necessary,supply sub- ntractor(s)name(s),a:ddress(es)and phone numb r(s)along with their ceitiEcatP,(s) of
insurance. Limited Li " Companies(LLC\r Limited Liabrlity-P erships(LLP)with no employees other than the
members or partners,are of required to carry walkers'compensation insurance. If an LLC or LLP does have
employees, a policy is re - Be advised that fi-N afdayitmaybe/ubmitted to the Department of Industrial
•Accidents for confirmation f insurance coverage. �o be sure to sign and date the affidavit \The affidavit should
be returned to the city or to that the appliration for the permit or lie is being requested,not the Department of
Uhlstrial Accidents. Shout ou have any questions re ding the/law or: you are regained to obtain a workers'
cornP ensation policy,please c the Department at the numbber listed below Self-insured comperes should enter their
m self- snan ce lic prise number the appropriate line. \ / '.
City or Town OffiriaisI\ 1 1
Please be sure that the affidavit is complete and printed legibly. The Department provided a spa,'- at the bottom
•
of the affidavit for you to Ell out i tine event the Office ofInjestigatiops has to co tact you regar...c.the applirant
Plrn se be sure to fill is the peg..- ,cense number which /be used as\a reference\umber. In ad.-t on,an applicant
that must submit multiple permit'i . e applications in any given year,n ed only [' one affida . indicating current
policy information(if necessary)an. under"job Site Add- ss"the applicant should ; -t ine"all locatit,. (city or
town)_"A copy of the affidavit that.; been officially ped or marked bye,city town may b provided to the
applirant as proof that a valid affida ' is on file for "ii -permits or licenses. A n-, ..is davit must e filled out each
year.Where a home owner or citizen- obtaining a li .1- or permit not related to an tusiness or •mmercial venture
(ie. a dog license or permit to bum lea;;es eta.)said p on is NOT required to complete - affida
.I sbo :(1 o have an questions,
The Office of Investigations would.him o thank you'� advance for your cooperation an.I �y Y cN- .
please do not hesitate to givens a call .
The Department's a ddress,telephone and r numb- - .
- - Th,Corm wealth of Massachusetts -
Departn t of Ind izial Accidents
Q.CC - f jvestigatio-x
1 FM Washington.Stet
! Bostan,MA Elul 11
- Tel#617 727-490 eat 4€6 or 1-& I IA..SSAFE
Fax#617-727-7749
Revised 4-24-07 - . w w w.ma..s -goof dia
• Town ofarnsfabIe
• Regulatory Services •
ttt�715--
Richard V.Scan,Director
�%ci5! • $�iiingDivis"on
4 •
t scar+� �4• Tom Ferry,Building Commissioner
9 tia� 200 Main Street, Hyannis,MA 02601
4'`rEo bud w w town_barnsiable.ma_us '
Office: 508-8624038 • Fay 508-790-6230
• HOMEOWNER LICENSE ETION
PATE: l2 • Z1 • Zo 1 ".• . .PlcxscPrint
JOB LOCATION 3 0-3-4 AMA - &rit s red-Lt- •
anmbcr \ • stnct age
��pp •
soME6191,M: D#cv�et MV./1 .L( J 'ff- if 2J-- 3'3 t ,
name homcphonc ii workphonc#
� ' 6 Kok3
CURRENT MAILING ADDRESS: ` r,
' city/fawn
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six unitsor less and to allow
•
homeowners to engage an individnal for hire who does notpossess a license,provided that the owner acts as supervisor_
MEF]inrION OR HOMEOWNER .
Person(s)who owns a parcel of land on which helshe resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached strictures accessory to such use and/or farm structures. A person who constructs more than one
' home in a two-year period cT,111 not be considered,a homeowner. -Such"homeowner"cha11 submitto the Building Official on.a.form
acceptable to the Building Official,thathe/she chali be responsible for all such work performed nuderthe buildin!:permit (Section
109.1.1) •
The undersigned`•`homeownef'assumes responsibility for rnmrliarice with the State Budding Code and other applicable codes,
. bylaws,roles and regulations. - •
The undersigned`•`homeowner"c " es that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and r andthat he/she will comply with said procedures and reqchements.
• Signature ofHomco
1
Approval of Bmldrrig Official •
Note: Three-family dwellings contan•,ing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section t27.0 Construction ControL
HOMEOWNER'S EKEllarION
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 1091.1-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 215) 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 caret amend and adopt such a form/certification for use in
your community. .
Q TFI ESTORI dmg permit fhrmsMPRESS.doc
. Revised 0613l3
e , u •
•
•
01.7Tgy Town of Barnstable
Regulatory Services - •
R.szar RYRfp
�^ • Richard V.Scali,Director
Building Division ' •
Tom Perry,BmHing Co,nmmissioner
200 Main Street,Hyam,ic MA.02601 -
www.town.l arnstable.ma.us
•
Office: 508-862 038 Fax 508-790-6230
••
Progeny Owner Mus
Complete and Sign This .ection
If Usin. ABuil. -r
•
•
•
•
I, • ,as Owner of the subject property
hereby authorize to act on my-behalf,
•
in all matters relative to wo author -. .yth;.s building permit application for:
• , - s ofJob)
'`'`Pool fences and . - .3 are the responsibility-of the applicant. Pools
are not to be filed o r utl1 zed bi ore fence is installed and all final
inspections_are pe ere rnmed and a epted..
•
•
Suture of Owner S' tare of Appltrant
•
•
Print Name/1 Print Name • •
Date . l
QFORMS:O WNIERPERIESSIONP00LS
. .
`2)( \AJAk
A e
r '(�OS � c r 6),,,ic,c)
(110) . 161` 0 7c.
lt Z____ efkA-A
TIE -0---
/ wzticlui,- S
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Mad\r) 1 Parcel a .?. ---
A lication # �,�Ja G
p pp
Health Division Date Issued f l
Conservation Division Application Fe i c
Planning Dept. Permit Fee S
Date Definitive Plan Approved by Planning Board 6 1-/-13 f/2
Historic - OKH - Preservation / Hyannis
Project S6C.X.t
reet Address 1 4 nvk &J'Il ,�P 10, oo &O
Village n5 b fry ,, 0,1111.3 b
Owner -Dad(A A.. .( 1 Address ‘. 71741 ripb1 (..Y/, `garnsiet6k 07-)
Telephone 50'3�Lia$,3315
Permit Request t 1,-Q cd1Ulr\ tADOYL Thi a q 6o'(Are- e3 R-X CkSS/Cr`ki a-e /�o/
la 1,P-4- , ��c�are .aa c apace. . Saha,aP"/ 3 u, icad- , 1 512 -
S -1 qi, yi:6izei'v2;&(4_,6) e--p cioskefee4e. ofclie ‘ i r/-' AdetZticidlerinc
I. quare eet: 1 t oor: existing proposed 2nd floor: existing propo ed Total new
Zoning District ics Flood Plain Groundwater Overlay
Project Valuation I ! c(Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
pF 9
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's H ghway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing p new Half: existing 1. new
, � q
Number of Bedrooms: existing _new 4 w p
y
Total Room Count (not including baths): existing new First Floor Roorr. ount
1 -71
Heat Type and Fuel: U Gas ❑ Oil CIElectric ❑ OtherCO .co
Central Air: CI Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:=0 Yea' No
-y
Detached garage: 0 existing ❑ new size_Pool: 0 existing ❑ new size Barn: ❑ ex'sting 0 gewze_'
CO rra
-
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)
Name -)05 k. I'lm1, 1 Telephone Number 1 --q?,S---1,%/
Address I b BM) `-J License # CS 07g�/5-
1 ru--r0 V`A,PK-^�L Oa / /6 Home Improvement Contractor# 9o23S--
/644/99/hr a L- C40/1 - eAL- TifIC 1 Worker's Compensation # (J"CV0,,.37 ,),00
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -?1"eizi ../ 3
(,-t-tw, • ,•11
/1,ei
SIGNATUREDATE 6//' /3
FOR OFFICIAL USE ONLY
APPLICATION#
DATE 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.
•
.+..I wr.. a.v.it., .i.a. . . tta..r rP . CA
c ' CERTIFICA °"'�'"'� °'�""'TE OF LIABILITY INSURANCE 6/4l2013
CERTIFICATE IS ISSUED AS A MATTER OF CONFERS INFORMATION ONLY ATM Ca ND MINI UPON TIRE CERTIFICATE I4OLD;UL TINE
ANITIFICATE DOSS NOT AFFIRMATIVELY on NEAMTYE.Y AMEND. E MMET OR ALTER 1I =mom AFFORDED NY WE PO
BILLOW THIS CERTIRCATE OF IISURANCs DOS NOT CONSTITUTE A CONTRACT BETWEEN THE MUM sousein AU
THORIZED
REPRESENTATIVE OR PRODUCER,NW WM MOTIWICIATE NOLfI&
lithe caracole Wider b am ADDITIONAL'
INSURED.fee ooig3esd mutt be eadwsed. If SUBROGATION IS WAIVED subject to
the term aid conditions of Me Nolen certain%eirds asp require an adonsatnl. A nalement on fete o lEbnie dose eta miler riatms to the
ceitlficete holder In Dies of Mare andoessenoMd.
, COUNTY
INSuRaNcz aammcr mC BEia (978)774-2463
123 Sylvan St I t+*(978)777=8415.
Danvers, IA► 01923 "nonnea
G
-
faflmeet AssaeED aOwDwi wear
Building
,DNuRERA:CCNm1Qr`CQ Ins. Co.
MIRED -ldin Perfacsaaaos Contraats ug, LLC swamD AMEN= Ina. CO..
INSURER C:Atlantic Charter
P.O. Box 533 seueee4ME Jena*
Truro, Ma 02666 INSURER$:
OVERAGES CERTIFICATE NU Eft REVISION NUMBEft
THIS IS TO COMFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN IHSU)TO THE INSURED NAMED ABOVE FOR THE POLICY P8ii0D
NDICA EcD. NOTWITHSTANDING ANY RECOMIBAENT.TETiN OR CONDITION OF ANY CONTRACT OR Mat DOCllToIT WITH RESPECT TO WHICH THE
CERTIFICATE NAY BE ISSUED OR MAY PERrADI,THE DQURANCE AFFORDED BY THE POLICIES DESCRIBED Ltd)IS 51MJECT TO ALL THE TERMS.
EO4CLUSIONSADD CONOMoNS OF SUCH POLICIES_L.DSTS SHOWN MAY HAVE BEBI RIUUC®9YPAESCIAMS.
1111 TYPE OF INSURANCE Rl POLICY MAHER (III IIYOOVI'YY��10 RdIOO I M�I LEM
CENRAL LtAWJTY s 1,000,000
8 CONNERBAL MOW 1141311mr FPEAf19ES(Ea amameee) s 50,000
COAIMS-MoDE a OCCUR NB)Go tAn),an.oenmd i 1,000
I — 3D8 Nnt
9441 11/19/12 11/19/13 risesoeAtroMAURY $ 1,000,000 4
r— GENsat. Amu/Am $ 2,000,000
LELitti AGGREGATE WET APPLIES Pet FR0DuCTS-CDi pAeo s 1,000,000
PO�Y n Ws. 1-1toc s
AUTOMOBILE LIABILITY _ '� S 1,000,000
—
ANYAUM GODLY INJURY(Par p0000) $
AU-1A OWNEDz Auras -
LQ39H3 ersOLYaWeraru�a11 s
NON
2/2/13 2/2/14 plummy-0mMo s
HIRED AUTOS _ attfos (Per fuXiline
s
_ UMBRELLA LMB OCCIA E ACN O -s 2,000,000
,. E UM -- aailsuIDE C�P3904112 5/1/13 �5/1/14 AGGREGATE s 2,000,000
De) 1 I REcreas N4 s;
E9RSIE�! Tin
Y N/A 23/ ]1/23/ F-E s S00,000
v eeyhi mis WCV00939900 =EA®fPLOYEFs 500,000
n T1af Oc OPER IONS Omar Dr8emm-Policy taw s 500,000
xwornao(IF opERATEOE S/LOCAMONST VBSCSES(A AVOIW Or.Aegeantl Remerta SmuisSe.I1 more spec 1s teamed)
C7i rs.,3 ....1.,
RTIFICATE HOMER- CANCELLATIONC w' 0
fir? L. `_
Town of BarnstableSHOULD MY OF THE ABOVE OLICIB3 BE _ ,r^ 4• BEFORE
Barnstable, Ma THE EXPIRATION DATE TI FpRO� WILL F ."=". IN
ACCORDANCE WIiHTHE POLICY ;
AVINORUED TINE =:
I -
01988-2010 ACORD 110t klghts iiiiierved.
I ORD25(2010IC5). The ACOI)name and logo are registered marks of ACORD -
OWNER AUTHORIZATION FORM
P MUA L<(1 t .b,/I,V Kt/A $t �l
(Owner's Name)
owner of the property located at
30-311 MP"& S�
(Property Address)
ri3a/AS Wok MA 02b 30
(Property Address)
hereby authorize (f i Y� �Q !r- Y�t'YLQl V C'� ,
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
Owner's *1 re
i-d?"/3
1/7b
Date
'� The Commonwealth of Massachusetts
—— Department of Industrial Accidents
=' ,_= _ Office of Investigations N
_�'�= R 600 Washington Street
`. - Boston,MA 02111 '
7
,L # � www.snass.gov/dia _ __ ..
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):E1 IIA_ - Y s1124-/ C
t
Address: ‘--P-ZY
City/Sta =/Zip: —17- kYb q,
oc e Phone #: l7 ?-- 7 /
Are y' , an employer?Chec' the a,propriate box:.- •'
contractor and I Type of project(required):,
1. I am a employer with• � �/�- 4. ❑ I am a general
employees(full and/or part- ime).*
have hired the sub-contractors 6. ['New construction
2.❑-I am a sole.proprietororpartner- •. , listed on the attached sheet. ,.7. ❑ Remodeling .,
Thesesub-contractors have
ship and have no employees r8. ❑ Demolition`.`
working for me in any capacity. ; employees and.have workers'
[No workers' comp. insurance _a, comp..insurance.: 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 1'0.0 Electrical repairsfor additions
Y
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. e ,N right of exemptionper MGL 12.❑ Ro epairs
insurance required]t `` ,' c. 152, §1(4),and we have no ���-,, /�
. employees. [No workers' 13. Other
K comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.. '
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: , Gill7c �' ��5:1
Policy#or Self-ins.Lic.#: t'l7�C_V . Expiration Date: 61, da3
7 /,G&/) . '•
Job Site Address:3° City/State/Zip: �` �. ,r
yi
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to securecoverage 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 certi er the pains and enalties erjury that the information provided
//above is true/ and correct. ,
Signature: Date: C71 /_. �.- I
Phone#: lJ - 2:' — .
,,,
Official use only. •Do not write in this area,to be completed by city or town official ' , „ ,, ,
City or Town: ' - Permit/License# u ,
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#:
1
P.
v •:
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 a§"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 indi idual,partnership,association or other legal entity,employing employees. However the
.owner of a dwelling house ha ing not more than three apartments,and who resides there' ,or the occupant of the .
dwelling house of another who,employs persons to do maintenance,construction or re air work on such dwelling house
or on the grounds or building ap.urtenant thereto shall not because of such employ nt be deemed to be an employer."
MGL chapter 152, §25C(6)alsos'.tes that"every state or local licensing agen shall withhold the issuance or
renewal of a license or permit toe ,erate a business or to construct buildin s in the commonwealth for any
applicant who has not produced a k•ceptable evidence of compliance with a insurance coverage required."
Additionally,MGL chapter 152, §25 (7)states"Neither the commonwealt or any of its political subdivisions shall
enter into any contract for the perform=nce of public work until acceptable vidence of compliance with the insurance
have been presented to the contractingautho •
requirements of this chapter t)'• _
Applicants
Please fill out the workers' compensation a fidavit completely,by ecking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), ddress(es).and phon- number(s)along with their certificate(s)of ,
insurance. Limited Liability Companies(LL or Limited Liabi Partnerships(LLP)with no employees other than the '
members or partners,are not required to carry '.rkers' compe ..ation insurance.'If an LLC or LLP does have
employees,a policy is required. Be advised that i is affidavit ay be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be re'to sign and date the affidavit. The affidavit should
be returned to the city or town that the application fe the p•rmit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions eg. ding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the i,. mber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. • ,... ' - w
•
City or Town Officials
Please be sure that the affidavit is complete and printed legi I . The Department has provided a space at the bottom
of the affidavit for you to fill but in the event the9ffice of In stigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license numbe which will b•'used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any give year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the,.pplicant should write"all locations in (city or
town)."A copy of the affidavit that has been /fficially stamped or Irked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or tenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit no,related to any business or commercial venture
(i.e.a dog license or permit to-burn leaves/etc.)said person is NOT requi -d to complete this affidavit. •
The Office of Investigations would 1ike1 othankyou in advance for your co.•.eration and'`should you have any questions,
please do not hesitate to give us a call./ '
The Department's address,telephone land fax number:
The Commonwealth of Massachusett -
,.1 Department of Industrial Accidents •
i Office of Investigations
i 600 Washington Street
Boston,MA 02111 - „y. ,
Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749
Revised 11-22-06 www.mass.gov/dia g- •
K .
• • .
•
•
•
Cire einsioffw &? nnan/u =
` O reof( aee. r - Menne or ingistratims wild for indlehhd use only
before the exphainm date- Iffoand realm toc
fr "` Zypn: OBIoeofCo»Ai irsandI ashler' - :,:
10 Past Plaza-Suite 5170
BUILDING = ,-.. .:-�::- r:;-r Boston,MA02116
JOSH EDMOPE/
1111,
Unuerseensary valid without
•
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License-TDB-078015 _ ?
:rr.
J061NOiD ' -
POBOX633
Truro MA 022666' ;
4 0i _
1rie.a Expiratio
Commissioner -
n44,.
Building Performance Contracting,LLC
Nauset Insulation
P.O.Box 1044 N. Eastham,MA 02651
Phone(774)316.4464 Fax(774)316.4462
Date '1` t
RE: Insulation Permits
Dear Mr Perry, lLWA/aThis affidavit is to certify that all work completed for the insulation work at:3D1`T D1 •
,b(e,
has been inspected by a certified Building Performance Institute(BPI)Inspector.All work performed
meets or exceeds Federal and State requirements.
Respectfully,
mond
CO+"• ..
Co
0-201
e7 3
- Town of Barnstable *Permit#
Expires 6 months from issue date
it
�I,T °� Regulatory Services Fee $ 3
K......ARNsTA7).: Thomas F.Geiler,Director el
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 02 761 " 0 3 .S
Property Address 30,13 4 A eu.,,, c,{- l Bo/hS L A/4\ (32.6 3 v
Residential Value of Work 4 L (000 r Minimum fee of$35.00 for work under$6000.00
Owner's Name
ame&Address ( Vic PVASfit 1 `r Cr.kcus 6ui,leL CI IliZ0 iZ)
30'j-Q Plat& 5 f <kS te.b (c i . Ak 6.26 3 d
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman'sCompensationInsurance XePRE PERMIT
Check one:
❑ I am a sole proprietor •
❑ I am the Homeowner NOV 4 .20�2
❑ I have Worker's Compensation Insurance :
Insurance Company Name ,
TOWN OF SARNSTASLE
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) C 5 CAt-L oc-r 0 At,-, M n
_ nailed)(shipping old shingI'esYAll construction debris will be taken to
Re roof(hurricane ( pp g
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side #of doors.
0 Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
E Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors.License is
required.
SIGNATURE: .—l •
t
•
�oF1HE Town of Barnstable
, , ss,. C r Services
Re ulato y
g
BARNSTABLE, Thomas F. Geiler,Director
� MASSD 163940tom+ `ti g' • Building Division
• Tom.Perry,Building Commissioner
200 Main Street, %lyannis,MA,02601
www.town.barnstabiie.ma.us
Office:. 508 862 4038 Fax 508-790-6230
HOMEOWNER LICENSE.EXEMPTION.`.`
. - Please'P,cin
DATE: 1( H ( 2Ot
•
JOB LOCATION: Dow Nla l rl w- EtivAcia 6/e"
number street village
"HOMEOWNER": v\A Q MUA4c a Jr1-0g- L{2tr' .j 3 / _,
name home phone tl work phone ii
n
CURRENT MAILING ADDRESS: 9' D cif x 37
6ov4,5 b/c ,. AA. 6 Z63o
•
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 4 ,d/or farm structures. A:person who onstructs 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 O'ficial,that he/she shall be resporsibi fir ,411 such work performed under the building permit. (Section
109.1.1)
•
The.undersigned "homeowner" assumes responsibility for compli .:+.c, it;1 the State Building Code and other applicable codes,
bylaws, rules and regulations. .
l
The.undersigned "homeowner"certifies that he/she understands the u Barnstable Building Departmert minimum inspection
procedures and requirements and that he/she will comply with said pro utS:: .:id requirements. ' -
Signature of Horn , 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 suci Homeowner shall act as
supervisor."
Many homeowners who use this exemption are unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for-
Licensing Construction Supervisors,Section 2.15) This lack of awareness ofte;:results,in.::a-ous problems,particularly when the homeowner hires unlicensed persons.
In this case,our Board cannot proceed against the unlicensed person as it would t'ith a licensed Supervisor. The homeowner acting as Supervisor is ultimately
responsible. •
To ensure that the homeowner is fully aware of his/her responsibi'itie' many crnmunities require,as part of the permit application,that the homeowner
certify that he/she understands the responsibilities of a Supervisor. On the last cc•`,f this issue is a form currently used by several towns. You may caret amend and
adopt such.a form/certification for use in your community.
•
I-.
The Commonwealth of Massachusetts
• Department of Industrial Accidents
='lilt=fl Office of Investigations •
EE = • 600 Washington Street
00}}�rr Boston,MA 02111
�,.Eelc
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): �/��fV i(�t J
• •Address: 3 6'1`( ,t \rl
City/State/Zip: got r c 6(t , AA - Phone.#: ` 6:�^. 2 •
.)
Are you an employer? Check the appropriate box: :Type of project(required):. '
1.❑ I am a e to er with 4. Q I am a general contractor and I
y _ 6. Li New contraction .
employees (full and/or part-time).* have hired the Sub-contractors
2.10 I am a sole proprietor or partner- listed.on the attached sheet. 7. [I]Remodeling
ship and have no employees These sub-contractors have '8. Demolition •
•
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp.insurance.t
�,��,, required] • 5. We are a corporation and its 10.❑Electrical repairs or additions
3. 1 I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions
`` `` myself. [No workers'comp. right Of exemption per MGL 12.Q 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.
$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(showingthe 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.
Ido hereby certi under ains and penalties of perjury that the information provided above is true and correct.
Date: i/Si azure: 1! 1 f 2 C� Z •
Phone#: �' �' 2� 3 1
Official use only. Do not write in this area, to be completed by,city or town off 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: ' v Phone#: •
•
Information and Instructions • •
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to .. statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or imp 'ed,oral or written."
An employer is • ..ed as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing el ged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of•6u individual,partnership,association or other legal entity,employing employees. T owever the
• owner of a dwelling ho r e having not more than three apartments and who resides therein,'or the occ t of the
dwelling house of another',ho employs persons to do maintenance,construction or repair work on h dwelling house
or on the grounds or buildin appurtenant thereto shall not because of such employment be deeme be an employer."
,
MGL chapter 152, §25C(6)also tates that"every state or local licensing agency shallwithh d the issuance or
renewal of a license or permit to',•perate a business or to construct buildings in the co ii r onwealth for any
applicant who has not produced.a ceptable evidence of compliance with the insurance overage required."
Additionally,MGL chapter 152, §25 7)states"Neither the commonwealth nor any of it political subdivisions shall
enter into any contract for,the performs ce of public work until acceptable evidence of oliatice with the inEurance
requirements of this chapter have been p _ ented to the contracting authority."
Applicants
•
Please fill out the workers'compensation affida , completely,by checking boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addres> es)and phone numbe 4 along with their certificate(s)of
insurance. Limited Liability Companies'(LLC)or L.s+;ted Liability Partn ships(LLP)with no employees other than the
members or partners,are not required to carry workers' •,.mpensation' ance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affi•• 't may be miffed to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be e to i and date the affidavit. The affidavit should
be returned to the city or town that the application for the pe or cense is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding 6,: law or if you are required to obtain a workers'
• compensation policy,please call the Department at the number below. Self-insured companies should enter their
self-insurance license number on the appropriate line'. ,"
•
City or Town Officials �f j •
Please be sure that the affiiavit is complete and printed°l gibly. The Departme has provided a space at the bottom
of the affidavit for you to fill out in the-ey9 the Office f Investigations has to G.'tact you regarding the applicant. •
Please be sure to fill in the permit/license I. er whi will be used as a reference number. In addition,an applicant ,
that must submit multiple permit/license applications any given year,need only sub co't one affidavit indicating current
policy information(if necessary)and under"Job Sit Address"the applicant should wri i. "all-locations in (city or
town)."A copy of the affidavit that has been ofc' lly stamped or marked by the city or to' .maybe provided to the
applicant as proof that a valid affidavit is on file or future permits or licenses. A new affda'.t must be filled out each
year.Where a home owner or citizen is obtain• g a license or permit not related to any busines' or commercial venture
(i.e.a dog license or permit to bum leaves etc)said person is NOT required to complete this affi 6•vit.
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•anif//fax number:
FThe COMELIOnviralth of Ma e-husetts • ,•
Department of Industrial Accidents •
Office of bavestigat ans
600 Washington Street
• Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-$ -�MASSAFE • ,
Revised 11-22-06 ' Fax#617-727 7749
www.mass.gov/did
Town of Barnstable -
otIHE Regulatory Services
� �5._
•.,�� Thomas F.Geiler,Director
*‘641,659:"
BABI Building Division
PAO Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
PERMIT# 0-0\cDO7e3 FEE: $ j -7;1
SHED REGISTRATION •
200 square feet or less
30 '41f MAIN ST 730.«S -�.t���
Location of shed(address) Village
Muns(711 a., \_ 4-1)ttAor C__
0
Property owner's name Telephone number
Z (1204;') � 03 -
Size of Shed Map/Parcel#
ci 70 I ��`
Signature Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
If over 120 square feet,you must file with Old King's Highway
(t)te.
Conservation Commission(signature is>required)��
Sign off hours for Conservation 8:00-9:30&3:30-4:30 `"`s
PLEASE NOTE: IF YOU ARE WITHIN 1'HE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,'THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
-
THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Vr
&
Q-forms-shedreg
REV:05201
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SP6iri :44' This Plan does not reouire
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• tc 1 a.pproval of the B d Of
.4* the Survey
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BOARD OF SURVEY OF BARgSTAB '••
a MAY 2 9 1959
le' 7;4 0 • PLAN OF LANICD IN
-.*- - S-0-. ,._ •
• \II
/3,._. . (z)"'/-•,,, SARNSTAE5L .
E. MASS.
. G. • ' . ‘-,
D?O 160 Z 5
co,(Hi
704, Town of Barnstable *Permit#
'\� Regulatory Services E-re Snr issue date
{ y
EtARYSTABLE. *'
y aA9S. -
,bj9. ��e Thomas F. Geiler, Director
Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
• www.town.barnstable.ma.us
Office: 508-862-4038
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: 508 790 6230
G Not Valid without Red X-Press Imprint
Map/parcel Number ( -�'p -7 7
Property Address 3 c> 7 q CLi c — f eraw
Yesidential Value of Work no d 0-13 Minimum fee of$35.00 for work under$6000.00
Owner's Name & Address !-F� t1 '73144
Contractor's Name atz. l ,ti..e ,,vti 6) 9-,)6.2...da. Telephone Number , -1';1->77ly
Home Improvement Contractor License#(if applicable) j O(j 4.) Q�
Construction Supervisor's License#(if applicable) / 6 1
❑Workman's Compensation Insurance •
CheI am a sole proprietor S PERMIT
U I am the Homeowner OCT
201
❑ I have Worker's Compensation Insurance
Insurance Company Name TOWN OF BARNSTABLE
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request (check.box)
P4e-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to I y cuvi J
❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof)
❑ Re-side •
of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .35) # of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc.
•
***Note: Property Owner must sign Property Owner Letter`}of Permission.
A copy of the Home Improvement Contractors License & Construction Supervisors License is
required . 647
SIGNATURE:
•
?:\WPFILS\FORMS\building permit forms\EXPRESS.doc
Zevised 072110
The Commonwealth of Massachusetts
Department oflnrlustrialAccidents
r
- �1- Office of Investigations
Iti N- _ 'a.„.::1 600 Washington Street
r ._., , Bostorn, i'LA 02111
rt stn►r.Inass go>>r'rlin
Workers' Compensation Insurance if'fidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusineVrganitatiouufndividual): /-r e . itret ea 0 13 wig-, .
Address: i( 12e
•
City/State/Zip: Cam►n t,J C/ La- Phone#: 5�s �v �1 J 7 �
Are you an employer?Check the appapriate box.: Type of project(required):
l..E. I am a employer with 4. ❑ I am a general contractor and I
loyees(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 stab-contractors have 8_ 0 Demolition
working for me in any capacity. employees and have workers' —
{No workers' comp.insurance comp_insurance..
7 . —Building addition
_ required] 5. ❑ We are.a corporation and:its 10.0 Electrical repairs or additions
3. _ :I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp_ right of exemption per MGL 12.0 Roof repairs
insurance.required.]r c. 152, §1(4), and.we have no
employees. [ND workers' 13..[11 Other
comp_:insurance required.]
*Any applicant that checks box#1.mast also fill out the section below showing their workers'compensation policy information_
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Canlractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities.have
employees. If the sob-contractors have employees,they.urust provide their workers'comp.policy number.
Iam an employer Mat 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,
Ida hereby certify under the p 'ns and pet 1 'es of that the information provided above is true and correct.
Signature: � Date:
9 (2S1/0
Phone#: � "?
Official Use only. Da not write in tins' area,to be conipleted by city or town ofciaL
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#.
6
)pTHEI\
•▪• BARNSTABLE,
"�A'S Town of Barnstable
9�elFD `��
Regulatory Services
Thomas F. Geiler, Director
Building Division
Thomas Perry, CBO
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
kl1 EY 13G/4-1 12 , as Owner of the subject property
hereby authorize Rtegf:'�10e�, e f�C.x+l2 to act on my behalf,
in all matters relative to work authorized by this building permit application for:
307(c miff sr ientv srAike A 0 2 &36
(Address of Job)
•
•
. L t
0.d/0
Signature of Owner Date
*hey gtt
Print Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
•
Q:\WPFILESIFORMS\build_ing permit forms\EXPRESS.doC •
Revised 072110 ;
Ir�r
•
•
ti
Town of Barnstable
�'...,.i.�..::� a�
Regulatory Services
' yABtE
• Ar ;,s. � •
Building Division
Tom Perry, Building Commissioner
��- 200 Main Street, Hyannis, MA 0 601
www.town.barnstable.m,..us
Office: 548-862-4038 Fax: 508-790-6230
HOMEOWNER.LICENS EXEMPTION
Please Pr'. t
•
DATE:
•
JOB LOCATION:
number street village
"HOMEOWNER"
name home phone ' work phone.11
CURRENT MAILNG ADDRESS:
city/town _ state zip code
The current exemption for"homeowners"was extend•d to nclude owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does no.'possess a license,provided that the owner acts as supervisor.
DEF r ITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she re, c`es or intends to reside, on which there is, or is intended to be, a one or two-
family dwelling,attached or detached structures accessary 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 ho; eo er. Such"homeowner"shall submit torthe Building Official on'a form
acceptable to the Building Official, that he/she shall b' respon ible for all such work performed under the building permit. (Section
109,1.1) •
The undersigned"homeowner"assumes responsibil'ty for complia ,ce with the State Building Code and other applicable codes,
and
bylaws, rulesregulations. •
The undersigned"homeowner"certifies that he/s understands the;To a of Barnstable,B,utlding Department minimum inspection
•
procedures and requirements-and that he/she will 'omply Withhsaid-proce res and'requirement's. • -
Signature of Homeowner •
•
Approval of Building Official .
•
Note: Three-family dwellings containing 35;000'cubtcfeet or larger will be r luired to comply with the'State Building Code
Section 127.0 Construction Control.
j� HOMEOWNER'S EXEMPTION
The Code stales that: "Any homeowner performing work for which a building permit is required shall b-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 suckwork,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 caret amend and
adopt such a form/certification for use in your community.
•
Q:\WPFILESIFORMS\building permit forms\EXPRESS.doc
Revised 0721 10 °
r
• :� Office*onmem }fa rrs&Business Kegu a License or registration valid for ir_dividul use only
=_ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
�— Registration: �•100038 Type: Office of Consumer Affairs and Business Regulation
Expiration: .6X8/2012 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
1.1....,-. ,A 0 NDER C. BLAIR -
.lip
Alexander Blair ; ,.,,
192 HARBOR PT ROAD,,, , y- o
CUMMAQUID, MA 02637 d —
Undersecretary Not valid ithout signatire
''" Massachusetts - Department epartmen Public S;tlets
9
Board of Building Regu
lations and Standards
Construction Supervisor License
Lifonse: CS 16187
Restricted to: 00
i
ALEXANDER C BLAIR l x.�
PO BOX 22 .4rTS '
CUMMAQUID, MA 02637
Expiration: 7/16/2011
(uniniissiunrr
Tr#: 17592
, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel ' Application #
i C10s Z `b
Health Division Date Issued ( t
l
Conservation Division 01c Application F J .
Planning Dept. Permit Fee tal®
Date Definitive Plan Approved by Planning Board Fir;
Historic - OKH Preservation/ Hyannis
Project Street Address 2 0 7 4-/ a,f u l-" -
Village 1 J ((2 rA)
Owner i+eAl81 G l3 f i f2 Address
Telephone r--LA `?
Permit Request f?--eiA a. g Cl7'1,• w Q IL 14.4l44--5 0:,
A' hfitoo oze
A' - + (i A-8/4-0L'
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation /v, 5 Construction Type Ai it
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Cl Two Family ❑ Multi-Family(# units) o
Age of Existing Structure Historic House: U Yes ❑ No On Old King's High gt: fEYes ❑ No
co
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other o
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) -c
Number of Baths: Full: existing new Half: existing w u,
-4
Number of Bedrooms: existing _newco
w '
Total Room Count (not including baths): existing new First Floor Room Cout rn
Heat Type and Fuel: ❑ Gas 0 Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: Cl Yes 0 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 Cl Yes ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILLDER OR HOMEOWNER)
Name Ge Girwdt2 (6K,I a Telephone Number 776 re 3
Address i v X 1 L License # C 3 / / S>
awri /vt,y C J. Home Improvement Contractor# /0 OW
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
OCJ ra44.4//
SIGNATURE DATE �3 7/v
FOR OFFICIAL USE ONLY
APPLICATION#
F DATE ISSUED
MAP/pARCEL NO. _ . „
= ADDRESS - VILLAGE
OWNER
`",t•
DATE OF INSPECTION:
3
FOUNDATION s '
FRAME
INSULATION .Ft '
c FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
ROUGH&LA": FINAL
FINAL BUILDING1.4
' 1 DATE CLOSED OUT
ASSOCIATION PLAN NO.
•
,
The Comrtiort}PecLUit of Massachusetts
•
• Deparfrrcertl of Industrial Accidents
I
�l Office of riivesftgaltons
I i s •6 600 FFash.ing-ton Street
�1 r Bosfo)t, AL4 02111
www,tnas,c.gov/dia I
Workers' Compensation Ins arance Affidavit; Builders/Contractors/BI Please
Print uegibl
Applicant Zn formation- ' •
Name (Busbies s/Organization/Tndividual): P — '
•
• Address: 0-60 C o- 2. ?�
City/State/Zip: C ,(/j/l4 Gem
Ara you an employer? Check the Ippropriate bor.. Type of project(required):
1.1 I I am a employer with
4. I am a general contractor and I 6 N w construction
e• mployees (full andl�r part-time),* have hired the sub-contractors i. Rcmodeling
listed on the attached sheet
2.K I a-m a'sole proprietor or partner-
These sub contractors have , —' Demolition
ship and have no eiuployces loyees and have workers'
wormingemp
for me in any capacity. S. C Building addition
w rap. insurance.k
[ND workers'.comp.•insuranec 10.❑•Electrical repairs or addi
r�quircd ] S. W c are a corporation and its
3, I am a homeowner doing all work officers have exercised their I I_` Plrrrnbing repairs or adcL
myself [No workers' comp. z-ight Of exemption per MGL 12 Roof rep airs
rnrance regriired]fi c, 152, §1(4), and we haven() •
• employees. [No workers' 13.,_ Other .
comp, insurance required-] .
*Any applicant that chcelo box{{1 roust also fill out the rcction below showing their worker-Fr' compensation polio'information. • .
t Homeowner who rubmil this a$tdavit indicating they arc doing all work and then hire outsidt contractors must submit a new affidavit indicating r icl
tContraetars !fiat chock this box must attached an additional sheet showing the name of the subcontractors and state whether Err not those entities have
uuplo) , If the sub-contractors have employcar,they must pro-visit their workers'comp. policy member. -
I am art employer Chat is provtdIng workers' compensation insurance for my employees. BeloW is the policy and job sit
' information. .
•
insurancc Coi.upanygamr; . • •
Expiration Date:
•
Policy# or Self-ins, Lie. #: • •
City/Statc/Zip;
Job Site Andress: - •
Attach a copy of the workers' compensation policy declaration.page (showing thapolicy number a.nd•expiralion da
Failure to secure coverage as required under Section 25A of MGL c. 152 can Icad to-the imposition of criminal penalties c
find u_p to 31,500,00 and/or one-year irmprisonmcnt, as well as civil pcnalti•cs in the form of a STOP WORK ORDER and
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 M.A.for insurance coverage verification.
•
-
Tdo hereby certify under the ai s•end pe allies of perjury that the information provided.2bove is true and correct
� V •
Date:S i an attire:
Phone #: Ogr' &—
•
Officers?use only. Do not wri{e in this arco, lb 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 S, Plumbing Inspector
6. Other '
Informatio thcu o Id►ycc..
Massachusetts General Laws chapter 152 requires all employers to1IIrtoo d workers' compensation another for
�on�ac� o
c c person as ... v p
�
defined
J'
ursuant to this
statute an employee is .
express or implied, oral or wnttca."
An an-t 1pyer i9 defined as "an individnAI, partnership, association, corporation or other legal entity, or any two or IDore
joint enterprise, and including the legal representatives of a deceased employer, or the
of the forcgoing•cngagc. in a rP employees. However the
receiver or trusteoof an• *YiduaI, partnership, association or other legal entity, employing
• owner of a dwelling house .ring not more than three apartments and who resides therein, or the occupant of the
dwellinghouse of another wk o employs persons to do maintenance, construction or
cpair work be deemod tn o bc such
dwelling
employer."
house
employment or on the grounds or building a:purtcnant thereto shall not because of
1-SGL chaptc 152,icen e or permit
also sta.. s that"every state or local liccnsi.ng agency shall withhold the issuance or
reneet�a-1 of a:License or permit too•' rate a buslness or ce of ecom linnet prj fh buildings
[nsuranc�°e age requlr d.for any
• appJicazttwho has jrotproduced•acc ��!table widen P y of its political subdivisions shall
Additionally,MGL ohaptcr 152, §2SC( ' states 'Neither the conum►'wcicth nor
or ant of its of do with the urh 11
enter.into any contract for,the performance of public work until a p
. acquirements of this chapter have been pros,■ted to the contracts • authority."
Applicants ifnecessary, supply sub-contractor(s)n�mc
ease fill out the workers' compensation Affida ,'t complctcl , by checking the boxes that apply to your situation and,
Pl ( ), addre•s(cs) and pbona numbcr(s) along with their ccrtifcetc(s) of
s
insurance. Limited Liability Companics.(LLC) or L....ted iability Partnerships an)with
or no empl ocees othere than the
members orparinors, arc not required to carry workc co.•pcosation insurance.
employees, a policy is required. Be advised that this aMD.4•vi.t may
crsub nd dato thc to thc Depaffiartment
of affi savit trial odd
Accidents for confirmation°f insuraninsurancesanec coverage. , .:o e e sure tosign
bo returned to the city or town that thc'application Jr.the p trait or license is being requesters, not the Department of
Industrial Accidents. Should you hav e any clues: ns regar•'tio g
the law ar if you are required to obtain a workcrs'
. co ensation oliey, pl�e call the IDeparture► at the nurrlbci listed below. Self-insured companies should enter their
� p
self-insuranoo License number on the a..rop r ate lino.
• City or ToTrp Officials
da 't is do. •letc and printed legibly. The 'Department has provided a space at the boo
n c affi Yl th
ra
Please be sure th tih
of the affidavit for you to fill out i c cent the Office of Invcstigatioi. has to contact you regarding mpp applicant Please be sure to 511 in the permi 'ccnsc number which will be used as a'cfcrcncc number. In addition, pp that must submit multiple Pe Is' 'ccnsc applications in any given year,nee,. only submit mac affidavit indicating current
olic' information(if poeess. ) and under"Job Site Address" tho applicant d 'hoeuld write "all J�y b P my�dcd (citY or
PY city
thc
��),",�cbpy of the eff�da ,t that has been officially stamped or mar by
a want as proof that a vali,J affidavit is on file for future permits or licenses. ' now a� it ustbbor 1lcd out cac venture
h
PP
year.'Whcro a)iap]c owner or citizen is obtaining a liccns c or p,cn'ntt not related to :-By
(Le. a dog license oz'permit to burn leaves etc.) said person is NOT required to comp etc this affidavit
you in advance foryour cooperation , should you have any Questions,
The Office oflnYcstigabons would like to thank p
please do not hesitate to give us a cal
The Department's address, telephone.and fax number:
The Commonwealth of 3\118ssaGl7ustts
J- partment of Industrial Accidknis .
Q.ffzce of Tn.Ycstigati.aus
• 600 Washington SG.net
Boston, MA 02111
Th1; # 617:727-49-0.0 ex.4.0.6 or 1-877-MA.SSAFE
Fax# 617-727-7749 . . i
Revised 11-22-06 • Vi'WW.rna_s ..gov/di a -
ofTHero „, own of Barnstable
to �Regulatory Services
a{xx5-1x03re, • Thomas F. GeHer, Director
�prFohkg? •��� -. Building Division
Tom Perry, Building Commissioner
• 200 Main Street, Hyannis, MA 02601
www•town.barnstable.me.us
•
Office: 50.8-862-403 8 Pax: 508-790-1
Property Owner Must
Complete and Sign This Section
If Using A Builder
•
He Air l
�l r , as Owner of the subject property
z, , .
hereby authorize ��� ��� &./4-I to act on my behalf,
in all matters relative to work authorized by this building permit application.for: '
30 4/C L./kF9 •
(Addtess of Job)
•
• /)-41/0
signa e of Ow er .Date
•
Print Name •
If Property Owner is applying for permit please complete the Homeowners License
Exemption Poirii on th'e reverse side
r
a
DfTHEro
sy
;pa -r
` own of Barnstable
bl
•
Regulatory Services
' ' • er,
sAxxsuecE, Gi) llirecfor
MAs� $
Building�`rFopi.
a Tom Perry,_13uilding Commissioner.. .
200 Main Street, Hyannis, MA 02601
y,wv.town.barnstable.ma.us
Fax; 508-790 6230
Office; 508-862-4038 _--_____--��—
-- -----c ==—=c===— HOOM.EOW ,R LICENSE EXEMPTION .
incnsc Print
DATE: •
JO13 LOCAT)ON: street village
numb. •
OMEOWN6R": c hone N ._ work phone if
'H hem p
name
CURRENT MAILING ADDRE111111S:.
state zip code
WI . . . . . ,
city/loti+n
for"homedwn...s:" was extended to include owner-occuuied d a a f{•unio less and
The current exemption
to allow homeowners to engage an indi,�,•uaI for hire e�t doe of po`ss sss license,,
supervisor. I5 i k' ITION OF HONIEOWN'ER -
sons who owns a parcel of land •i•which• e/shcresids or;iritends,to reside, on which there is, or is intended to•
l'cr ( )
be, a one or two-family dwelling, att.,bed or der,ehed structures accessory e°considered aa ho°rncownerh.�Suchs, A
person who constructs more than on home>n a ',I.-year period shall
"homeowner" shall submit.to the B `)ding Official .• .a form acceptable to the
9 1 di g Official, that he/she shall be
res.onsible'fortall such.work ierfor fed under the bui'dzn_`}h�crmi • (Section� ( C,
,t 9• t \' i�.R' c
The undersigned "homeowner" as, es responsibility fo, compliance with the State Building Code and other
•
applicable codes, bylaws, rules.an regulations,
i undersigne
d "homeowner"certifies that he/she undersign a the Town of Barnstable Building
procedures and
minimum inspection procedures .Ind requirements and that he/i.e Will comply with
requirements, ‘. `�
Sig-nature of Homeowner
V. l
Approval of Building Official
•
Note: Three-family dwellings containing 35,000 cubic feet or larger wil1•be required to comply with the
State Building Code Section 127.0 ConstruCtion
C• o o1. ,EXEMPT/ON
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from thc.provis ions
of this section
Section 109.1,1 -licensing of construction Supwisors);provided that jf the homeowner engages a person(s)for•hire to do such
. work, that such Homeowner shall Act u supervisor," the res onsibtlilics of a supervisor(sec Apprndiz Q,
Many Homeowners who use this ezerription a're unaware that they arc assuming P
andix ,
en results in
us
ly
wRhen &•Regulations for Licensing Con truction c ons, In this cuc,s;Section our Board can)o proceed against the unli This lack of awareness censed persona snit would w-ith a licensed
when the.Homeo.wnerhira unlicensed p art of the ermil apphcs�on,
Supervisor. The hdmcowr�er acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, asp P
that the homeowner certify that he/she understands the responsibilities
of a of Supusesor. On
r the Iasi page of this issue is a form currcntly used by
or
1
e\ Office of"Cornum f rs iness gulatio License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
__ Registration: -.0.100038 Type: Office of Consumer Affairs and Business Regulation
pp
10 Park Plaza-Suite 5170
Expi
ration: 6/8/2012 Individual
Boston,MA 02116
A •NDER C. BLAIR i.3 = ..-"
F ;
.1?
Alexander Blair i;i,-:
192 HARBOR PT ROAD,,,s.
CUMMAQUID, MA 02637 Undersecretary Not valid without signature
Mass,tchusetts - Department of Public Safetl
Board of Building
Regulations and Standards
Construction Supervisor License
LInse: CS 16187
Restricted to: 00
x".
ALEXANDER C
BLAIR
PO BOX 22 d
CUMMAQUID, MA 02637
Expiration: 7/16/2011
ummisiuner
Tr#: 17592
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>, v\ 0 e ,0 4� This Plan doos not require
�, N 9,1•01 4,j,. , . ,`o the approval of the B d Of Survey \,/
voeci
vQ/- '
BOARD OF SURVLY OF BA '+STAB
•
• 6� oe .
0 MAY 29 1959
'•s, 7 PLAN OF LAND IN
o C`1
,, ...� E�ARNSTAE5LE , MASS.
N CZ
. O BeAc.oNatNc To
ST
.S
r Mois MACAULE.Y 4OWAPQ
.� SCALE I IN =4-.OFr, MAYIS, 195 -
NeLSON Be/NRSe RICJ-ARO LAW YY t
CCNTCRVILLG, MAST •.l ,
i 1774? 1 4 g 1 1
The Commonwealth of Massachusetts
° City\Town of
i'; nI
Barnstable
�
New and Renewal Certificate of Inspection
In accordance with 780 CMR, Chapter 1 (The Sixth Edition of the Massachusetts State Building Code)and Chapter 304 of the Acts of 2004(an Act to further
enhance fire and life safety),this certificate of inspection is issued to the premise or structure or part thereof as herein identified.
Identify Name of Establishment Certificate No.
Issued to DANIEL DAVID HOUSE 304-2007-110
Identify property address including street number, name, city or town and county Certificate Expiration
Located at 3074 MAIN STREET, PO BOX 829 12/31/2007
BARNSTABLE, MA 02630
Basement First Floor Second Floor Third Floor Fourth Floor Other
Use Group
Classification(s) nn
Allowable
Occupant Load
This certificate of inspection is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been
inspected for general fire and life safety features. This certificate shall be framed behind clear glass and\or laminated and posted in a conspicuous place
within the space as directed by the undersigned. Failure to post or tampering with the contents of the certificate is strictly prohibited
Name of Municipal Robert M Crosby Name of Municipal Thomas Perry Date of
Fire Chief BuildingCommissioner
Inspection
Signature of Municipal Signature of Municipal Date of • 6/13/2007
Fire Chief Building Commissioner` Issuance
41HE�° Town of Barnstable
14i� 9••
^ Regulatory Services _
g rY
7NSTAB,` Thomas F. Geiler,Director
D;. Building Division
Thomas Perry, CBO,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
•
April 28, 2005
Barnstable Historic Society,Inc.
3074 Main St.
Barnstable,MA 02668
To Whom It May Concern:
The Barnstable Historic Society, Inc.,presently located at 3074 Main St. in the village of
Barnstable, is a non-profit corporation. Because of the non-profit status they are allowed,under
Chapter 40A, Section 3,to use and occupy this building.
Sincerely,
L15—
Thomas Perry
Building Commissioner
TP/AW
•
. TOWN OF BARNSTABLE
• SIGN PERMIT
PARCEL ID 279 035 GEOBASE ID 18791
ADDRESS 3074 MAIN STREET/RTE 6A ( PHONE
BARNSTABLE ZIP —
t
LOT BLOCK LOT SIZE
DBA DEVELOPMENT , DI ST:RI CT BA
PERMIT 76873 DESCRIPTION 4 SQ & 2 SQ BARNSTABLE 'HISTORICAL SOCIETY
PERMIT TYPE BSIGN TITLE SIGN PERMIT
CONTRACTORS: Department of
ARCHITECTS: Regulatory Services
TOTAL FEES: $25.00
BOND $.00 O*
CONSTRUCTION COSTS $.00
753 MISC. NOT CODED ELSEWHERE 1 PRIVATE 0 _ -
* BARNSTABLE, *
MASS
i63q.
"r� a
7
BUILD G ON
BY v // -� r�.
DATE ISSUED 05/25/2004 . EXPIRATION DATE "
,
• Town of Barnstable
rpHE
royti Regulatory Services
Thomas F.Geiler,Director t _
T&'MAss Building Division / C)
\o c• Tom Perry, Building Commissioner
(�
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us c+- rV
2
Office: 508-862-4038 Fax: 508-790 6230"
V) y
cry
a Wr
I
Tax Collector
6IME C-5- 21.v
Treasurer
����
Application for Sign Permit
Applicant: 13Ary14J S'7 AI3Ze lism io 4 S DG t( l Assessors No. 211 0 5n
Doing Business As: fq M( Telephone No. 3 6a zqO L
Sign Location
Street/Road: 3,97 V MAiiv o�i (Rre (s A) --Bpait,S774gtc
Zoning District: Old Kings Highway? eVo Hyannis Historic District? Yes/1c
Property Owner
Name: Tu 0 ITN Ni , (IA R. .'T- Telephone: 3(.Z- 4 777
Address:9( Wsrtboo0s p�rnOui &or 0?47(Village:
Sign Contractor
Name: NoM fi4 ., SSE' /4ir4G'EO Telephone:
Address: Village:
Description
Please draw a diagram of lot showing location of buildings and existing signs with dimensions,location and size of
the new sign. This should be drawn on the reverse side of this application.
Is the sign to be electrified? Yese (Note:If yes, a wiring permit is required)
I hereby certify that I am the owner or tha I have the authority of the owi---4 make this application,that the
information is correct and that the use and construction hall conform to the provisions of Section 4-3 of the Town of
Barnstable Zoning Ordinance. L
Signature of Owner/Authorized Agent: Date: 3//2/ Y
Size: Permit Fee:
Sign Permit was approved: YEA Disapproved:
Signature of Building Official: r 1t 2t— Date: 2 Vet r
Q.•I WPFILESI SIGNS I SIGNAPP.DOC
e a...et cs-Uc'- c575- 6tit9
21 May 2004
To: Town of Barnstable
Regulatory Services
Building Division
Fr: Barnstable Historical Society
Box 829
Barnstable 02630
Re: Addendum to Application for Sign Permit dtd. 5/21/04
Barnstable Historical Society has leased the historic Daniel Davis House (1739) at 3074
Main Street, Barnstable from Judith M. Barnet, 45 West Woods, Yarmouth Port from
November 2003 through May 2005 with an option to buy. This house is adjacent to the
Sturgis Library and now the headquarters of the Society.
It is desired to have a modest colonial-type sign in front of the structure to announce the
Society's presence. On 10 December 2003, Old Kings Highway Committee approved the
sign and its proposed location and issued a Certificate of Appropriateness.
Attachment A is a copy of the house plat showing the location of the sign in front of the
house. The sign is the same size as that of Sturgis Library to the east.
There was no contractor as the sign was created by an artists' group in Boston to the
specifications described in the copy of OKH Attachment B.
Attachment B, page 2 is a sketch of the sign with smaller "Open" sign to be hung below
Attachment C shows the sign's legend (double sided)
Should the Society be unable to raise the money to purchase the house by the end of the
lease in 2005, the sign would be removed.
Clyde R. Claus, i irector,Barnstable Historical Society
Telephone 375-6468
Tn//ft.>, Bd -=
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o l�
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-CIA (-5.-- ,--..-" , ,ilit 1011,.
'14
�y �o -S Par ;Ili. ® p i .:` ,�� d D' �p� k.r This Plan does not re�,u ifo
tI d = N tj the approval of c�ta );� ,d C,i .;;�rve
Ma jel ro sf•M �� — �� ate. a+
7(,c., --__ V (
Mpr Goner 1( D w • O kJ
lob` ,g.-1 • `r- <.- " (n 4 :#00.1'1" —&276----—"ill " . , ,, .
`j
c-I'''.. 7/ hi •
. BOARD OF SURVEY OF BA1'8''AB
-�'~ 8 _ MAY 2 9 1959
T PL A N OF LAN a I N
"v 7 S .
4 I. O W
�,`�� /35 6� N " "A BARNSTABLE , MASS_
I3AftNSTAQLE GYQrr-e,) F "- R`` A B�Lon.G s.v To
EGISTRY OF DEEDS co''es MoRRI S MACAULEY E-IOWARC)
n
)l_)N:f 1'.}59 )" SCALE I IN=A-O Fr.. MAY 151559
l_:;{_ 1 . 5.5 h1.�4 M NELsowJ BEArtSe kRe t•t rto L ow, SIJRV EYORS
C e r-i-r a Ftv e u t_ . Ms{ss.
•
•
Old King's Highway Committee - Attachment B
Description of Proposed Work: 3074 Main Street, Barnstable
Barnstable Historical Society requests a Certificate of Appropriateness for the
installation of a temporary sign(s) in front of the building for the term of its tenancy
through April 2005. After that date, should the Society purchase the building, it will re-
apply for a permanent sign in the same location.
LEGEND see page 2 of this attachment
SIGNS two-sided wood; painted white with black borders and letters in a style
similar to the sample legend on page 2; two eye hooks inserted at bottom
from which a smaller, removable sign will be hung
SIZES a] main sign: 22" wide by 24" high
• b] bottom sign: 14" wide by 5" high
SUPPORT to be hung from the arm of a white-painted 4 x 4 wooden post
measuring no more than 82" from its top to the ground (assuming arm will
extend out from the post about 10" from its top); see sketch on page 2 of
this attachment
LOCATION parallel to the street, 96" in from the pavement, 48" east of the front
walkway; there is a privet hedge 48" wide at its base that parallels the
pavement; see location marked on Plot Plan
•
. . --....10=011■ 4.-
. • , • , 1
1 •
Old King's Highway Committee • Attachment B, page 7
SUPPORT POST
i 'Zt9
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