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Home My WebLink About0249 FALMOUTH ROAD/RTE 28 ,� 1 � ' O �J �r tl � i I �.. Engineering Dept.(3rd floor) Map 09 Parcel ,� Permit# r 0 6 House# r Date Issued 9 ® — 60 Fee �� .1wE rq�� MR , TOWN OF BARNSTABLE 'F°"'°''�� Building Permit Application Pro'ec tree Address�S�� Village 6 4 Owner�jvl..� UUc�n,run Address Telephone Permit Request G First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No. 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number �c7 R /(J 9/ —r Address r7 1 e--2+v 6-Sgnn License# rp b(-U� , _ Home Improvement Contractor# �2a z 6 Worker's Compensation#AiC /-3J:)-►!M-J62 B/"L-S7- NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO T—llW)I SIGNATURE DATE76 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) The Commonwealth of? hvuachuticttti J __- v . ;.___--�;_.,- Department of Industrial Accidents ' ` ! Office 01111 1192Aons 600 11 aAinr ton Street Boston,Alas. 02111 `-•. Workers' Compensation Insurance Affidavit �161OGt information• Please PRINT leg jy_,,� � "'"'�•""'"'� �� -- name: locition• city (" r�ei � r}'YWe, phone �e39o� I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity ._.,y..:..�s,t.�^'!"'�!n"'•;•T.""�...>s^ET?+7Arr�+'r!�R1V�1!�.ep*f�+•;R�l�.?�!.a�''��• .�1�,�_��.Y'.•'r{"°�y.....,.s 1 am an employer providing workers' compensation for my employees working on this job. compunv name: `F��1 ti tl ress tom✓ city: M phone#• q incurnnce co t_l ///(�� t►�licy#ac 'ITam a sole proprietor. general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comlinny name: address: city: phone#• inturnnee co 11 lice# �- .. - e _ ._... +rr..ei.« ':?�.v+..�..y.y:...-�,.�.«�^-.Rt'_'`_ iT".>rr••-s•�eb�'�.�,��T?r,7•,�ww�..,�rr,.��..+M.;.—t.=�.sG..:a:.!.-+r..!•:'�r_.+eaoi.T�4�"-..,....._..� company name: address: rite phone#• insurance co Policy# Attach additional sheet if necessary =w—' �' �� t.'`�'"TF { Ir. `+ w• ' � ��y+•��y� -._.:Jrr• i.�. ru � -3,Yj,.-'�.�_.,�.•_.. -., _ ..`�.c:._..e� -.�fY�is�sslt'�.�"Y*�•_YLIOL, Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andior one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement mac be forwarded to the Office of Investigations of the DIA for coverage verification. I do herebr certi tit •r the pai nd pena c of perjun•that the information provided above is true and correct. Si=nature Date 4 Print name ��t �✓� (� Phone# P iicial'use only do not write in this area to be completed by city or to"-n ofricial city or town: permit/license'InBuilding Department Licensing Board. check if immediate response is required OSdectmen•s Office [31{calth Department contact person: phone#• nUther Cre.,:ed 3l9;riA) - r 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 enyplovee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An empinrcrr is defined as an individual. partnership, association. corporation or other legal entity•, or anv two or more the foregoing enga__cd in a joint enterprise, and including the lei-al representatives of a deceased emplover. or the receiver or trustee of an individual partnership. g ) P artnershi , association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling hous or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employdr. MGL cha.pter 152 section 25 also states that even,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 anv 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 ha,, been presented to the contracting authority. vr Applicants Please fill in the workers' compensation affidavit completely, by checking the boa that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that tite 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. Pleasc be sure to fill in the permit/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. Tile 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 Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 AWE : _ The Town of Barnstable �. �' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: /�124 Est.Cost Address of Work: Owner's Name M/l S No t0j,10 Date of Permit Application: I hereby certify that: 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. -K A, nx4lyl -A-tA,� Date Contractor Name Registration No. OR Date Owner's Name ,�T+, ''des �a�n�'�>r::, { ��]'' �' '�•. .S:F1',' ^...- /,. •+�?';' tw ,y"9.�� +:c,. v.,��.aR -q„,;,�, o s�,i�'-� ,,,,�t Gx T � Y ra. � "'lw�� f / / '/ / � ® '� *.1�'�'k" N vM��IX" 4 p e'1M+y{Z�✓y'P'' "1M Ky�} 'r=�+p 1'Y'�"T""K,s •* S¢�.,�,Y K � �4� _ / I I / I ��/ 'e�4 � -n ,^�� '�:�"Y '�+,}a*w .ta�1: "� �"I�i � . � '��h�,�.i�� L".�t ��r .�.A ��. , 4 � �' �� S^14`, y� . .• tj� '� j.��r��y(,b+„ � �-,��.. p,.,. ' apiJy z � ��tR. 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