Loading...
HomeMy WebLinkAbout0032 GLEN ROAD r ' I I a 311 o � 04 4 b O._ I � 9 -� a — —— — _ _i a �� � o Z � � � � Q � n @ � I \� �- , I iI 6 I -- ,_ -- -. -..�_.� A .* r .� ,�.._ - - _ _ - - - _ _ _ 1 j . - _ tom. � �...� �' � � G �� I i � ,. _ � � _� Town of Barnstable -� • ng �nxuvsrA P,ost::Th�s Card So That it is:Visible`Frorn the St"reet� Approved Plans`Must bye Retained onJob and this Card Must,be Kept M P ,.p Gck K / s 9 6" FPostecl Until Final spection HasBe�enZMade : �� �' Termft Where a Certificateof Occupancy is,Requrd,such Building shall�Not be Occupieduntil a Final Inspect�onhas beenmade Permit No. B-20-674 Applicant Name: Michael Rockwell c/o The House Company Approvals Date Issued: 03/04/2020 Current.Use: Structure Permit Type:. Building-Siding/Windows/Roof/Doors Expiration Date: 09/04/2020 Foundation: Location: 32 GLEN ROAD,HYANNIS Map/Lot; 288-019 Zoning District: RF-1 Sheathing: Owner on Record: CONNOLLY,WILLIAM J III TRUSTEE Contt' A6r Namet,MICHAEL S ROCKWELL Framing: 1 Address: 21 BEECH ROAD #,q� � � x Coritractor Wcense CS=074034 2 WESTON, MA 02493 ? Est. Project Cost: $ 12,000.00 Chimney: Description: Reside house Permit Fee: $61.20 ., Insulation: Pro ect Review Re Fee Paid $61.20 J p Date 3/4/2020 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six onths afterissuance. All work authorized by this permit shall conform to the approved application and ,he approved construction documents for Whit, this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures;shall be in compliance with the local zonmgy"laws'and codes. r Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. � g ?• .. Electrical The Certificate of Occupancy will not be issued until all applicable signs ures by the Building and Fire ar Officials e provided on this permit. Minimum of Five Call Inspections Required for All Construction Work ' ,,Y ,. Service: 1.Foundation or Footing ; Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:. Regulatory Services l", Thomas R. Geffer,Director Building Division v� g Tom Perry,Building Commissioner s6;g. �t0 .200 Main Street, Hyannis,MA 02601 www.town.barnstablean&ns Office: 508-862-4038 Fax: 508-790-6230 APProved: l1A -3 Fee: '_ Permit#: c;W/ 3O !� � HOME OCCUPATION REGISTRATION Date 13 Name: Phone#:��0 Address: c�bt_ 6,:,1 e4�_RA ViIlage: �{71�/� Name of Business: Type 5.f Busines �� SC�/J�'i �014Map/Lot: y is e intent o It section tPow the residents of the.Town of Barnstable to operate a home occupation within single family dwellings,subject to die provisions of Section 4-1.4 of the Zoning ordinance,provided tlhat the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no.increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to.the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated im excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors, electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard: There is no exterior storage or display of materials or equipment.. • There are no commercial vehicles.rel<ited to the Customary Home Occupation,oilier than one van or one pick-up truck not to exceed one ton capacity,and one..trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation •. If the Customary Home Occupation is listed or advertised as a business, die street address shall not be included. • No person shall be employed in die Customary Home Occupation who is not a permanent resident of the dwelling unit I,the unders4pied,have read and agree with the above restrictions for my home occupation I am registering. Applicant Date: i Homeoc.doc Rer.O1/3/08 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission*to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. T DATE: Fill 'n please: W law,ry r APPLICANT'S YOUR NAME/S: �.64.9 ���✓� a y BUSINESS YOUR HOME ADDRESS: bti k 77/ /4 4--) An TELEPHONE # Home Telephone Number NAME OF CORPORATION - . NAME OF NEW BUSINESS c TYPE OF BUSINESS n-IV Pam' CGS IS THIS A HOME OCCUPATIpN?- ES N �— S MAP,PARCEL NUMBER', d Assessin ADPRE SS.OF BUSINESS:: / (. 9) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM ISSION R'S OFFIC This individua has b n'nfor rffi oaprmi requirements that pertain to this type of b � .COMPLY WITH HOME OCCUPATION j�wgi Mnr RULES AND REGULATIONS. FAILURE TO MM — COMPLY MAY WEIJLfi IN FINES. (FCJA BOAR OF HEALTH ` This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: 4� 6 Attn: Marybeth McKenzie From: Deb Beresford Date:July 12, 2013 Good Morning Marybeth Thank you for taking the time to help me get to the bottom of this quest that I have been on with the town since March! Here is a synopsis of what I am trying to do as a home business. I believe all of this falls under the "Cottage Food Laws" as prescribed by the state. • As per the regulations this would be for sale at local farmer's markets • All items are non-potentially hazardous foods(as I have checked with several other local health departments) • 1 will be preparing these items in my home. THERE IS NO COOKING INVOLVED WHATSOEVER. My business is two-fold. • The first would be to premeasure spices for a specific recipe, package them and sell them at the Farmer's Markets with a recipe card. o This requires me to obtain the spices from a wholesale company (which I would probably do no more than quarterly), measure them according to the recipe I am packaging them with and package the recipe and spice pack together o Again, no cooking—just repackaging them • The second would be to "make and bottle" Pure Flavored Extracts for baking and cooking. An extract(or Flavor Concentrate) is made by macerating or percolating an ingredient in a solution of alcohol. o These extracts are made in accordance with FDA regulations to ensure that I am offering extracts and not flavored liquor. (for example the FDA requires you use 13.35 oz vanilla beans per gallon of alcohol and alcohol must be minimum 35%ABV) ■ Typically I would have no more than 5 gallons of liquor on hand at any one time ■ This liquor would be broken down into smaller(more often than not, litre size) bottles for the ingredients to steep(macerate, percolate). One bottle per flavor. ■ They will then be bottled and sold in 4 oz and 8 oz bottles ■ - Because I am using the FDA required recipes,these are not considered drinking alcohol and are strictly used as flavor concentrates Well that's pretty much it in a nutshell. Please let me know if there is any other information that you need from me as I will be very happy to supply you with the answers. Hopefully we can get this permitted and I can sell for the last half of the season's Farmer's Markets. Thanks again for your assistance. Have a great weekend and I look forward to speaking with you next week Deb Beresford Message Page 1 of 1 McKenzie, Marybeth From: McKenzie, Marybeth Sent: Wednesday, July 17, 2013 9:06 AM To: 'Deb Beresford' Cc: McKean, Thomas Subject: RE: Extract Business synopsis Hello Deb Beresford, Here is a list of requirements for the board of health: An address you intend on using is required. A detailed list of what you are packaging. Listing your product as being non potentially hazardous does not meet our requirements. One servsafe certified person. Water source,town or well. Septic or town sewer? Floor plan of kitchen and proximity of bathroom. Does the bathroom have a vent or window. If any of the product is to be refrigerated, then thermometers will be required in the refrigeration unit. A certain area must be designated for storage of product and containers that you are using. Please indicate area on floor plan. If you have a dishwasher a maximum registering thermometer will be required. Sink facilities? Drain board? Soap, paper towels are required for hand washing. Floors walls and ceiling must be clean and washable surfaces. Do you have pets? If you do they must not be in the vicinity while you are prepping or packaging any product. Laundry facilities, if located in the kitchen, can not be used during food prep times. Where are you storing poisonous or toxic materials. please indicated on floor plan. Labeling requirements. State requires ingredients, weight, address it is prepared. You mentioned that you are measuring out product, if you are selling it by weight the scale should be certified.You should check with weights and measures to find out their requirements. Zoning would like a complete inventory list, associated quantities or anticipated volumes to be distributed. If you have any questions please feel free to ask and I have office hours 8-9:30 Tues thru Fri and Tues afternoon at 3:30- 4:30. Sincerely, Marybeth McKenzie R.S. -----Original Message----- From: Deb Beresford [mailto:debberesford@hotmail.com] Sent: Friday,July 12, 2013 4:22 PM To: McKenzie, Marybeth Subject: Extract Business synopsis Hi Marybeth Here is a synopsis of my home-based business-attached. If you could just reply back that you received it, I will look forward to hearing from you when you're back in next week. Thanks again Deb 7/18/2013 T, :1 4r Dear Ms McKenzie Apparently the town's email system is not working because my reply email to you and another town employee bounced back I believe that 1 have included everything that you requested from me in the email for my Extract/Spice business. Please let me know if there is anything else that you need and thank you very much for your assistance Deb Beresford 32 Glen Rd, Hyannis MA 508-771-1462 - - s As per your request: Address: • 32 Glen Rd, Hyannis, MA 02601 Certification: • 1 have been safesery certified and have attached the certificate Producs: I have included a separate list for Zoning Department • For Extracts: o Vanilla Bean,Shredded Coconut, Orange Peel, Lemon Peel, Lime Peel, Anise o Vodka, Potato Vodka, Marker's Mark Bourbon,Tequila o Once the extract ingredients are mixed (as per FDA instructions)they are stored in the alcohol bottles from which the alcohol came and left in the pantry for about 2 months o These extracts will be sold in 4oz food grade amber-colored,capped bottles o I haven't a clue how many will be sold through the various Farmer's Markets. I will have about 100 4-oz bottles to start and certainly hope to sell them all • For Spice Packs: o See attached list of 44 spices o .There will be 1-lb of each on hand at any one time o They will be contained in food grade plastic zip log bags in the pantry storage area • Labeling o I understand all the regulations for safe labeling and have incorporated those requirements into my labeling(weight, ingredients, address, etc) • Measuring o All measurements for the spices are done by the teaspoon or tablespoon not by ounce or weight. They are measured out by what the associated recipe calls for. No scaled required Kitchen Requirements: • I have attached a(very) basic floor plan • Cleaning - o All surfaces,appliances, ceilings,walls and curtains are always kept clean • Storage o Pantry storage off kitchen(noted on plan) o There are no toxic, poisonous or dangerous chemicals involved in this process o Any household products are stored away from prep areas(cellar,workshop etc) • Refrigeration o Nothing requires refrigeration o Always clean • Oven and Stove o No cooking or heating required o Always clean • Dishwasher o Adjustable Thermometer is on the water tank r o The only items that will be washed for the process are knives to cut beans and peels, cutting boards(plastic used for safety reasons),funnels and storage bottles o Always clean • Sink and Counter top o Water Source:town o Sink with same temperature water o Hand Soap, Dish Soap and Paper Towels are all at the sink o Always clean • Bathroom o Proximity of closest one is about 25 feet o Home is on a Septic system (pumped, inspected 1 month ago) o All 3 bathrooms are vented and one has a window • Laundry Facilities o, Located in basement and area away from kitchen • Pets o I have none Basic Floor Plan 32 Glen Rd,Hyannis MA submitted by Deb Beresford �t Family/Dining Windowe 10 x 16 Room Vented Bathroom Bathroom nrccnen tt.� x iz q, Vented.Bathroom D/W Sink Hallway Stairway to basement Storage Pantry 8x3 Workshop Hallway Hallyway to Front Door Living Room , StateFoodSdfety.1 ITM .€n1 1 v-cre £�F`�r�1ynxh� k�`TN'i, MM��??o-��(F�f ?y,� 4+ySyC.,.'Ate, l :j_'"`my'#�F>,Fm„r,�m.,�} S �F39^�`�=96?� h4F �i'i"N,7t� �ar�4ha�,"{�,'°pS �Y '��fl9t�a�>�- r'�Ft4r�`E'b� V ,'''��erF°-,Ft5<� }'1f":+1lyJjwW45 ' HH +x v- y. �h r Lertificate Tra' indmi-ftig ' Issued to Deb Beresford Verify Certificate at www.foodhandlerverification.com for successfully completing the State Food,Safety.cornT'" Safe Food Handling Course Online Course Covers: Food Hazards - • Personal Hygiene - - Cleaning and Sanitizing - - Time and Temperature Regulation • 6UF1 -Q2JYY6 May 24, 20 13 Verification Number Date o Completion(valid 2 years) Christie H.Lewis,Ph.D.,President Provided by StateFoodSafety.com`°" ,j Spice List` `� cf '� 1-lb food-grade zip lock labeled plastic bags for each spice 1. Ajwain, carom seeds (Trachyspermum ammi) 2. Allspice (Pimenta dioica) 3. Anise (Pimpinella anisum) 4. Basil, sweet(Ocimum basilicum) 5. Bay leaf(Laurus nobilis) 6. Caraway (Carum carvi) 7. Cardamom (Elettaria cardamomum) 8. Cayenne pepper(Capsicum annuum) .9. Celery seed (Apium graveolens) 10. Chicory(Cichorium intybus) 11. Chili pepper(Capsicum spp.) 12.`Chives (Allium schoenoprasum) 13. Cilantro, coriander greens, coriander herb (Coriandrum sativum) 14. Cinnamon, Indonesian(Cinnamomum burmannii, Cassia vera) 15. Cinnamon, Saigon or Vietnamese (Cinnamomum loureiroi) 16. Cinnamon, true or Ceylon(Cinnamomum verum, C. zeylanicum) 17. Clove(Syzygium aromaticum) 18. Coriander seed(Coriandrum sativum 19. Cumin (Cuminum cyminum) 20. Dill weed (Anethum graveolens) 21. Fenugreek(Trigonella foenum-graecum) 22. Garlic(Allium sativum) 23. Ginger(Zingiber ofcinale) 24. Juniper berry(Juniperus communis) 25. Lavender(Lavandula spp.) 26. Mace (Myristica fragrans) 27. Marjoram (Origanum mcjora,-aa) 28. Mint, all varieties (Mentha spp.) 29. Mustard, seed.(Brassica juncea) 30.Nigella, kalonji,black caraway, black onion seed (Nigella sativa) 31. Nutmeg(Myristica fragrans) 32. Oregano(Origanum vulgare, O. heracleoticum, and other species) 33..Paprika(Capsicum annuum) 34. Parsley(Petroselinum crispum) 35. Peppercorns: black,white,pink and green(Piper nigrum) 36. Rosemary(Rosmarinus offcinalis) 37. Safflower(Carthamus tinctorius), for yellow color 3 S. Saffron(Crocus sativus) 39. Sage (Salvia offieinalis) 40. Tarragon(Artemisia dracunculus) 41. Thyme(Thymus vulgaris) 42. Thyme, lemon(Thymus X citriodorus) f 43 Turmeric(Curcuma longa) 44. Za'atar(herbs from the genera Origanum, Calamintha, Thymus, and Satureja) These spices will be measured out by the teaspoon and/or tablespoon, in accordance with the specific recipe that accompanies it. They will be,packaged in a food grade zip-lock labeled plastic bag and attached to the recipe card. Let's estimate about 100 of these sold at Farmer's Markets Extract Products: 1. Vanilla Bean 2. Shredded Coconut 3. Orange Peel 4. Lemon Peel S. Lime Peel 6. Anise 7. Vodka 8. Potato Vodka 9. Marker's Mark Bourbon 10. Tequila will have about 100 4-oz bottles to start and certainly hope to sell them all ,..,,w.F fi c.,..... -_?'... ;_ +�, -ti«,.y.. -. '.r ,..:"!,,. .-k �i',YY�� ^t' "^'t7ry.�:`R'?^ ^8=ft, n't' .•r,x• k. .k..; ..� .. ,. .. .... .. a.:,. }-✓,i �.� Y �r. ..... P. i .d'k � �3,�. .:. w?.._tS,� 'J:� �x� ..e.x .Y S .r1 e . f t {{ ;4 o Mfg. �F/ •. ,.e, .,.- / - _ ..._ - x - 'n2i S 4. >� `�ta&a �'t� i°�'i�i£q�,.;J' •I N< �.` Q'. 'p x. ��t. � ,aaxe +"', s IS ®� o*7NEto TOWN OE BAI NSTA.BLE t i BA"STA AFL i NAB& �•� - UILDIHG INSPECTOR o wax a• t Kostas Macheras APPLICATION FOR PERMIT TO ::.......................................................... TYPE OF CONSTRUCTION -Woad Frame home ` �' `�'� ```•• ••••••••••• ............F.g b,...2 Q.,...19..7.3.......19........ TO THE INSPIrCTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... ..Lot #6 Glen Haven Village Glen Rd. � Mass. y ..... .... ..... ..... .... ...... .... ................................................ ProposedUse .............................................'Ti om'e'""'................................................................................................................. Zonm District R. C. - / GI �7 i ✓ g .........Fire District ....... ..j......./..................................................... Name of Owner Kosas'"NTacTieras' Address kg..LT Name of Builder :.:..... .... . :.. :.:..: ....:...::........,..Address ..:............................. Kostas Macheras �'ante"""............................... Nameof Architect .................. ................:..............................Address .:.................................................................................. Number of Rooms ....:......:..:.fz rooms..................................Foundation ...........poured..zement....................................... Exierior Roofing ......:....................... .........stiirigle..,......• asP'�alt........................................................... Floors .................................:.....:............................::............:..:..Interior hard wood sfiee rocTt................................................ Heating ..................................................................................Plumbing ..................... hot air pl.antic.................................................. Fireplace :..................................... ...................,................Approximate Cost y .................. � ...........es 2'2,n00 Definitive Plan Approved by Planning Board ------- Aril 19___49 Diagram of Lot and Building with Dimensions on Plot Plan enclosed SUBJECT TO APPROVAL OF BOARD OF HEALTH 90. 0.0 F,I�,f 0 s ` �/ 1 - i I hereby agree 'to conform .to all the Rules and Reg ions of t J Town of Barnstable regarding the above construction. �r. Nam .... .1?.� L.].... -.' �J.......... Macheras, Kbstgs I _. ry z No 159Q9 : Permit=for .:. one sto ` i s3 ngle*..fandlp."awelling ............. ................................ Location r*len Road ) .. .............. Owner ............... �anns - Kostas. . ..kSacheras. . . ..:, 1 ......... . .. .... . ........ . . Type of Construction ;f e _..r .am;..............,' Plot ....... ................... Lot ........#6................... Permit Granted February 20 73 t .........0.. .......................19 Date of Inspection .............19 Date Completed .... - ;PERMIT`REFUSED i ............................................................ 19 ........................ ....... ................... ..... ....... .................... 1 . ........................................ ...................................... t (� ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................:.. t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 61 Map l Parcel Per # Health Division o n Ll Date Issued Conservation Divi ion G— Fee •�� Tax Collector ' ''' �Z 0 SEPTIC SYSTEM MUST BE Treasurer �ZOa6). INSTALLED IN COMPLIANCE ENVIRONMEKIAL CODE AND TOWN REGULATIONS Project Street Address c;2, T7 Village Owner Address S3 gX '2 Telephone F-( Permit Request ® o 1pt:�4S7_ 34_ e�o Square feet: 1 st floor: existing proposed 3 2nd floor: existing proposed Total new Estimated Project Cos 000 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes W%o On Old King's Highway: ❑Yes �"o Basement Type: d-Eull ❑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: A�3as ❑Oil ❑ Electric ❑Other Central Air: ❑Yes k o 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 BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE • ` 1 FOR OFFICIAL USE ONLY PERMIT NO. Y' 3 c _ 7 DATE ISSUED { MAP/PARCEL NO. Fit ADDRESS ES t VILLAGE OWNER,'- DATE OF INSPECT' ' FOUNDATION Y FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL j> PLUMBING: ROUGH FINAL �t GAS: ROUE + FINAL rr FINAL BUILDING ' +; DATE CLOSED OUT n R c' po +.. `s ai1 ©© 0 ASSOCIATION PLAN . �r r { Yi 'l S i wa, Q- -2 Y- L " �rva�a o� SL FvN DRY -' 1 r { -r i I certify that this property is located CERTIFIED PLOT PLAN in flood hazard Zone C (outside the 500 year flood) as identified by the Depart ,� ment of Housing and Urban Development(HUD) . LOCATION . . 1�!�!r` ?-? �� SCALE .. .:3�r .. .DATE Date ?.,a. PLAN REFERENCE .... . . . . Re .`hand==Surve or . . . . . .. .... . . . . . ....... ... . . CERTIFY TH A T TH E..... .. I certify to its title insurance company SHOWN ON THIS PLAN(S LOCATED ON THE GROUNC that there are_:no -visible encroachments AS SHOWN HEREON . or easements-except as shown and that this plan was prepared under my immediate supervision. DATE THE y�P °� The Town of Barnstable : ROUMSTasc.s. � g Department of Health Safety and Environmental Services 1659. �ATEnMpta`0 Building Division . 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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: Le �0 { E4410Estimated Cost Address of Work: Owner's Name: I ", v Date of Application: 00 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. Date Contractor Name Registration No. OR Da Owner's Name q:forms:Affidav _� "_�' The Commonwealth o Massachusetts —, � f fl - ---� . Department of Industrial Accidents r ' Office of/nsestigations -.�:I 600 Washington Street . " "'Boston,Mass. 02111 Workers' Compensation Insurance Affidavit x e/� r . name: u location: o� �� V0 c •�/1, hone# '` /J �Y O ff l. I am a ho eowner performing all work myself. ❑ I am a sole r rietor and have no one workingin capacity %%%%%%/%%%%%%%/%%%/%%/%%%%%%%/ /O%%%%/%/%%%%%/��%%%/%%%%%%%��/%%/O%%�%%%/�%%/�/�%%%%%�%%%%%�%%%%/% ❑ I am an employer providing workers'compensation for my employees working on this job. :::>:::::; ::::>:::;. ;:.::.....:::>::;.:;:::::::.. .: c46 muany name`... ::............:> ca;: ,. ... . :: :.:::::..: :.::. ...... ::: address: ::.;:..;;:. :,:>::>: city :a>;::;:; mHone# .;:::::::;:.:: ;.;:.:.:::.;::::>:;::::;:... :.. .: 66,,....,:::. ohcv.# tnsurance>co. .... .:...:::: ......:..:...:::::. ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'..compensation polices::::.:::::::.::.:::::::::.::.:::::::::::.::::.::.:::.:::.;;;;»;;:.;::<::.;;;::.: :.::;:>:;;; >:.:.>.,.;>;;>;;;;:;... :.;..:.. . .:.:.:i comnanv name :::::.:::............................ ......... address. .. ; ::. . ...::... .:.;::.. ::. .:.:... ..:.;:.;:::..;:.::.;:::;::;;::<:.<:>::::>::>::>;<::>::>:-.--.. ::.::::>::>:::.:>::;:::::::_:.:;.:.;:.:::>::> ::<:;:::;::>>::>:>::»:.;.>::;:: ::::::::,.'hone C1tY' m .:::::::::::::::::::. tmsnmt e;ca . .:.:. _ . .. cammanwnanYe: :<::> ::;:<>:::>:::;;:: address. an .::.;::....:::.:.. :...:. :.. .:... ...::.::.:...:.::. :..:::::.::.. ctt�- X.,.,:.::.:::::.::.:;.;::..: . :::.:::X....::: :.:.::::. .::::.:.:.::.:: ...... :::...::.:....:::..:.::.:;::::::.:;.;.;::::. ....... :::::.:::::. ......... .......... .......... .....:.::::. :nitfrance.co oli .# %/ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one years'imprisonment a9 wefi a,dvfi penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Offlce of Investigations of the DIA for coverage verification I do hereb under the pains and . o that the information provided above is truo d eorr t. Si tore Date --/�/o — - j . Print name r�e VC c �J ` �/'� Phone# 7 75 7 S l official use only do not write in this area to be completed by city or town official City or town: permitdicense# ❑Building Department • ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire, express or implied, oral.or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance 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 the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investggations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 ESTIMATED PROJECT COST WORKSHEET Value LIVING SPACE square feet X$55/sq. foot= � GARAGE (UNFINISHED) square feet X$25/sq. foot= PORCH square feet X$20/sq. foot= DECK square feet X$15/sq. foot= OTHER square feet X$??/sq. foot= Total Estimated Project Cost U v' 1.990915b Building Division ►� 367 Main Street,Hyannis MA 02601 9 rt319• ��� • �ArEO MP'I� Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commis_ HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 2 number street illage "HOMEOWNER": 6 U41— Df . , r- 3.—T( came home phone# work phone rt CURRENT MAILING ADDRESS: dry/town state up code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner'assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner'certifies that he/she understands the Town of Barnstable Building Department tun inspection r es and requirements and that he/she will comply with said pr es and requirementu— A. v Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors):provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors.Section 2.15) This lack of awareness often results in serious problems.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities.many communities require.as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:FORMS:EXEN9FTV i`1 A�ADssessir's Office(1st floor) Map ' I C �O Parcel (// Permit#- /3%,3 .2--- Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) 2 q� -DAYPN` Date Issued o2 7 - 94� Board of Health(3rd floor)(8:15 9:30/1:00-4:45) r .. .01 MIT BE Engineering Dept. (3rd,floor) House# t _� �t� dQ9 BLED IN. WITHVIROMMEN Ta �� TOWN REGND TOWN OF BARNSTABLE Building Permit Application "Projec Stre$ddress oZ � Village Owner ! V-�G[ �Z_ Address 2 Z(o , d Telephone Permit Request First Floor /5 _ square feet Second Floor /V square feet Estimated Project Cost $ '!7/l f/-10®0 Zoning District Flood Plain Water Protection Lot Size 16 G( �c,, f Grandfathered? Zoning Board of Appeals Authorization Recorded Current Use e-S tDX,ri c Proposed Use Construction Type [ c v ij=.i2 _ Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure a 3 y� Basement Type: Finished Historic House /�� Unfinished Old King's Highway lqD Number of Baths 1 ( No.of Bedrooms Total Room Count(not including baths) �r First Floor 5 Heat Type and Fuel Central Air D Fireplaces 1 Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds f' Other Builder Information Name_ �' Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS LL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE D A BUILDING PERMIT DENIED FOR THE FOLLOWING REASONS) FOR OFFICIAL USE ONLY PERMIT NO. I , DATE ISSUED MAP/PARCEL'NO. , , ADDRESS VILLAGE ` OWNER t + A DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL Y' PLUMBING: ROUGH FINAL GAS: `ROUGH FINAL FINAL BUILDING " c' e ' r4 0�C C� DATE CLOSED OUT W; D ASSOCIATION PLAN NO. I t I P To Date Time !A HI VOU WE OUT M of �7 Phone � /S-- Area Code Number. Extension TELEPHONED LEASE CALL CALLED TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU URGENT RETURNED YOUR CALL Message i �r Operator AMPAD 23-021-200 SETS �JZ] EFFICIENCYe 23-421-400SETS CARBONLESS PHOiVE CALL G A.M. FOR DATE TIME P.M. M PHONED.: ' OF RETURNED;; MPHONE YOUR CALL`,. AREA C DE NU BER EXTEN O •_ A5E CALL MESSAGE WILL CALL AGAIN CAME TO SEE�YOU <: ','M_uTS TO SEE YOU SIGNED ffl IllV@fSpl' 48003 O m "4 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE -_.I 1276 JOB LOCATION Number Street address Section of town "HOMEOWNER" 07-� v .�P�'� _ _. Name Home phone Work phone - PRESENT MAILING ADDRESS `776 Z Via. Cit town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official on a form acQeptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109. 1.1) The undersigned "homeowner" assumes responsibility for compliance with the Stat Building Code and other applicable codes, by-laws, rules and regulations. g tions. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said proca=es and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. 4� 1 February 05, 1996 Ralf Crossen Building Commissioner 367 Main St. Hyannis, MA 02601 Mr. Crossen, This is a statement to acknowlege that I, Tim Fuller of 160 Marston Ave., Hyannis Port, presently have the property at 32 Glen Road, Hyannis Port, under agreement to purchase. Attached is an application for a Building Permit for a Residential Addition. Thank You, Tim Fuller J s i i i I certify that this property is located CERTIFIED PLOT PLAN in flood hazard Zone C (outside the 500 year flood) as identified by the Depart- ment of Housing and Urban Development(HUD) . LOCATION SCALE . .. . .. ... .DATE Date l PLAN REFERENCE �,��•%��:', '�'�, �' `�-''�,"w�':wry . �. .,�. . . . . ... . . . . . . .. . .. .�. . . . . Reg. hand .Surveyor . . . . . . .� . . . . . . . . . . . . . .. . . . . . . . . . . . . . , .. :::. 1 CERTIFY THAT THE :::: . I certify to its title insurance company SHOWN ON THIS PLAN IS LOCATED ON THE GROCND that there are no visible encroachments AS SHOWN HEREON . or easements except as shown and that this plan was prepared under my immediate supervision. DATE . . . r REGISTERED. LAND C�16 C/ a - - r � �r a ` II ,, C rl?CIO ro 771 JI 0 ! ��� k f ' .-x ' _•.� `. ... r q. ...1i•.r ,h .. y .. _ .. ,1.�'1ti..1 114wr.�. ...•; u i :;'�, 'I� I�t�,Y� 1�1,� �; . Q 6��7 7`�; �---'• YA'�vvr�r�f' � /-�t? ��"�i®� dui J +.t', /�/, ��j�•C r ci4� • ii :,ail tltl it :.$ iia ✓,i:` + � ;t Clam! �. 41f,�f 1 i5til vll �� .� t t c ( 1 j fi i l '1w :> (, Y ` as J i`!n$,' 'q5 4 air t , t r } p s� i zr 6f f�,f• � I 10,110{ jjt'pl;r#; H a��:� i t f Vd'�:, q,f ��,'Hj .ts a,'ra rN4' 'r'=J m:: x i a Le .? , .;[, r}�r. �;f,. e kf rtarn N lir j ��jt� ++t'd� �^ik., r E.. � ®®•- �� C � e yy 1� Al W, `4 r(�aa,�y+tl sax # q'+p¢�I r c dY4 L�' - t. ply .e�.hppl+ ,iX.("1 d c 'f a..�:: +. , r erbrS t - 4 , {j. �+IN�", et F I � i, ,� r� I �fl � l}1",=T� �'�i£�;�•f�1�p Fi i``,i +�",F�'7 c k a 13..:'� gar .�" 4*�iA3` i �F `� ': ,®.. Q`�' �� i Ilk � riliw� � ")Il tCry j^�c.�U 41141, � ! t J� • Y y 5 -.}t -� x ` + . r ,g `t, .I ffII �VZ 4 ry- �3��t r'I G=,t+��Pld�ll��1���{���'k 3y�ly.,�,.;.��� .,g,,=y { t�, ��r• � ��' kat J.��� /� / , � 'yc�l yy +�'ti CX. i;�ia �!�rd/• l�.4 roe,, 4 1 »le e� �:M ?� �1; � v � �. Ir � ,�rijl, ;91 '�1 "f d r, �b wj,,. � r=�. t '� ''# �,'� `� •.,�} v _av , r' r I' I ��G� ?11VIf�l�� I�I�tl,�1 I.C�f.#�1t+ � �'�`� L t+"h• "� `sl; ���'�o*��� `fir��.� ,.:v" t ,.3 {r Oil t al,1 a t • k:�" �id4 _� -r,r BSIS II].E t .V tr r F?:*k 'ti .�_ •...V .� l �'tla�ll{'Sill +nx MEAN: k if 4 1 ts sit 92' ry& a VKr'6 o +-i , �j�l��+e {{++�•°�� ���i�� �&�+i"�� 1 '�'1, � a 1� � ii;'�� tt :t i �,.� r �.. i k-dr I.1 .fl 11 1 �41��� ��1�,•h�,l{�..1 ld F I:l .'' (�,� t y ._.4 • � - j� �.A� i�'..Y jilt awl 41 l- j i N .'.' 1 1 ..�.. •„-� 1 1 ri '�� °ap M�°,� 'P .i ,. ( , ,d w • + �I' 1' ,�"���t'1 Lt•p. wf�alJ;�`# n1F �I 1 J',� i-•+��.•ta' ! re'' 1;.�I.,u ,.( •±- .a,. I� jl11� t t The Town of Barnstable . Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02MI O&ce 508.790-6227 Ralph CrW= F= 508-775-33" Building Comte For office use only • - Permit no. Date AFFIDAVIT SOME nuROVEMENTCONTRACTORLAW SUPPLEMENT TO PERwr APPLICATION MGL c. 142A requires that the"n construction,altetatiozM renovation,tegair;modernization,conversion, improvement,removal, demolition, or construction of an addition to any Pry owner 0=zpied building containing at least one but not more than four dwelling units or to====which are z4aartt to such residence or building be done by registered eoutra=rs,with attain c==pdmM along with other Type of Work.-__ Address of Work: Ow•ner.Nantc: tia-�P �— Date of Permit Application: I hereby certify that: Registration is not required for the following rcason(s): Work coduded by taw Job under SI9000 _Building not oww-o atpied Owner Pig oaRt pc=zt Notice is hereby green that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WrrSU1QIiEGIS�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 caner: y`/ 7& / �si� Na Dat-e OR�,+M NfhNE ! The Conttnonlvealth of Massachusetts - Departnuent of Industrial Accidents z�-� ;� : 1� OIIlceol/�est/galloos - • 600 11'ashin im Street ' �\';�-• � Boston.Alas. 02111 Workers' Compensation Insurance.Afftdavit ARnhcant Information: 1'Iease PRiIVT'leg�ly a,�, - , �� � � "� •� name: . kytr, citx !TI/ r, rT`Im--a homeowner performing&I work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ 1 am an employer providing workers' compensation for my employees working on this job.. compi} name: address: citi,: nhone#• insurance co. oR lily# 1 am:,sole proprietor,general contract ,or homeowner isle one)and have hired the contractors listed below who have the following workers' compensation poLces: company name: address• city phone#• cu . .�:_ ycm✓ nrav-?-r.?'- ixe�x + .,�� _ - iav[�yy►QT�3'. .6%?0" ctimpam•name: address: '//City: �'nhone#• u nee co. .# :Atiach additioiial'sheet if rieeessary : —•'Y �'};'.`t,"�•11"++i?7ti# ?•*h{: �•`'' Failure to secure coverage as required under Section 25A of hIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification zn hereby cerrif•�nder'lie pains and esralties otf peryug•that the inforniation provided above is true and correct rev ate tint name 7 25 �s � COs area to be completed by city or town oRcial city or town: permitAleense# nBuilding Department (3Licensing Board ' check if immediate response is required Selectmen's Office �1lealth Department contact person: phone#;. nUther IMwd 1-93 PJA) 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 emplm►ee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An emplityer is defined as an individual, partnership, association.corporation or other ; gal entity, or any two or more of the fore;;=oing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1'52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant,rho has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. I.•—+..,.�-.r►-r.��'rn��"•�.�`,...•,�fl,•:v:•e. .;:. 'i'^�.- ,, - '.y.:.. t • .T. .. _ .its '.a"I:r-''l� —�,,; , .. rr Applicants Please fill in the workers' compensation affidavit completely, by checking the box 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. r.^-^J^•1�rRwPCDp.�7A7't^.aL!�►•7 n. ,..o'+•ew•TR>r!?�uR ... ,. 's � � e ... .. 'y. �1�' '•1, r{F] d c: �.�� �-•i.• .... • ,! : -y" ... •.;:.' - •, .. :.•.. i>. :ir .+..•.•.v".'1 _rr.: ;Sr�t •r.•.S'ii,?i�!3.. n+se',rh , .. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the 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. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. :.,.... �•.r.r:r .� ,: ,••tw . .. -aj...�.. .. .1 T2Y. ..� y. 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) 7274900 ext. 406, 409 or 375