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Home My WebLink About0044 GOSNOLD STREET vv � o�<e � / _ _ _ _ � a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Z � l �{0 Map Parcel: Application # Health Division Date Issued Conservation Division Application ` Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/Hyannis Project Street Address 4LA C�sf lcld. SIT- , Village Owner r�C�C� 'r - •v' oc Address 2SE ��►n2:.v-�5 ��'�,.� -�`'� a��S Telephone ! - ZZ 6SZ1 Permit Request 4 'v v'1-Jc_r' C4.�✓v�t��'L( Square feet: list floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil aElectric ❑ Other Central Air: ❑Yes gNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: 0 gxisting 0 new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other•= t6 C Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ l Commercial ❑Yes V No If yes, site plan review# ZC Current Use Proposed Use !° 32 .� ray f" APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number ll'+�_bSS 5E2:1 Address �Cl �"� ` License # G`�M6 t,��,tiL Home Improvement Contractor# a1 Worker's Compensation # `�� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 06e_S_b�� SIGNATURE DATE I ® I�'- I G FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ,.s— r l'-4—� ; r �,;:MAP/PARCEL NO.i,_i '3 ",ADDRESS VILLAGE OWNER _ DATE OF INSPECTION: ti FOUNDATION,! >4- FRAME --A'INSULATION<{ ` y`{ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS -G P F -ROUGH s�'H QiA FINAL - 1 �SFINAL_BUILDING ' ' ,{g .CaC, 4 .4: t - • i. ,. DATE CLOSED._OUTF ; ASSOCIATION PLAN NO. s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 1 I{;•t� . U Boston, MA 02111 c.Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �`� Address: �'— City/State/Zip: Z i UL. Phone #: 'S — (05�-. Are you an employer?Check the appropriate box: Type of project,(required): 1.❑ I am a employer with 4. El am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2`0,,� I am a sole proprietor or partner- listed on the attached sheet. $ � ❑ Remodeling ' Nship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ]0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] . 13.❑Other *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 their workers'comp.policy information. 1 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. Lid: #: + 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, I do hereby certify under the ains a.d penalties of perjury that the information provided above is true and correct Signature: �' Date: ' , t► i Phone 4: Sd S`.L&IS<> Official use only. Do not write in this area,to be completed by city or town official i 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#: 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 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, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall nbLbecause.of such employment be deemed to be an employer." MGL chapter 152, §25C(6)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, MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. 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 and fax number: ",`" .v The Commonwealth of Massachusetts , Department of Industrial Accidents f Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax #.617-727-7749 www.mass.gov/dia Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 °M Boston, Massachusetts 02116 Home Improvement Ctrtor Registration Registration: 127350 Type: Individual Expiration: 10/14/2012 Tr# 205493 P i DERRIC SCOTT DERRIC SCOTT 49 W CENTRAL ST r NATICK, MA 01760 _ r �OwUpdate Address and return card.Mark reason for change. .__ Address ❑ Renewal ❑ Employment Lost Card DPS-CA1 -D 50M-04/04-GGIO12166 Office�fonum� t a�r�u��nes` "fin License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 127350 Type: Office of Consumer Affairs and Business Regulation A " 10 Park Plaza-Suite 5170 ExpirationQ/1 /2012 Individual Boston,MA 02116 D C SCOTT $ DERRIC SCOTT 49 W CENTRAL STD,t- �fa tii NATICK,MA 01760 `' `Y Undersecretary XbTvalid with At signature V - � BOart/ohU'S•f tts-D Re Licen On r c ion S Re melm inn o1�'Uhti('S str�cteato; CS �i0j6 Upervisor s•!nd St.ln 00 License darts. ERRiC s� 49 W CENT ITT RA SAT iCK MA 01�60 Auper z expiration. Try. 412412012 - F . J Town of Barnstable 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 I, &VNF T K V 1 1 ) ,as Owner of the subject property hereby authorize � ' �o to act on my behalf, in all matters relative to work authorized by this building permit application for: &os /VLq Lb (ST, (Address of Job) 4 w107 d Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. I C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 i> N N s 1 S ,-72-ry-) cO -yrr a S---nA�q cY!aM I S i� i