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Home My WebLink About0012 KEEL WAY 1 a keel (.J� f r7 Town of Barnstable *Permit 00 _ v E;pi m 6 Henn issuedate Regulatory Services Fee EL M Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 f www.town.barnstable.ma.us Office: 508-862-4038 1 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESEDENTIAL ONLY !h�l Not Valid without Red X-Press imprint , Map/parcel Number C) Property Address 1 W14yz� i Minimum©Residential Value of Work$ 5J�s �— fee of$35.00 fdr work under$6000.00 i c Owner's Name&Address Tayt gi 141/e ��4 s� ,P 91 It Contractor's Name [i/C 7.0/2, V+ °/ed V, ! A ! Telephone Number 157� p ��►' � � ,1 � /� Home Improvement Contractor License#(if applicable)< ca m.�� Email:l� CM19I1t %�Clb[•i�1/4t 9ly`�)60,041C-157,!�r°' � p Construction Supervisor's License#(if applicable) X-PRESS PERMIT � ❑Workman's Compensation Insurance j Check one: am a sole proprietor S E P 17 2013 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance i Insurance Company Name TOWN OF BARNSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof) ❑ Re-side 02''Replacement Windows/doors/sliders.U-Value 30 (max;munx.35)#of windows #of doors: 0 ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S andinspections 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. Mire A cop requiy of Home Improvement Contractors License&Construction Supervisors License is . SIGNATURE: QAWP=S\FORMS\building permit formsEXPRESS.doc Revised 060513 �r He Commonwealth of Hassachuseffs Department o,f Indushial Accidents Office oftm esstigatians s 600 Washington&S—eet Boston,MA 02111 wt4ryU.l)iassgovldi a Workers' Compensation Insurance Affidavit:Builders/ContractorsMectricians(Plumbers Applicant Information Please Print Le_ihIy Name(B�a�inP' �fion/IndiVidwl): e C cityfStatrJZip /iiP�Atsb� lS'� �'2 b ® Phone 4 �'a 46 2 - 7 /0 Are you an employer?Check the appropriate box: p pT :l Type of. o'ect r 4. I am a contractor and I ��'�= 1.El I am a employer with tt 6_ [—]New ctinstnxtion employees{full,and/or part-time).* have hired the sub-contractors 2-[KI am a sole propaetor or partner listed on the attached sheet +7- ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition. w for me in an c ci ,_ employees and have workers' working Y ap'a � $ 9_ ❑Building addition [No workers' comp.insurance comp-insurance required] 5. ❑ Vtre are a corporation and its 10-0 Electrical repairs or additions 3-❑ I am a homeowner doing all wcTk officers have exercised their 11_.0 Plumbing repairs or additions myself. [No workers'comp- right of exemption per MGL 12_❑Roof repairs insurance id,]b c.152,§1(4),and we have no 13..�t?the employees.[No works' comp-insurance required.] *Any apptic=that checks box#I mast also fin out the section below showing they wolkesa'compensation policy imflmution- TI,Homeownem who submit this afddxvit indicsfmg trey we doing all woa:k and then hire outside contactors mn submit anew affidavit indicating such- XContcwmrs that check this boar must attached an additional sheet showing the Dame of @le sob-Lazit2ctDrs and state whether ornot those entities have exopkoyees. If the sub-contactors line employees,they must pmuide their workers'comp.policy number. lam an employer that.is providing workers'compensation insurance for my emp&iyem Below is the policy and job site information. Insurance Company Name: Policy 9 or Self-its.Lic-#: Expiration Date: Job Site Address: City/State/Zip: Attach a ropy of the workers'compensation policy declaration page(shoming 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 31,500.00 and/or one-year inTrisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fiw of up to S250-00 a day against the violator- Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA liar insurance coverage vetiEcation- I do hereby certify under the 'ns andpenaWas ofpetyury thattdte information provided above is true and correct DateZ Phone#: 3-49 ©,;fj`uzaI use only. Do not write in this area,to be completed by cio or town o i'ciaL City or Town: PerndtUcense# Issuing Authority,(circle one): 1.Board of Health 2.Budding Department 3.CityfI own Clerk 4.Electrical Inspector 5.P'lumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 not because 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 certificates)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 burn 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: The Commonwealth of Massachusetts Depait=nt of Industrial Accidents Office of kyestigatioas 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-M-MASS F'B R.vised 4-24-07 Fax#617-727-7749 - www.mass.gov/dia oFE r Town of Barnstable Regulatory Services &AR'&M E hrnss. Thomas F. Geiler,Director 0;9;{16 Building Division Tom Perry,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 oYC6 cW A EL S �U64,/N�/al as Owner of the subject property hereby authorize IY 1 C To12 W P I M i K R 1 K-E to act on my behalf, in all matters relative to work authorized by this building permit WA y 11YA N>VIS (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of ner Signa of Applicant t � �Y Print Name Print Name f 113 Da Q:F0RMS:0WNERPEFMSSI0NP00LS 62012 �WHE� Town of Barnstable ' Regulatory Services hUM'dB Thomas F.Geiler,Director AN Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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 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 minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. 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 Cont<ol. 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 t amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content0utlook\QRE6ZUBNIEXPRESS.doc Revised 053012 Massachusetts - Department of Public Safety> Board of.Building Regulations and Standards Supervisor Construction Su isor j � � License: CS-000.998 VICTOR J WHN1tWN- .P.O BOX 69 s W BARNSTABLEMN Expiration 09/29/2015 Commissioner •' C��e�p'oo�vnwaacuea�c�C✓/UCCWdacfruae(C _ Office of Consumer Affair§&Business Regulation ; OME IMPROVEMENT CONTRACTOR egistration 100053 Type: j ;%Expiration 6/8/�014 Individual - VICTOR J.WIINIKAIENi1 Ili Victor Wiinikainen 58 CAPE COD LN " BARNSTABLE,MA j Undersecretary � 9 % u Massachusetts -Department of Public Safety' Board of.Building Regulations and Standards Construction Supervisor License: CS-000998 VICTOR J WE NIA PO BOX 69 ' W BARNSTABLE M0 Expiration I .Commissioner 09/29/2015 License or registration valid for individul use only j before the"expiration date. If found return to: -Office-of Consumer'Affairs and Business`iceguiation` - 10 Park Plaza-Suite 5170 Boston,MA 02116 ' Not valid without signature I I ' r�- X-PRESS PERMIT Town of Barnstable *Permit#2 ` Expires 6 jron issue date Regulatory Services Fee • 1ARNSTMIA • TOW ` pro R _TAILS Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town barmtable.ma.us Office: 508-862-4038 Fax:.508-790-6230 ]EXWESS PERAHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address L Z- residential Value of Work�21 CS cP Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address '6 gA,,y,,,W T& C I Y i—e- Contractor's Name V�WoA & /At'V Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 499 ❑Workman's Compensation Insurance Checc one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑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 ❑ SmokelCarbon 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 require SIGNATURE: The Crrmmoms�ea th to,f Massachusetts Dement o,f'lndwhid ccideids Office o,;f Invesfigations 600 Washington Street Boston,H4#211.1 wn-ry namgm1dia l leers' Camp,nsafim Insurance Affidavit B��ders/Cuniractnrs/E.lecfricians/Phimbers Apphcant Infarmatian Pease Print Lem 1I Name o: V)c.�i Addrm: rg 64�9 coo City/StatelZtp:SAA�YS71'045,;M oaiAa . PEoneik Are you an employer?Che&the appropriate box; Type of project(rewired): 1.❑ I am a employer with 4. ❑ I am a general coafxactor and I b_ ❑New con tnxtion employees(full aradlor part-time)-* have hired the sub-contractors 2. ram a safe paroprie4oi txpartazes- listed an the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g- ❑Demolition Wcddn.g for me in any capacity- employees and have vrodcers' 9 ❑B g addition IN-o w,od cars'Comp.insurance comp_insurance— required] 5. ❑ We are a cntporat�ica and its 10.❑Electrical repairs or additions 3.El I am a hoa;necrwaser doing all wcxck officers bane exercised ffiek i 1_ElPlumbing repairs or adtlitians of exemption e-rlwfGL myself [No workers'camp- I ,and we have no 13.❑Rs of repairpps,�� i�s�ce required,]T c.152, (4) o�vorl`h 13.❑OtherREt!, Cr?V employees- comp.insuranm requires.]. •Any appli�that cheds th box#1 mast also fiA out e section below shavrimmg their warless'caarpensatian policy infallaat cm YY^Homeowners wbo submit this affidavit=Urzdag they—d—g an-at anal rhea hue outside cwtacmrs mast mbmu a new affidavit md=dng mch 'l.II�tiYd'OIS that chx'4 this boa marst amcbed au s&hd-n._I dr—,t shot—g the Dame of the su3r-cmrtractm Dad segue whether ar ncn s'hose entities haee emliloyees. iftbe soh-co/rtmaors haste em*ayees,theramstisiv'aide then workers'tamp.police number; f rrtn an empkygr that is providing.moricers congw ardion insurance for azy auTio;vm Below is the poHir y andiab sits information. . Insurance Company Mamie: Policy-or.rself ins.Lim# Expiration Date: Job Site Address: City/Stzwzip: A€tach a copy of the workers'compensation paUcy dedaratitna page(showing the policy member 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 S 1,500©0 andfor one-yeas'imprisonment,as well as civil penalties in the form of a STOP WORK f}RL1IIZ and a fine of up to$250-00 a day against the violathr. Be advised that a copy of this statement may be forwarded to tie Office of Im-est gafions of the DIA for wsurance coverage vedfimfim i do hereby cc ralydar s nndp$nrr,Tfi$s ofpsty�tnkwat iraraaa#iaa provided nb®,re is true acid correct: � � Phone 7 0,01cial JLW 0111): Do not}mite 61€his area,to be completed by city or t officiaL . City or Town. PermitUcense# Lssaing Anifiarity(circle one): : 1..Board.of Health 2.Budding. Department 3.Q.tyffawn Cleric d.Tlectrical 1 nspector S.Phambmg Inspector 6.User.. :... �xxsrnst E *' �: ,�� Town of Barnstable Regulatory Services Thomas F.Geiler,Director. Building Division Thomas Perry,CBO Building Commissioner 200 Main.Street, Hyannis,MA 02601 www.town.ba rnstable.ma,us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder ' as Owner of the subject'property hereby authori d 'C�� l)A(f ze �l n to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job Signature of Owner Date P 6A6,e� Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on;the reverse side. n-4UrVVTT .,e....:.F.....,acvovcoo.4-- .. .. - . ��oFzr°i1,� Town of Barnstable Regulatory Services t�nxrtstesr>r Thomas F.Geiler,Director 16_19.1HAS9. A1�g' . Fo�{ Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.m.a.us Office:. 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-OccuQied 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.tvhich there is;oris intended to be, a one or two- family dwelling, attached or detached structures accessory to such use and/or farm stnuturesAA 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, by.aws, rules and regulations. Ths undersigned"homeowner"certifies that he/she understands the Town"ofkBamstable Bt ildingQepahrment minimum inspection procedures and.requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 15,000 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 persons)forhirg to do such work;that such Hoineownei shall act as r, 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,m part of the permit application,that the homeowner cei-Ty 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 t amend and adopt such a form/certification for use in your community. . tPorrv�rtoiuvecr`CL a��lcrJaacicoteCCJ j Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration:. ""` 100053 xpiration t;/8%014 ., Type. Individual �. I VICTOR J.WIINIKA'If�'EN Victor Wiinikainen `' n 58 CAP �`�� 0� ➢, ' E COO LN BARNSTABLE, MA 02630 Undersecretary I. ��• N 'lassachusctts- Department of Public S:afet% Board of Buildinh Regulations and Standards _ "Construction.Supervisor License License: CS 998 VICTOR J WIINIKAINEN PO BOX 69 i W BARNSTABLE, MA 02668 /L Expiration: 9/29/2013 ('ununissiuncr Tr#: 2436 License or registration valid for individul use only before the'expiration date. If found return to: ulation Office of Consumer Affairs and Business Reg 10 Park Plaza-Suite 5170 Boston,MA 02116 ` Ir Not valid without signature <I I * - Massachusetts- Department of. Public Safch Board of Building_Rc ;ulations and Standards Construction.Supervisor License License: CS 998 VICTOR J WIINIKAINEN PO BOX 69 W BARNSTABLE, MA 02668 t, Expiration: 9/29/2013 ('ununisviuncr Tr#: 2436 } P � > Town.-of Barnstable *Permitaol�� ExpireX647�,�_ . i Regulatory Services Fee HAM • L+arisraBLa, 9 1619. � 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 Fax: 508-790-6230 E RESS PERMIT APPLICATION - RESIDENTIAL ONLY %1 Not Valid without Red X--Press Imprint Map/parcel Numbe D ee Property.Address l �5, G %4y -1 residential Value of Work . Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address TIC, k /41 J e11A-d K94/�/f_ Contractor's Name V Telephone Number,'f"a —3 9L 6 Home Improvement Contractor License#(if applicable) /011150 1;> X-P rh Construction Supervisor's License#(if applicable) Mi ❑Workman's Compensation Insurance ER 3 2013 Chec e: [111I am a sole proprietor �� ❑ I am the Homeowner Or El have Worker's Compensation Insurance ��`STA Insurance Company Name ' Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing-layers of roof) eRe-side.4cx j l/V(P 4,& X g. �t't GA13 Z, Sr #of doors Replacement Windows/doors/sliders.U-Value (maximum_35)#of windows ❑ 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 i require SIGNATURE: L��V � QAWPF=\.FORMS\building permit forms\E)2RESS.doG Revised 053012 • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street -Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): .y Z•C,1 q*R k !l'/ � Address:-5-9 C O P City/State/Zip g Phone.#: �r& -334Z --� Are you an employer?Check the appropriate box: Type of project(required):. 1.❑ I am a e to er.with 4. ❑ I am a general contractor and I Y 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.D'1~am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling have ship and have no employees These sub-contractors8. ❑ Demolition workingfor me in an capacity. employees and have workers' > Y P h'• $ 9. ❑Building addition [No workers' comp._insurance comp.insurance. required.] 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' comp. right of exemption per MGL 12.❑ oof repairs insurance required.]t . c. 152, §1(4),and we have no a employees. [No workers' 13 ' Other�°C�tf1�c 4�1t,t1j 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. tContractors 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.M 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 statemerit may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce nder th ains and penalties of perjury that the information provided above is true and correct Si afore: c l Date:® 2 ®. _ Phone# Official use only. Do not write in this area,to 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: l Information and Instructions r 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 not because 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 a1cense or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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: The Commolawm1th of Massachusetts Department of industrial Aceidcnts of ee of Investigations T 600 Washington Street Boston, MA 02111 TO. #617-727-4940 ext 406 or 1-977-MASSAFE Fax##617-727-7749 Revised 11-22-06 www.mass..gov/dia Town of Barnstable Regulatory Services MMSMU y Asa Thomas F.Geiler,Director 059. �m '°rfnru►+'' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b a rn sta b l e.m a.u s Office: 508-862-403 8. Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Joy,-CC c/4 LS' as Owner of the sub l property hereby authorize V JC 1"GP2. b611 i N 1 K A N Eli to act on ray behalf, in all matters relative to work authorized.by this building permit: ld " /ZtFL Z04 Y 1/YR wA11 s /* (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted."" A e�r�l. Signature of caner Signature Applicant' ,Ca22� IAIC- tD/Z JD� .GE /1cP geL-5 Print Name Print Name, a113 Date Q:FORM&OWNERPERMISSIONPOOLS 612012 r_ . e�. BIKE r Town of Barnstable "s Regulatory Services BARNSTAB14 • Thomas F.Geiler,Director MAS& 1639' ,�� Building Division TfD MA'1 A Tom Perry,Building Commissioner 200 Main.Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street .village _ .HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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-familydwelling, 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 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 mi imurn.inspection procedures and requirements and that he/she will comply with said procedures and requirements. 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) Thislack 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. Worms:homeexempt Massachusetts Dej►,artmcnt of Public Safety Board of Bgiltling Regulations and Standards Construction Supervisor License License: CS 998 ,x„=, ,, VICTOR J WIINIKAINEN` -* PO BOX 69s H W BARNSTABLE, MA 02668 Expiration: 9/29/2013 Commissioner Tr#: 2436 oa��rzoaacaea i'o� i— Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR a. Type: j egistration 1,00053 Uxpiration:ff-6/8/ i�14 Individual VICTOR J.WIINII4i"4N�t-i} r%•�1 Victor Wiinikainen 58 CAPE COD LN bndersecretary BARNSTABLE,MA.02630 Massachusetts Dcj)artment of Public Safety Board of$gilding Rcl ulations :uid u standards. "Construction Supervisor License License: CS 998 VICTOR J WIINIKAINEN ` j PO BOX 69 k W BARNSTABLE„MA 02668 _ ' Expiration: 9/29/2013 CommissionerTr#: 2436 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 _ . Not valid without signature Ik lI Town of Barnstable *Permitlip # .� Regulatory Services 6,�°nt, gin llwzrid� H�Aus�r�R s . ,b� Thomas F.Geiler,Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstab ld.ma us Office: 508-862-403 8 EXPRESS PERT APPLICATION - RESIDENTIAL.ONLY 508-790-6230 MI Not Valid without Bed X-Press Imprint Map/parcel Number (p Property Address r , '❑Residential Value of Work Minimum ifee of S35.00 far work under S6000.00 Owner's Name&Address Contractor's Name / Telephone Number Home Improvement Contractor License#(if applicable) _ C 2onstruction Supervisor's License#(if applicable) ]Workmen's Compensation Insurance Check one: ❑ I am a sole proprietor❑ I am the.Homeowner I have Worker's Compensation Insurance ^€Qvv isurance Company Name L^ - 'orkman's Comp. Policy#_ � a opy of insurance Compliance Certificate must accompany each permit. :t•mit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of r000 ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value #�of doors (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town departrnent regulations,i.e.Historic,Conservation,etc. ***Note: Property Ownei must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re i 'FILESTORMSIbuilding pe it formslEXPRESS.doc sed 0701.I0 i 9 The Commonwealth of Massachusetts Department of. lndustrialAccidents ItOffice of Invesligations e 600 Washington Street Boston, MA 021.71 �?' www.mass govhlid Workers' Compensation Insurance Affidavit: Builders/Contractors!Electricians/PIumbers Applicant information Please Print LezribIy Name (Business/Crganization/Ind vidual): Address: City/State/Zip: 4 Phone #:_ • G'/7- 7c) ,-�4� . EEII an employer?Check a appropriate box: Type of project(required): a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on'the attached sheet.t y: Remodeling . and have no employees These sub-contractors have S. ❑Demolition king for me in any capacity. workers' comp. insurance. g Building addition workers' comp. insurance 5. ❑ We are a corporation and its ired.] ofFicers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additionslf [No workers'comp. c. 152, §](4), and we have.no I2.❑ Roof repairsance required.] t employees.[No workers' comp..insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and theirworkcrs'comp.pbliry information. I am,an employer that is providing workers compensation insuran cefor my ernplayees Below is the poficy'and job site information. Insurance Company Name; ° Policy#or Self-ins.Lic.#: Expiration Date:_ ®.� Job Site Address: I CA_ > City/State/Zip: /j0Jt-- 0��•-� Attach a copy of the Workers' compensation policy dec aration 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 SI,SOO.00.and/dr one-year imprisonment',as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of `. Investigations of the DL4 for.insr,rance coverage verification. do hereby certify under th and enables of perjury that the informa7ivn provided above is true and correct: i afore: Date: hone#: v Ofcial use only. Do not write in this area;to be camp eted by city or town bffzciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.PIumbing Inspector 6- Dthr•r The Commonwealth ofAfassachuseits Department oflndustria'lAccidents i ,• Office ofInvestigations ij 1 r 600 Washington Street / Boston, MA d2111 www.massggvlrlid Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPIumbers Applicant Information Please Print Le��Iy Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: , Type of project(required): l.❑ 1 am a employer with 4. ❑ I am'a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ Lam a sole pr•aprietor or partrier- listed on the attached sheet �•. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑•Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ' 10.❑Electrical repairs or additions 3.[] I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself, [No workers' comp. c• 152, §](4), and we have no 12.❑ Roof repairs . insurance required] t employees.[No workers' ' comp. insurance required.] 13.❑ Other *Any applicant that checks box f 1 must also fill out the section below showing theirwor3mrs'compensation policy information, t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit it new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contracton and their workers'comp.policy information. Jam-an employer that is providing workers'compensaton insurance for DU employees Below is the policy"and jab site. information. Insurance Company Name: .Policy#or Self-ins. Lic,#: Expiration Date: . Job Site Address: City/StateMp: 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$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and tarred 3igna��re: 'hone#: official use only. Do not write in this area;to be completed by city or town" iaL City.or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other �1 Y 3 ;777 �7 7 ...vc-�� .,f-"�l - x `: '^ , /� r{�>oo� � ✓ 7Qda �l License or reglstrat►on va1►d for►ndrvidul use on... :k x Office of Consumer A air sines Rcgulai401i,unt$ } before the expirat►on date. If found return to. f'c .pry HOME IMPROV MPW CONTRACTOR IQgistration' 159729 Type Office of Cons Affairs and Business Regulation 10 Park Plaza:Sutte 5170 E,MY raEi<o1i 5/27/2012 DBA Boston,MA 02116 T TRAN%R`QTrt)=i C 13UCTION } p �n I TONY TRAM QUINCY MA�b169( ��K �' x N1gt val► tv►thout signature tincgrsecr�x��ry 7; ° i��Bu11�i1ngl2egul$tlon!$r>11d 6 T,-n & Y f e x A kan�ards, �Construcfion d t r s i1pi3rvlsbr'Llcense � tFa k t,1 i a #�. �'; �Y,► L�c�'rtse�GAS 99030�{(y��'��'�`a��M,s��'�w �: _ - 9 •G "Lti y.. Exp � t rya tj -��'3�/29/2012 I�4✓,, '�' ,T a� Phjv R TgNY TRAN 4 e 4 r OIBO X860 4 '' `y G}a!y{�BQSTON+MA .t':I k ��.✓y4�4 +'�/yyY,'• fdrw �iL.*mf C(�'i. g,� F i � ,,ray,�COInI11i3310��11}}8r�1y��,�y�r+i`1 n 1 7 r � HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND;CONFERS NO.RIGHTS UPON THE ERTIFICATE HOLDER. THIS CERTIFICATE DOE'S NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURER 8 AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. 1[MPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(it ) must be endorsed. If SUBROGATION 8 WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement A statement n this certificate does not confer rights to ti1a certificate holder in lieu of such endorsement PRODUCER ` Tran Insurance Agency 1480 A Dorchester Ave Dorchester, MA 02122 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Tony Tran ; Dba Tony Tran Construction 1 Po Box 8804 Boston, MA 02114-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIHCATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co LTR M!OF UISURMC! POLICY NUMBER POLICYEPPEC`M DATE POLICY ievo AncH DAT! A WORKERS COMPENSATION AND MPLLOYERS'LWBILITY � LIMITS E PROPRIETOR/ PARTNERSIID(ECUTIVE OFFICERS ARE: WCL o EXCL❑ 9852518 8/06/2010 8/06/2011 ATUTORY LIMBS OTHER Coverage Applies to MA Operdons Orly. 3. ACF9 ACCIDENT $ 1,000,00 ISEASE POLICY LIMIT $ 1,000,00 ISEASE-EACH EMPLOYEE 1,000,00 DESCRIPTION OF OPERATIONSIVEHICLEW31PECIAL ITEMS RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR TOW TRAN. f CERTIFICATE HOLDER CANCELLATION BILL RYAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE 12 KEEL WAY WIHTE THE POLICY PROVISION& HYANNIS. MA 02601 ALITHORVED REPRESENTATIVE ' i Town of Barnstable y .M_ : Regulatory Services �' Thomas XAM F. GeUer,Director ` l3uildh2g Dj isi0yj Tom Perry,Building Commissioner 200 Main 5trcct Hyamaj,MA 02601 www.to w n.b arns tab l e.ma,us Office: 508-862-4-03 8 Fax: 508-790�230 Propex-ty Owner•Mxxst Complete and Sign This Section If Using A Builder; L r, elo7Al as Owner oftbe subject•proPestp hereby a�orize to act on my behalf '. in all mains relative to work authorized by this bunting perms application for. 4V0• (Address Of b) 2—/0 l ' Signature of / �U Print Name If Property Qwneris applying forpermit lea$e'coia Iet Homeowners License Egempt�On Form on the re P e, the - verse Side*. I � T � Town of Barnstable 0 •• s.laxaT.Rr v; Regulatory Services $ Thomas F.Geller Director ` BuiIding Divisioi3 Tom perry,Building Commissioner 200 Main Street,Hyann:,MA 02601 ' . www.town.barnstable.ma.us Office; 508-862-4-03 8 Fax: 508-790-6230 Propel OviterMus t Complete and Sign This Sec'don If Using A Builder as C>wner of the suhject•propertp hereby authorize to act on rap behalf, in 22 matters re Z&E to work authorized by this buz7ding permit application for. (Address of b) Signature of Date Print Na mP If Property Owner is applying forpermitplease'com p lete.the Homeowners License Exemption Form on :the rever-se side. Assessor's map and lot number ......... SEPTIC / INSTALLED STEM BUST LED E IN COMP Sewage Permit number ............. .. .. ....(�. WITH ARTICLE I( STATENCE ARYC you THE t0� OWN OF BAR SPIAODE 11 TOw" i B9BH9TABLE, i 1639. UUIL I INSPECTOR 9 �. �,�,Q Gil L APPLICATIONFOR PERMIT TO ..........`.�..:............................................................................................................. TYPEOF CONSTRUCTION ............ .. ...............................:..................................................................................... ....... .....:�.................19 .A TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to 'the following iinformation: Location ............. .........., (r /.° .:.. ...!. ..v.................................................. ProposedUse .............T ..... ...........--t-.............................................................................................................. Zoning District ............. ...........................................Fire District ......... ?'ti.. ................................ Name of Owner .. �!� y '� Address /� �/ ��.. ..............`.. ........ .......... ... ......... . .. ..........................'...... Name of Builder ..... � '�. '�'`'!.........................Address ........................................ ...... .: Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ................/I.--/?y... ?`v.........................Foundation ��.�.,-ff Exterior .......... .. ........................Roofing ....... ��............................................... Floors .........................................Interior ........... ................... .............................................. Heatin G'''`"� ......................................Plumbing .......... �:..�...................................................... g .............. ......... ................... Fireplace ..................................................................................Approximate Cost ............X.. ............................... Definitive Plan Approved by Planning Board -------------------_-----------19________. Area .... ..: Q.....9.®....�'.: . Diagram of Lot and Building with Dimensions Fee � a� SUBJECT TO APPROVAL OF BOARD OF HEALTH S, 6 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....fi��:�..�.�-�-�. ......�.............................. Holmes, Eugane No —.q-�797.. Permit for ........... .{�dwell i r4g ........&. ...damk....................................... Locotion --JLZ..Ae aI.]@ay................................. ......................�. ................... ' Holmes ! OwnerEugene —.-----------..—..------- ^ � ' �r��ma ^ , . Type of Construction -------—------ . / _____,_____________,_______ | � - Plot ............................ Lot ___________ � . � . ^ Permit 8,ontes{ ---AQ.V.9pb.%r..5......... 73 . ° - Date of Inspection ------------lg �` ( Dote Completed ----.lg ~� / � f � . 0 � | PERMIT REFUSED � ----~--~------------.. 19 | � . . . ..,------------------------. ( ^:_-----.---.-----.---------. " ......---.--.------~—.-------.-- ----~--.--.-------,~ --.----. ` ^ Approved .................................................. lQ � . � � ^ � —_--------------...-----.--.. . , ---------------------'---^^'' ` } |