The URL can be used to link to this page

Home My WebLink About0011 LOOKOUT LANE oo,( .-.Oct .,r I *11* Town of Barnstable Permit PLO Expires 6 months from issue date 0 Regulatory Services Fee 1Zs • f + IARNSTS. -PRESS v� b g Thomas F. Geiler'Director Building Division Tom Perry,CBO, Building Commissioner PEAR 3 Y 2010 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us . - OWN 0,F S,qR/VST q� � Office: 508-862-4038 Fax: 508� O�E�230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number z 2�C16 t Property Address j Zo G kO e Residential Value of Work Minimum fee of 25.00 for work under$6000.00 r Owner's Name &Address C /r! tAA ACJ a �Gc J 57(, RA, Telephone Number �r� `1 Z3 Contractor's Name . C Home Improvement Contractor License#(if applicable) 3 6 3 Construction Supervisor's License#(if applicable) ❑Workman's.Compensation.Insurance fk one: 7 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(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value i . ' (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of 1 e Home Improvement Contractors License&Construction Supervisors License is s e red. SIGNATURE: QAWPFILESTDRMSIbuilding permit forms XPRESS.doc ✓lie Porrvreauueczllfo�i�aaaaclZciaetta Office of Consumer Affairs&Business Regulation License or registration valid for individul use only f HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration r 113834 Office of Consumer Affairs and Business Regulation Expiration: 7/1.9/2011 Tr# 286596 10,Park Plaza-Suite 5170 Type,ndiv duals Boston,MA 02116 I EDWARD H GRANGER'111i, 3j- I EDWARD GRAN GER-fll� 1/ ; - fb-1.'J•' PO BOX 716/50 JONES RDa� MARSTONS MILLS;MAG0264&, << f Undersecretary Not valid witho t sig ture Massuchu'setts- Depal-tnnent of Public SatctY Board of Buildin-' ':Construction Sutgul.ttions and Standards ' pervisor License License: CS 58261 Restricted to: 1'G EDWARp H GRANGER PO BOX 71.6 F MARSTONS MILLS.MA 02648 1 (`ommissione'r. Expiration: 121211201, Tr#: 10809 r l The Commonwealth ofMassachrrsetts Department of Industrial Accidents Office of Investigations ►'_ dOO Washington.Street jti l Boston, MA 02111 rvwm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indivi dual): Address: 'ZO )a-n e_� -Ao Pa ?20Y IN, 5 5 �S d 6 City/State/Zip: Phone M q7i �-3(14 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. El We are a corporation and its ME] Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or addition myself o workers' com right of exemption per MGL y [N p. 12.Q Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box VI 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. tContradtors 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 andjob site information. Insurance Company Name: — Policy# or Self-ins.Lic.#: Expiration Date: Job Site Address: 11 CAO F-d M � City/State/Zip: Yl 11 S Attach a copy of the workers' compensation policy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 fin 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 "nsurance coverage verification. I do hereby cer ' t der th ains and penalties of-perjury that the information provided above is true and correct. Signature: Date: 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): I.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other C'nntart Per.enn' Phone M 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" dividual,partnership, association, corporation or other legal entity;or any two or more of the foregoing engaged in ai joint enterprise, and including-the legal representatives of a deceased employer, or the receiver or trustee of an`indMdual, partnership, association or`otherlegal 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 comonwealth nor any of its political subdivisions shall enter into any contract for-the performance'of public work untim l 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-contractors)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'returiied to the city or town1hat..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 Departmenfat the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sire 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 permiUlicense 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 " Revised 4-24-07 wwwanass.gov/dia i �7NET Town of ]Barnstable Regulatory:Services ♦ • + 5 uRxsrnaLE, Thomas F..Geiler,Director noes. . . Y 1639. 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 Sigi �Tl is`Se'ction If Using A Builder I, FW e y �tk VA+ZA as Owner of the subject property hereby authorize =' W:'A M to'act on my behalf, in'all matters relative to work authorized-by this building permit-applicationjf or. (Address of Job) 1 Signature of Owner Date u-S A R-d j' Print-Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. lei _ 4 Town of Barnstable T Regulatory Services* * Thomas.F. Geiler,Director uxrtsrwst.e. s 9q,P amp Building Division Torn 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 shalf 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 Ho eowner Approval of Building Official Note: Tbree-family dwellings containing 35,000 cub}c 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 roquired 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. cati To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit applion, 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 fonn/certifrcation for use in your community. Q:\WPFILF-S\FDPMS\homrt-xempt-DOC 4 J OpYNE Thy, Town of Barnstable e Erpires 6 nrohths from issue date STAB : Regulatory Services Fee BAM II� Thomas F. Geiler, Director yPIfD�`.,0 Building Division Tom Perry, CBO Building.Commissioner 1 o Y, g 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 3�,5' 16 7 Property Address f//4,' - v [Residential Value of Work Minimum fee of$25.00 for work under S6000.00 Owner's Name& Address ��1�' C ;IT ``"�✓Cf�/tl ztq6 &gdVe 61 , wew5 / fey qzg Contractor's Name ��G�(//�'�� C5 °��y��G— Telephone Number aj Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 5& Z I X-PRESS PERMIT ❑Workman's Compensation Insurance Ctyeck one: S E P 16 2009 I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [Replacement Windows. U-Value (maximum .44) "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. Ho e Impro ement Contractors License & Construct Supervisors License is required. SIGNATURE: Q:\WPFILES\FOR'MS\Express\EXP ESSPER T.DOC Revise060409 �l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �3 Y 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): Address: —� /t/e(O - (- f �� 01l�S�� City/State/Zip: Phone #: �� ✓�`''� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 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.❑ Roof repairs insurance required.].t c. 152, §1(4),and we have no 13.9 Other �e�lqt:e mea' employees. [No workers' comp. insurance required.] V/1 Alp 0� *Any applicant that checks box#I 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 andjob site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: �oO)taUj LAJ City/State/Zip: H ,1 h w 6 z-�® / 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 nder,theL�Insand penalties of perjury that the information provided above is true and correct. Signature: Date: // G Phone M 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#: 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,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, §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 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.tnass.g ov/dia �ZHE I•o Town of Barnstable ,d Regulatory Services �$"M �'g,` Thomas F.Geiler,Director '�fo►ray. 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 E 'N n til-g W_n ( as Owner of the property subject J P P nY hereby authorize -A R-4 On A .A) Ca to act on mybehalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date [4G A]R �v S A Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMIS SIGN Town of Barnstable Regulatory Services BARNMBLE Thomas F.Geiler,Director MAss. 9q, .ezq. �� Building Division ArEo � 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 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 t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORM S\homeexempt.DOC - ✓�ie 1°anintooacueaC ��Cwoac�ivaeCld ) Office of Consumer Affairs ' usiness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:h" .,113834 Office of Consumer Affairs and Business Regulation Expiration: 7/19/2011 Tr# 286596 10,Park Plaza-Suite 5170 Type r, Individual.= r„ Boston,MA 0211ti EDWARD H GRANGERrlll EDWARD GRANGER _ PO BOX 716150 MARSTONS MILLS;MA<02648! Undersecretary `= L= Not valid witho t sigodure t Board of Building oils andand.-Standards y Construction Supervisor License 3 License: CS 58261 / Expiration 12/21/2009 Tr# 9724 s ExRestion Gr G EDWARD:H GRANGER €- PO BOX 716 MARSTONS MILLS,MA 2648 Commissioner I Assessor's office(1st Floor): 1 Assessor's map and lot number a J /� -�' �Pyoi TN[ Conservation(4th Floor): Board of Health(3rd floor): - • Sewage Permit number =' s�"�it ' 1639. Engineering Department(3rd floor): .µ House number Definitive Plan Approved by Planning Board 19 + APPLICATIONS PROCESSED 8:30 a 9:30 A.M.,and 1:00-2:00 P.M.only ' TOWN OF BARNSTABLE 'BUILDING ( INSPECTOR I k . APPLICATION FOR!PERMIT TO Re—roof } TYPE OF CONSTRUCTION R =�Lo 19 94 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Lookout -tee N3APnni c ., MA _ (1?6ni Proposed Use NA Zoning District $B Fire District gyarl1}i s g i r(Q—D 4 s t is tr Name of Owner Henry Lu,fardi Address Lookout Drive ;/ v*N-4,S Name of Builder St .Peter Builders Address 3715 Main St . Barnstable Name of Architect NA Address Number of Rooms NA Foundation NA Exterior Roofing B i t e c Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost l/� G Area Diagram of Lot and Building with Dimensions Fee y�< OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construct' Name Construction Siipervisor's License � y�v LUGARDI, HENRY No 36588 Permit For Re-ROOF Single Family Dwelling Location 11 Lookout Lane Hyannis , Owner, Henry Luaardi Type of Construction Frame Plot Lot Permit Granted Apr i 1 4 , 19 9 4 Date of Inspection: ,e Frame 19 Insulation 19 - Fireplace 19 Date Completed 19 • r • r v v r r i r _ i \�-.� 0 i;OSTOi , }�L2S$/,�i3�S�-�-S 02113 -W,0RXFRS'COMPENSA-n0N INSURANCEAFFMAVI3 :• .rich s prinapal plsccofbusin=lrc6dcnccat: . _ LC3 do hereby ecr 6—.under the ins and <=7ujy% du,: p2 paralrxx ofpajur�; zlut~ [] I =m an cmplovcr providing the following workcrs'compcnSazion covc2Sc formYcmpl job. oyccs orl;irs oOni< Insur2ncc Company Policy Numbcr 6-I 2m 2 Solc proAricrornnd hew nooncworking for me [) l zm 2 soft proprietor_gCnc.J cones--aor or homcowncr(cizdc onc)end hrvc hired the concrscrors iiszcd bcIo• �-hoo h-zzvvc zhc foIIow nn iagwork,=:-compction insur�m politics: - L I 1A eA 36 1T�mc of Conti aor Insur.-ncc Companylpolicr Nzmbcr I4mc ofContraor Insu.mncc Cornp:nylpolicy Ncmbcr Izmc ofConu_aor r'-... 1Poiicy I.r%=2rcc , Nam la homcok-ncr Pcrf0m,ing ill 6<work myscf- crVploypcfccc:to Lo rtiictct 1—c1l.nZofnotror<L�Lr<caCitrit�" L �u.<StritVCtl�Ccctrc�iif��v�.Col7: nr..-J«<2 t0 'C L<�ctzca••r<r s1�o fcr:lct oc cc t�<FtCVtlt XPP-'Lcc=t Utt<tO1K OOC Lr<O<tm�• b<crrplcy<n`Lcr i�cac�-<u'Cc.�Pc::_t;o /Sec�CL C]52,«c J Of perr„t r'_r<h�<c«t='c 1<rJ r::r.•,cf�cr-_lover q:czcr a Lac (5)). c7�<ppl:rtico by[bCcxc•-a<f roe] TK<DS< <oF*ci t_::::,< <r.«Za;<c.a N-cr'ft_<ic� S«vcr, fin<cfvr ccSJSee.Ge�.L�cr:-;r�crr_.ctcry tocrc o _olGYt752c=1c:�tot�cir..pct:c::r,cf ra;r,�P«=3uc P Y - r- z dt S(,c t7C&Or<-<r c�� Since- this 79 I_.iccn:cclPcr lztcc Liccn:orlPcm, ;tzor f j� i I � 1 t 8£92.8 VM aluely aolvaisw)wov tg xog 'IaaalS weld S F salad 'IS '3 AaluPIS 067£Z798 u,ot;eJtdx3 1VfIOIAIONI.: - adAl IZ888I uotaerIST&id S 13V81NO3 1NMAOMI 3NOH COMMONWEALTH i DEPARTMENT OF PUBLIC SAFETY F_)tauotO potssasacnrrent `—� ,4.,�_.,oac�;;;s®ttsatafo8ui/ding ® OF ONE ON,IAA TON PLACE � BOSTON,IAA 02108 Gcdalac.•:�ra6/orrsrocation r MASSACHUSETTS ut irds/Icraae. I_I C EN SE CAUTION EXPIRATION DATE CONSTR. SUPERVISOR FOR PROTECTION AGAINST 06/20/1995 -. 7 EFFECTIVE DATE LIC-NO. THEFT, PUT RIGHT THUMB RESTRICTIONS 4: ': PRINT IN APPROPRIATE NONE o 06/30/1993 00034b 8 BOX ON LICENSE.. 0 STANLEY STPETER °3691 MAIN 2 BLASTING OPERATORS z BARNSTABLE MA 02630 m MUST INCLUDE PHOTO. m PHOTO(BLASTING JONLI �F�O.00 u NOT VALIf»JNTIL SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER . ��'� SIGN NAME IN FULL ABOVE SIGNATURE LINE THIS DOCUMENT MUST BE SIGNATURE OF LICENSEE CARRIEDON THE PERSON OF THE HOLDER WHEN_N• ONER OTHERS-RIGHT THGAGED INTHISOCCUPATPN. I � ' �oOHE roy� Town of Barnstable *Permit# yP O� apires 6 months from issue date ,RNAB,� : egulatory Services Fee as, D . MASS. gym° Tho as F.Geiler,Director GpA i639. B ilding Division �►� Peter F.D atteo, Building Commissioner 200 M Street, Hyannis,MA 02601 Office: 508-86 -40382 �. �qR 2 f'r Fax: 508-790-6 30 V `D owiv 0 200 EXPRESS P T APPLICATION - RESIDENTIAL Ol ,q Not Valid without Red X--Press bnprint R^lS'rq `F Map/parcel Number — O �L—e Property Address) 1 y L4OkV6 7 44AyC , 10-4 /il IS [<esidential Value of Work . 7 975 ' Owner's Name&Address 0/,?. 970 "IAI S'T a167, reS'T,6 p, /17i� ®/6VT Contractor's N elephone Number ro Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) G S OS'8 E�Yy MWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner $ ❑ I have Worker's Compensation Insurance Insurance Company Name 4 6iei0(&7— S'T Workman's Comp.Policy# Wif 0,06 2 S"7 2�5_400 Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) [O'Re-side ❑ Replacement Windows. U-Value (maximum.44) r: Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg > Revised121901 TOWN OF BARN>TATrbk BUILDING PERMIT APPLICATION Map Parcel 10 SOWN 0 S `RNS�ABLE Permit# - Health Division �R 2 , g; $ Date Issued Conservation Division ;�l zl I26o L Qt L Fee i Tax Collector �-Ityuo - y ' 3 10 D Ja— DIVlSi0N Treasurer O �- 4�'�`I,,rN". ;St�ST JHTA[iti t�.a�3�'r'.N. Planning Dept. :cn:U0T10N ^ R:if, raoK it'15101v Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address I L Village /V Y14AA115 Owner l�CA/wK LUS�2�/ Address 70 dlI/�/.t/m5 " lLf�•�C ST�,�� /17i4 Telephone So Sr -756 - y66`7 Permit Request XE4(1«n 6Xls7-1 4tg,— SGMe kr, ®riri� X 6 e fk— Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation y, Sdoo -oQ Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. 0 Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 0 No On Old King's Highway: ❑Yes ❑ No Basement Type: 0 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 v Total Room Count(not including baths): existing new First Floor Room Count i Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other vCentral Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:O existing ❑new size Pool: ❑existing 0 new size Barn:O existing ❑new size Attached garage:❑existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial O Yes 0 No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name r 2Az—c A11,1<411A Telephone Number ,rob' -z,so -0eo Address l o g License# _ CS O yBaYY Q 6�, ?SPrnc Home Improvement Contractor# 75r Worker's Compensation# Ale®O&25 725i4ao ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO c2ti Yore- .�z -7 7i6le- SIGNATURE DATE 034N� _ `."' - yr �,I-•. FOR OFFICIAL USE ONLY tx. PERAVT NO. DATE ISSUED .f MAP/PARCEL NO. r ADDRESS - VILLAGE OWNER f DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' r GAS: ROUGH FINAL FINAL BUILDING DATE-CLOSED OUT =, ASSOCIATION PLAN NO. 9 .- RESIDENTIAL: ' SHEDS -POOLS-DECKS-OPEN PORCHES- GAZEBOS DETACHED GARAGES , FEE VALUE WORKSHEET ACCESSORY STRUCTURES >120 sq.ft. (Sheds,detached garages,gazebos,etc.) >120 sf-500 sf $35.00 $ >500 sf-750 sf 50.00 $ >750 sf- 1000 sf 75.00 $ >1000 sf- 1500 sf 100.00 $ >1500 sf—USE NEW BUILDING PERMIT APPLICATION DECKS ` x$30.00 (Number) PORCHES x$30.00= $ (Number) IN GROUND SWIMMING POOL $60.00 $ ABOVE GROUND SWIMMING POOL $25.00 $ RELOCATION/MOVING $150.00 $ (Plus above fee if applicable) PERMIT FEE $ Q:forms:dkcost eff:082301 Tlie Commonwealth of Massachusetts Department of Industrial Accidents 0117ca ollcriaatloas -- = 600 Washington Sire& Boston,Mast O1111 Workers' Cora ensatioa Insnraare Afrldavk location city r>��-..�,s�o�r N/.o 02 63 9 e�,on�s 52�6 !&d ❑ I am a h=wwoar pufhaniag all wmk myself: ❑ I am a sole Propndor and have no one wmicing in oa tins ' b workers for �8 l 0 as mY p ...........x•:w•:r:�:.:.,::-:.:r.�::•v .. ::.}:.x�•.}a.�4:!<+.:}V!�•e:a...:...... ••+:t.. ... ... yr-� .' p •^-.`•y':A??`K:KAR'!'"yn:.<-";XeeK�:.'"+....'. ..,..:r.., ..... ....,:�.N}w,:.r...... .:... ..�•.:...:...........r,...�� .. . .. ram'' •:'' ..,....}.,... .:.......... ..........r. ....:.:....h:... . . ...r. .. .... , . ,.�'^"~ . . .ace. . . .� - �......:..•:.,-::.:::.-•... ...,�..,,•.,•x':; �><::;.z r ... r.r .... .. v}• ...oa .., ... .w.>.:..<w•,w.a..,:.•.,:.Rr.}:}:,-}•-}r:::r}. -r.::w;:;� <'��: :�:.. xrr,.,,,..a.."rcrr:X:}•:....r.,., • :.r•:, -Y .:•>;::!•r .: {• :. ... y< ...�.;;• }•t;..:{r N:<;}w:<::: :<>::>>;;>:>: �eomas��tnmG-' • f" �.:. .:"�,te:•:.;....::{:;�,:::::r�.s.,,��<.::;a... V } ...arr :4XZ!t. w`4 rr• ......w:..rrw .......:....:...:. ..... ....:...... ..r. ... .. ..... .. ..............,:........................,... ... .. •: .,-.. :.. ,•>.i::'-viK:::':. ::Cax<''• <Y 'iw\`lva+'w ;f,:f......:...,••,•:r:xi:ii:Xv' .iv:•r,a:.Y..ti}�%: •; :r{:`fry ..:x.:.R;+") of t ��>r�p;<�<�,'`� .;!V .. :.r. � .�.::.::.. ..... .. ::.,i.4R�I,��v .'M\YYrM} .}� •,�y�y/p... -:Y', .•T,•nV�fp"j•::?i�?ia!{v .,�'.:,}...;..v:•. . ::�Y}::::;:.{'- o+ :Aw:��. A�.�.�.•�:-.�{�...;..,,•,:ti::x;::.:jii::."-..v:n..�.,.r.<•.` .£.!a.^.a.:«:r.`.nan�Y�� )'}, rw r...:�,vwv.....vw,:,r...... : v:. .. .,:• v:: .: •.• .. � .. :a .... is•.w:.. ,•}...:..:�.w•.: w ::rrr.!-:::!r:+:.:.�Ffiww / `r. +:i•. .. �^�r!'S�. tR ...r�tp�1�IIR .h• e 4M, <\ 3.NO— R:�':aC MNI :L. - r4 _:wx t.� Y^• �,i •.�..•.• Ja•.?o)tt... J i w :...x• ❑ I am a sole Vcp=a4 general contractor,or homeowner(circle=4 aced bave bisod the==cto:s listed below who bm the fou wM9 r.rx wodccs'arm�oas as . ... . r.w ......................T.r..,....... ................r.,a... ..xw«4...F......a......................... .........., ....r..... ...,.:....:.A................ ... .,rw........r.r.:..:.,,.... ...:.rw.. ... ,a o-. .'�� n.v.w .........:.. :.w..x,.ww. .::::wv♦:vv.v:;r::.:...........L.... .x.....n•i.:!.:.,.. .::.._::• < .•:.:v^7w.{:x::}•::{\\. .>...}X. \,!,:.!i: ..•....,..::tw..,........•:•:...................v,.+.:. ..:.........w.. : ....n.w. v.n.:...... •.::. .... ....,,, ,{� 1 \ •< ,.,., ,.r1:.a.?..'.:?F::>:;i::v ....,.:... .......r.:.:,:•.v.,......n....:m:::v.:....wv................y+..v...:r..\ a. ..n.r.....r.,...naA,•.nMn.:............. n.r: ..a .F.......:•:.......... .......}......,. ...,..................... ...... ..,w•r .,•.,•:.• .................... ....:•x:.�.�:::r:::•:•<MY,•< ,`;�r1.�}tt�.• :.;•S?is2;o�%C..::•}•,:dfrr:,}>.,:;..•;<�;::::�:tu�t�•x,}Y�.,..a•,,•}.;•.;:::•::.:�:.;:..;. v-FY:aa+••:•:••:3?y<:::;to}:{.a:.a}r,ra•:}:�r>..w..,�•.: wxu.,-...,..rU::a•::}.,i::?;:{:::wcr.:�.:=}`:!: �C .. .:d,..,.,:},k.w ..x....: x: ti<,.. •. •(u:W..�`J.+-icfu;wca�;t!.y.�� <9��( lk.t.:...�Sjc?goa��i�;.�.�<u{a sa:}::;:•• wvxw.x:v:t'Y:A\ x:n•v.:v.,:. :a.....,..,A�..{.. vaOY�t`,``J`,llri.:: �• <� 9`'2Vxf... C• ..:.�wa•:.x....•..x{•:•}:;.r.;)':..r........M'...gw:...},;i.:„•.�...:::•i^{x.:..,.} }.rR�,;a:,;::r:..... mmyam►Bam a •w•1.•.a (exwwnc• Aw� w ..ace .�., „••:}.:•r..•:.:,}•. ace{.x{{.y... ...4. •Xe+: M Jam`. ;!{awt� I !:�•:.•.-...v ........: ,J:Z•>: �, 3N?'•�i}Y'•.... .. .J: 77F.�7.C81WP1�'o"�/•+w' .;. V.d,:a.•w•.7•\•::...:::..�,.:......... ... ...' •;��Y�..t•>y> X,..;.,t:�' •..Y:iteX x'�yi.\:a�i��y,,, :::{•}::• .... 1FCa.-.}a'}'K?�,`<y{rQt�*.y't•)?{?rfj:�: :..�:.WYr\ .•., ••:':�:�. -:��t;: ~;:4: �...:.. ..'•..'...�j•.'M.� tMga •:�'tL:`{ii�v +V}:a!}}:::��::..r{<tv,.;,n..v ,Ax•.�.'.•.�..-:::.n:rr. ..r.•. ?`P,�!'�...,:..iw•...:•.:.v......r.:xw va•...:.:..:::....:.... J.vxa<:1'.....} 'eaay;:::': ;%b,::. �v''-i•,,� -K\:?``.tXsk::::!.;<:.;: •�ICL'IIRC�IC:'>:t:r:::::.,.,-x:..... ..-x•.,-..,�.N. .:..:.. ... .w... •. .... .,,..�•.,tit».c '•.•/ Nw ....:.....r.....a..>•••M...:�\...{,.:•.:.-m..�.,;.,v:.rr.II.r;.IIV..�-.7.1.,.II J.Nmr:...>.:r:C.}•..:a°w:.`.•:{-.`.n,.r..,.�..; i•x'Y\>�r:R:r::.>}r�.r:A....X,1;.-.':,.-4:::•e:::➢rA.?;•��l.ri''�..:•,<t'`La.J'•w•..r>Rv.:.rm:.Y.v y:-Fx.?..+v??;"-•,.:.}'S:--.✓r:,.„•:.:.-i•arJ.. A," Ma J..W.. -„:.•}}.f:.,<•',.'�+!-:O.v, vv.. : , r � :....::�... ......' .......:...-.'.... .. �6��Nb �^,$,�'?\`jMXA;:a'rRL:v'•?�L?�i:'•��•�:`--{'`�..K2:+»iYvr,i.<,2•:.a,,c'}%a.,;"•.:`.�:�;•:..::,.:,,-;•}.,:.{:;:::•`:::.�i-.:;:•Y:;.:,::2>•:::::::::::•}.:.:: :� .wwr:'a•.._:{•:•r:�:.:;Y>.�..; ..-{.x•.�i„+.:::FX:Xrw:{.;.. �«n'.�.•...�o�:i:::>�.:�;...........,:r:�:.::�5 ..,�::.�: a-�.:;w wY4.x�:.•:a.w a v.to.•00)r7. .« •{.t,.":{{!vr.::w•:.'SH'A:r:;'::)t�.w'-.:._-.3.....:::..........:. .a:x,.w:. r •.. �w-:. ...... ....::�: . .. J>.Ln>aeA.,- w,•.,... ........`t+a.:•:w•::.:a.......... .; .. '`- \'6Q-�'1.�;+�.',.kaaD`.\`..,,,::;y.jnJ;{::.;:•x;•Y:;•:i•}>,..: x...w.aro.,•.:..,.a..v-::.-w.:nr........�:::.�:::xr:.:,,.. .. \..o\•: ..<.. , ...+.- .,:-•.}'1:r•:.•.:. C!t...:::��...........-:w.............w: ..-.........a:,.x::w•:�:a<.r•:<:{�:a"v}ice:{:.:rt,,::n.:.. xrr.,.vw:�:nA:X ?Ow: .4 .�:Ji w''}':'-.1Y`F�:>{`,-�i'�„Kivh �.vw..•ry•:::::::x:•w.w::�v::::wvv.'{v:r.} :F ..v.....}.•.,vw w...::v:{xii+:LJ'{<•:v::r.:J:{tiY)CiOCW:' .... ......,w ..Yv •;.{:\CwLii>.S\:{wi:}iwiriy';.;:};: •:x:....:: ........{.;,v.•..:w::::;,...r. ,{C:}}�^:3ti{:r!i:[[i4iii':ii+!:::}::.....:}...�.w.v?:::}•:}::F•::::- `^... +'�Y•'•,•• 00 �a .... .:.}•i:::{:i:iw t,v:..'J.v::;,.ix:. v v.w......- .w....... 'awv}Y.M..W��",Liv,YAi ..:: }:.F•.:.}.:• +w4wy'•:{{{.iv:.... ....Y.v..:::.,:w:n... ....::•..:.:...=..w.:. T:4..,...v::.:w::'.:... w::. `�. .. ..:........... ............ .......:{:.}::Y•::.v ...v'•x-.v:.v:,v} .vvw4> •}' .t <,�'vy•�,0.X!��:+<. .••w .e�.�•.��`^nx�rn��Cyy-pp':tiV.t,`:v 1?ri<vi:!}::ti?::vn i.?:�:!4:.. ...... .....:. .....::•:w•:v.........ova},.:,.::.ar....:.v::+::•v.:..........Kaya...w.A. ........-.>.7av::;...?O�a?'0°�.X°'X.wya,�c!�: v. ...,.4:�3�-.�v v... ...-..vwQ,C:w-3.� �i:�:. .:...:... ...:.v�....r....v.:..::f ...::r w ..Jwv-.-:::}.a.... .....r.,,,......c..:. -.,,.-....,,...:--:::�..7.•}.:..::}"�w"' .. ...:.}:w......, .. .r?, art..,>\.:-:>......}..,. .:•x}:.:•.y:•.;!;};w:, .:rr....xrw}}.v....:..... .,.w......x.....{.:::?•.....w....... ..............:.}.......; v..wr...MYn.a,.,n. x.•..vty-:::r••:w.a �..... xiw ........ .......w• .....xrnw ...v...a,.a........ .. .. .rF:: ... a.....wv.nvv.. w. xr S2•.Tw �!e�!lte. ..•nwr:x•+-rA.w:..,w,a :J{a;!>�+:;i::i$:?�ii:}:!� A....w.Y.....:.n.......w::v....t.......1!:•.avw........t.,...•.. .)a..a r. •r.,vv: :..:.,^. ... :...✓ >J3:.._pw :•:....w.:.. r�i ,•':.%i.(. 2 rtitCn"'!..........v::.. ... ..::..r.......rr...........v/.}t}...... ....,.w:w:..::�. a....}v.}.ryrr ..,:r• ....wv. \,;.x. ..x'ut vS�:... ,:.\,C..-'.w.f;.xr::.�::.;.{T{•:.a:r•::::.�:;„. ..i!.. r.yaw. a$�}}?ca r.A+ �'trX::A.�..:x::+•:,-• {i.}a.{;s;-::: >;x .;{: :a}o:.;}Y•: ...:�•::-.:......w:.,�::a..::••::`%;•:!:;"'},:}•F•.�.:w::an•••::-:{{•}x:wo•>:::.-... -::::::.::::•.:w.. MK .cp. tk:, .x.- rCw..4:{w•.•<.wra. ::-: ..:..•w:•+.:w•:.a..- .,x.,-..,..aw...:}�a.:v:::-•:-r:.•.,..T,.,.:{r,.a...,�r:w.. ,.r,,:..+•. .r, -- .<Y�:•::r.,.<:aY:,.. ,>�•>'•...atx. :w'. .... ,,. s Y +>a4 k�""'x^%' �C�'?A^:{{a.\ :wa):u�'ea.rfiaca:r}•w.x �r.� ..:•: ::�, rw hhia'k�..... •::ux<at•-w�::.r...•..F•:.::..t•:::}:•:.,vw.,:•.{'�....x?.3g•Yao+\. .�°8{�-.�7.-,'� .�r.!•�•}}... ... ... .�,tt''t• r JFw+^C h r}4'cMw.aaw a:3.. ••..::,a:::}::.w:.r.•w•:.x:':•w:!•,}•.,w x r......: +...:r.,r..-• ..,:•.:.!•w,••::•:::.•: r..,.,....::- UM :..�.. ..... ......,r. o. ...... o.... : r....w .r .......:.a•.,.................-:r\.Y.at -Y. JkHn ,.,, ... :,� v:,,,, .wr•r:. .......... ...... ., ..ye.a.6..waxr r....r.. .,........ ............Z.C. ... _ `ta..' .Y::::.;•::.,� ...,.::•-:::•:..,r:.a... .....:• _ :r..x. a..r.w•++»T..?Z}.+-r.!•caw _:..:. ... F r?3>``il•^:.,,a. .?xZ;J� :.A\�"��SiviC;race},•::::w•:::2•�:��: •,••tv,.ace,a.tw,iW;j!?:i}Y}}.$.!•;i`!?t;M^a .v.::- �. ::•..•• Y.C11J!C}�YAL,v0lI.0�v�,r�'vr.`:�?,N:y��..v,.:M..... w:h:•::::w...w%N.•:� ......... \{Y::xa„v v:r{w;.., w»>.,X.}:.....w.v.:...:•:•. ��qq Faaore to SOCIM eoeerap a os 8eetiaa2SA of MQ.L4 s3ssiteai to tb des�eai pmailies of a tloa to t1.S00.00 mdlar aoe 7"O! o wea as ei►a pmsma is tba form of a bTOP WORK OBDFS sosi a�a di100.00•daT apimd a�I madsasfsmd asa!e wgf of this statssamt naI be forwat+ded to the OfMw of Imwerdpikm cf tba DIAf*r.w""p I do hereby catOy undo the pacers=d pasazdff ojp — pr��abavr u try Ord carrel P:mt nam A= Ojdx i use only "not wrka in tWs um to ba completed b'7 dt1 or taws oafdai dty or town: P ' ❑❑utecsc►msin t B r � 0 ebsdcif tram��•f'responsa is.rsgaired ❑sdecccLas orate _p$mub DcgSrC=SZt eoatad person• 'P��+ ��r own"9193 PJAJ l Information and Instructions . ' Massachusetts General Laws chapter 152 section 25 requires all empIo Yem to Provide workers compensation for tbzir ;mplovees. As quoted front the."Law", an employee is defined as every person in the service of another under any cow of hire, e:cpress or implied, oral or.written. An employer is defined as an individuaL partnership, association, corporation or other legal entity, or any two or more o: ed i oint enterprise, and including the legal rcpreseatatives of a deceased emplover, orthe re=.n'er 0. the foregoing engagn a J rP , However the owner of a trustee of as individual., parmership, association or other legal eatity, employing employees. dwelling house having not more than three apartmr-=and who residrs therein, orthe occupant of the dwelling house of another who employs persons to do maintenance, coas^uc*drin or reps r wale on.su h dwelling house or oa the grtnmds cr building appunenarrt thereto shall not because of such employment be deemed to be as employer. MGL chapter 152 section 25 also stasis that every state or local1censing agenci shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for nay appllcsat who has not produced acceptable evidence of compliance with the inrnn+na coverage required. Additionally,nczxhrrthc commonwealth nor any of its political subdivisi=shall enter into nay contract for the performar=of public work sail acceptable evidence of compliance with the insurance requ t of this chapter have been presented to the corraacdn authority. - pgwxw lip P -Appiimuts etuatiaa aff davit complctrly,by t+wkm the.box that applies to:your,situ and Please fill is the workers' �P maybe supplying company names,address aaId phone atmrbers along with a cmdffcate'of insurance as all affidavits su to the Department of Industrial Accidents for of�' over cage. Also be sure to sign and date the affidavit: The affidavit should bq resumed to the city or tow utbatthe appiicatiaa for the permit or license is not the Department of Industaai Accide�s. Should y?a have=y�=regarding the"law"or if you being mpzt4 brain a world'campensatina Policy,Please can the Depa=,mt atthe comber list--below.arc required to o OPW . City or Towns ace at bo of thr Please e be s that the a$davit is caaaplete and pried legibly. The Departme�has provided a sP bottom of Pleasevit f>zr yoti to fill out in the event the Office of has to cmgact yva regarding the aPP be sere tti fill is tbeprawn—'s=�e auatber which wfil be tuod as a Tcfetrace at�l;er. The affidavits may be r t^ the Department by mail or FAX unless other n=gcmmrft have beeamade. The office of Investigations would like to thank you in advance for you cooPcrada and should you have any questions. please do not hesitate to give us a call- . F / The Department's address,telephone and faxztarnbca The Commonwealth Of Massachusetts Department of Industrial Accidents amce of lmiesduadons 600 Washington street Boston,Ma. 02111 fa=#: (617) 77.7-7749 phone #: (617) 727-4900 ezt 406, 409 or 375 P 32 325 /I _ MA 5 #53 -r _F fa Eft 1 PA E _ Y N _ CCIJRa►r STANDAR ND ,j/;, 12 NOTE nol aY wmbL h rol II nppeN o-'- 77 r� — WU11706EfNRWRY MAP 32 \. FOfi OFXCIDUOUSTYEES 05 \ P 326E OF UM ':OW :E: AP 3' MAP 325 178 # 166 25 43 �4 :MAP 5 f 1 4 a 1 _ 145 O --- �, MA 25 CEl7WMBER "—^—�- -.—. 98/ .. - 7l' 153 . — - YE01T C'JNIOUF UNE ; MAP 325 MA9' ,owonnxrou IE 17 .. 1 8 1�16� ; �9a �dONE MAP 325 # .3 32 MAP .5 EE# 5 9 6 REWNN6WN1 � I 10 _ #2 �, _ ��, ,WL701ADTRAIX . --�\ `, MAP 325 4 IE�. E 325 MAP 325 MAP 325 1 6 YAM am �4 �J 9 6Qj _1�_1— _ - - — o T O 1 R 9m lm 60.41 li-1P5a M7ormMlPTc-1.' s �*;MRI'Jjtmw W. bH0P 315 o wanIOU v? J ddi af EmE III aarV .1 dmd Air W.na fm uaZN V # .. .,... MAP 32 156 MAP 25 fAdgnycbnse ivatic:rn.dgn 03/20/02 12:40:07 PM r I HONE INPROVENENI CONTRACTOR Registratioo: e Rication: 7/19/02 TYp i ua i DALE R. NIKULA DALE NIKULA &F-; 3 UNCLE HARRY'S NAY ADMINISTRATOR -HARNICH MA02643 � �� `�`�"",�„ :� ✓lce-�om�naruuea,/�i o��/�aaaac�zuaell A' 1B0ARDbF BUILDING REGULATIONS { -License: CONSTRUCTION SUPERUISOI3 Nurhber--C <04,8044 f l _F Exp res'09/16V003 Tr..no 4307 DALE R NIK(-J 3 UNCLE HARRY HARUVICH, :MA 02645' Administrator w I The Town of Barnstable Regulatory Services Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner . 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790=6230 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: Xff3t-lE1.0 sv ?C - Estimated Cost K S00 GO Address of Work: Owner's Name:' -- Date of Application: 0 ��— I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 OBuilding 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: Q 3d�i'a y /�2 6-7 97 Date Contractor Name Registration No., OR q:forms:Affidav :rev-122001 } r C c LA � Z 0 P05rS ,A-r6P -SoK)aT0P e- . Mk- f�Eit12Y ZUS4kPI LU0, 17- MAJ6- .2 x8 Pr or-'-,Ts 16 ON CT , 2 X12 PT 5-T Ai2 S712If-.AGERS - I X4 OPHO66OVI T12�tafl� _ M4H000tJY IJEO<f(OG PZUN T)4E LENIT-# O7= p C�- SC2EEO W 67 W,3 DErz PECk-- m EE r X4 M PNo-,OOY �cT" VEpT1 cAt-L-Y orl 4 S` ANCL cs PR6 0 01 c,�G SckCc-,',j /,uC7 ViE-( Fkoa/r Or /-1,DcU 494: pr ST/A-I1Z- RAIL Sx fi 31-1OCu,v /n,1 A7T, Pr b7o, y SNbGr/.{✓ /,c/ .rI77": ,Qit1DT0, - '; _ .___. - , i ��;f :�• i 's. 1 :` \ t: e �, �'r. p `.r .ri .. �. s"" ra'... �- .� � �� .;..`y �