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HomeMy WebLinkAbout0063 MAIN STREET (HYANNIS) �� rq A S I ` BOSWORTH ASSOCIATES 17 P.O.Box 685 I 1645 Falmouth Rd. Unit C 2nd Floor Centerville,MA 02632 i { BUILDERS•DEVELOPERS•PROPERTY MANAGEMENT 508-790-2422 Fax 508-790-5982 Chandler Bosworth I NMI f 'v t s e >`��� ! c� 'i � .� •� - j ,f � �,�� �,:;, per' �` ,,� � .�_ �' — 4 'ti 2 t �.' � i � r�^ � i +y. } .r � i� �4 \ a � , S - .A "' t _..i APPLICATION NUMBER........................................................... *For Tents Only* Date Tent.(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP.tank 20 lbs. or>:Yes No , if yes,,a gas permit is required. Natural Gas Yes No ifyyes;a gas permit is required. y If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel'Type " Testing Lab ; Offsets from combustibles: front 4 back.` left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: 'r ' Telephone Number Cell or Work number I understand my responsibilities under.the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date Signature Date ZZ All permit applications are subject to g official's approval prior to issuance. SCANNED � 0 a a Application number.... Fee ...................t BUILDING DEPT. �� � Building Inspectors initials.....�............................ OCT — 1 ZOZO Date Issued............l.v.. . .. .............................. TOWN OF BARNSTABL Map/Parcel........ .Y.,�)..... ..I...... .................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: - - :5d\4170,01�bwff i� 1! /��'►r VILLAGE / Owner's Name: Phone Number Email Address: Afliq Cell Phone Number Project cost$ 1040tolloo Check one Residential Commercial OWNER'S AUTHORI TION As owner of the above o rty he authorize a dOE52L 0124W to make applicatio or uil n e c 80 CMR Owner Signature Date: CyAi3& TYPE OF WORK0000, Siding Em Windows (no her change) # 3S EYDoors (no header change)# DInsulation/Weatherization U Roof(not applying more than 1 layer of shingles) 0 Commercial Doors require an inspector's review ---,. - , N Construction Debris will a going to n+-T 6�Co - I A 'j Um . ® Certificate of occu] accy\with no construction (complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License#��: ®f[ (P / - (attach copy) Email of Contractor Phone number 6"00�''111%) ? 7, ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN . .....�............�.....r ...... ......�ww�w.0 xffj •—�M&a wnMnAM.iw. nt8-0+nc w nrMAARWr•wu n APPLICATION NUMBER � *For Tents Only* Date Tent (s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>%Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes,-a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back.. left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building.Code.. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date IAT ' Signature Date C0.143i ZZI All permit applications are subject to g official's approval prior to issuance. N • 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): j Address: ' ► City/State/Zip: Phone#: - � 1-0 / ��✓� Are you an employer?Check the appropriate bgxr Type of project(required): 1.❑ I am a employer with 4. Nrl 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 p.n the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have, g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• t 9. ❑Building addition [No workers' comp.insurance ,comp."insurance. required.] 5: ❑ We"are a corporation and its 10.❑Electrical repairs or additions q ] � officers have exercised their I I. PIumbiii`"re airs'br additions 3.❑ I am a homeowner doing all vrork`�" ' ❑ g P • myself. [No workers'comp. right of exemption per MGL 12.❑Roof re airs - • insurance required.]t c. 152, §1(4),and we have no 1 ' employees. [No workers' 13.❑Other Agy I comp.insurance required.] i s � I! t *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. _ y Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure-coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this'statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby er Mrtairs f p 1�tnformadon provided abov is true and correct Si ature: ;9Date: 4 Phone#: /U ~ C��� 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#: •y -y�a Information and Instructions . l 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-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 returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts ; Department of Industrial Accidents otrice of Investigations 600 Washington.Street +� f. Boston,MA 02111 Tel.#617-7274900 ext 446 Qr 1-877- 14ASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Vice l(cYn�rrzc�Hccurall!!npl�nr(•(.C�daccf.�rcJe�CJ Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE;,_Individual before the expiration date. If found return to: Registration;-., Expiration Office of Consumer Affairs and Business Regulation 11/04/2021 1000 Washington Street -Suite 710 WARREN BOSWORTH JR Boston,MA 02118 D/B/A 130SW0RTH ASSOCIATES' WARREN C BOSWOATH JR 1645 FALMOUTH RD � GG.1'Q(lsmk' CENTERVILLE,MA 02632 Undersecretary Not Valid Wit gnature Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement,Contractor Registration - Type: Individual Registration: 114889 WARREN BOSWORTHJR. D/B/A BOSWORTH ASSOCIATES Expiration: 11/04/2021 P.O. BOX 685 ' CENTERVILLE, MA 02632 § y z D Update Address and Return Card. SCA 1 d3 20M-05/17 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr�Uc#6AUpervisor CS-019611 Expires:09/22/2021 WARREN C BOSWORTH 1, f. PO BOX 685'. CENTERVILLE%MA 02632 ;�`- 11�1V` ' Commissioner Construction Supervisor Unrestricted Buildings group than 36,000 cubic feet(991 cubimete s)of enclosed less space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)7273200 or visit www.mass.gov/dpl CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DONYYY) 712020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.i HIS 10812 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY,AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I-,IMPORTANT: If the certificate holder is an ADDITIONAL INSURf;D,the pollcy(ies)must be endorsed. If SUBROUATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER, NTACT _ Isabella _ Arthur D.Calfee Insurance Agency,Inc. PHONE 508 540.2601 -L FAX : 508 457.17a5 www,calfeeinsuronr.e.com E-MAIL — 336 Glflord Street DRESS Isabella Calfeeinsurence.com INSU1RLR{S1 AFFORDING COVERAGE NAtC!f Falmouth MA 02540 I ER A: Western World Ins-CRML#n INSURED INSURER B; The Hartford Insurance Co Niko's Carpentry Inc 219 Pond St INSURER C;— — — Ostetviile MA 02655 INSURER p; INSURER E: INSURE F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD "INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR,CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE iNSURANCF AFFORDED BY 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. I Z TYPE OF INSURANCE DDL S R POL(CY EFF POLICY EXP POLICY NU R MM1Do MMi LIMITS COMMERCIAL,GENERAL LIABILITY EA('11 OCCURRENCE A ClAiNS-MAOR X OCCUR 1 DAMAGE T�}RENTED 1000 000 REMISF'9/Fy�lXurrenewl S 10{)t{0d — I NPP8d18481 02/2212020 )02(2,212021 ME,r)EXP(A y cnq,eL46n : '5,000 PER ONAL&ADV IN;II iRY a aoa,000 _ r,EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE T.2 000,000 JECT X POLICY U D f ECT LOC i iPRODUCT:,-COMPIOP AGG ffi AUTOMOBILE LIABILITY j i I t,OMB(NEp SINGLE LIMIT i I �,) I i ANY AUTO BODILY tNJL(RY(Per porsnn) $ ALL OWNED Sf HF_r}I}LED i AUTOS AUTOS BODILY INJURY(Per eccidontj $ N0N-OWN:D HIRED AUTOS AUTOS C PROPERTY DAMAGE UMBRELLA LIAR 1 OCCUR EACH OCCURRENCE $ EXCESS LIARI IC,LAIM8-MADE i i I AGGREGATE DF RE?ENE I — WORKERS COMPENSATION AND EMPLOYERS'LrABiLITY I I j STATUTE 1 ERH ANY PFO?RIETOFL'PARTNERIEXECUTIVE Y/N !1 F,L.EACH ACCIDENT $11)Q,Q©0 B OFFICEWMEMBER EXCLUDED? nEI N I A i 6S60UB-1 K8614440 20 02123/2020 02123/2021 (Mandatory In NH) li yes,dea o under 1 E.L.DISEASE,-EA EMPLOYEE,I$100 000 CRIPTION FDPERATIONS batn E.L.DISEASE-POLICY LIMIT $500 000 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional ROM8*e Schedule,may be attached it more spape is required) GL•Carpentry•interior WC•Carpentry Certificate holder is listed as additional insured when required by contract. CERTIFICATE HOLDER CANCELLATION Bosworth Associates SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 685 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE;WITH THE POLICY PROVISIONS. 1645 Falmouth Rd Unit C 2nd floor Centerville,MA 02632 [AUTHORIZED REPRESENTATIVE <ILM> Phone:(508)790.2422 y Fax: 508 790.5982 I 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered Marks of ACORD 7 7,! MAIN ST » ZO. iNN E,4 Plorl of 0PARK WAY PLACE •. eycannis ass. 19. a 4 z .tati� D.W. sodit,h. Scale C7 1 p 10 F, t t»cw. y, 0 4. PROJECT d 1`IAlI�TE: ADDRESS: PERMIT# a . PERMT DATE: �. LARGE ROLLED. PLANS LN e s : BOx SLOT Data entered M`MA.PS program on: (� BY: � i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ( '7 Application# ;C-7 1 Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Fee //5�� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 167 3mo)_ 54— Village Owner r. c ���,���?-� cQ P rJ Address Telephone Permit Request Q_d !aJ o Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new r Zoning District Flood Plain Groundwater Overlay 0 Project Valuation Construction Type f Lot Size ' Grandfathered: ❑Yes ❑No If yes, attach supp g docur&tatiorr Mpw Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's ighway-'❑Yet ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# - Recorded❑ - - - Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name ,i �c Telephone Number -'7 7 Address S� 4`-' ' License# 42cr`2 O 2-�7 UV T 14-�tm ei Home Improvement Contractor# ' Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR DATE FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' The Commonwealth of Massachusetts ` Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Md 02111' w)vw.mass.govldia ' Workers'Compensation Insurance Affidavit: Builders/Conitractors/Electricians/Plumbers A licant Information 'Please Print Le 1 Name(Business/Organization/Individual): Address: City/State/Zip: 5 PhoneA Are you an empioyer7 Checkth . ppropriate box: :Type of project(required} 4. I am a general contractor and I 1;❑ I am a employer with 6, ❑New construction . employeeq(AM acd/or Part-time),* • have hired the sub-contractors • listed on the•attached sheet. 7. ❑Remodeling 2, a'sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑Demolition employees and have workers' working for me in any capacity. $, 9, []Building addition [No workers' comp,insurance comp, insurance, ❑ 5 [] We are a corporation and its 10. Electrical repairs or additions . required.] ' 3.❑ I am a homeowner doing ill-work . officers have exercised their 11.❑Pl g repairs or additions " myself.[No workers'comp. right bf exemption per MGL 1 Roof repairs insurance.re ed t c. 152, §1(4),and we have no ] employees, [No workers' 13.❑ Other 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 mutt submit anew affidavit indicating such. $Contractors 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'camp.poltdy 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: '/2e a-4-V s' X 5- Policy#or Self-ins,Lic.#: C_- /? 00 S� ` Xpiration Date: �/" "' eT � � City/State/Zip: c Job Site Address: 1� ,2�G� i • Attach a copy of the workers'compensation policy.declaration page'(showing the policy numb 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fond 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 maybe forwarded to the Office of Investigations of the'DIA for insurance coverage verification. Ido hereby certify under thepal dpenalties ofperjury that the information provided above,is true and correct. Date' Si tore: — Phone Official use only. Do not write in this area, to.be completed by.crty or town official. City or Town: ' .PermitUcense# Issuing Authority(circle one): :1.Board of Health Z.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 ofhiie, 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 tie commonwealth nor any of its political subdivisions shall Y P . enter into any contract for,the performance ofpubhc-work until acceptable rAdene6•of•comj1:6*:With•tlie 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-contiactor(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 sel€kwura=e license number on the appropriate'line. City or Towli 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 Sire 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 ConmonwWth of M&m4us4da Departmont of Industrial Accidents Qffte of TaU'Vestipt oas Bosto MA 02111 • . Fax#617-727-770 Revised 11-22.06 WWW.MaS&SO '/did f �pIME Tow Town of Barnstable. " Regulatory Services a i + BARNSfABLE, • r Muss. Thomas F.Geiler,Director .6 s 0 39 � Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 50.8-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property he authorize - to act on my behalf, in all matters relative to work authorized by this building permit application for: . c (Addiess of Job) Signature of Owner D e Print Name Q:FORMS:O-W-NERPERMISS ION 011 aaacLiaaEllo Board of Buildinge94 s and Standards. t40ME WWROV011 6IT ONTRACTOR Registration• ti 1,190` Exp�ratFon / 4/28'. TYge. I �ividuo' MICHAEL J.ARONNE MICHAEL.ARONNE 34 CIRCUIT'.RDJVORTH WEST YARMOUTH, MA 02673 .1 $4uty Admmistrgttrr ; -�:,,. . . .: .�. b ,. : . r,�l' , vt;'� e3• .,�� � -.�; e ..sue .a; �. . ,, ,�;t. Assessor's office (1st floor): ` J�S Lam'-ri N e oFTME ro_A Assessor's map and lot number ........................... Board of Health (3rd flood- number' Sewage Permit number ��'!��G.... ...�'�/�`�// +�'� ' /" ! Z DAR33TAXLE. i Engineering Department (3rd floor): SAM � O 1639• !� Housenumber ........................................................................ aMala` Definitive Plan Approved by Planning Board ________________________________19 -------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. only TOWN OF . -BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...( ......�� , , ...............................1�1�` 6 .5 �� ..................�................. TYPE OF CONSTRUCTION ..I,.� .�!l..c)......... V iM��" 1. ....................................................................................................... . !..�• .. 19-. � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 0�'!1'l- Sk ....61 L,�oV m ... .................. Proposed Use DAY! C. ...... 1..... ..k .. ' !......r* ...:................................................................................ } . ....... Zoning District ..... ."..'.....................................................Fire District `1 2+ YN, r1 I 'S ......................................................... U. 1. c,N t^ ' Name of Owner t �.:.......... �_� 1. �.....e•:1....��..`�.....,..I;�c��Yl� .�>.... ��............ .... ............................Address ....................... ..........,......... Name of Builder ..r...!, .i...WP ...... ��.:....I.A�..'.Address ..!4�.......... ........... ..�. ► ?NV�.�..?.�..... }} 1 ......................... .. Name of Architect ........ .....................................Address ......."""" _,___. ..................................................................... • Number of Rooms .... r..:.a..0..:................:*'x....�...............Foundation �. ..���tF.�..c.c'vt.:.�J�.�.� ..K. .........5 1 (( IJ Exlerfor '. .. ..........,. `.........1+E .... .......Roofin .... 5���, �. .....f !7t�"< .N.�<: g V............ �t �'. Floors .:u.. . .. . .............. .. /��..���. ....L..<<\..t...t.e�.:....Interior �� t`.. "-... r4�.:... 4 .. �1 N.� '� .................. Heating .... y..). .�. .................................................Plumbing ..f K�.�......�?...� 15 ! f D t•-� ............ . ........ ...... . , f2 Fireplace ......P.K..(` . ..�:�,5..............................................Approximate Cost .......`1. .a �� .:.. . (1............................. T Area ....Z...U..��.!�.................. Diagram of Lot and Building with Dimensions Fee 'A� �` �� �1E= � Stir �� d ��, 1.-)� 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 . construction. / 1 (-- R Name ... .:.. ........�...... Construction Supervisor's License ...f` .!. ?...- .1 .., . 1 GOLDEN, WILLIAM DR. A=342-017 ' C42 No ..3.1893 Permit for „ADD TO Dr. ' s Office ................ ....................I............................ Location .....63, Main Street ................................................ ...................Hyannis Owner .....D William Galden Type of Construction .......Fra.me... .. .. ........................ ................................................................I.............. Plot ............................ Lot ................................ Permit Granted .......Kay...13 ................ 88 Date of Inspection ....................................19 Date Completed ......................................19 Assessor's map and lot number ....O`7�, " ��fTHE ♦ Sewage Permit number ..:.'.,, Ilap ���,���/{�1 � �Q , Z BAHBSTADLE, i House number ......4 0,<!Y! .................................................. �J so rhea 1639. 9 V � 11 wd � TOWN OF BARN' A/BLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...M—W....4. ..........c',k,--C O?s E(, ............................................:......... TYPE OF CONSTRUCTION .......-P:­- f4 V .e—.t`................................................................................................. ............. ......................��...:..r..............19. Z" TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 0 .-..-.-� ... .� .....5... ... .......°.. ..i.:A...!!.!v'........." ......................................................................... ProposedUse 1 /�7�'t c�Q�a P.I.!�g..................................................................................................................... ZoningDistrict ..............0P.. ;......................................Fire District .............................................................................. Name of Owner $ . ; ` ..I............. AddressP.t4,1W'^lc+9..v...r.a.i.......i.(w1................................................S. � ft .��5... 5 ......�......... . `Name of Builder' : .....Address �........... ' �4t ! � t L-A I Name-of-Archi-tect ...............................................................Address .................................................................................... Number of Rooms ........Foundation .....:,IaC�U e (M��� ........................................................... .................................................................. Exterior .......'..... ..... �.. t r«, I ....................................Roofing .... ...?....................... ...................................... Floors 4,1A0..QF.-""!...................... .Interior (�Ct �.f..�t.!A-(�l.i Heating ...Plumbing Z 6A-!-............... .r: .='..........!........................................ Fireplace ..................................................................................Approximate Cost ....... . Definitive Plan Approved by Planning Board -------------------_-----------19________. Area ......eq:.- 7.. �............... Diagram of Lot and Building with Dimensions Fee t ,........ .��................ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS fi I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable :regarding the above construction. / Name .... .................................. �-_ GOLDEN, WILLIAM M. D. A=342-°17 9�4a - i7 No 23856„ Permit for ..REMODEL & ADD TO .................. . Doctors Office Location 63 East Main S eet Hyannis f.................. ............... Dr. William Gol en Owner ........................... ..............."....................... Frame Type of Constructio ......................................... Plot .............. .............. Lot ................................ s � Permit G anted ;„.March 5, 19 82 Date of specti'an ....................................19 \ . �s Date Co m p leted ......................................19 _''�� � C" 4, p Assessor's' office Ost floor):. �� ` F �-*TNE TOE Assessor's mpp and lot number ............................ f Board sof Health.•.(3rd floor): MUST CONNECT TO TOWN SEWER Sewage Permit numberfo �.:........ .. :: Z 33JHD9TGDLE,AM i W Engineering Department (3rd floor): '°o rb e• e� House' number ..................... ' Defiri_ti:ve Plan Approved by Planning, Board _____________________.______19_ _____ . APPLICATIONS ,PROCESSED 8:30-9:30 A.M. and 1i00=2:00 P.M.. only t w • r TOWN OF BARN.STA.BLE. .. BUILDING I-NSPECTOR APPLICATION FOR PERMIT TO ...C... ? r V�-..J......a � �b�':.. ..��,5 O`- LG ,1 .. .... TYPE OF CONSTRUCTION .�a. ......: .Ma h!!t' :........*....... ...... ...... ........................................ • ..... ... oo.. . y TO THE INSPECTOR OF BUILDINGS: The under toned hereby applies for,a permit according to the following information: Lo S c� Location ... .. .1.!'L+.. C.: .. .11. L.. .. ...... - Proposed Use '....+..i',.5.......� .�: ....... ..�.....?G� CYYI ... ..... .............................................. .. Fire District Zoning District ..... '.�...... ....... a Y1 �'1 1 �...... tact Name of Owner C-... W1^.....�JiA.� 4��...._..........Address 1'�C� 1C .. .... VLe. L+C1�LICj�� Name of..Builder ............. ....... ...s�...... ••.:...�.. ....Address ..... ...... 3...... �. .ri. +..1. ..... Name of Architect ........ �.n.p........................................Address ..................... ......... :.:., Number of Rooms ....... ..............:.................:........Foundation .... Exie iorw.Cr�: ...s1.4�.uj.� ._.......... .... ......RoofingSp! .� .. ..�. ,�. Floors t 0...e .."oG j�SI ' �y :` ..Ga..c. . ... b 1�.. "b.r.... .:. �1 . .............. ` �..X �� .....Interior: .............. �.. � .....V . Heating. ....�� :�'S.. .�.K ....: .................... .::..............Plumbing .. .�. .r.. _. .,.�.aa +.:..�..r .l � .;..�.....,...... Fireplace ....... ..1!�5v 2 ....................................Approximate Cost .. . .�?�Q.Q.t�....f� �.:............. Area ... .Q...S. ................. � / `l Diagram of Lot and .Building with Dimensions . Fee �..:.. . .............. l,J S l OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS . I hereby agree to conform toy all the Rules and Regulations of the Town of Barnstable regarding the above construction. V Name ... .1...... ... ... ................ Construction Supervisor's License .. ..d :ObLDEN, WILLIAM DR. k. Sf ,1 No 318 9.3 Permit for .ADD TO r hDr.s.... Office ............................... t +•' ' Location ......6.3...Main Street :... `.......Hyannis . '` ' Dr William Golden: Owner _ R•. Type of-Construction .....rare•••••.... i ....:..........•. ...: .................... 5 ... .... • ......... - ,- ,., tr t ,• 'i a Plots ... ....... rot :. .? ........ 1 may 1-3 , -.:. .•h� 8 8 .. - �:k • �•._, � �-".` � Y Permit G'ran,ecl ...................... ............19 Date of frispection ` '"..... .. l-9 Date Com_pletecl ........ /�' ' `.......19 ne ' ^�` � � � • Y y •d_ .. �� .. _ - i1 a �f j "N .... a � Assessor's map and .lot number ..................i�� .... THE Sewage Permit number' .. .0.. ..... .. BBBBSTADLE, i House number ......i9 s ARA ................................................ �p i63g. 0� • ,o� �9 . - 'EO YPY Or• TOWN- 'OF -BAR.N LE BUILDING INSPECTOR APPLICATION FOR PERMIT TO F,-t 0 LC� �l�............ .... .......... ?.................................... ........................... . ..,.. . . .... TYPE OF CONSTRUCTION ........� O-A f�................................................................ ............................... ................................. ..........19. .Z TO THE INSPECTOR OF BUILDINGS: The undersigned hereby, applies for a permit according to the following information: Location ?- ....4�...!"l'!q. ...:. ..........:..4� P,,V AJ I..�....��........................................:. ProposedUse B�iyLD 7..... 6.F _g............................( ................................................................... .................. Zoning District ............../....r..!.!.:: .......................................Fire District Name of Ownerr 9L C ! - .................Address�PF- t;J �. �..'..'.".�..... Name of Id,�jr' �D/O.Y[�1!''l! .. ��:......Address J. !�1`�"� ...K-o! ........ �14.... 14'-- 7t) " rceet— .............................:....::.........................Address Numberof Rooms .......... ..Foundation ...... ........................................................ ....... .................................... Exterior ^ :.Roofing ....... ��.....5......�..... I ................................... Floors .. .Interior Heatingr.`...................................:.................................:....Plumbing :.r.Z...!f..... .kt S !............................................. Fireplace ..Approximate Cost 3..!.t.M Definitive Plan Approved by Planning Board __________ _ _________19_______. Area ...... . 2 ..................... ..�........... Diagram of Lot and Building with Dimensions Fee nn © Gr..................�"'..... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barn le egarding the above construction. Name ... . ................ ?....f�. S'..... -GOLD1iN1/,` WILLIAM M.D. 23P56 REMODEL & ADD TO No ................. Permit for .................................... Doctors Office ............................................................................... Location ..............1�...�. X � ............ ............ .................Hy.a.nni.s............................................ ... .. ....... .. Owner .... W1.1 114TR...QQ.Ideu............... Type of ,Construction ...FXAMe.......................... ...............................................4................................ Plot ............................ Lot ................................ Permit Granted ..Ma......r.....c..h...5......................19 82 Date of Inspectiong/ ...............1,9 Date'Completed .................. ..19 1 14