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Home My WebLink About0341 NORTH STREET �3�/ /1/o,�rF, sy' — — � _ � � � ' ,, ' y '(` �� TL4x , c�� iascr Al� 14-7 Ilillli 11 j-------- --1 IIIIII41IIIlilllllllll!ij��uu�,jminii�j®� eeetee� Illllllllllllllliil!!!Jlii!!�l�l ""illlll�li!!i!!��Ii!!i!!!II' "��=��' now 'T BEACH ..._J Illh� �� IIIIIIIIIIIIIIIIIIIII ILLE, MA • •• • C 7 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION o� _ Me Map Parcel --Application# G Health Division Date Issued 161,11,67AV Conservation Division Application Fea 6 Tax Collector Permit Fee Treasurer 6�0ct✓cp Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Z LA � SA-e.-_,L �A sjcsip�LIS L Village \\ Owner Address Telephone S O `�� 1 \— k r) 9, co Permit Request 1�� ►.� h; Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain AIM Groundwater Overlay Project Valuation L (IDb _Construction Type Lot Sizes - Grandfathered: ❑ es ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes No On Old King's Highway: ❑Yes o 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 t �llumber of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: 0 Gas ❑Oil ❑ Electric ❑Other Central Air: U'�es ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes a No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size i Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: { Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 'Yes ❑No If yes, site plan review# r � � c Current Use Proposed Use -R U DER INFORMATION ` — Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# Zk ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY � 4 APPLICATION# l r DATE ISSUED ' MAP/PARCEL N0. ADDRESS VILLAGE , OWNER DATE OF INSPECTION: L. FOUNDATION " FRAME ' INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL r } PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT k ASSOCIATION PLAN.NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations tS00 YYashingtoit Street Boston,MA 02111 www.m ass.gov/dia Workers"Compensation Insurance•Affidavit;,Builders/Contractors/Electricians/Plumbers { � Applicant Information Please Print LeLrib1Y �l-aee(Business/Organization/Individual):. •Address: Gi /State/Z Phone.#: Are you an employer? Check the appropriate box. -Type of project(required):. �r 4�`❑ I;a�m g neral contractorand,I 1.❑ I am a employer with f , 6. ❑New construction . employees(full and/orpart_time).* En�;ehrr�ed the subcontractoo `the'athached°see7. ❑Remodeling 2.❑ I am a'sole proprietor or partner- -. _�ship and have no employees ese subcontractors have g, Demolition workin forme in an ca aci emplo_y_eesvand-hmye workers' g Y P ty + .. �_ �.�...... - � 9. []Building addition [No workers' comp.insurance covip.msurance "" required.] 5. F1 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.D'Roof repairs insurance aequired.]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. ;'Any 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 notthose entities have employees. If the sub-contractors Piave employees,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees Below islhepolicy and job site information. 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage,verification. I do hereby fy' der the pains•and penalties of p ,ur}' at the information provided above is true and correct: Sienatur 1 Date: �• o Phone#: C d Official use only. Do not write in this area,Yo be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: IJ The Commonwealth of Massachusetts Department of Industrial Aecidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit ,Builders/Contractors/EIectridans/Plumbers Applicant Information Please Print Legibly Business/Organization/Individual): CO �/ �f'� b 1��® • �Address �--�G� %��1�;��e� . . City/State/Zip: roo, t/T Are you an employer? Check the appropriate bog -" -Type of project(required):. _ 4. I am a general contractor and I 1.❑ T am a employer with � 6. ❑New construction employees(full and/or part_time).* have hired the M'b-contractors 2. I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition workers' comp.insurance comp.insurance.$ [No wor required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work . officers have exercised their 11.[]Plumbing repairs or additions right of exemption per MGL „ ..-- myseli: [No workers comp. 12.2� of re. S insurance re aired t c. 152, §1(4),and we have no ' -- ❑ q ] employees. [No workers' ..13. Other comp. insurance required.] . *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. rf the sub-contactors.have employees,they must providb their workers'comp.policynumbcr. Iam 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 iip 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 u er the pains-and penalties of perjury that the information provided above is true and correct: IDatp� . G "Senature;i -- Phone#: . Official use only. Do not write in this area,'fo be completed by city or town offtciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: