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HomeMy WebLinkAbout0034 OAK HILL ROAD __ /, ' � `���- C_.__� � - -----�',. Town of Barnstable *Permit — IN Regulatory Services ee 6 monthsjrom issue date • snxrTsrnez.�, •� • Richard V.Scali,Directo CA r 17 Building Division Paul Roma,Building Commissioner IIr (j . , 200 Main Street,Hyannis,MA 02601 M �a7- www .town.bamstable.ma.us Office: 50.8-862-4038 ! �� Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / c z Not Valid without Red X-Press Imprint Map/parcel Number O ✓ /f �] / 1�� Property Address ,I q ®Cr esidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address r rl C or's Name Telephone Number Home mprovement Contractor License#(if applica e Email, n Supervisor's Constructio License#(if applicable) ❑Workman's Compensation Insurance. Check one: or 0 a 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 Reques check box) e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Co tractors License&Construction Supervisors License is required. SIGNATURE: - G QAWPFILESTORMS\building permit forms\EXPRESS.doc 06/20/16 vJ 0 �9 b �s 1 17re Comrrrorriveald:of Massachusetts Massachusetts Department or,f'Indushial Acciderds �► - — OfTwe OfImV!'StdgatrfJrrs _ 600 Washington Street _ Boston,CIA 02111 tt+ m.rnasmgov1dia Workers' Ilampensatran Insurance Affidavit-S.nildersiContractursiEIecfricians/Plumbers Applicant Iuformatian Please Print f�e�ibly Name(BusinesslDrga�zationflndiviAnal}_ 1./a`r �c 9 �%s9 S !vs��1a',o-- ii} Address Cityistaterzip Are you an employer?Checkthe appropriate box: Type of project(required).- I.❑ I am a employer with. 4. ❑I am a general contractor and I employees(fall aadfor part-time)-* have hired.the sub-contractors 6. New cansfrucfiiog 2. I am a sole proprietor orpartner- listed on the attached sheet 7. ❑Remodeling ship and have no employees. . Thew sub-contractors have g.•Q Demolition woddng for[sae in.any capacity- employees and have workers' [No nriarket�' comp.insurance � comb.insnrance.l 9. ❑Building addition . d.] 5. ❑ We.are a coipomflon and its 10.�Electrical repairs.or additions re quired officers have-exercised their 3. I am a hnmeoumer doing all work 1L0 Plumbing repairs or additions niyysel [No workers'cramp. fight of exemption per MGL 12.❑Roofrepairs insurance required-]7 c.152, §1(4),and we have no employees-[Ito worker' 13.❑Other comp.insurance required.] •AzLy applicaat that chedsbox OE1 mast also fUoutthe see@anbelowshowing dmirwaikers'compensatiaap01ic9infbMad n_ #Hameomaers who submit this z±Hmft in,dirating d wy arm wing all walk and then hire auto CaatIBCtOr5 amst submit a new affidaest indica3iae SntTi fCantractorsthat rhea this bax must attached as sdditiand sheet showing the name of the sub-contractors and state whether or not those enMieshm etnplayees.Ifthesub-contowtutshace employees,they mustpmuide their markers'comp.politg number. Ian[an en[plal�r t1[at is prox�tiing y[-orkers'corrrper[srrtior[insrirance,jor rrrS*enrpTny-ees �BeFoav is ii[e paTicy arrd jab zita informaliom Insurance Company Fame: Policy ifl or Self--ins.Lic.4*: F-kpirat on Date: Job Site Address: � l f Cc�� /�%// /�c� City/State Zip: Attach a copy of the workers'compensationpolicy 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$1,500.0G and for one-year imprisonment,as well as civil penalties.in the form of a STOP WORK ORDER and a fine of up to$ O-00 a day against the-violator. Be advised that a copy of this statement maybe forwarded to the Office of Imvvestrgatiom of the DIA for insurance coverage y'erificattian. .Trfo herRby ce&fj,r:atdcr the pains ar[d iJ We v er my diatthe ircforitra vaprm-idedabmne is trus and carrect Sit3tattire: u c Date: /7// Phone 6- to G/ O lcial use onTy. Do not Fvrke in this area,to be completesd by city or town o f 4ciat City or Ta.nm: Perndtff icense# Issuing Autharit3(circle one): , 1.Board of Health 2.Building Department 3.Cityfrmen Clerk d.Electrical Inspector S.Plurnbmg Inspector 6.Other Contact Person: ' Ph-one#: s information and lastruc ions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their CmFIoyees. pursuantto this s atate,an employee is def aed as."-.every person in the service of another under any contract of hire, express or implied,oral or written." An ernp&yer 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 - dweIIing house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenaatthereto shaR not because of such emplaymentbe deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Ticeusmg 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 mnr sance.coverage required" Additionally,MCrL chaptra 152, §25CM states"Neither the commonwealth nor ELy of its political subdivisions shall enter into any contract for the performance ofpublic woik until acceptable evidence of compliance with the insurance.. requimmenfs of this chapter have been presented to the contracting authodty." Applicaat� , Please fill out the workers'compensation affidavit completely,by checkiag the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addresses)and phone numbers) along with their cerlificate(s) of insurance. Limited Liabi y Companies(LLC) or Limited LiablZity Partaerships(LLP)withno employees other than the members or partners,are not required to cry workers'compensation insurance. If an LLC or LLP does have employees, a.policyisreguu-ed. Be advised that this affidayit maybe submi�edtotheDeparfinentof Iudus�7al Accidents for confam.ation of insurance coverage- Also be sure to sign and date the affidavit. The affidavit should be rst=e:d to the city or town that the application for the permit or license is being requested,not the Department of T„rh,ter,;ai A_ccidents. Should you have ally questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number li,-t below. Self-insured companies should enter.Their self-h3 sT ra ce license number on the appropriate at. City or Town Officials Please be sure That the affidavit is complete and printed le pIIy. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in.the pe;n inWlicense number which will be used as a refs ence number. In addition,an applicant That must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current p olicy infb=ation(if necessary)and under"Job Site Address"the applicant should write"all to cations 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 fine permits or license& Anew affidavitmust be filled oiA each year.Where a home owner or citizen is obtaining a license or permit not related to any business br commercial venue (Le. a � dog license or permit to bum leaves etc.)said person is NOT rred to complete this affidavit The Office of Investigations would hike to thank you in advanco for your cooperafiou and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax nmmer- e Cammaa Ith-of MassachU&Ctts ' Depadment of Iliclustdal Agents • �Q��asbin�tan Strut i Bostou,MA Q21 I I T(,-L#617,727-4900�xt 4€6 or 1-977-MASWR Fax#617-727-7749 Revised 4-24-07 � �o�f dia Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division t RAIN t Paul Roma,Building Commissioner 639. A�� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 7 f Please Print DATE: Z l_JOB LOCATION: c % /� �7l// V / vlGi j4 a; z2 number/ street f village "HOMEOWNER": 16 i Cam' %Y�f �l C��S,� 1r F ? pj�1�C1 �' 2 6'� - - 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,of 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 ,Y „ �VE Town of Barnstable Regulatory Services ` Richard V.Scali,Director Building Division. Paul Roma,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 Sec 'on If Using A Builder I , as Owner of the subject property hereby authorize to act on my be , in all matters relative to work authorized building permit application for: ( ss of Job) **Pool fences and are the responsibility o e applicant Pools are not to be filled o utilized before fence is ins d and all final inspections are pe orined and accepted. Signature-of Owner Signature of Applicant Print Name Print Name Date QYORMS:OWNERPERMISSIONPOOLS k Assessor's office (1st floor): y �E/a THE Asspssor's nap and lot number y. .✓.fl� ....:..�1�:.. _ I�($P��CSYS�.E - Toy` Board of Health (3rd floor): - t, r `LEA/��® Sewage Permit number ..................................... .� .f. �/ �i/� Z B>HHSTADLE, i Engineering Department (3rd floor): ,. H T,T��$`���� 9oc ,"e IL e� House number .......................................��`��.J. .... � '���'tv ����nje er �0 �\ APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only: �Q6� � 5� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ... .:f ./.Z ...n......... Ce�.CiLI. *l.:Q.i. .................. ' TYPE OF CONSTRUCTION ...W.O.C).CCf -.fl1.` .................................................................................... 19�h TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following, information: 0 Location .... .......Q. .K........ .!..Z-........ ................ ......'1... nX.l S............................................................ ProposedUse .....45:U',Kx.....R1.Q.0.!:1.l....................................................................'................................. ZoningDistrict ....1.....................................................................Fire District .....................................).......................................... Name of Owner ./ -e/7 YlC T ..... c :. ..�. ..L ....Address ... .f... .... . . .....7!...�` .4....1 t Name of Builder .. �F.l.. ....M.,...�.10JA.(C0Address ....�.)....4—ante/l .. .n......4. .A.TVI../ Nameof Architect ..................................................................Address .............................../...................................................... Number of Rooms ..........� ...P0.\J.fe.d�.... ffr,.......................................................Foundation .Qi►..O</...C....�......�..G. . b.s Exterior .....W-6.0- .............................................................Roofing ....A.-S.J.010,,,x...C................................................. r �Q ............Interior ..... Floors ...... .. .�..Ot./.`..�..�i1°................................. �.�.�.E_.T.. ................ Heating .......mil Q n..L� ......:............................................Plumbing .................................................................................. Fireplace .................................:.................................................Approximate Cost . .. Definitive Plan Approved by Planning Board ____-______'____________________19-------- . Area Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH a S>'rn6L S c;,A Room CesS PO Q ! 30 to �.�d� Qej- Room P-c-nc. _f _ 7`6S t7 jo ©o / OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS NI'l-L 12 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. e Name C. ....... Construction Supervisor's License ...011r.4...1.9....... 1 y BUELL, KENNETHI W. vl r No ,,. 9725.... Permit for ...Build.,Addition„ Single. Family..Dwelling,,,,.,,,,,,,••...,..,. Location r 34 Oak Hill Road .............. X { .....................Hyannis............................................ Owner Kenneth W. Buell . . ........................................ Type,of Construction ......,Frame - - ....................... ..:.................. - ............F................ Plot ............................ Lot ................................ Permit Granted ..........Ju1Y. ............19 86 r. Date-of Inspection 19 tDate Completed ......... '.�� 4 .....19 " . 4 IN •rti. I a r Assessor's office (1st floor): �j *THE Assessor's�,map and lot number �yo...... �� ! '. Qo ... . . Board of Health (3rd floor): Sewage Permit number ...... ........................ .'f"&q.07*1 H,aBSTADLE i Engineering Department (3rd floor): #3,41 r15 'oo 1639 �e0� Housenumber .............................................................. ......... 'tt c Mix 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 .......C.a./.?...SZK"..:'-T.......0-..)Il.........� �UY�IL(i`U�n TYPE OF CONSTRUCTION ...f. a (J.v...... ' Ic� 'I!;e.................................................................................... 19. /�.'�......._..................... t.... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information. Location ;� 7' 0,4 T L- - Roe • A ........................................................................................................................................................................... ProposedUse ......5 u.n.....R-nar1'7 ................................................................................................................ ZoningDistrict .........................................................................Fire District .............................................................................. Nameof Owner ......................................e....:.,..........................Address .................... ................................. Name of Builder ...A .� ,j Address ... .. �z'ra`7` L/a ...4:. .. d.t. '... Nameof Architect ..................................................................Address .........................................................................,/......., .....�a.�.t..�. '.C./.........-�?Number of Rooms .......... .....................................................Foundation Jf Exlerior ..... . ? ............................................................Roofing ...... .. .. 47— ................................ Floors �7.!1..C..r. .. ' ..................Interior ..... �. t. ,.}�, O .. .... "...!...! ................ Heating I� G !1 t® .... ............................ Fireplace .....................................................Y............................Approximate Cost ................................................... Definitive Plan Approved by Planning Board --------------------------------19--------. Area ...z: ?.f'71.. {� Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 1Q(�, • � o - 7,A -- Od knom RGrnG- l7 O r- 6 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. - f � s Name .. ... ..........................................i..f........................... Construction Supervisor's License C1........................ ....... 9-3 Hvannis Owner ....Kenneth ����_Buell _________ � � Type of Construction ......Fzame......................... -------------------------- . - � P|ct ---------. Lot .---------. . - � | Permit Granted .......Iuly..3.O°...............lP 86 Date of Inspection ....................................l9 ` ' | ' Date Completed ------.------.lV ' ^ / ' � ' , � . ' � . � ~ ` . ^ - ~ � ' . . . ' - - ' - | � ' / ER neering Dept.(3rd floor) Map Parcel s Permit# ' House# L/ FJS Date Issued �G y Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) 4 t 2 e I 3 Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00) v`�� 1`Z`G:L , 111E 19��i1 ipfizi��1 N tip T L - - b ��� C. I�,BARNULASTABLE r- TOWN OF BARNSTABLE - Building Permit Application > Vrojectress/ ��,r�,y OAK Pig- F,>t7 /�p� ,/ C Village Owner 1� 2 /J�-yL Address .3 " 4w,4*4L ,ram Telephone 779 �8Gvr Permit Request C 11�&) First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ OOM Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No r Dwelling Type: Single Family (�K Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes Zo On Old King's Highway ❑Yes 4EJ!No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Areas .ft. Basement Unfinished Areas .ft Number of Baths: Full: Existing New Half: Existing - New No.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 a Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes IXlo If yes, site pla.review# Current Use Proposed Use Builder Information r Name� /Zz Telephone Number `12,��6,Ir Address le A 144 021 TS'License# G�.4-1 Zz/ 2tw-_2 - t Home Improvement Contractor# IGy 70re Worker's Compensation#of-&,2va l NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON-THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE o - DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY x r t PERMIT NO. DATE ISSUED!. MAP/PARCEL NO. t - ADDRESS VILLAGE f t OWNER 4 , DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL t FINAL BUILDING i DATE CLOSED OUT ASSOCIATION PLAN NO. �--� ✓i2� Z� I 0 I _fOME .IMPROVEMENT CONTRACTORS REGISTRATION j of Building Regulations and Standards t ti -One Ashburton Place — Room 1301 :Boston, -Massachusetts 02106 - • HOME IMPROVEMENT CONTRACTOR '-L-------------------------- P.eS=stration 100740 Expiration 06/23/98 Type — PRIVATE CORPORATION _ aJ HOME IMPROVEME.)fi CONTRACTOR F Rejistration 100740 CAPIZZI HOME IMPROVEMENT, INC. I Type - PRIVATE CORPCRATION Thomas Capizzi , Sr . Expiration 06/ 3/98 1645 Newton Rd . I Cotuit MA 02635 CAPIIZI HOME IMPROVEMENT, INC TSaias Capizzi, Sr. Newton Rd-. I M1CMINISTA TOR Catlit MA 0261. I DEPARTMENT ONE A31iBUR i D05 TUN, I-/ L10N'SUPERVISOR LICCNSC Expires: . ;icl"eds"L� _ .`fir •"� .Z�• a .. _. .. ... •- - ,L,;-SECURITY; 0 . 030-58- 49d ,_{ �S Xi GAPIZ�I:-JR:* , Rol- �•�.�yy•am��y7,,- ./ 1I�i i The Coninton wealth of Massachusetts Department qf Indtlstrial Accidents 1 - Office afitivestigatians 600 li ashin,foil Street Boston,A1ass. 02111 ,~ Workers' Compensation Insurance Affidavit Applicant inf rat ' am location: 41:�/J sir. LO7T/rT i� ��6 3s' 9S7 Phone f y2. I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ' .__.a.:w, i.t..i:a.+ �s:'t..au�`.r `Z^•-- •`�'y v�- r- ��:�x;�`'�`a'w^-_f!_'r.^:,��-_.;...1�_•,__;,�.T,. 1 am an employer providing workers' compensation for my employees working an this lob. r ' company nan4c: address: cite: hop #: insurance co �" / :�7 %i Policy L.1/b RM/ ..-es- .'t:qr--*-•,•r-sus <. _+:a..Y.+'*r"rr.� tea*- .—D. �,,.. .q_»e..*.r. ...., El I am a sole proprietor,general contractor,or homeowner(circle one)and hav:hired the contractors listed below who have the following workers' compensation polices: company name: address: cite: phone#• insurance co. Policy# —___._.......__._.__.tt—._._. _ :v tw.:;'arr 3:ar.r:t,� -r_L.YJ_:iin1:.l.a.11i:L+. -�+-..+_:..i�s....��T'L'=`— �.,��.,. c ✓ —._. .-� .L .t.. comnanv,name: address: _ city: hone#: insurance co. oliev# iVt jch edditi6nal sheet if neccssa .fir-.c"�C�+-rc '�""c• .-+t;a�;�y�, ;;�c-'^_ ,�`i�a��;^`;r 4�'.�-'=;iia,may'-M'!'y,-r t'_.-•---'--"'-__._�.+__....__.._�. ,_.- _4 ':.c Failure to secure coverage as required under Section 25A of AlGL lit can lead to the imposition c`criminal penalties ora fine up to S1.500.00 and/or one%ears'imprisonment as ivell as civil penalties in the form of a STOP 11'ORK ORDER and a rice of SI00.00 a day against me. I understand that a cope of this statement maN be foncardcd to the Office or investigations orthe DIA for coverage vc-ification. t do hereh)•certify and t ants aad realties of perla{y that the information provided dove is true and correct. Signature Date Print name �i1�di �Cl�!/ Rhone official use onlydo not 4crite in this area to be completed by sit} or town official cih or town: pernlitAicense# Buil dingment k: O O check if immcdime response is required OSice olentcontact erson:f- phone#; rlL_.,,.+.--r,:-••n-_.. (fMscd `PJA) The Town of Barns table 26AAEL � ir Department of Health Safety and Envonmental Services - 1 p Building Division 367 Main Stroet,Hyannis MA 02601 Ralph Cmss=a p SOS-790.6127 13,R caunnissiorc F= 308-T15-33AA Y For c fice use aidy • ' permit no. AFF DAVIT WR0 CNTRA_ HS ppLIT�PERhIITO APPLICATION e•=onstrnction,alterations;renav=iM rtair. o� MGL c 142A rzquires that the Occupied oonstrucd= of an addition to'nay o�iaer impt�vemcnt,.gal, demolition. or u�or to Bch are ad}a� ceding containing at least an e but not more than four dwelling along with other . to such residence or building be done by registered=actors.with certain ° i 'type of Work: rfG G� Est.Cost � �&p4 L Address of Work: ' Oaiter.Name: �v — Date of Permit Application: I herchr certify that: i Registration is not required for the following teasan(s): Work excluded by law —Job under s1,000 Building not 0wns-0o"4ied ow=ping cwn pm=g . Notice is hereby gh'=that: � CONTRACTORS OWNERS PULLING THM OWN PERIxT OR D G NEB�►� ACCESS TO 'THE FOR APPLICABLE HOME Il�ROVF.M 4T WORK DO ARBITRATION PROGRAM OR GUARANTY FUND UND13L MM c 142A SIGNED UNDER PENALTIES OF PEP-My I hcrcby apply for a permit as the agent of the crew=-: 0 - Regi atioa Na Date CO OR '