HomeMy WebLinkAbout1160 PHINNEY'S LANE (9) Lt�i 7' 'dt6 �'`� ,2 7.3 0 ►moo �'
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
t,
Map Parcel ��� �� Application #
Health Division Date Issued
Conservation Division Application Fee II
Planning Dept. Permit Fee l�
Date Definitive Plan Approved by Planning Board � ����bq
AoL
Historic - OKH Preservation /Hyannis
Project Street Address ► n t
Village
Owner P�►A lce�t 1 Address SGY1ne.
Telephone st, >
Permit Request 1 lQkacemeftk
tz maoub5.
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation AACO.00 Construction Type r
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) A
Age of Existing Structure aSlArS. Historic House: ❑Yes /No On Old King's Highway: ❑Yes l/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:
►-• a 4
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ .y
_n
Commercial ❑Yes ❑ No If yes, site plan review# CO C"
Current Use Proposed Use
r
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) 1-,p7/
Name �� �-�f� Telephone Number G 1(P �/ �u✓
Address ill �� �/�/�� ��iP Ufil License # -IA41-7
V9901 / WA) 69 :2, Home Improvement Contractor# I(o' 000
Worker's Compensation # 0 CC Soo a g15Aw Annc(
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE < DATE 4 � o
I r «
r FOR OFFICIAL USE ONLY
APPLICATION#
DATEISSUED `
MAP PARCEL NO.
ADDRESS VILLAGE
OWNER-
DATE OF�INSPECTION: ,f
FOUNDATION
FRAME
INSULATION
5 '
FIREPLACE
t ELECTRICAL: ROUGH FINAL f f
PLUMBING: ROUGH - FINAL
T
` GAS: ROUGH FINAL
y FINAL BUILDING
DATE CLOSED OUT ;
ASSOCIATION PLAN NO.
� r ,
f4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
i�•�'� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual):-�aket'$, NFjSoc taiee D Inc
Address: O 07t, �o�3 -
City/State/Zip: Phone-#: 'E $-3CQ- �2AA5 `
Are you an employer? Check the appropriate box: Type of project(required):
L eI am a employer with �, 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. T. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers'.comp.insurance comp. insurance.$
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 11.0 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
employees. [No workers' 13.®Other 1,
comp.insurance required.]
*Any applicant_that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:kko C
Policy#or Self-ins.Lie.M Lk")CC Soo2►�5�0I�O Expiration Date: AI a-bl 1
Job Site Address:Il(ob V)h►VI , Lw1 ee,%nj. O atp3a 0nit ity/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 tip 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 under the pains and penalties of perjury that the information provided above is true and correct
�Si - a� Date:
Phone#:
FOther
only. Do not write in this area, to be completed by city or town official
n: Permit/I icense#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: 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
including the legal representatives of a deceased employer,or the
the foregoing engaged in a joint enterprise,and incl g g p
of g gJ
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 vsrith 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-con6actor(s)name(s),address(es)andphone 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
e which will be used as a reference number. In addition,an appli
cant
that must submit multiple permitAicense 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 maybe 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
e
(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 idents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617--727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
sTti Town of Barn-stable
Regulatory Services
rBARNSTAHM
MAM Thomas F.Geiler,Director
Eo Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize dV (- Re--,s,6c-t(3Ae—c-=,TV'%Cto act on my behalf,
in all matters relative to work authorized by this building permit application for.
11C� �
(Ad ss of10
,f' -
signature-of- fwne"r Dom:at
�tetr, c(e1 '
Print Name
If Property Owner is applying for permit please complete the
Homeovvners License Exemption Form on the reverse side.
i n I
Town of Barnstable
{
Prof'TH
Regulatory Services
4
•
T homas F. Geller Director
awttx
•
srwsc.e. •
•
htAss.
Building Division
PrED Tom Perry,Building Commissioner
_. ._
200 Mairi Streeter Hyaffiis;NIA 02601
www.town.barnstable-ma.us
Office: 50 8-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
cityhown state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
dual for hire who does not possess.a,license rovided that the owner acts as
to allow homeowners to engage an individual p • ,, : �P. ;
supervisor.
DEFINTIION OF BOMEON'YNER
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
arm strictures. A
'1 dwelling, attached or detached structures accessory to such use and/or f .
be, a one or two-family g, ry
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"bomeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,riles and regulations.
The undersigned."homeowner"certifies that.he/she understands the Town of Ban nstable,Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
SignatiLm:of Homeowner x
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or-larger will-be re'quired'=to°c"omply-vn the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMYTION
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 emgages a persons)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 responsibilidts 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
scvcral towns. You may caret amend and adopt such a forn-dcertifrcation.for use in your community.
Q:forrns:homcexempt
Uatbe 6126fa009 T me1-1117 PM Tor 0 9,15083626115
Cli ntffi:9742 2BAKERAS
ACORD CERTIFICATE OF LIABILITY INSURANCE 6/26109`"'YVYY,
`PRODUCER THIS rrERT1FIC7ATE IS ISSUED AS A MATTER OF INFORMATION
Dowling 8 O'Neil Insurance ONLY ANDCONFERS NO RIGHTS UPON THE CERTIFICATE
Agency HOLDER:THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
973 lyannough Rd., 'PO,Box 1990
Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC
INSURED INSURER A National Grange Mutual Insuranc
Baker 8 Associates,lnc.
INstl(tERB Associated Employers Insurance
P O Box 923
INSl1fIFH l;:
Centerville,MA 02632-0071 INSURER D
INS(1RFR F
COVERAGES
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDIT ION;:OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
SR POLICY EFFEINE POLICY LTR TYPE OF INSURANCE POLICY WRI1KR pA � ATE n� LIMITS
A GENERAL UABILITY MPJ7223M 04119/09 04119110 L ACI f OCCURRI"J - bt 000 000
DAMACd TO RTNFFI:
VNtA(1;(3RF-CA1f*
ROAL GENERAL I IABII I IY I^ §500�AIMS MADE: DOCCUR MFD L XP(Any me pewl'i E10 000
PERSONAI.8 ADV iNARY St 000 000(AWRAI.AGCRI:(;AN 52 000000 LIMIT APIA TES F'ER PRODUC I S COMI!0P A(-,G §2 000 W0
T'OUI:Y JECT PRO
LOC
AUTOMOBILE LIABILM
CUMIiiNFI1 S'NlilT 11M°I �
ANY AUTO ILA�iCrinorll
Ala OWNED AUTOS HOOILr"JURY E
SCHEDUI ED AUTOS (Per person)
HIRFD AUTOS HOUR Y INJURY
(Pw a:.ddrnti
NON-UWNI-U Atli OS
PR014 H-1I UAAMA(A, b
(Per ardnnnl(
GARAGE LIABILITY .AUTOONt' EAAi:CIDI.N1 § ^
ANY AUTO UIIIIR THAN I"A ACC
Al11 C ONI
EXCESSAIMBRELLALNBILITY ---_ E.A011000URRENCL
71 OCCUR D CLAIMS MADE A(y(Hl GAIT b
UL DUC I IUt I. 5
RF TENT ION § - _ b
B woRKERs cowiiNsATm Am WCC5002454012009 04123109 04123110 X 'R ST.L I 11L
EMPLOYERS'LLMNL Y I1 I'ACITACUMNI s100,000
A PROWL.TOFLPARTNEWFXFCLIT MI-
OFFICFR/MFMf1F.R FXCLUDEU'?
NY NO I L U151-ASf_ IA FMI9 UYEE $100 000
'1 yyes Liesalbe under I L UKA ASE POI iCY LIMIT $500 000
SPL.CIALPROVISI(NN'Oeiow
OTHER
DESCRW TION OF OPERATIONS I LOCATIONS I VEHK:LES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECNI.PROWSIONS
Officers are included under the workers compensation policy.
Insurance coverage is limited to the terms,conditions,exclusions,other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD""of THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE EXPWATKIN
Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL ._.,Il. DAYS WRITTI N
Thomas Perry NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAN ORE TO DO SO SHALL
200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER I1S AGENTS OR.
Hyannis,MA 02601 REPRESENTATIVES.
AUIHORIZERt ED PRESENTATIV/E `
ACORD 25(2001108)1 of 2 #S59110/M58469 LS1 o ACORD CORPORATION 1988
The'Commonwealth of Massachusetts William Francis Galvin -Pub]; Browse and Search Page 1 of 2
A
The Commonwealth of Massachusetts
William Francis Galvin
r.
r Secretary of the Commonwealth,Corporations Division
One Ashburton Place, 17th floor
i. .ram Boston,MA 02108-1512
Telephone: (617)727-9640
BAKER & ASSOCIATES, INC. Summary
Screen
Request a Certificate
The exact name of the Domestic Profit Corporation: BAKER&ASSOCIATES,INC.
The name was changed from: BAKER CUSTOM ALUMINUM&VINYL COMPANY,INC. on 1/8/2004
Entity Type: Domestic Profit Corporation
Identification Number: 000522085
Old Federal Employer Identification Number(Old FEIN): 000000000
Date of Organization in Massachusetts: 01/01/1996
Current Fiscal Month I Day: 12/31 Previous Fiscal Month I Day:00/00
The location of its principal office:
No. and Street: 521 SHOOTFLYING HILL RD.
City or Town: CENTERVILLE State: MA Zip: 02632 Country: USA
If the business entity Is organized wholly to do business outside Massachusetts,the location of that office:
No. and Street:
City or Town: State: Zip: Country:
Name and address of the Registered Agent:
Name:
No. and Street:
City or Town: State: Zip: Country:
The officers and all of the directors of the corporation:
Title Individual Name Address(no PO Box) Expiration
First,Middle,Last,Suffix Address,City or Town,State,Zip Code of Term
PRESIDENT MARK BAKER 521 SHOOT FLYING HILL
CENTERVILLE,MA 02632 US
TREASURER CAROL BAKER MRS. 521 SHOOTFLYINGHILL ROAD
CENTERVILLE,MA 02632 US
SECRETARY BRETT BUSSIERE MR. 521 SHOOTFLYINGHILL ROAD
CENTERVILLE,MA 026323 US
DIRECTOR MARK BAKER MR. 521 SHOOTFLYINGHILL ROAD
CENTERVILLE,MA 02632 US
http://corp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 3/25/2009
i
6
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A _62
te
Board of Building Re ula ions and-
- of -
- - One Ashburton Place Room 1301
y Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 162600
Type: Private Corporation
Expiration: 3126/2011 Tr# 282 11`i
BAKER & ASSOCIATES INC.
MARK BAKER
P.O. BOX 923
CENTERVILLE, MA 02632
Update Address and return card. Mark reason for chau.j e,
0 s0m-oaro4-s101216 Address , Renewal Employment Lost( ,ir.
1��i�1�Ntltttec`ti� s �t`It :i�li�i�.���z t►# �'ttl�lic '� tt�#��
Bu.tt�cl �►f� F3��ii+tlel�� �4:;lall.l�9+1)ti� :tfit� '�tlr�tl,�rI�
._ Construction Supervisor License
License: CS 74477
Restricted to: 00
BRETT J BUSSIERE '
111 WAREHAM LAKE SHORE D
EAST WAREHAM, MA 02538
Expiration: 1/6/2011
Ae
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reqistration: 162600
Type: Supplement Card
Expiration: 3/26/2011
BAKER & ASSOCIATES INC.
BRETT BUSSIERE
521 SHOOTFLYING HILL RD
CENTERVILLE, MA 02632 Update Address and return card. Mark reason for change.
u,., �a, c, soon-Dana-cioizie Address ! Renewal Employment Lost(a!
Engineering Dept.(3rd floor) Map 4g Parcel 0f/ erJt
House# Z k _Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30)
Conservation Office (4th floor)(8:30- 9:30/1:00-.2:60)
Planning Dept.(1st floor/School Admin. Bldg.) V THE rq
Definitive P roved by Planning Board '19 INSTALL E
L
TOWN OF BARNSTABL'VIR®NM ® D
TOW °�®v s
Buildin Permit Applica on
Proj t dd ss
Villag
Owner Address
Telephone
Permit Request
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ y0
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑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
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
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 ❑No If yes, site plan review#
Current Use Proposed Use .
Builder Information
Name Telephone Number 7r-7! 96 d
Addresses� —e-- Z License# O S"( S yo
Home Improvement Contractor#
(!:7 Z 9 3 Z Worker's Compensation# 6JZ a 6 d Z 3!57�o j
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
SIGNATUREz2a_ E�E_
DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. t
DATE ISSUED
MAP/PARCEL NO. -
ADDRESS VILLAGE .
OWNER -
DATE OF INSPECTION:
FOUNDATION
FRAME � , . . •. ., 4 _ ,
INSULATION
FIREPLACE F
ELECTRICAL: ROUGH FINAL
f PLUMBING: ROUGH' FINAL I
GAS: ROUGH FINAL
4 FINAL BUILDING ' i =
DATE CLOSED OUT
ASSOCIATION PLAN NO.f
4 4 '
\, ; 75°0 ' STANDARD LEGEND
\`+ 77.0
/ •-•• + note:not all spnhols will appear on a map
0. `. _.
GOLF COURSE FAIRWAY
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,
' •'': \i' 7-3,5 _� � EDGE OF BRUSH
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f CONIFEROUS TREES
i�• �•. ...� I — — — � \ ..-7YJ I MARSH AREA
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•' - - � ., ' . ,�� �•- PROPERTY LINES
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�' __ �` 4 •- PORCH/DECK
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R'. DOCK/PIER/JETTY
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ASSESSOR'S MAP BOUNDARY
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• ° I PRaPER1Y e0UNaARIFS,IXt AAt Nat TRUE LOCATIONS,mN B-391
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VEGETATION,TOPOGRAPHY AND PLU,IMETRIC DATA IN11RPAI11D
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r ^!' •'-\ \' / r30 AC .... FROM 1989 AERIAL OVER FLIGHTS,PHOTOGRAPHYAT I'-8a0'
# 0;36 AC 11 FR
, ' � � �...1 ... �� 'T MAPPID Ai I"=100".PARCEL DATA OIGIIIHOFROM I'e 107
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\/ / i`1{_,i ... + II '� fNGIN[ERING ASSESSORS MAPS,989
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The Commonwealth of Afassachusetts
Dc partnu•»t of Industrial Accidents
600 Washine�ton Street
r+
0 Boston, Alas. 02111
Workers' Compensation Insurance Affidavit
AalOant Information• Please PRINT leb%bj�s,a R
name*
location•
City nhone#
1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
"..�w..a:L+=-'•—�`'-''-'°y"'a'.�.."�k..':.iw.�.�,.m--�---• _. 1'.a:..m ..:a"�.�-"`�"`""' +... t�..�...�.._�.�
I am an employer providing workers' compensation for my employees working on this job.
company name:
address•
City: nhonc#•
insur ce go, 120ficy#
�, .. •... ♦ ...+.. .is.;,': •�ir±.y...,..4!.Y.Y-n Ky.:T fr.•.,:.+: !!en'•,q"'/�n:V+�MrLM.,TTITT
I am a sole proprietor, raLcont�o or homeowner(circle one)and have hired the contractors listed below who have
the following wor•ers' compensation polic
m an y name-
address• )49)60
phone 0:
a /
insurance co. L is•# lot�a �as�
I �". - '.4:.r7'« ':�1Y'ttti-e"--r.s....:.'T•:Y^,4�T��' Y.T...�.pte,•.'7,.a1.T� r� ••?G 'T "y�.:,'�i.-Tm..� ."'^,..��.•.:-:a�itaYr �......._.y�
�......�.:....._..rr�. ..._'_. ._.:..I:a• u�.- ".:.+dJr.�r' -.^ -11T� ��7!I. Dr'; f a.rrx:uic
company name:
address:
city abone#•
insurance co nolic}•#
Atiach additional sheet if tiecessa-—n r-"_r'�;•►: .sr rf_ : r. r��..,';,tc.=,!��' a?�...._•.�- ,4 -^'�.�.`•- `"'.'
Fuilure to secure coverage as required under Section 25A of DIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a
cope of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereht certifI,►under the pains and nalties of perjun•float the information provided above is true and correct.
Signature Date z
Print name Phone#
,{• rllffd/ t•
official use only do not write in this area to be completed by city or town official
city or town: permit/license# riBuilding Department
[31,icensing Board
C3 check if immediate response is required OSelcctmcn's Office s_
0I1ealth Department
contact person: phone#; MOther s.
(revised V95 PJA) r - -
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The Town of Barnstable
MASS
satuvsrasz.E,
161rg. ,0�' Department of Health Safety and Environmental Services
pTFDMA'�� Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
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:/J,T; 5x/o ..¢err Est.Cost
Address of Work: D
Owner's Name h •'�a.� L -� �p�,�-�
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$1,000.
Building 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 age of the owner:
l5at6 Contractor Name Registration No.
OR
Date Owner's Name
Al
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71-
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DEPARTKENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number: Expires:
SCHULZE
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CENT*ERVILLE, MA 02632
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