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0080 PINE GROVE AVENUE
�' � ��vl, e G v�o�e �v e � , . _ _. --� - - __ _ ___ ---- --T -- - -- - � .�_ __ _ � Town of Barnstable c ,x �z,.� � �a - �' f's �', '�,,�, ';,k, :.�h€ ��, KAM Pos"t.Th�s,Card So Thatit is V�s�bleyFrom the Streets Approvetl Plans Must be Retained on�J�o'b andthis Card Must be Kept ,, Shed fANN t.E,.. • 3 "s' - £ <:-ts 1 7 Posted Until Final Inspection Has B„een Made s q • i639 , . . u . . .3 lZe istra ion Far ° Where a Certificate of Occwpancy is Requ,rred,such Build ng shall NotAi,Occup ed until a Fina1 Inspection has been made - g t Registration Number: B-20-602 Applicant Name: RUSSO, DANIEL&HILLARI Approvals Date Issued: 02/27/2020 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 08/27/2020 Foundation: Location: 80 PINE GROVE AVENUE,HYANNIS Map/Lot 290 074-003 Zoning District: RB Sheathing: Owner on Record: RUSSO 1 DANIEL&HILLARI '� '� Confracto"r Name:= Framing. 1 Address: 80 PINE GROVE AVE Contractor License: 3 2 o HYANNIS, MA 02601 Estro P ect Cost: $0.00 ri Chimney: Description: install a 16x12 shed Permit Fee: $35.00 Insulation: Fee Paid $35.00 Project Review Req: ti V Date 2/27/2020 Final: Plumbing/Gas K Rough Plumbing: .. g g: k _ Building Official Final Plumbing: and invalid unless the work authorized b this ermit is commenced within sa;months after issuance. This permit shall be deemed abandoned Y, p All work authorized by this permit shall conform to the approved application andhe'approved construction documentfowhich`ths permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structuresshall be in with the local zoning by law and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public mspectiori for the entire duration of the Final Gas: work until the completion of the same. Aqi,ure Electrical The Certificate of Occupancy will not be issued until all applicable signats bAi,y th613UiIding and fire Officials are p rounded on this permit. Minimum of Five Call Inspections Required for All Construction Work ' Service: 1.Foundation or Footing :; 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed ._. 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: g p 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department Final All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT f I t Town of Barnstable 3UILDING DEPT. THE royy Building Department Services FEB 2.6 2020 Brian Florence,CBO �, • ��,JVtretl vve_.e-+a—ee'ee.e,.�AH��...r—s, R•IMSTANA = Building Commissioner �pr 16.59. "'���` 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 SCANN!''3 PII=# � a" bog. FEE: $35.00 FEB 171020 SHEp REGISTRATION RESIDENTIAL ONLY 200 square feet or Iess Location of shed(address) VfIlage -71—�"l-t $' Property owner's name Telephone number Size of Shed Map/Parcel# e Date Hyannis Main Street Waterfront Historic District? A V� Old King's Highway Historic District Commission jurisdiction? �V p You must f le with Old King's Highway Conservation Commission(signature is required) Sign off hors for Conservation 8:00-9:30&3:304:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE IBM APPROPRIATE COMMISSION FOR DETAILS. T�[S FORM MUST U ACCOMPANIED BY A PLOTTLAN Q-farms-she&cg REV:08/6/17 S L oT 4' 28].92 w 36.z t' ;- �ytP L Z p r 39-o r /4 m of�L t o(o frcpm.s Lit 2 7 w c 7 1 c 337.64 ��� y, W / ' 44.7�_ \JET us.No 408.68 w L JOB # 90-243 CERTIFIED PLOT PLAN PREPARED FDR: LOCATION. PINE GROVE AVE BARNSTABLE SCALE: 1 "=60 ' DATE. _ 10/25/90 REFERENCE. .LOT 2 PB 449. PG .71 KEMPTON NICKERSON I HEREBY CERTIFY THAT THE STRUCTURE. SHOWN ;00.'.THIS, -PLAN IS,. LDCATED ON THE SCANNED- FEB GROUND-IS SHOWN HEREON: FEB 2 7 2020 o���tN OF Algf y � JOliN o,, o MCELWEE down cape engineering, inc . No.33s02 �^ CIVIL ENGINEERS LAND SURVEYORS — . . /o%��o ROUTE 6A YARMOUTH MA DATE REG."`' URVEYOR .14 Town of Barnstable Post This Card SoThat it is;Uis�ble From th;e Street Approued'Rlans Must be Retained on Job and this Card Mustbe Kept Building Posted Until,Final Inspection Has` Been Made , :" . 5f._:.,. ,. ...f ab ° Where a CerEificate ofOcc pancy is Required,such`Building shalt Not be Occupied un#�l a Final Inspection has been made Permit .-�k.-...,,, Permit NO. B-19-3004 Applicant Name: Keith Cliff Approvals Date Issued: 09/25/2019 Current Use: Structure Permit Type: Building-Stove Expiration Date: 03/25/2020 Foundation: Location: 80 PINE GROVE AVENUE, HYANNIS Map/Lot: 290-0747003 Zoning District: RB Sheathing: Owner on Record: RUSSO, DANIEL& HILLARI CQntractor.Name: -, KEITH A CLIFF Framing: 1 Address: 80 PINE GROVE AVE Contractor Licenser CSFA-058557 2 HYANNIS, MA 02601 Est.,Project Cost: $2,344.00 Chimney: Description: INSTALLATION OF APPROXIMATELY 17 FT.OF;6" DIAMETER Permit Fee: $35.00 STAINLESS STEEL LINER INTO FIREPLACE CHIMNEY FLUE AND Insulation: COMPONENTS FOR USE WITH WOOD STOVE �_ Fee Paid' $35.00 Date. 9/25/2019 Final Project Review Req: Plumbing/Gas Rough Plumbing: Building Official x Final Plumbing: This permit shall be deemed abandoned and invalid unless the work author¢ed?by this permit is commenced within six months after'issuance., All work authorized by this permit shall conform to the approved application and the approved construction documents for which�this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shalVbe in compliance with the local zoning by-laws'and codes. This permit shall be displayed in a location clearly visible from access treet orroad;and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the BuiIding an d_!Fieii 64iciais are�provide this permit. Minimum of Five Call Inspections Required for All Construction Work: A" Service: 1.Foundation or Footing 2.Sheathing Inspection m Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Perso c ting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department \ All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Town of Barnstable Building a Post This �Card Sao That�t isV�s�ble;:Fcomsthe;Street ApprovedxPlans Must berRetamedon Job and"this Card Mustbe`Kept ".. ass ` • 3s PostedUnt�1 Fna1 Inspection Has?Been IVlatle 3A ,., ...<,:, _ x,, .� P. yam ea ° Where,a Certificate:of Occu anc s�Re u�resucfi Building shall�Not::be Occupied until aFnal Inspection has beenrnade Permit Pe;*mit No. B-18-3735 Applicant Name: DUCHESNEY, PETER& DAVID Approvals Date Issued: 12/21/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 06/21/2019 - Foundation: Residential Map/Lot: 290 074 003 Zoning District: RB Sheathing: Location: 80 PINE GROVE AVENUE HYANNIS N, ContractorName ,- Framing: 1 Owner on Record: DUCHESNEY, PETER&DAVID Contractor License: Address: PO BOX 1218 Est Project Cost: $ 10,000.00 SOUTH DENNIS, MA 02660 P $ 101.00 ermit Fee: Chimney: k Insulation: Description: create one bedroom,bath and wet bar in basment Fee Paid $ 101.00 pate 12/21/2018 Final: Project Review Req: must meet 9th edtion 780 CMR f n Plumbing/Gas Building Official Rough Plumbing: Final Plumbing: 411111 1111,11 Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized b m this permit is commenced within six onths afterissuance. All work authorized by this permit shall conform to the approved application and the;approved construction documents fo which'this permit has been granted. Final Gas: # ng I" s< All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws an 3 codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Electrical work until the completion of the same. �� IN � Service: The Certificate of Occupancy will not be issued until all applicable signatures by°the Budding and Fire Officialsare provided on.this permit. Ak Minimum of Five Call Inspections Required for All Construction Work:''- '` Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health WrTre applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 2 - DE Application Number........ -: ILOWG DEFT: * ` Fee........................ Permit Fee..................................... Oth.. er r I" NOV �� 2018 r TOWN QF - .. �A{i�Si"4,SLE Total Fee Paid TOWN OF BARNSTABLE Permit Approval by.. !�...-D..............on. �.2. 1i BUILDING PERMIT .... ...................Parma............ . ..-. .. APPLICATION - Section I—Owner's Information and Project Location Project Address C� �;� rrcna- � VillageyCa�l� Owners Name Owners Legal Address 8D 6,c>v— Al- City o ev\�S State /Vk A Zip M-lIO 1 Owners Cell# 7J1- Z-77�-1-�t l?� E-mail tir�✓s 5�� `�cA e �'°'� Section 2—Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Sttvcture ❑ Change of use ❑ Demo/(entire structute) Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ElRenovation ❑ Pool El Insulation Other-Specify Section 4-Work Description T rct m%Lgte :2J9201 9 Application Number. ". ................................. Section 5 Detail Cost of Proposed Construction [O,m® _yo " Square Footage of Project Age of Structure 27 Dig Safe Number # Of Bedrooms Existing Total#.Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist WFCM Checklist ❑ Design Section 6—Project Specifics Wince ❑ Oil Tank Storage ❑ Smoke Detectors Plumbing ❑ Gas ❑ Fire Suppression Heating System ❑ Masonry Chimney ®'Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I an using a crane ❑ Yes No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage . Percentage of Lot Coverage, #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required _ Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last undated:2/9/201 S 3a, 13 fh I II i ------------------ s � C` 1 fj�'�,�►� I 13e D b v/ oo _ `..JJ I ( I i I I o LlvlU ROO DETECTOR REVIEW ED 1 /3e® �- ,�IST.�' .E B�JILI iNG DEPT. DATE FIRE DEPARTMENT 90TH SIGNATURES ARE REQUIRED FOR PERMITTING 0 . 1 � � v S � j 1 ! i i t i � 3 t R i i �l j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 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): N N l r7 Address: tit r,� er, � City/State/Zip: r x Phone#: SV Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.`®Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.g] I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 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 must submit a new 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'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: 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 1/��--/ �` /2--- Date: Phone —Q_ 17 51 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,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 cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.govfdia Application Number........................................... Section 9-.Construction Supervisor Name Telephone Number Address City State zip License Number License Type Expiration Date Contractors Email Cell# 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.Attach a copy of your license. Signature Date Section-10 -Home Improvement Contractor Name Telephone Number Address City State Tip Registration Number Expiration Date I understand my responsibilities under the rules and regalations for Home Improvement Contractors in accordance with 780 'F CMR the Massachusetts State Balding Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your HIC... Signature Date Section 11-Home Owners License Exemption Home Owners Name: Telephone Number -Orc-2.-7 -g t?cc Cell or Work Number �S- 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 docamentation required by 780 CMR and the Town of Barnstable. Signature f -�, �_ Date APPLICANT SIGNATURE Signature Print Tel Number s, -2 -et 17$ E-maul permit to: 4'e &Lw Cp r T en4 tin^A70 Section 12—Department Sign-Offs Health Department © Zoning Board(if required) 0 Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercid work,please take your plans directly to the fire department for approval i Section 13—Owner's Authorization L , as Owner of the-subject property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application for: (Address of job) ' Signature of Owner date Print Name Lest wdatmh 2J9=18 291.92 36.Z't r 0 390 ` pis 4(� a�z 55 m co ,.1 'n4 W o ��' -,d- N N to 111-64 0 44.7 r= �IE71._.j!-.0 t> OL JOB # 90-243 CERTIFIED PLOT PLAN PREPARED FOP.- LOCATION. PINE GROVE AVE BARNSTABLE SCALE: I °=60 ' DATE: 10/25/90 REFERENCE: .,LOT 2 PB 449 .PG 71 KEMPTON NICKERSON I HEREBY CERTIFY THAT THE STRUCTURE. SHOWN _ON THIS. PLAN I.S.—LOCATED ON :THE GROUND AS SHOWN HEREON. `N OF Mqf JOHNyG� down cape engineering, inc . o McELWEE No.33602 �^ !' CIVIL ENGINEERS „LAND SURVEYORS ROUTE 6A YARMOUTH MA DATE REG.� URVEYOR DEPARTMENT OF PUBLIC SAFETY COMMONWEALTH 1010 COMMONWEALTH AVE. a OF BOSTON,MASS.02215 ENCLOSE CHECK OR MONEY ORDER y MASSACHUSETTS LICENSE FOR REQUIRED FEE, CONSTR. SUPERVISOR EXPIRATION DATE MADE PAYABLE TO 06/30/1993 5 EFFECTIVE DATE LIC-NO. "COMMISSIONER OF PUBLIC SAFETY RESTRICTIONS ; 06/30/1991 000236 m (DO NOT SEND AS m DONALD E PIPATTI (�p 0 RMOU ; ORE BOX 365TH MA 02673 P EASELIOTE w Y ;+ E FECTIVE `4 i 19089 PHOTO(BUS7ING.P-ONLY) FEE:00.00 , 1 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER 0 . �T ��3 SIGN NAME IN FULL•ABOVE SIGNATURE LINE NATURE OF LICENSEE _ THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF (/��. COMMISSIONER THE HOLDER WHEN ENGAG _ ,/i� C�'•"' OTHERS-RIGHT B PRINT ED IN THIS OCCUPATION Ad�� 20OM-2.87.81429 r Assessor's office(1 st Floor): 90 Ze `7 Z/ 0 0 Assessor's map and,lot number / of THE to Board of Health (3rd floor): MUST CONNECT T0ATqVj4# OBERv E D Sewage Permit number C�' 9 77 ` _" ` "'� Barnstable Conservation Commis 3 RAN STAnca Engineering Department(3rd floor): clue V House number �,��1 `�3�`` ° ,639• Definitive Plan Approved by Planning Board 1 �� APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only Signed Date TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO w l L Cl SzV"/11 j elf o O L TYPE OF CONSTRUCTION 1�Pl�/yJfa C4y Y-/e 19 4/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location eqb ,9/!ve d2yauc Ayc— Proposed Use �4//A1/N9 �DaL Zoning District IJ Fire DistrictX� Name of Owner JAVItJ.��P 9�p LL Address J�N-f 4VC Name of Builder �ycheid Poot< Addresse'y AeuyI Name of Architect /�// Address Number of Rooms Foundation yr'/ e /6 Exterior d20'V CV W e. Roofing Floors Interior VI AI)rZ Heating Plumbing Fireplace Approximate Cost Area `-� 00 Diagram of Lot and Building with Dimensions Fee �e7� :S,PP4 rA�C SA 1,Vt 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. Name Construction Supervisor's License ©6O o2 3 4 SMALL, DARNLEY " No 34449. permit For Build Swimming Pool s Accessory to dwelling - Location, 80 Pine Grove Avenue Hyannis r; Owner's~ Darnley Small Type of Construction Frame Plot Lot # Permit Granted July 11 , -19 91 R Date! of Inspection 19 Dataompleted 5 19 R-s 03 F- 0 r f *INC TOWN OF BARNSTABLE Permit No 34038 . . BUILDING DEPARTMENT 0I Cash ......�80.00.�Jiv TOWN OFFICE BUILDING w ` HYANNIS,MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to DARNLEY SMALL Address lot #2 80 Pine Grove Avenue, Hyannis USE GROUP FIRE GRADING OCCUPANCY LOAD E A THIS,PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL`'NOT BE OCCUPIEDkUNTILrt SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY.,COMPLIANCE WITH'}TOWN, ,REQUIREMENTS AND:[N ACCO.RDANCE WITH SECTION 1190 OF'TH.E MAS$ACHUSETTS STATE.` BUILDING CODE: .May. 2 91 x 19.. ;w uilding Inspector - - I `" Iz'�'�1'^T'1d""9r,!"'Y*'y P'p"r tV4�7 v_-et•t-y ;v69viy5tr{�'!J' 7��� "q K'y°.sa`•}K�,»w?''t.,t .,'^ i t 1 t. •t,, ' ,fT�f ���xf'a TOWN OF SARNSTABLE �',r h 'J i� BUILDING DEPARTMENT Permit No �� x}fR k '►, •'io}� 9T �4 + TOWN OFFICE E,I,JI�DING CeSF1 r iatk8�r� t I 1 z;n'r ear y� HYANNI f a { S. �-0260.1 Bon 4 f , ??�w.r ,�;i�" 1 ,t �..t r ,�r„rt�c^��'t,r�,�'yt�•,. .13f CERTIFICATE OF USE AND . lrs r OCC.UPANC g dIssue to ,� DARNLEY SMALL ,+� rdi7 ( ►t �t J` .rove Avenue !S ass t, '� +,i7r to 8.0 Pir�.e C 'A �,t?t7.W,�aAAI�n•Sy`yx• ;ter r�}� t, , H}tannis ./ r •rr-SS1I• , n'✓4'+YTiF ��.�• r(�+"t�i! ✓ ti"lx,�SR° y� rh.r t1 �e �c ��; x h i 41,4E` t ,U PS4Ml i �Y f+9�' rf n ..-1'IIZL GRADING i tit x , raf L.n"P tF THI ati 3 f" Q� NC ''L t y t50 v C G k U A h `��fl: ,�I{LI NOT':BE VALID AND THE BUILDING.; Y�•'�5 $r'�` r�J4`;yrr',�r �t '± " n = rrT D BY > SHAYL*NOT�sBY(�OGIIPI$ i;Ftfl�fi ri a ' FIE BUfLDING:.'.INSPECTOR UPON SATISFACTpRytGOMP)rXA[VCE t xk .4REQUIREMEIT$AIyD�IN ACCORDANCE WITH'SECTION lI9 6OF T �cII �row,* �' F BUILDING CODE !` ` HEIAS$ CHUSE $ ` r + , •+i't .A y 'rt r,/�.ti ',v r J �.` i + 4� /4'j�. r y� ' +Y'• 19 +t i,L1. Y °. s i �► � ;f�+f} �' 14 �i�.K} it ." ' 1 .i' uild�nglnspector ��r t -V. , 1`� .,,r�a4'.d(•J'Ftr�,r�� ��,��.a Ihd�' t,L rw r.:f _ l 4 J a fjr1�„�._,�34. n� �ayy C'r" ,{S 7 :t^k Y,f �, � t���a1ir 1 r. _ ;'.!'Y�'�1�?^��''y�a����,�,i/�,�•t'Sf�4�tii� � ` a' � :r 7 r a �, 3�f �i*• 'v� .. ..1 i t �i 4 jS t� 4 ed �f ra ��r ct�. 1 s TOWN OF BARNSTABLE sit h 4 BUILDING COMMISSIONERS OFFICE r "`VF� ' DATE 12,21,5 1 PAYABLE PTO• ACCT# /oo 764/ OS M. K. Nickerson VENDOR# 13 This Way Osterville, MA AMT. aD,d-D 02655 � � PO# ra" APPROVED BY - 'R F1�rf�f� ♦ {fa.1,1,.•&?�f',t'� vT in}�' J'�Y; wec z �•41�' '7 a IM l 3� / y Zvi G y y� st�'' RQ ',s•x h , f`� '. FQr.T.-•-'-•P'a.• �..�;.;v. ,-,��, '-- R.IJI L® ■ TC�•WN..O� BARNSTABLE, MAS$ACHUSETTS � •' �■n(a�-o y■■ -.�• .•i`✓• .z.ate' r �.i: , r r•1 - .. .M E R;■-... Am29�-(3 'c October 31 90_ '. '• DATE 19 PERMIT NG.� APPLICANT' Me.Nickerson ADDRESS_ 13 This Way, Osterville; MA 019828 .,(N0.) (STREET) (CONTR-SUCENSEI PERMIT 10:-:Bui1C1 dwelling ( 1 ) STORY Single family dwelling NUMBER OF (,TYPE OF IMPROVEMENT) NO. DWELLING UNITS' ' (PROPOSED USE) lot2 80 Pine Grove Avenue, Hyannis KING''; < AT (LOCATION)' 'ZO (NO ) (STREET) DISTRICT...'. BETWEEN AND (CROSS STREET). .. (CROSS STREET) SUBDIVISION LOT BLOCK LO E { BUILDING IS TO BE FT, WIDE BY FT, LONG BY �— FT, IN HEIGHT AND SHALL CONFORM.IN CONSTRUCT.IC TO.TYPE,'' USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS:. Town sewer #3395 AREA OR K Nickerson): -" ''80.00. VOLUME 1E)]5 SQ. ft. ESTIMATED COST S 100,000 FEEMIT �. 83�75 (CUBIC/SOUARE FEET) owNER; DArnley Small ADDRESS 133 E. 46th Street Brooklyn, N. Y. 11203 BUILDING DE PT, BY OF ANY APPLICABLE SUBDIVISIOONN R FROM THE DEPARTMENT OFVPU WORKS THE ISSUANCE OF THIS PERMIT DOES NOT••RELEASE}THE APPLICANT,FROM(THE f,COND1TIO RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR 1, FOUNDATIONS OR FOOTINGS. MADE, WHERE A CERTIFICATE OF OCCUPANCY IS LECTRICAL,I PLUMBING NSTALLATIONAND 2. RE- M PRIOR.TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERSIREADY TO LATH). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. OCCUPANCY, POST THIS CARD SO IT IS VISISLE FROA01 STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 6 1 Vow 0� z z r Z 5 , - a fl S HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT'w I Q % rrJ R i Vert- ... OTHER BOARD OF HiAL WORK SHALL NOT PROCEED UNTIL THE INSPEC• D VOID IF PERMIT W! TOR HAS APPROVED THEVARIODUS STAGES OF WORK IS NOT STARLL TEDULL MONTHS OFCON THE y CONSTRUCTION. INSPECTIONS INDICATED ON THIS CARD CAN PERMIT IS ISSUED AS NOTED ABOVE', ARRANGED FOR BY.TELEPHONE OR WRIT- NOTIFICATION. t•...,' ''. v. fir: 77i� Ki�,y+„�,._. sad•„t..'"nrr�•�S^:APT rr S �^CpF P`i�7, '.Pa -qR;�v- i'�!R"" S^�gR�R°.c WN•OF B,4yRK$�gBLE,.MA$SACHUSETTS "BUIL r !t w� A 2 October 31 9Q�a� n DATE 19 PERMIT'NOLE�R APPl1CANT' Ms�Nickerson ADDREss_ 13 ThiOsteryilla; MA;, QT9.828 REET) - (CONTR S:LICENSE) PERMIT TO Build dWe111IIg ( "1 1 STORY: Single' family dwelling WELLING go. UNITS (TYPE OF.'IMPROyEMENT) NO .1-PROPOSEDUSE) 'AT (LOCATION)I' lot #2 80 Pine _Grove Avenue, Hyannis ZONING (NO ) .(STREET) 'DIS.TR1CT „BETWEEN (CROSS STREET). AND (CROSS St REET) 'SUBDIVISION LOT BLOCK LOT SIZE BUILDING.IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM.IN.,CONSTRU.CTIC TO TYPE'` USE GROUP BASEMENT WALLS OR FOUNDATION . -(TYPE) REMARKS: Town sewer #3395 AREA OR. (M.I�• Nickerson) 80..00 VOLUME.' 1675 8(]• ft• ESTIMATED COST $ 1009000 PERMIT 83�'.�5 _(CUBIC/SOUARE FEET) FEE •„•:$ OWNER DArnley .Str1811 ADDRESS'' 133 E. 46th Street Brooklyn, N. Y. I1203 BUILDING.DEPT. BY i FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIO MINIMUM OF THREE CALL OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. INSPECTIONS REQUIRED FOR APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS.BEEN PERMITS ARE. REQUIRED FOR {, FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL,I PLUMBING NSTA�LATIONAND ELECT 2. PRIOR TO COVERING STRUCTURAL QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL. 3. FINALINSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE.,OCCUPANCY. • POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 2 )2 �' ^ 9I �Ip , 2 / / C Ci , l � 3 �7/ �z S HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT l�;L�, T 7a G(J A ry OTHERC- rl Y-�(�r, I - 1 1- 9 1 BOARD OF HEALTH 62_t� WORK SHALL NOT PROCEED UNTIL THE)NSPEC• PERMIT WILL BE AND VOID IF CONSTRUCTION TOR HAS APPROVED THE VARIODUs STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE INSPECTIONS INDICATEp ON THIS CARDCAn CONSTRUCTION. PERMIT IS ISSUED Co!AS NOTED ABOVE', ARRANGED FOR BY:;.TELEPHONE'OR WRIT NOTIFICATION. L c�T 4" L oT 3 293.92 LoT Z i w f 0', � o L1 d' \, w 313.64 o447 i ��/E7 L_s1 N O (' 405.85 w L I JOB 90-243 CERTIFIED PLOT PLAN PREPARED FOR: LOCATION: PINE GROVE AVE BARNSTABLE SCALE: 1 "=60 DATE: 10/25/90 REFERENCE.- LOT 2 PB 449 PG 71 KEMPTON NICKERSON I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. OF JOHN yes down cape engineering, inc . o No.S3602 ! Q, i CIVIL ENGINEERS o +� LAND SURVEYORS ROUTE 6A YARMOUTH MA DATE REG. URVEYOR _ J A p"M TV Wo A", 4. v!7 AT yon 1 Q Q 5 , ; .;� Z. . " ,� . .I � 4;-v Q JQ,r 'f sm', Est Ax ' I Qn. r AW NW I I 4i n0wl yQ0 • J 0, rl �42 rIM4-f ...... ow Ktp 4, jj ;,_3 YAP"0 tk o,"4 Mum; -�Tll wig Solr. Too �rs "W KIM" I. enF 'is12" as ....... ivy,001.& -law. mew k; 5.4: Q 0, 00, J4� APO o:t to- Ab"T T-too p SETS?& 1. j 1`4 WNW"" p owls-; &.4, "'z IV TZ e,asc vev V7 ��fe MANST Q A 911,� '4 ;-, -:1 ",e� 4, Y:, ""M W,AR w k An� , -whom', 1 NVM VA YAA:*�..".1J. 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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 (J 11_ 0 IV e t✓ 0/0 M t= TYPE OF CONSTRUCTION W60 12 1) v I,� .z y 19 96 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location r �� �iQe u� �%` Vit3ella/�S. Proposed Use D t-e Ft,-1 Al Zoning District Fire District Name of Owner 0_W9N, C—X c3yn a LL Address 133 E- 5146 27 4 '9Y4V- a64,_ZIW03 Name of Builder ,[ ,�,�1�/�i�Ei2S�� Address /8 —FAIIS 4.1.4`/ aSr6fQ1a_6_ /9- Name of Architect Address Number of Rooms / Foundation 00 IVC2 97K7 i Exterior �� �' J Roofing WA 7�" Floors .Interior: _S66EEmE/ R -� Heating � Al Plumbing Fireplace Q 1Q/CIC Approximate Cost w. Oa® Area �7 .47 7� Diagram of Lot and Building with Dimensions Fee lS.J� 20 ro � o TIP)- 9 OCCUPANCY PERMITS REOUIRED FOR NEW DWELLINGS 2,0,�'� rV 5 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name / i ®� Construction Supervisor's License 7 � U J i SMALL, DARNLEY Y s No 34038 Permit For One Story Single Family Dwelling _ Location Lot #2, 80 Pine Grove Avenue Hyannis Owner. - Darnley,, Small Type of Construction Frame J t Plot Lot i 1 y ' Permit Granted October 31---, '719 90 Date of.Inspection 1216130 19 y Date ompleted 19 c4 W - ✓^ 1 C7a6Ct. (3C,nct�S - . i , Lj Assessor's office(1st Floor): O � ,�.. Assessor's map and lot number Hof Tw a toy Board of Health(3rd:floor): \ Sewage.Permit number 'r"'1' t DASd9TODLL i M Engineering Department(3rd floor). MAN House,�number �,..� °o�t6396��� Definitive Plan Approved by Planning Board i9 `� ✓ �' ��r APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE ' BUILDING INSPECTOR T11. Y APPLICATION FOR PERMIT TO �C�/G Q �L(//�I/�(/ �OO C j TYPE OF CONSTRUCTION 10,--e 4A L"yr fe. 19 9/ TO THE,INSPECTOR OF BUILDINGS: Y The undersigned hereby applies for a permit according to the following information: Location s �o l y(f bV YOUC Au c_ Proposed Use ���+//i?9/A)9 7 004 Zoning District Is Fire District V'y/s Name of Owner JAVwd ey_ J 444b Z� Address 6O pi iU(f A ou< 4yc Name of Builder / ,(JCl�I6{' ➢`DOGS Address Name of Architect /V/A Address Number of Rooms Foundation L"e X) Exterior �0 (JCY rJ�e Roofing Floors Interior L. Heating Plumbing i Fireplace Approximate Cost .D?6Oi f Area Jr�zz . 00 Diagram of Lot and Building with Dimensions Fee X S�p4►�Atc Sti OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS j I hereby agree to conform to all the Rules and Regulations of the Town of�Barnstable'rega�ding the above construction. Name Construction Supervisor's License 060 c,7 3 SMALL, DARNLEY A=290-074-DO3 0 7Y-063 No 34449 - Permit For Build Swimming Pool Accessory to Dwelling Location 80 Pine Grove Avenue Hyannis Owner " Darnley Small Type of Construction Frame Plot Lot Permit Granted July 11 , 19 91 Date of Inspection 19 i Date Completed 19 ER IT COMPLETED 1 Assessor's office(1st Floor): `/ �r Assessor's map and lot number �O7 Board of Health(3rd floor): Sewage Permit number v - t asaasr`'si6ci I Engineering Department(3rd floor): (� /� y,,l . House'number _umber �� iC !1 IF!l ' °° 'ayq:� Definitive Plan Approved by Planning Board 19 APPLI' ATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only 1 TOWN OF BARNSTABLE �. BUILDING IHSPECT.OR APPLICATION FOR PERMIT TO ,� t (� J r--�6'7- /�o n7(- TYPE OF CONSTRUCTION TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit,according to the following information: f, Location G _. r,? i/1(r f := �7 �l.�.aeA - _ Proposed Used Zoning District Fire District ~ f Address c L YA,A f / Name of Owner 12 ���,4 Y +. ,'x'a')to,1-f1 r a Name of Builder Address ' ` 1-14`1 . Ir Name of Architect Address Number of Rooms /,*2 Foundation f ^vrfe t: Sri= Exterior �?If'tn%f �?fl . /� !�e .t`" './sou;r )Roofing f� i 7 r�-. Interior \ I.tAr"it'* f J� fYS.v: fit.` FI-�n_._c. ___ _ ___ _--_ -�•-. _ ._ _ - Heating ,�/� tl 1� 1 Plumbing Fireplace s:. �"j+K 1 Approximate Cost f s•.r I AreaG/ra f +. ' Diagram of Lot and Building with Dimensions .� Fee �'jL., / 5 ifD J OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ,p• ( �1v E I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. I� (f1 •�f(J)Jjj r� r. �. Name Construction Supervisor's License '' SMALL, i7AR1VLEY A=290-074 . 003 ' No 34038 Per=nit For One Stor Single Family Dwe lii Location Lot #2 , 80 P e Grove Avenue t i Hyannis r Owner. Darnley Small Type of Construction Frame { i Plot Lot Permit Granted October 31, 19 90 Date of Inspection 19 t Date Completed 19 ; 3 � "E MI �fIKETj Town of Barnstable *Permit# �+ Expires 6 months froin issue date Regulatory Services Fee BAM. ABLE, �� i6&� Thomas F. Geiler, Director ArfD MAC A 70 7� Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �'d `1 14&d Property Address 6ine 6vc-* true 1,CL"--w c residential Value of Work E Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address_vu.�ey S Contractor's Name Telephone Number Sots- ZY0 160el6 Home Improvement Contractor License#(if applicable) T , Construction Supervisor's License#(if applicable)�d, �0 ❑Workman's Compensation Insurance p� Check ,one: RESS PERMIT I am a sole proprietor ❑ I am the Homeowner JUL 14 Z009 ❑ I have Worker's Compensation Insurance TOWN OF BARf�OTA�L Insurance Company Name . Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) e-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property 0 ner must sign Property Owner Letter of Permission, Horrid.Im �r v . ent Contractors License& Construct Supervisors License is required. SIGNATURE: QAWPFILES\F0RMS1Express\EXPRESSP M1T.D0J Revise06O4O9 :'a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 �••'y www.m ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel ibly Name(Business/Organization/Individual): a.0 Address: a3J LL,,� L.,,P— City/State/Zip: tl c y�Avv,-,, tM;U,,, — Phone.#: so 9 6,1-l Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-tim.e).* _ have hired the sub-contractors 2. '' I am a sole proprietor or partrler- listed on the attached sheet. T. Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. employees and have workers' 9 Building addition (No workers'comp. insurance comp. insurance.$ required.] 5. Fj We are a corporation and its 101:1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]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' 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic. 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 up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains a7f penalties of perjury that the information provided above is true and correct Sipmature: - Date: Phone#: ��©8 - 4�"400 P3 Official use only. Do not write in this area,to be completed by city or town official .'City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or tiustee 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-contractor(s)name(s),address(es)and.phone number(s) along with their certificate(s)of insurance, Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to'carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy.information(if necessary)and under"Job Site Address" the,applicant should write"all locations in__(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e,a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. ue Office of Investigations would 1 ke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigat>ion:s 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.mass.gov/dia i 1rEro 'Town of Barnstable ' Regulatory Services r 9H"Rx 4"$ $, Thomas F. GeHer,Director 1) a�� Building Division 0 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town_barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, r. 1PAA SM6`� , as Owner of the subject property hereby authorize ` to act on my behalf, in all matters relative to work authorized by this building permit application for. P,n 2,f To v:e- ALe= �q .(Address of job Signature of Owne Date la r �1 Print Name If Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. Town of Barnstable THE Regulatory Services Thomas F. Geiler,Director Building Division prED A Tom Perry,Building Commissioner - -200 Mairi Street Hyannis;MA 02601 a www.town.barnstable-ma.us Office: 508-862-4038 Fax: 509-790-6230 HOl\1:EOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# , CURRENT MAILING ADDRFSS: city/town stater 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. DERNMON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that be/she shall be responsible for all such work performed imder 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 Bu stable,Buildipg Department m;=UM 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 hameowoer perfomring work for which a building permit is required shall be exempt from the provisions of this section(Section io9.1.1 -Licensing of construction Supervisors);provided that if the homeowner cngagcs 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 responsibilities of a supervisor(sex Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.1 This lack of awarrness of rn 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 bomwwner is fully aware of his/her respormbrilitics,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the msponsnbilitics of a Supervisor. On the last page of this issue is it form currently used by several twins. You may caret amend and adopt such a fonnlcertification.for use in your community. Construction Supervisor License License: CS 57540 Jl 4 1 Exptr ton-12/28/2009 Tr# 14108 ,?Restnctiq, G' s DAVID J GADY 235 TIMBER LN _�7'G MARSTONS MILLS,`MA`0 648 Commissioner , Board of Buddin �a��a � �1e g Regulations and Standards HOMEIMPROVEMENTCO NTRACTOR II r registration valid-for indi�idul use'only License o Registraftoti: a 114561 before the expiration date Board of Buildin If found return foc lug Exptrafion 10/4/2009 Tr# 260861 g Regulations and Standards One Ashburton Place Boston F FetF ,Ma.02108 DAVID GADY CARPENTRY David Gady 235 Timber Ln t� Marstons Mills; \ f r '0 MA . fldimnfstrator f � d ; — y r Not valid i► ou si lt p _ g? tore: bt �n of � a I �Zh � L9'82L T. ,O —— T j TOM 7 N 'dPW z - ,er •fir,- �.�.:,.,-�._•�. _ _ _'.. 4 b _. q. � _ _ _ _t g 5 � 1 • j g•Tp 9 92 (0 Lo j i aT T$ n•, � !b I E' a, Q Ab I \ 5•ZZ `\ 26 Zg S g' T `b.itx 6r b'La! 02at b. ,.' err F1d r yX, e •c f,,. ;5 ,r ,�� \.: _ _ •�- �F b.F2 � e W �49L I i• . E