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Home My WebLink About0005 PITCHER'S WAY s �%rchers �u�y -- — � --- _ _ .� _ __ Town of Barnstable Regulatory Services Expires'6 mon r m iss a date g rY At MASS. Thomas F.Geiler,Director 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 . Prope Address Residential Value of Work l/5�� Minimum fee of$35.00 for work under$6000.00 Owner's-Name&Address GI'd Oil hQ i Contractor's Name ,{�pw Telephone Number Home Improvement Contractor License#(if applicable) V �' Construction Supervisor's License#(if applicable) �J ❑Workman's Compensation Insurance Check one: XPRESS PERMIT ❑ I am a sole proprietor PERMIT ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance SEP - 6 2012 Insurance Company Name WN OF BARNSTABLE Workman's Comp.Policy# 1 A41-2 Zji }-Z1��'11?1 -4. (,?- Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-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) VRepsl1a #of doors ement Windows/doors/sliders.U-Value ! " (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. i *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.:Historic,Conservation,etc. ***Note: Property Owner u t sign Property Owner Letter of Permission. A copy of the o e I pro ement Contractors License&Construction Supervisors License is required. SIGNATURE: QAWPHLESTORWbuilding permit forms\EXP S.doc Revised 053012 The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations .600 Washington Street Boston,MA 02111 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibiY Name(Business/Org=ation/Individuai): . Address: Ali City/State/Zip: Phone.#: Are you an employer? Check the appropriate box Type of project(required):. 1.❑ I am a employer with 4. a general contractor and I employees(full and/or part time).* have hired the stab-contractors 6. ❑New construction . 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 officers have exercised their 11. Plumb' repairs or additions . 3.❑ I am a homeowner doing all-work ❑ P myself [No workers' comp. right of exemption per MGL . 12.❑Ro epairs 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 subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. 'I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Policy#or Self-ins.Lic.#: 1 Expiration Date: 0111QA1;;; Job Site Address: city/State/z ip Mki > Attach a copy of the workers'compensation policy declaration pag (showing the policy is a 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 maybe forwarded to the Office of Investi ations of the DIA forirMance coverage verification. I do hereby certify under a pa s d pe �)esqf perjury that the information provided above is ue it correct Si ature: Date: Phone#: Offlc4d.use only. To not write in this area,to be completed by city or town official- City or Town: Permit/License# Issuing Authority(circle one): .L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact PeFson: Phone#: . Sep 06 12 10: 51a Michael Bedard 1 -401 -246-2868 p. 2 CERTIFICATE OF LIABILITY INSURANCE CATg(MOaDOrr7Y7, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1 CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNEt,Y AMEND, EXTIEND OR ALTER THE CGVP-RAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTNORQED REARESENTATfVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If A eertt6cate holder Is an ADDITIONAL INSURED,the polley((es2 must be endoned. it SUBA(XATION IS WAIVED,subject to than Terms and conditions of the Policy,certain policies may require an endorsement- A atatement on this cenificato does not Confer fights t9 the cartiftcate holder in lieu of such sndOf6wwr11 a- PRODUCER PAUL B SULLIVAN INS AGCY INC rAtIFACT 1467 S MAIN ST . I 1 fMAx G_t+o FALL RIVER, MA 02724 AOMW MM12ERiSlAfF-Ftm d:OVERAGE NAOC! _-- a9UREA A e19WWR a: JOSEPH DUARTE&JOHN DALEY IMMMERC: DSA J&J REMOOEL(NG ---" 15 WILSON WAY wauRfiRo: MIDDLEBOROUGH MA 02346 OSUMI 6 — RF I COVERAGES CERTIFICATE NUMBER: 1295IN2 REVISION NUMBER: THIS IS TO CER7IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SUED TO THE iNSURED NAMED ABOVE FOR THE POLICY PERIOD IS I INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CCNDITION OF ANY CONTRACT OR OTHER DOCUME,VT WITH RESPECT TO WHICH THIS 1 CERTIFICATE ARAY BE ISSUED OR AAAY PERTAIN,THE INSURANCE AFFORDED Bry THE POLICIES DESCRIBIN E70FED HEREIN IS SUBJECT TO ALL THE TERMS, t EXCLUSIONS AND CONDITION OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAIID CC AIMS. 'AMR POL►er NIN1em V eve LDS I CTR TYPE Of NSWUNCE GEl(ERJ1L tNe111TY I Ii ELEALO1M1O 1 COMMERCIAL GENERL LABILITY OCCUR O9T CSf(:A UnR af tooEaCteaa:pREe erscocen l SfS PERSONAL 6 A17V IN.RMY S i GENrRALAcaREOATIF S !I I PROOUCTS-COMfIfOP AM $ GEM.AGGREGATE L(Id T APPLIES PER: S POLICY PRO LOG , Liff '� ■71ct t s Aurot�Blt.E UA9LrtY BODILY%JURRY(Per person) ALLOWNEO > lE0 i I BODILY PUURY(per ecrilerr) : AUT AUTOSALrTOS NON•CWKq:D K O1A CE S HIRED A1.ROS AUTOS It EACROCCURRENCE S UNBRSLLAtrAS AGGREGATE S EXLE99 Lt" CLAIMSAAADE GEO RETENTIONS S I I $ VIC'YVORREAa COMPIMATION Wc6-31S384800-072 2122012 2r2f2013 ATtI- ,� RY 10Oti0 A AND tm toYERS'UAWLRY Y I N i f E.L.FACH ACCSiEHT = •Hr PROPR!ETORIPAR1NEKVkCu`iNE Q NIA f . O.FiCERI■rEr 9CR FXCLUDE07 4 I 'E.t.i]ISEASP EA EMPLOYEE i 1 0 (NhndalorV in NN) E.L.DISEASE-POLICY LAAT S SOODO !I IPT[ 1 undM I IPTION OF OPERATIONS t»bw DESCRYTgN Of DIP EMTIONe f LOC,ATION9/YEfeCLE9 (Allah ACOnO tot,Adddion0I11■ZX;9cA■6uh,B lmrctp■�■b r■Wlr■dI Makers compensation insurance coverage applies only to the workers compensation taws of the state of AAA. NO PARTNERS ARE COVERED 81.THE WORKERS'COMPENSATION POLICY. CAN EL CERT AT H SHOULD ANY OF TNEA80VE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE ac o�EWM4THEPOLILICYPRMSO NOTICE rnLL BE o1=LnrESIm IN 200 MAIN STREET IiYANNIS MA 02601 AOTMORIZEO 08"IeSENTATNE .. L Jefl EkirI a A 1986?A70 ACORd CORPORATION. All rights reserved. ACORO 25(201 OMS) The ACORD name and logo are registered mad"of ACORD LT a An PeQe l or L COLT hO t.i79�to71Anc etc end Super Sede Sr ALL p.eviOUSLy`�+cueGlcc e�Li:C ates. ) i rn _yyi�pp �({-t--yy,. .. anna t C r. �(` -d 3 Irta tor 14 - ....... CQJ;Stratia^ A . r . ;i Typw Pa�tnefs`'0 f ., cxpir3zan.* /1 i/ � 2 7332 Joseph Duarte _ -- --------- -- . .. ......... 15 Fall St. Wareham, Ma. 02571 - ---------- Update Address Pad return card..Njark reason for rhao%t Address �} 4ene �P C2 �arsfsldysrtent 11astEsrd 7PS-riAl f,? b0?v-C4/Od-�4C123E : ��-^'TT•• � ,,,�� Eiscnsa or registration Valid fcr irYdividnl use arty pffie:o on�0sum errs �iaes� eau before the 6%pirstion date. If found return to: HOME ih1PROVEMFNT CONTRACTOR Type; OfFoce of Corasurntr leffarrs end ftusauess Regsala(zor4 Registration: ..•132349 ko park Plaza-suite 5170 Expiration: :?►111l2013 Partnership Pus#pal lvIA 02116 Sosaph Duarte l 15 Fall St. of Y d�r►t out signature Wareham,ma 02571 Ug(ler3ECfSiA6V ila �:a�harsstt<-Dcli �4rt 4tS..Of P inn 4t1 sUt fi!Ord.. . kvio r r 9 Sti;tr•d(if 6uiitlitz. R ConStrution Supervisor License License: CS 70077 J0SEp4j C DUARTE 15 FALL_ST WARE,MA 02571 �- ExQirdtion- 92 Tr#: 7048 ( .nuuitvioncl' - - - - z9t6s6z 69:1z ttez�ze�ie I0 30Vd 2012-08-10 20:26 2612EXPDTR.PHONE 5089574714 >> Home Depot AHS P 1/7 HOME IMPROVEMENT CONTRACT ;.�� PLEASE READ TH IS t / Sold,Purnishul and hlstalled by: Branch Name: Boston Date: 'l0 '! �— I'HD At-Home Services,Inc. d/b/a The Home.Depot M-11ornc Services 345A Greenwood Street,IJnit 2,Worcester,MA 01607 Toll Free(WO)657-5182;Fax(508)756-8823 Branch Number:31 Federal M r#75-2698460k MH Lic A C 02439:RI Cont.Liett 16427 ,Q CT Lie 4 HIC.1165522;MA I tome lyrprovcme t COntracror Rrg.0 126/893 Installation Address: its State Gip Purchaser(s): Work Phonc: Home Phone: Cell Phone: Home Address; (If different from Installation Address) City State Zip E-mail Address(to receive project.communications and Home Depot updates): ❑I DO NOT wish to receive any marketing entails from The Home Depot Proiect Information: Undersigned("Customer"),the owners of the property located ai the above installation address,agrees to buy, and TIID At-Home Services,Inc.("The Home Depot")agrees LO furnish,deliver and arrange for the installation("Installation")ul all materials described on the below and on the referenced Spec Sheet.(s), all of which arc incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Jub N: ttmemul ttcremnn) Products: Sec Sheet(s)#: Project Amount ❑Routing Sidin Windows ❑Insulation 7 nZ r ?104❑Gutters/('nvurs ❑Enuy Doors ❑ ❑R,xATng ❑Siding El Windows ❑insulation []Gutters/Covers ❑Entry Doors ❑ ❑Routing ❑Siding 0 Windows ❑Insulation $ []Gutrers/(:overs ❑Entry Doors❑ ❑lloofing ❑Siding Windows ❑hisulaliun I I❑(;utter~/Covurs ❑Entry Doors El $ Minimmn 2,5%n Deposit of Contract A mount.due upon exeLution of this contract I'[tlal(',UlttrflC.t.AltlOnnt Maine.Pturhasety may not(ICpusil more(.ban unt+third of the(.:nnntteLAntuunl. Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one foe'each Product as defined by all individual Spec Sheet)and pay any billimCC due. As applicable, each Customer under this Contract agrees Lo be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a C;hangc Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if Thu Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the horns,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required Lo complete the job was nol.included in the CJon ract. Payment Summary: The Payment Summ l ary /5 included as part of this Contract, sets forth the. total Contract aniount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to it completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before worlt(in that Product is complete, In the event of termination of this Contract.Customer agrees to pay The Home Depot the Costa of materials,labor,expenses and services provided by The Hume Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. 'rHE HOME DEPOT MAY WIT1111OLD AMOUNTS OWED TO TIIE IIOMP; DN;POT FROM THE DEPOSIT PAYMPN'r OR OTHER PAYMENTS MADE, WITHOUT LIMITiNG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that.this Agreement is the entire agreement belwccn Customer and The Home Depot with regard to the Prodders and Installation services and supersedes all prior discussions and agrccmcnls,either oral or written,relating let said Products and Installation.This Agreement cannot he assigned or amended except by it writing signed by Customer and The Howc Depot..Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a Copy of Lhis Agreement, Accept by: Sul fitted by: x a' X p ('us orner's Sigm re ate Sa cs :onsulrant's Signanre. Data x In 5�,/O •/_2}Telephone No. Custom r`s Signature Date Sales Consultant License No. CANCFAA,ATION: CUSTOMER MAY CANCEi. THIS I (as dpphucablr.) AGREEMENT WITHOUT PENALTY Olt OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE. HOME DEPOT BY MIDNIGHT ON THE THIRD BUSiN.F,SS DAY AFTER SIGNiNG THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS .A FORM TO USE IF ONE 1S SPECIFICALLY PRESCRIBED BY LAW IN CIJSTOMFR'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE RH V ERSK SIDE:AND ARE.PART OF THIS CONTRACT 04-11-11 C-SC White—Branch File Yellow—Customer C fice of Consumer Affair and Business 1Zegu atioi� 9 10 Park Plaza - Suite 5.170. . Boston, ssachu.setts.02116 klen e'improve w. ontractor Registration �- Registratlon: 126893 TYpe: Supplement CaN . r z ��^ w Expiration: 8/3/201�1 . The Home Depot At-Home .servi `� W RIC.HARD' .FALLbNE WAY M r � 2690 CUMBERLAND PARK 1 ATLANTA; GA 303.39 hr" �yg� Update Address end return card.MarkrensonJor change. Address [] Renewal .n .Employment rJ Lost Cnra DPS-GA1 � 50M-0410�4•GG�110771218p �Y7. '1fJ097fA)LOOL[1J@lZG[/i 0�✓+ '�"•'7.1t68 . Office or Consumer Affnirs 8c'Business Regulation Liconse or registration valid.for individul use only before the expiration dnte. If found return:.to: OME IMPROVEMENT CONTRACTOR p{fice of Consumer rYf7airs attd Business RcglYlntion r'� 1 ;typo: 10 Park Plaza-Suite.5170 Registratlo n: ;I26893 Expirat(tin::1�8{3'��r Supplement Cana. Boston,MA 02116 ' rr 1 The Home Dep01�A3 H4tnee?Vles RICHARD FALL(SNi�r;_iTjE 2690 CUM13ERLA�IR p.4 ti�CJ�A..S "' �� 4of with ut A nature A°T3rAA,`GA 30339''rs?S� Undersecretary Town of Barnstable *Permit# FIT If'k. C Expires 6 months from issue date • Regulatory Services FeeKAM 4 3A�iSPABi�. `0$ Thomas F.Gellert Director EDN1P`� Building Division Tom Perry, Building Commissioner X-PRESS PERMIT 200 Main Street.Hyannis,MA 02601 J U L s - 2005 Office: 508-862-4038 Fax: 508-790-6230 TO N OF BARRlSTABL EXPRESS PERMIT APPLICATION - RESIDENTIAL ONL Not Valid without Red X Press Imprint Map/parcel Number c2f l ZZL. Property Address `, 'W UC---:;e �(Vct, AResidential Value of Work Minimum fee of•$25.00 for work under$6000.00 Owner's Name&Address <TVt Telephone Number So 77/`"b� Contractor_s_Natne � 9 -----eP_--.----.----.._ -- --. Home Improvement Contractor License#(if applic 0( Construction Supervisor's License#(if applicable) []Workmen's Compensation Insurance Check one: ` I am a sole proprietor U 1 am the Homeowner ❑ I have Worker's Compensation Insurance t ' Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Vrxkroof old shingles) All construction debris will be taken to o (stripping � ) ❑Re-roof(not stripping. Going over existing layers of roof) - �../�aaoczclzuaP,t1.c ❑ Re-side Board of Building Regulations and Standards , HOME IMPROVEMENT CONTRACTOR Replacement Windows. U--Value (maximum.44) Regastraton ,_136003 E cp�ratron 3/N/2006 *Where rewired: issuance of this percent does not exempt compliance with other town dep } Tyke Inliividual In ***Note: Property Owner must sign Property Owner Letter of BRUCE P. MILLS; Home_Improvement Contractors License is aired. BRUCE MILLS , 16 CROOKED PONl52D<_, HYANNIS, MA 02601 "� ` Signature Administrator QForms:expmtrg Revise063004 r °Frti Town of Barnstable °^. Regulatory Services BAMMA131A Thomas F.Geller,Director 63 `e� Building D1viS10n RFD NiP'�p . Tom Perry, Building Commissioner 200 Main Street, liyannis,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 n� 7 AAJ ,as Owner of the subject property hereby authorize ( , t r to act on my behalf, in all matters relative to work authorized bythis building permit application for: P 1162Agw, (Address of Job) �Jd Tgnature o er Date Print Name n•4nu Ad C•nLUTNFR PP.R MTS STON _ u The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 M www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/orpnization/Individual): Address: Cd`06 �2C� ��✓t V�C� , City/State/Zip: d� 0 ( Phone#: �C7g- �7�� 66 Are you an employer?Check the-appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 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 8. Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions ,and we have no myself. [No workers C. 152,comp. §1(4) 12. 'Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box III must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is provi 'ng workers'compensation insurance for my employees. Below is the policy and job site information. O✓ 7/wCO- �T4S, 60 Insurance Company Name:Policy#or Self-ins.Lic. #: 7 O l C-� Expiration Date: 7— 3 /'6S^ r 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 maybe 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 Signatur Dater ^ 0,�_-6 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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 shall not because of such employment be deerried-tohe-=-employer•" or on the grounds or building appurtenant thereto 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 h 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 fixture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Whelan, Angela From: Schlegel, Frank Sent: Wednesday, October 01, 2003 11:45 AM To: Whelan, Angela Cc: McKean, Thomas Subject: Address change for Map 289 Parcel 178 Hi Angela._I just changed the address for the above parcel. The"OLD"address was#270 Scudder Avenue, Hyannis and the"NEW"_address is#5.Pitcher-s Way, Hyannis'. I have corrected pentamation but you will need to update any hard copy files. THANX 1 Assessors map and lot number...��.................:.�. ....... t SEPTIC SYS F t e t 72 ��C:r /c b - �0..� +, 1A3 A �.�6�•I ;Y117e�'� D N Ow Sewage Permit number .........;.................................+......:..... ��@�'�.� TIT r . = j H rA 1 ea$B�&Ls. : House number ,...... J'i0 .... : ..... .... "t�� 1`i� ' L CO � " 1 � �6 .F � 5�4i��.� �.�6� n �c 4 39• �0 s: .q+W�.A;Te I /147 �0 MAY a 4. TOWN OFF BARNSTABLE j ' Al BUILDING INSPECTOR APPLICATION FOR PERMIT TO s/�✓ '1...v:•••••:..../1... ��". .(1....:.. `?.............................. .TYPE OF CONSTRUCTION ....................... �'��1 ?�r .1..l`.:........... ............. ........................... ........ k '' ...2. .'..................,9.. y. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit actor . t th following information:' C� > ..... -.. .. -�__- ........................... .......... .......................... ..... C-� �/ Location ProposedUse ..........:.�/� 's.. ..l..f............/04 ...................................................................................................... /.,,Zoning District ............ ...... .... ...................:............Fire District ......... ............................................... / , // , , C�4 l . ��.Fl�S,Address ........:.:.:.. ,,...7.... ,000............ 9 �%2 Name of Owner ............ "��... C '" Name of Builder .....................Address ................. Name of Architect ..................... ........Address :............................................ .. Number of Rooms •............. ..... ......,....................................Foundation .... (�.� .......r��..��.......,...................... e 000, Exierior ...................`Z/ ...0 . ..........Roofing ......... ,� !G ......................... / Floors L/.. ...11i............. ......................:....Interior ............. /l..�.7G.. ,,' �..l ............................ . Heating ............... .. .rlf..,,�........��. `.....................Plumbing .....:...........0... ..... .................... Fireplace .................... .. . ..ir.............................:.........Approximate Cost ................�J...:.�. ............. r / Definitive Plan Approved by°Planning Board ________________________________19________ . Area ......�...................,.......... Diagram of Lot and Building with Dimensions Fee. ...... t:. U�tJ . .......................... SUBJECT TO APPROVAL OF. BOARD OF HEALTH s OCCUPANCY PERMITS°REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of B ble regarding the above construction. Name ........ .. ..... ..... ........ 7. < Construction Supervisor's License -: A INT-ICKULAS, IARRY a ` No` 26646, Pe mit for ....l z Story.............. •. .......,Si11gle..Family..IW&Ili ... ..:....... Location Lot 10 t...� � . . ...............HX .... s.............................:..:. Owner ....�ry, ...................................ul ............. Type f Construction .. Frame...... i .................... .... ............ ..... Plot............................. Lot ................................ Permit Granted �une..29....................... Date of-inspection ............................. . ... .19 , Date Completed .�� .:r ........:I9 cC _ ,r I F �•c M t,• �j 0 r 3 f: : , 0 �/ M v � 16 o O � _ . 030 ROSfRT ryC gROCE PLDRE N r CERTIFIED .,PLOT PLAN No sv � o C oT Io ITC tt l�. �,�/ y NEW CONSTRUCTION ONLY , I prQ°° S r"" - '' 0-1 Y A M N i s.. P 0 2 T .TOP OF FOUNDATION IS;._._„ FEET fO4' ,^�!C rat IN Y A®®vE I.®w POINT of ADJACENT 2Q�,o/1Q ,fiJ .�. , :ROAD. s HO DATE� -23--$y ' "E E g EERIAG G® " 2 l�LI:EI�T " ickAAs 1 CERTIFY THAT THE ,��r�l� EGISTEREO REOISTEIREO SHOWN ON THIS PLAN IS LOCATED CIVIL LAND"{ Jow.,N0, vZ ON THE GROUND AS INDICATED MOLD T4 DR.DYE CONFORMS TO THE ZONING LAtry9 EN0INEER SURVEY®R OF 1 RNSTA®LE , MA83. T! 2 MI A I N STREET cm..�I,Ys , � : .,.. H YA N R I S, MASS' $MEET,..L.OF DATE -REG. LAND SURVEYOR f ,y TOWN OF BARNSTABLE Permit No. __ �� _______________ . r�L. Building Inspector 1 smsr.0 Cash --------------- - ur► ,ego. _ ' °"°� � OCCUPANCY PERMIT Bond ------__�__�1____ - Issued to T arrl �� Address Lot 10 270 -Scu&,L- ' A�rP-rny-. rl`alzl l s Wiring Inspector ` , Inspection dates C7.. r, f Plumbing Inspector 3 _ Inspection date Gas Inspector + z- t � Inspection date 1 Engineering Department—I `�� F,G � Inspection date�f f T Board of Health -!.� r a� ' Inspection date drr/-7 •� THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. .... ... ..... .................. 19 ................... .............. .. .................... .... ........_.. -- Building Inspector Assessor's m' /�ap and lot number 5 ry f�/�.1r...�/.�.....N.�.. ��'...'..r.. Q ? E Sewage Permit:number ......... ............................................. • f Z BAWSTADLE, i House number" `. '�� ..�� r ras9 ,..;..,................ �p 163 \0� t �0 NAY a' s . TOWN OF BAKNSTABLE i BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........,,� .��..!� � � TYPE OF CONSTRUCTION ......................... �^'`6`- ...('.................................................................................... ...........................19.. . TO THE INSPECTOR OF BUILDINGS: J� eollolwinZg SThe undersigned hereby applies for a permit according to the information: ' Location ...G U ...... ,• ...::. ............................................. ......0 � ProposedUse ...;........ > �►a-x.. ....................I....... .. ........................................................................................................ Zoning District ............. ..... ......-?...................................Fire District ..........1; .......... Name of Owner ........... /a/Address � �� /�, /cy" . Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ........................................Foundation ....f�A:.....:. ..................... .......... ............................................. Exterior / ...Roofln �� '� 4 .................. ... . ....... ...................................... g ................... •......................../............................... Floorsft /�.. ....................Interior ............. //i ............................. �- ,� Heating ..................:!.....��...:.............�:... �''......................Plumbing .................c�`�.......��e:.''.�' r Fireplace .................... .....;�.. .......................................Approximate. Cost ................� ... ................ f � Definitive Plan Approved by Planning Board -----------_-------------------19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ( ' I hereby agree to conform to all the Rules and Regulations of the Town of Barris"table regarding the above construction. Name, ....... ....!.... ...... 7- ,� ........ ...... Construction Supervisor's License ....................� -�.. - a I NICKULAS, LARRY A=28840 _ J 1 1 Sto ; No Permit for .. ......... '................. Single: ..Dwelling........................ zc Lot 10 Scudder Avenue .............Hyan?? s.............................................. a Owner ...........;.....rY.'Nickulas........................................... Type of Construction FX .............: L ' ................................................................................ Plot ............................ Lot ................................. ` Permit Granted ......June...........29....1..................19 84 Date of Inspection .:..................................1.9 Date Completed .:....................................19 a