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Home My WebLink About0149 WEST MAIN STREET �i / �� )J, Awo S�, Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.bamstable.ma.us Pre-application for Business Certificate Date Mapc� Parcel Applicant Information Applicants Name VVi t Applicants Address // 02.6� Email Address Telephone Number Listed ❑ Unlisted (� Business Information New Business? Yes No Business is a registered corporation? ------------------------- Yes No If yes Name of Corporation 771, . S"-4- -, t►'IL. Does business operate under the registered corporate name? es No Is the business a sole proprietorship or home occupation? _________ Yes If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business ;�csat Business Address .` 1 � Uf�Ari��y AID buo l Type of Business Wilding ommis Toner Office Use Onhy Conditions �. pZ Building Commiss ner (�A �fiit ate tP 3 Clerk Office Use-,Only TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I Parcel Vc'3 Permit# Health Division ' t Date Issued Conservation Di 'sion J � Z�Lam— Fee �'t Z S. = 50. Tax Collector oCb 'Do� Treasurer Planning Dep Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address i c f << e `�. WI A. 6- Village ' , 1 ��; A n Vl k S Owner Address -e1�li r1�f�; ►� rrrzis Telephone (0 Permit Request %P 19) t t{ i 1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation `3 oQQ\oO — Zoning District N Q Flood Plain Groundwater Overlay Construction Type r Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. :E Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) c- Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's H way: sO No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Xr- r- 4 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: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 21 Yes ❑ No If yes, site plan review# _--Current-Use- --- Proposed-Use BUILDER INFORMATION Name �"y1�t��L e{' S� Telephone Number 6_0<5 Address A7 sa License# 8(4$5N b' Home Improvement Contractor# 1,2 01 Worker's Compensation# 6f_- S9013y ALL CONSTRUCTION DEBRIS RESULTING ROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE � � '0 oZ FOR OFFICIAL USE ONLY r. PERMIT-NO. DATE ISSUED MAP/.PARCEL NO. ADDRESS VILLAGE OWNER , DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r r `r . r ' S DATE CLOSED OUT ASSOCIATION PLAN NO. i The Commonwealth of Massachusetts == -- Department of Industrial Accidents ,� '=--•- 0I/Ice of/oeest/gat/oos - • 600 Washington Street J Boston,Mass. 02111. Workers .com ensation Insurance davit �� name vYl A r \fie C1A� location city �e n l 1l phone# 16 D S q&6 C-r`�? 1 b ❑ 1. a homeowner performing all work myself. r ❑ I am a sole rietor and have no one workill m ca achy I am an em 1 er residing workers' compensation for my employees working on this job.: Y n t0 D >s:«:>;' c1 phone# ..........:.::....................:.� ......... .... ... ..............:....:::::.:..:...............:...............:...�:::::::::::•::::i:i•:_:.ii:::::: i.::... .:::::::.:::.r.i:.::::v'..'!i{v:..::i ::.:::::.G :h: -._-.+ii. :::::;:• -.Y.;:.;'.4:-: ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: X. eom an nam .............................. ...... ............ . "on ��XX .......................................... bhev $:>::i'i::::::::i':•,••:: ::i: ::i:% ':: :?:::�::i-: i ::is:::2` i:......:<:::;:;:::::::`::i:::::•::::::i:•:::•:;;:::> '.'.:.' % %"::$:ai.':'::i:': . %i:.?:....:< :22::: ::: i'.r::%;:::':2;:` .%;.<: ': :%i:'<:: :;;`i?i::::....;:'<::2::Y;:i.:;2:<::;"`:a:%;5X. :;:�::�::i:%;>:-::;;;::-»>:•:•:;;:j;:�:::•>:;+:::-:>:`::.•:..•._::.:::. ESS. ... ::.:::::::::: `ltin air<b :::::..................... oa=i:. MI s�'>,::} .y;i:;.:;`•.`'?.::::''':::::.:j:�:{�'t'.ti :. ' `:� .!;::::�:' : ::;: li �iouaraitce 'Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years,imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify th ains p of perjury that the information provided above is true and coned Signature Date Print name "Ml FIt'IL �� S Phone# Chetck do not write in this area to be completed by city or town official town: per>teit/licwe# ECufiding Departrnent iceru Tg Board ediate response is required electmen's office ealth Departarent phone#; ther_��. (revised 9/9S PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 e7ag'ed 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. owever 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 section 25 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,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 filh'm the workers' compensation affidavit completely,by checking the box that applies:to your situation and supplying company names, address and phone numbers along with"a.certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of fim rance 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. F j City or Towns 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,penmit/license number which will be used as a reference number. The affidavits.maybe returned to the Department by mail or FAX imlegg-othei arrangements have been made.- w_._. . :.0 _..w.._.. The Office of.Investigations would like to thank you in advance for you 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 r Me of,Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 4.06, 409 or 375 .-d��.,�,.. .,.: t� � 1� �� 1 g yr�� '� �'� � `�. � � �� ,. � < i �: �� o ,�. , ,� ! ^ ` l � � ' ' � � � � � � ,I t � -e -�:..a r,, j � � -� � _ �� ; �: I r- ca cry c+'a �., J �. r•+ �. � ..:• g � � `l i x � E "'a � t r• m � �� 1 1:0 9 ., ._ �� j N 4 A W _._._ I N __�____.. _�___—xr._..-___._... � � 4, ____—