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HomeMy WebLinkAbout0094 ANCHOR LANE , . t .� � � '.n �� ,. �VEA Town of Barnstable Building ' Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept BA&MbTABIE. - • Posted Until Final Inspection Has Been Made. Permit DrFo„w<° Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a•Final Inspection has been made. Permit. . . Permit No. B-20-1146 Applicant Name: Paul Mazzola Approvals Date issued: 05/18/2020 Current Use: Structure Permit Type: Building-Deck Expiration Date: 11/18/2020 Foundation: Location: 94 ANCHOR LANE,COTUIT Map/Lot: 024-122 Zoning District: RF Sheathing: Owner on Record: HILL, DEREK C Contractor Name: WAQUOIT GROUP LLC G.C.I. Framing: 1 BUILDERS Address: PO BOX 1664 2 Contractor License: 152253 COTUIT, MA 02635 Chimney: Description: replace existing deck Est. Project Cost: $9,000.00 Permit Fee: . $ 110.00 Insulation: Project Review Req: 11 1 Fee Paid: $ 110.00 Final: Date: 5/18/2020 Plumbing/Gas Rough Plumbing: Final Plumbing: Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and 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 work until the completion of the same. �i' Electrical ' Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. 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: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health 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. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 5 Town of Barnstable -- _ Building �- Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Tosted Until Final Inspection Has Been Made. Pey�1111t ,ear' ;Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. { Permit Permit No. B-18-3320 Applicant Name: Derek Hill Approvals Date Issued: 10/19/2018 Current Use: Structure Permit Type: Building-Deck Expiration Date: 04/19/2019 Foundation: . Location: 94 ANCHOR LANE,COTUIT Map/Lot: 024-122 Zoning District: RF Sheathing: Owner on Record: Derek Hill Contractor Name: Framing: 1 Address: PO BOX 1664 Contractor License: 2 COTUIT, MA 02635 Est. Project Cost: $5,000.00 Chimney: Description: Remove Old Deck. Expand And Build New Replacement Deck. Permit Fee: $ 110.00 Insulation: Fee Paid: $ 110.00 Project Review Req: Date: 10/19/2018 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: 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 work until the completion of the same. _ Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 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: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT I , � ` i .,. .. •yam, - "�i - \ e ► ;`'.e TOWN OF"BARNSTABLE ,72-_11 -,, 4Permit No.Building InspectorCash 7/3 'O0 •e7P OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building' Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Cedar Acres Realty TruS jAddress South Yarmouth T,ni- 1 n4 494 Anchnr T.anP rnt-11it Wiring Inspector Inspection date Plumbing hnspeCt�Orf/ Inspection date'f4 © Gas Inspector .,,/,c- . j°10 Inspection date:)A �. An Engineering Department Inspection date/ — �U 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. 136�.._......... is .......... ..( _ ............._ Building Inspector BUT 03 LoY ` 29 !-= P60loo L o`t' 104 .M1 00 , 62t L a`f 12c9 f t a-• e 130,00 ®G V .L A &I HOW i KAcj o lk/ w 1=TJ, ay `- . -rHEa ca Nis ~R • G'GS P. A L 1 _ o J U- 1,YY. '2)7-:!) 1 HEREBY CERTIMTHAT THIS F0IJNOATlOt{. t11 1S LOCATED ON THE LOT AS SH¢W(j AND n� CONFORMS TO THE TOWN OF 9 Ne13`�'T741.'a s NOR _ONlMG REGULATIONS=RFlpAR1Dfpr, SETBACq 6RDSS of w " FROM STREET LINES ANO (,OT-OHM � 5 Fftessor's map and lot number ............ ....... S T HENE Sewage Permit numbe .Z...... SEPTIC SYSTEM MUST AUST LE, House number .......................... INSTALLED IN COMPLIA V &I 39- WITH TITLE 5 T;P CODE TOWN 'OF BAR IV5 KIRATI AN ONS BUILDING AN�S; PECTOR APPLICATIONFOR PERMIT TO ....... ....................... .......................................................................................... TYPEOF CONSTRUCTION ........... ............................................................ 9 .............. ��..................19..7e.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: )0 6. Location ...... .......:1.......... L/ .................................................................................... Proposed Use .......4............... .7.........................................................................................;................................................... ZoningDistrict ........................................................................Fire District ........!�I/ ................................................. DName of Owner ....11 ...44.w. Address ..... ................................................................ Name of Builder ... ... .................................. Address ..... ................................................................ ... ........... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ............rlqk.......................................Foundation ........A.................................................................... Exierior 4s ..../. ................ ...Roofing ..... .... ........................... Floors ........ ............................... .................................Interior .............................................. ................ Oro'!.94...........................Plumbing ..... ....................................... Heating ...ZZ/ 9 Fireplace .......d (E., , ................................................................Approximate Cost .......Q.. ....................................... Definitive Plan Approved by Planning Board ------------19 27�� Area .........../ ............. _q ,) 7-1' Diagram of Lot and Building with Dimensions Fee ........S........... .................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 34,o all Ea q' 35 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding tpe above construction. . ........... ........ .. .............. .........................Nam,/�.A................ Cedar Acres Realty Trust Iva 2150-�...... Permit for ...one.:$tory..dwe-1•ling ............................................................................... Location ..To.t.. 1Dla....94..AnGhDr..La.,............ .........:.........................Cot t............................... Owner ..Cedar:..Acres..R"lty..•Truat••••••.••• Type of Construction ..frame............................. Plot ............................ Lot ................................ Permit Granted ..................Ju3:y.....26....19 79 Date of Inspection W........ .................19 Date Completed .. n.. 19 PERMIT REFUSED . .......%. :r............................. 19 ............4`i «� n 'P........................................... .......... .�a.a .b .':Q............................................ .......... . .. e iY. .......................................... .......... ..n. .............................................. Approved • 19 ............................................................................... Assessor's map and lot number .. ..................��.`�.... . Z _. OFT E•T�N .Sewage Permit number .......................... .. .................... � j .. t BABB9TABLE, i House number MA86 :................................... O� 039.. 00 D YPY a\ TOWN OF BARNSTABLE BUILDING INSPECTOR T APPLICATION FOR PERMIT .TO ................ 4. ......... ......... ............................................................. /w �,� TYPEOF CONSTRUCTION .................. .... .......................:....................��............................................... ' .................19..71 TO THE INSPECTOR OF, BUILDINGS: The undersigned hereby applies for a permit according to the following information: �o /lJ� �r.. c....rac.e-.........,:.......:.�J. .................:........:.....:.................................... Location ................................................. ProposedUse ......./ :.............................................................................. .. ................................................. 'Z ning District ........................................................................Fire District /✓ . C ....1 !� ................................................. G�G,C ( LQD / i� Address /Name of Owner ....,.1.!.... .......ram.. ........ ..... ........�... ,\........................ ...................................... 7,_(.4; Nameof Builder ......�. ............................. ................Address .................... ............................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .....................................Foundation........ .... ..... G ..........? ..................................... Exterior ......................Roofing ..... ...i.• ........::. ......................•... Floors S........................................................Interior ....... -i ............G ;.................................................... Heating .......::.........:.:....:."Plumbing ..........(...............................................:...................... J Fireplace " Approximate Cost................................ ...........7.. ....................................... Definitive Plan Approved by Planning Board 1_1�__ ._________19 Area .......... ::`. ... ..... Diagram of Lot and Building with Dimensions Feed ' SUBJECT TO APPROVAL OF BOARD OF HEALTH t (I { �d U i pit 35 � t ` I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .� A Names ............. ............%:.•................................... Cedar Ages Realty Trust A_24-122 No ...... Permit for one.-story.-dwell-ing ............................................................................... Location ....lo-t.. •10.c4.....9,y...Anch-ar..L-a.:.......... .......................... ........................................ Owner ......Ce..dar...Acxes..Real.ty...Trust....... Type of Construction ........ ame....................... ............................................��............................ Plot ............................ Lot ................................ j Permit Granted..............Julp....215........19 79 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ..... 19 .. ............. ........ ..................................... ................................ ........... ........ .......i................ �. �. t!......!................ Approved.......:q.}........................................ 19 ............................................................................... Town of Barnstable Building Post This'Card So That it is"Misible From;the Street-Approved Plans Must b`e Retained on Job and,this Card Mustbe Kept ,�$ Posted Until Final Inspection Has Been Made a' ' Where a Certificate of Occupancy is Requ►red,,such Building shall-Not be Occupied until.a Final Inspection has been'made:l Permit Permit No. B-18-307S Applicant Name: Derek Hill Approvals Date Issued: 09/20/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 03/20/2019 Foundation: Location: 94 ANCHOR LANE,COTUIT Map/Lot: 024-122 Zoning District: RF Sheathing: Owner on Record: Derek Hill Contractor Name-. Framing: 1 Address: PO BOX 1664 Contractor License: 2 COTUIT, MA 02635 i " �.t Est. Project Cost: $3,500.00 Chimney: Description: Removing Old Cedar Shingles. Replacing With=New Cedar Shingles. Permit Fee: $35.00 Remove Rotted Trim. Replace With New Trim. f - Insulation: p ! , Fee Paid: $35.00 Project Review Req: at 9/20/2018 Final: Plumbing/Gas I� Rough Plumbing: Building Official ( Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized 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. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street oe-road and shall be maintained open4or public inspection for the entire duration of the work until the completion of the same. _ Electrical Service: The Certificate of Occupancy will not be issued until all applicable signatures by-the Building and Fire Officials are provided on this permit. 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: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. �.�J� � 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" (asset forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT �AQ ^-I Town of Barnstable RECEIPT 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-598 Date Recieved: 3/6/2017 Job Location: 94 ANCHOR LANE,COTUIT Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: ELIAS VOSSOS State Lic. No: CS-074285 Address: BROCKTON, MA 02301 Applicant Phone: (508)427-6444 (Home)Owner's Name: HILL,DEREK C Phone: (207)577-6799 (Home)Owner's Address: PO BOX 1664, COTUIT,MA 02635 Work Description: DIRECT REPLACEMENT OF PATIO DOOR WITHOUT ANY STRUCTURAL,CHANGE C O �" ! `n � t7o 3 Total Value Of Work To Be Performed: $2,968.00 o rr Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Elias Vossos 3/6/2017 (508)427-6444 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $2,968.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 3/6/2017 $35.00 XXXX-XXXX-XXXX- Credit Card 2082 TotalPermit Fee Paid: $35.00 .............................................................................................................................................._.........................................................................................................................................._...._....._..-- '"CTHI&IS.NOT`A PERIVIIT���# � �- Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee swxrtsrnBM v "AM 0$ Richard V.Scali,Director n ArFD MAC A Building Division TO0 4P Tom Perry,CBO,Building Commissioner /l/, 16, 200 Main Street, Hyannis,MA 02601 ,f www.town.bamstable.ma.us ci•9 n, Office: 508-862-4038 Fax: �S&' 0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �4F Not Valid without Red X--Press Ittrprint Ll (� t� Map/parcel Number o�' �as Property Address I �l A►itr'ko try Cp -f-y,� 1_j__ V��n/1 // oa,63, Residential Value of Work$ S(00 Q Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ► c, �q �I Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit 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) e-side Replacement Windows/doors/sliders.U-Value(j' I C1_9 (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical& Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy oft ome Improvement Contractors License&Construction Supervisors License is requi SIGNATURE: C:\Users\Decollik\AppD cal\ ' rosoft\Windows\Temporary Internet Files\Content.OUtlook\2PIOlDHR\EXPRESS.doc Revised 040215 Regulatory Services pQ1 ror, Richard V. Scali,Director Building Division anrsrtsTnete Tom Perry,Building Commissioner MASS. Y 039. ,0� 200 Main Street, Hyannis,MA 02601 �prFn s www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: Please Print �— /J `(��S r JOB LOCATION: ,/�W /J nCt7av- ".7"a number street � , village "HOMEOWNER":�P�C �r I / aO 7-J-27 p+7Cj 01 name home phone# work phone# CURRENT MAILING ADDRESS: �d X 16,C-1I cotz) + WW� Ca s— city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,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 he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigne "homeowner"ce ifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures rea en a t he/she will comply with said procedures and requirements. Sig u of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 i The Commonwealth of Massachusetts ZM Depardment of Industrial Accidents 09ce of Investigations 600 Washington Street _ Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Base-moo, ani2�onl &vidnal}: —De(�A C_ Address: ci N A-v?c eta r L cityistat&z><p: +,j,'-, b2 a '35- Phone ik Are you an employer?Check the appropriate box: T project 4. am a general contractor and I Type of P l ((required):1.❑ I am a employes with ❑ I g 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.Ng:rRemodeling 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. d] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.0 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.]i c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required] •Any apphcand flat checks box#1 r also fal out the section below showing their workers compenut, n policy infmdnatioa 1 Homeowners who submit this affidavit indicating they are doing all work.and then hire outside contractors mast submit anew affidavit indicating sack koamactors that check this boar must attached an additioaar sheet showing the name of the sub-cmmamrmrs and state whether or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy ntmyber_ I am an employer that iffproWdfkg worlrers'congmLu dion insurance for my employem Below is the policy and job site informad6m 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. I do hereby eel*' I under a pain s of perjury that the information provided above is taste and correct Si ture: Date: �� 1 Phone M — —6 7 9 Official use only. Do not write in this area,to be completed by city or town official. I City or?own: PermittlAcense b Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ?/z3bv Town of Barnstable _ � Regulatory Services Richard V.Scali,Interim Director `"R''„ 14 Building Division jEo ►` Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# C� l OZ FEE: $ SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less Location of shed(address) Village I flee. lc C- H :l l a.o 7- 177 7 - 4�; 7 T J Property owner's name Telephone number I D k l 1a.o s a �-}- Size of Shed Map/Parcel# S1 ; ignature Date J -� 3� Hyannis Main Street Waterfront Historic District? --1 C" Old King's Highway Historic District Commission jurisdiction? ® r-- If over 120 square feet,you must file with Old King's Highway / rn Conservation Commission(signature is required) Sign off hours 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 THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:110413 V V L 0`Y ? c? >✓ 12 q 10 130;00 o w w 1=TD r�Y -Th,Eo co NSA . Ca e P. SC A L J.Q. LY 1�_>>7'�) N0 I HEREBY CERTIFY THAT I)IM FOUNDATIOI tN..Of it IS LOCATED ON THE-LOT AS S#t9GH(`1 aEID o� CONFORMS TO THE TOWN OF 1MG REGULATPONS�REGAR> (p SETBACi� GR ' FROM STFtEfT UNES{tioO lOT'C11VES 62 �,►�, � Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee 3 S . • eaxtvsTna>E. i639 • Richard V.Scali,Interim Director Building Division X'PRS �wwwam�T Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 JUN 19 '1 4 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTI= ARNSTABLE 0 l U ,�� Not Valid without Red X-Press Imprint Map/parcel Number p Ol-1 J► ) /� ,1 �1 / t�-� Property Address l cl /'1 n C.ko y- L__,-,,n e_ l-n u►�� �1+ U c3,6 9J Residential Value of Work$ 1 — 'Miinimum fee of$35.00 for work under$6000.00 Owner's Name&Address Deco- c C n" I qq Avichor L.,, Cr-fZ�t+ n7.k Contractor's Name Telephone Number (�0 7,5_27-C Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ am a sole proprietor am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit 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) ❑ Re-side q Replacement Windows/doors/sliders.U-Value .a \ (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home I provement Contractors License&Construction Supervisors License is re SIGNATURE: TAKEVIN_D\Build" g Ch ges\E MI SS PERT\EXPRESS.doc Revised 061313 I 2 to CommotrrypeaUh ofMassachrrse-tts ---- - --- ---- Office of ITfVe-S'LlgLtfiUTrS --- --- - — - ------- 600 ffimyyhurgfon&reef Boston,MA 02LI'I wn'w.iriass:goi-1dia Workers' Compensafionlusurance affidavit:BuilderslContz-actois/EiectricianslPlumbers Apphcant Information Please Print, b . Name(Ba3dwm/0rganization&dhddnan: b-- cl� t mess: q (-1 AV4 l C, , City/state]zip: (fo) �Ij,'-�— 15 Phom i�- a07 -�� -� 7<� _Are you an employer?Check the a ---4. I atxta contractor and I � ] - I..❑ I am a employer with ❑ g�� 6- ❑New construction employees{full andlorpart-time)* have hiredthe sub-contra dors 2._❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ;;T�emodlig ship and have no employees These sub-contractors have g_ ❑Demolition. w for mein an capacity- employees and have workers' orking Y inci3rartc�2 9_ ❑Building addition [No workers.,comp:insurance comp 5..❑ We area corporation and its 10.❑Electrical repairs or additions ed_] . 3. I am a homeowner doing all work officers harm exercised their 1I-.❑Plumbing repairs or additions myself [No workers'comp- right.of exemption per MGL 12.0 Roof repairs insurance required-]t c.152. §1(4),and we have no employees-[No workers' 13-❑Other comp-insurance required-] *Az[y appHcBnt that checks boa-g1 umst also fill out the:section below showing ffi&erodes"compensation polity infbrmatia iL I Snmeowners who submit this affidavit ind afmg they are doing as wwk and then hoe oaztside contractors must sabmrt anew affidn-it inefirstinv sorb =Contractors that r Tioa this boa mast attached as additional sheet shoving the name a£the and suite whether ornot thasu entities hMM emgioyees. If the subtontmains have empIofees,they Tou provide their workers'comp.police number. I am am employer ihat is prmdd&W trorkers'c-omperrsrrlion insurance for my employee Betotc is fhe policy anal job sill in,;jrormaliom Insurance Company Name: Policy#or Self-ins_UC-;�: Expiration Date: Job Site Address: City/Statelzip: Attach a copy of the workers'compensation policy declaration page(showing the police 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 S1,500-00 and/or one-year imprisonment as well as civil penalties in the ftm 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 ffie DIA for uLsuranc,e coverage verification. I do hereby certrfy rt aprons allies ofpeditry thatthe information proti&d abosre is truce and correct Sit=nature: Date: 6 h 4-ki Phone 00kiai use only. Zoo not write fn this area,to be completed by city or town official. City or Town: PermitUcense# Issning Authority(drde one): L Board of Health- 2.Budding Depar bnent 3.CitvIrI av a Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 r Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an enployee 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 staffs that"every state or Iocal 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 alay applicant who has not produced acceptable evidence of compliance with the insurance.coverage requ.ired." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political si.ibdivisions shall enter into any contract for the perbormance 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 msurance 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 lime. 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 pemit(Ecense 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 (Le.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 kvestiptiom 600 Washuagtan Street B aston,MA 02111 TeI.A 617-727-4900 W 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mas,-,.gov/dia Town of Barnstable Regulatory Services ��oFtrte roiyy Richard V.Scali,Director Building Division txsTnsrE Tom Perry,Building Commissioner arns� r 1639. ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / J/ Please Print DATE: JOB LOCATION: —L."I ��CrycU\/ (i ✓L �G }' number / ) street village Dg,,�e l) HOMEOWNER":ie+/f a�q7.777E 7c� 9 name home phone#, work phone# CURRENT MAILING ADDRESS: ��({� c( city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,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 he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned' meowner"ce ' es that he/she understands the Town of Barnstable Building Department minimum inspection procedures quire an at he/she will comply with said procedures and requirements. gnature f Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 061313 r a �TME � Town of Barnstable Regulatory Services 9sw MASS,isg Richard V.Scali,Director VOTED 39. 16 e Building Division 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. as I 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) "'Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner . Signature of Applicant Print Name Print Name Date Q TORM&O WNERPERMISSIONPOOLS _ Town of Barnstable *Permit# a Expires 6 mondss from issue date Regulatory Services Fee BAMSTABM 0A9' $a63p. Thomas F.Geiler,Director �� _ 'eTfDMArp Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERwr APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 01),9 Property Address 1 y INy1 L-"I e + 4— M Residential Value of Work A SC> 00 minimum fee of$35.00 for work under$6000.00 Owner's Name&Address es 1- C Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) X P R F R R P r m 11 w IT ❑Workman's Compensation Insurance q; Check one: S E P 2 7 2012 ❑ I am a sole proprietor RI am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# 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) YRe-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .35)#of windows "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Own st sign Property Owner Letter of Permission. A copy ome me Contractors License&Construction Supervisors License is I r SIGNATURE: C:\Users\decollik a cal\Microsoft\Windows\Temporary Internet Files\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 07211 r � ,per The Commohw' ealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 6Y °y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly. Name(Business/OrganizationAndividu d): . L C_ H'1 ' Address• ( Ll tJ G-a^� City/State/Zip: CCU , > s_ C)_&-6 3 Phone.#: G7 S77 �� cl Are you an employer?Check the appropriate bog: Type of project(required):. 1.❑ I am a employ with 4. ❑ I am a general contractor and I mP Y er 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 workingfor me in an capacity. employees and have workers' Y P tY• $ . 9. ❑Building addition [No workers'comp.insurance comp.insurance. t ' 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑Plumbing repairs or additions 3.eI am a homeowner doing all work*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 xg1ification. I do hereby certify under ains-an ena ' s of perjury that the information provided above is true and correct Si ature: Date: �( Phone#: SCR C 7 0 C1 iOfficial use only. Do not write in this area, 16 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#: r 1 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-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 orpermit 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 o ee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4500 ext 406 or 1-877-MASSAFE 1 Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia Town of Barnstable Regulatory Services BARMASM Thomas F.Geder,Director 1639.�h Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 2L&4 JOB LOCATION: %Q�1 �l/IGIq(� v/ +V number uumbe r street 7 village W"HOMEONER": �IC C, H-11 l�.J�-��7'(O7ctq name home phone#/ work phone# CURRENT MAILING ADDRESS: p n &6 (o cy Co+v ✓ k 0-0116-is— city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,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 he/she shall be responsible for all such work performed under the building_permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersign ` meo tes that he/she understands the Town of Barnstable Building Department minimum inspection proced re requir ents that he/she will comply with said procedures and requirements. C- i e of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&c Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 j r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2 Parcel ��� Application # C (� Health Division Date Issued ate- Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board G Historic - OKH _ Preservation/Hyannis Project Street Address Village Owner �� �/� G �`� Address �!1e� elf"� /yJ�• Telephone Permit Request I �j d� �, -Ail,I Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ales ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes IrNo On Old King's Highway: ❑Yes ❑ No Basement Type: Dull ❑ Crawl Nalkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft),�I Number of Baths: Full: existing_ new Half: existing new Q Number of Bedrooms: existing new vi Total Room Count (not including baths): existing new First Floor Room Count ' ? Heat Type and Fuel: 21 Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes p<o Fireplaces: Existing New Existing wood/coal stove: ❑Yesj9TN o Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new ' size_ Attached garage:0 existing Linew size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use ` f 44_ Proposed Use ski,E'__ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number p b Address - C lq' License # [CC 0_.�rnziP 40— Home Improvement Contractor# Worker's Compensation # �< 3F� f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Av- F, FOR OFFICIAL USE ONLY 4 V APPLICATION# DATE ISSUED MAP/PARCEL N0. Qom., s - - ' s i } ADDRESS G VILLAGE i OWNER t M ^ fi DATE OF INSPECTION: FOUNDATION r FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH 'FINAL PLUMBING: ROUGH - FINAL:`' GAS: ROUGH ''FINAL " FINAL BUILDING DATE CLOSED OUT "? ASSOCIATION PLAN NO._ The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations �J y�E� 600 Washington Street /I Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Built:lers/Contractors/Electricians/Plumbe' rs Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: t �J City/State/Zip: Id `phone #: -t`t / 0-<'/ Are you an employer? Check the appropriate box: Type of project(required); r I a a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction .❑ I am a sole'proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub contractors have S. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9 ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I,❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12,❑ Roof repairs insurance required.] t. employees. [No workers' comp. insurance required.] 13.❑ Other ;Any applicant that checks box#I 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4•-1/o Policy#or Self-ins. Lic. #: f;(�ly��f�3 ®� sl� [�`' �I ���,, � Expiration Date: Job Site Address:_ "`1f `tL% kxnep City/State/Zip: � /c l' elllS, 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 V,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 cert�under the pains and penalties of perjury that the information provided above is true and correct Siemature c � „ Date 9—/,o l Phone#: �O� - 2 �-5- !`' 0 F only, Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual, partnership,association, corporation or other legal entity, or any two or more 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 inio any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis 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 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 retumed.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 n Please be sure that,the affidavit is complete and printed legibly. The Department has J s provided a,space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to comae``' -regarding the applicant. Please be sure to fill in thepermit/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,ne4bnly 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 proofthat 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 (Le, 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: '� U The.Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax ## 617-727-7749 i www.m.ass..gov/dia ACO® OATE(MMr0D1YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/27/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Silvia, NAME:-• Kath---'--_y— The Fair Insurance Agency Inc. PHONE (508)775-3131 FAX (508)790-1677 619 Main Street ADDREss;fairina@capecod.net-- -- ---- ---- PRODUCER A0003194 P.O. Box 430 cysT9M�A1tL._--.--.____--..----'---'------------. Centerville MA 02632 INSURER(SLAFFORDINGCOVERAGE —__-- ! NAIC0 -----_.--- _ INSURED INS URERA AIM 26158,•.--._._ West Barnstable Brick Co Inc DBA --_u_--'-'----------"---------_.—.—.i—- INSURER B: Doug Williams Custom Building INSURERC: 222 Pine Street INSURERD;_.-- 1 INSURER E: I Centerville MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER:wc11-12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. f ---- '--_...----- ILTR l-- TYPE OF---- NCE--------- -D� UgHl NUMBER MMfDDIYYYY ! MOMIUDDnYVYT ---- LIMITS GENERAL LIABILITY ! I j EACH OCCURRENCE ($ OA IXGE TO RENTEb-------•--------------- COMMERCIAL GENERAL LIABILITY l I ! PREMISES(Ea ocarre�xw�—_ S CLAIMSa ADE t OCCUR ! ; 1 MED EXP(Any one person) S --- -_--_ j - 1 PERSONAL&ADV INJURY $ -GENERAL AGGREGATE --------- -- GEN'L AGGREGATE LIMIT APPLIES PER: i PRODUCTS_COMPIOP AGG i$ POLICY I I PRO- -- LOC E —.-_.. ---- $ JECT i I AUTOMOBILE LIABILITY i I ! COMBINED SINGLE LIMIT i S ! I ANY AUTO I i ! ! 1 "----------"._-- -------•- _._' I ii BODILY INJURY(Per person) S ! I ALL OWNED AUTOS �........ ; I E BODILY INJURY(Per accident)13 j SCHEDULED AUTOS I j I -....__-`.._..__._._'---•--_. ._. J PROPERTY DAMAGE`- ------' --- ! HIRED AUTOS I ` (Pef accident) ,S i I NON-OWNEDAUTOS 1 ) is I UMBRELLA UAB 1 OCCUR I I EACH OCCURRENCE S - ' i ff ---- 1 EXCESS UAB _.__.......__._.-..—____-_...:_.....�.. ...........___._.� I I AGGREGATE I_$.._._.._.._-_._ --__'--CLAIMS-MADE I I i DEDUCTIBLE I I'------ _---.-.-i s.—___--------- RETENTION S I I WORKERS COMPENSATION : WC STATU- ; OTH-1 A J.Twy-L(MI.LB.: R_: AND EMPLOYERS'LIABILITY Y/N � � � r � — -- ANY PROPRIETORlPARTNERIEXECUTIVE I I 1 I EL EACH ACCIDENT S 100,OOO OFFICER/MEMBER EXCLUDED? I NIA I--_._..-.---__.-..------°--•-_---•-- (Mandatory in NH) I L614354012011 1�4/6/2011 /8/2012 E.L_DISEASE-EA EMPLOYEE!S _— 100,000 If es descriDeutMer 1I ---— ---- DESCRIPTION OF OPERATIONS below I ! !E.L.DISEASE-POLICY LIMIT I S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Kathy Silvia/FAIKS1 ACORD 25(2009109) ©1988.2009 ACORD CORPORATION. All rights reserved. INS025(2oo9o9) The ACORD name and logo are registered marks of ACORD Town of Barnstable 0 Regulatory Services uxxsreBM So "uE- Thomas F.Geiler,Director 163¢. •Building Division Tom Perry,Building Commissioner 200 Main Strcct, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject .property hereby authorize Qc fit e js A to act on my behalf in all matters relative to work authorized by this building permit application for. I (Address of Job) t( Signature of Owner Date l Print Name If Prope . Owner is applying for permit please com fete the Homeowners License Exemption Form on the reverse side. Q:FO RMS:O WNERP ERMISSIOTI I CM THE 'Town of Barnstable r•�s- - y��` yo Regulatory Services sAwrsrwars = Thomas F. Geiler,Director Maas. t63p. 16 Building Division RFD µAi Tom Perry, BuJlding Commissioner 200 Maid-Street,_Ayannis,MA_02601 www.town.b arnstabl e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HO TEOWNER LICENSE EXEMPTTON Please Print DATE. JOB LOCATION: number str=t village "HOMEOWNER": name home phone# work phone# CURRENT WILING ADDRESS: city state`\ �l :� zip code , The current exemption for"homeo ers"was exten ed to-include owner-occupied dwellings of six units or Iess and to allow homeowners to engage an in 4 'dual for who does not.pAsess,a Ji6cnse,pi-oviad that the owner acts as supe1Y]sOI. DEFIJ<M OF HOMEOWNER Persons)who owns a parcel of land on ch helshe r sides or intends to reside, an which there is, or is intended to- be, a one or two-family dwelling, attached r detached iructures accessory to such use and/or farm structures. A person who constrgcts more than'Inc home ' a two-ye period shall not by considered a homcowner. Such "homeowner"shall submit to the Building=O cial on.a' rm acceptable to;tlie Building-Qfficial, that he/she shall be res onsible for all such work erformod i'-d the buil L,permit. (Section 109.1.1) The undersigned"homeowner"assumes respo ibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulatio 4 The undersigned"homeowner"certifies that-he/ a unders .ds the Town of Barnstable Building'Depazt�ent'. minimum inspection procedure liana rogtiir�emcn and that he/sho will comply with said procedure sand requirements. i Signature of Homeowner • U� i1v��� �j �', � ;fir',. . Approval of Building Official " Notc: 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. HOMXOWNER'S EXEMMbN .The Code states that: "Any bomeowner performing work for which a building permit is required shall be exm*-npt from the provisions of this sectign.(Section 109.1.1-Licensing of construction Supcnrisors);provided that if the homeovmrr engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor" lrEany homeowners who use this exemption art unaware that they are assurrring the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Camoruction Supervisors,Section 2.15) This lack of awareness bftan results in serious problems,particularly when the homeowner hires unlicensed persons. In.this case,our Board cannot proceed against the unlicensed person as it w'ou)d with p licensed Supervisor. The homeowner acting as Supervisor is ultimatc)y responsible. To ensure that the homeowner is fully¢wars of his/her resporuibilitics,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the responsibilities of a Supervisor. On the last page of this issue is it form currently used by several towns. You may care t amend and adopt such a fomr/certification for use in your community. Q:fomts:homccrcmpt ■ 0 Attic Beam � by Weyerhaeuser 2 Pcs of 1 3/4" x 11 7/8" 1.9E Microllam@ LVL O�w/-Beam®6.36 Serial Number:7005107030 �User:2 8/2/20119:18:36AM THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN Page Engine Version:6.35.0 CONTROLS FOR THE APPLICATION AND LOADS LISTED d 15'315l16" Product Diagram is Conceptual. LOADS: Analysis is for a Drop Beam Member. Tributary Load Width: 13' Primary Load Group-Residential-Living Areas(psf):20.0 Live at 100%duration, 12.0 Dead SUPPORTS: Input Bearing Vertical Reactions(Ibs) Detail Other Width Length Live/Dead/Uplift/Total 1 Stud wall 3.50" 2.20" 1993/1284/0/3277 L1: Blocking 1 Ply 1 3/4"x 11 7/8"1.9E Microllam®LVL 2 Stud wall 3.50" 2.20" 1993/1284/0/3277 L1: Blocking 1 Ply 1 3/4"x 11 7/8"1.9E Microllam®LVL -See iLevel®Specifier's/Builder's Guide for detail(s): L1: Blocking DESIGN CONTROLS: Maximum Design Control Result Location Shear(Ibs) 3205 -2729 7897 Passed(35%) Rt.end Span 1 under Floor loading Moment(Ft-Lbs) 12018 12018 17848 Passed(67%) MID Span 1 under Floor loading Live Load Defl(in) 0.340 0.500 Passed(L1529) MID Span 1 under Floor loading Total Load Defl(in) 0.559 0.750 Passed(U322) MID Span 1 under Floor loading -Deflection Criteria: HIGH(LL:U360,TL:U240). -Bracing(Lu):All compression edges(top and bottom)must be braced at 12'o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. ADDITIONAL NOTES: -IMPORTANT! The analysis presented is output.from software developed by iLevel®. iLevel®warrants the sizing of its products by this software will be accomplished in accordance with iLevel®product design criteria and code accepted design values. The specific product application,input design loads,and stated dimensions have been provided by the software user. This output has not been reviewed by an iLevel®Associate. -Not all products are readily available. Check with your supplier or iLevel®technical representative for product availability. -THIS-ANALYSIS FOR iLevel®PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. -Allowable Stress Design methodology was used for Building Code IBC analyzing the iLevel®Distribution product listed above. -Note:See iLevel®Specifier's/Builder's Guide for multiple ply connection. t H OF 0,�s,.9 PROJECT INFORMATION: OPERATOR INFORMATION: MICHELE oy Q for: D.WILLIAMS Michele Cudilo o CUDILO rn Michele Cudilo, P.E. ° NO.34774 STRUCTURAL. I.. 109 ANCHOR Phone:5087717601 CENTERVILLE Fax ':5087717163 9F°� aEp mcudilo@comcast.net `S7GkgL C Copyright 6 2009 by iLevel®, Federal Way, WA. Microllam® is a registered trademark of iLevel®. r i t j i 5 i i f i ;I i i f i i j 1 T 6 0-1 Zy kul stssol/Ls o ./itP,1�JOOJU))t4W_!)ClZ�Clt (.'[-;.•CUL.i1ClCYtf[.iE a + i ? w c Mr a� OlTice of Consamer ABairs&Bdsrness Regulation HOMEIMPROVEMV. ENTCONTRACTOR a } sue 3 F , ISO_ TYPe: y u f _ ��? Registration:"Am 102227 F. - DBA Expiration: 7J1/2012 Ttus card acmowledge� ha�thrrreotpelsas s tul(ytcompteea a our, a 'M rang Cwirse rn� �c L WILLIAMS CUSTOM BUILDING z Construction Sa� d Health�....a �^ '`'' Sp` ". s•,, a-l.4•" 'cus'nr� k . +k€' f�uafos '.nrni2!T•` *-. t't�r ' `� wx r :'may t im' ''�• u"fi}G 4•:�i a4.. t x•- t'�-3',����� �::. �� s�����`����`;��e . 222 PINE S 1 Undersecretan�ii �5Nr CENT ER +E.MA 02fi32 ss r[framer?name.. pnntFor type) � �' `"'�(Course�'end d'ate)�`. License or registration valid for indicidul use only before the expiration date. If found return to: --- - — - -- Office of Consumer Affairs and Business Regulation - •f4r� s 10 Park Plaza-Suite 5170 eL.111,1,t.- W �all'.e;�i.:Lti t, •i h rr:r�4 : R it 1IA021tb a:b � v. r. ' �� 3 rIf_ Boston,m. W Y �: — Not valid without signature . ry rasac mof:�*•'•-�....-,_-•.;.tea.:cr�s�:�.�'r�,s�cmE�ss�a� - .__ All BAAOtmtis¢sb srzies 12es.�A:�ir_•;es - - rw� r setafiss�csnis�erecro l�re:I.�sS t. 1{ t+•:rci?t!.rt[•- Iirparntcrtt.ni Puhlir Brr[rd rrf' Btrildin itc�ulatiurt. ,tilt] Standard! License: CS 16981 �nm Restricted to: 00 DOUGLAS L WILLIAMS SR " PO BOX 1069 CENTERVILLE, MA 02632 Exairdtion: X 2012 19320 Tr. i Y Town of Barnstable *Permit# /ell Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee AUG — 2007 Thomas F.Geiler,-Director, Building Division TOWN OF BARNSTABLETom 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 J^C� Property Address h 2 L N esidential Value of Work !'��• ' Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address_JD Si id f 150V 0 f' Contractor's Name Telephone Number , Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ' N',,Yam.the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to e-roof(not stripping. Going over--I-existing layers of roof) i ❑. Re-side i ❑ Replacement Windows/doors/sliders. 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 Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmirg Revise061306 �4 The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations a ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumber" ADMIcant Information Please Print Le 'bl Name(Business/Organization/Individual): . C Address: u� ^�4/1 City/State/Zip: Phone.#: Are you an employer? Check the appropriate bog: Type of project(required):. 1.❑ I am a employer with 4. Ej I am a general contractor and I . employees(full and/or part-time).* have hired the sub-contractors 6. New construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition workin for me in an capacity. employees and have workers' g Y P tY t. 9. Building addition workers'comp.insurance comp.insurance. equired.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑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 fin out the section below showing their workers'compensation policy information. t Homeowners who subnrit 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 providt;their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy and job 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains•and penalties ofperjury that the information provided above is true and correct Signafore: t Date: / 7 Phone#: Official use only. Do not write in this area,to be completed by city or town off ciaL 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#: