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Home My WebLink About0009 CAP'N ISIAH'S ROAD �. � � , ��,. l',D� �hS'��i s __ Town of Barnstable *Permit# Regulatory Services EFee 6monthsfiome sMBxszasM • y� mass. Richard V.Scali,Director 1639. ` Building Division .� l:-• Paul Roma,Building Commissi ,gr + 200 Main Street,Hyannis,MA 0201 www.town.barnstable.ma.us SUN 1 Office: 508-862-4038 � 8P790-6230 EXPRESS PERMIT APPLICATION - RES T VAY Not Valid without Red X--Press Ittiprint Map/parcel Number 4 3 x n (r,(„ / Property Address CGQ �► •` �/� 'S 6a+-1 - N /7 J ❑Residential Value of Work$ r3 d�d Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name A�c.� L . O Ve. ` I Telephone Number �0 8" 3 '3 7/ Home Improvement Contractor License#(if applicable)/^^b 0 20� Email: Construction Supervisor's License#(if applicable) C..)c FA - !0 S y�7 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [g-Phave Worker's Compensation Insurance sa Insurance Company Name A 1- - k 4 f Workman's Comp.Policy# w C C- Soy -- S O Gol a 1 -ay )6 Copy of Insurance Compliance Certificate must accompany each permit. Permit Re uest(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 D-Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows I #of doors: '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&Construction Supervisors License is • �quired. SIGNATURE: I C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.0utl00k\L.7U69LF2\EXPRESS(2).doc 01/25/17 f The Comnnonivealth of Massachusetts Depardnent of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 imm mass gmt/dia Workers' Compensation Insurance Affidavit: Builders/C4ontractors/Electricians/Plumbers Applicant Information Please Print L,e6bly Name(Business/Orgmization&&vidual): L).•,p [ . 0 c r pt Address: -3 5-/ ,k-,Ia R J City/Stat&Zip: 4�4_�,J O I6 01 Phone#: SU �3 ? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer Bath 4. ❑ I am a general contractor and I �,�employees(full and/or part-time)-* have hired the sub-contractors 6. Neu.,construction 2.I� t am a sole proprietor or partner- listed on the attached sheet. 7• �emodeling ship and have no employees These sub-contractors have. g_ ❑Demolition working for me in any capacity. employees and have workers` [No workers'comp.insurance comp-insuranee.I 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]Y c. 152,§1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also till out the section below showing then workers'compensation policy information. i Homeowners who submit this affidmit 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 tie of the sub-cmtasttors and state whether or not those entities have employees. If the sub<outtacton have employees,they must provide their workers'comp.policy number_ I ain att employer that is proi4ding rttorkers'conipensatiott insurance for my etttployee,& BeIotp is the policy and job site information. r1-. Insurance Company Name: A r y l, ►,o ' Policy#or Self-ins.Lie. cc-—So v - Sd 16 a co I - 2 v t: Expiration Date: Job Site Address: � C_Gt0491•1 -I_SJ*c tj _N ra City/State/Zip: Cc' f,%,f /41-' d'.)6 3Y Attach a copy of the.Workers'compensation policy declaration page(showing the policy number and expiration date.). Failure to secure coverage as required under Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 a day against the.violator. Be advised that a copy of this statement may be forwarded to the Office.of Investigations of the DIA for insurance coverage verification. 1 do hereby certi itrtder the pains and penalties of pedury that the information prodded above is bate and correct Si ture?� Date: �r l Phone#: a v 3 — 3 Official ttse only. Do not write in this area,to be completed by city or totpn official. GO 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#: 6 Massachusetts Department of Public Safety �f Board of Building Regulations and Standards License: CSFA-105994 Construction Supervisor 1 & 2 Family DANIEL OWEILL 351 MEGAN ROAD Q ' HYANNIS MA 02601 ' } = '\ I, DI 111 t. 1�=/►l^^^ l� Expiration: Commissioner 10/23/2017 C�/rc�nur•nrnicrucn/(/n`CYlliu�cic/rr:;n.(It Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR �^ TYPE:Individual r Registration Expiration 168722 05/14/2019 DANIEL 0 NEILL D/B/A DAN L.O'NEILLCARPENTRY DANIEL O'NEILLCfQ -- 351 MEGAN RD HYANNIS,MA 02601 UnderseCretan I Registration valid for indivi 11 d al use found return to ..ulation before the expiration date. �pffice of Park PlazaConsumer Suite 5170 and Business Reg Boston,MA 02116 r Not valid without signature Construction Supervisor 1&2 Family Restricted to: of the Masslc'lluseVts Failure to possess a current edition ortrevocation of this license. F Code is GOVID State Building MASS. DPS Licensing information visit: W' NOTICE NOTICE TO TO A b m EMPLOYEES ti" EMPLOYEES �a Bye" The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5016201-2017A 07/12/2017- 07/12/2018 POLICY NUMBER EFFECTIVE DATES Rogers & Gray Insurance Agency Inc South Dennis, MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE Daniel L. O'Neill Carpentry 0 351 Megan Road Hyannis, MA 02601 EMPLOYER ADDRESS 06/08/2017 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER i • seRtvsrasLE. • Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Paul Roma 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 / V e., Y , as Owner of the subject property hereby authorize �`^ �d' ( I to act on my behalf, in all matters relative to work authorized by this building permit application for: (fc, C% (fc,+,„� iA- (Address of Job) (-7 Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Loca]\Microsoft\Windows\INetCache\Content.OutlookU.N69LF2\EXPRESS(2).doc 01/25/17 �. Town of Barnstable *Permit# Ea pires 6� the from issue date Regulatory Services Fee 'BWWABM Thomas F.Geiler,Director N►a+° 01? rod Building Division N�FegR Tom Perry,CBO, Building Commissioner ,A N$Tge` 200 Main Street,Hyannis,MA 02601 �C F www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-79.0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL, ONLY Not Valid without Red X-Press Imprint Map/parcel Number 0 3 l)O(� 6 Property Address ( Rd§iddntial Vaiud of W& �l0)v- 00 Mi®iiiiuiii R6 6f$35.00 i6e w6rk uiiddr$6000.00 Owner's Name&Address_ -f- W, `�'�� O Ue-, I r co+C,1 �A az� 3s Contractor's Name VC.r n,2 0 N e Telephone Number Hdmd iiiipPovddidrit Cofltrdctor LicdiM#(if appliddbl6) V Construction Supervisor's License#(if applicable) FA l l 0�) � / q ❑Wdfktiiaii'§C6bdpdtisatidii Iri§&-dd Check one: ❑ I am a sole proprietor. ❑ i am the Homeowner I have Worker's Compensation Insurance Insurance Company Name / ►t�% ��^ e eJ J `��^��o'^C �"(h PG��' 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 I I #of doors Replacement Windows/doors/sliders.U-Value v `l (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 Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is equired�. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 oF� . S • BARNSTABIZ • 639. Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstoble.ma.us Office: 508-9624038 tax: 508-750-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize 1�1 � to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature 4f Owner Date (�La-�4 � 6 ^ I Print Name If Property Owner,is applying for permit,please.complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massachusetts Department of Industrial Accidents Office 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(Business/Organization/Individual): �q L• V GU(( Pent. Address: C) 6 r7 I r City/State/Zip: Gv 4-,,4 O J 3 Phone#: Are you an employer?Check the appropriate box: I am a general contractor and I Type of project(required): 4. 1.[A I am a employer with ❑ 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. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor mein an capacity. employees and have workers' y p �'• $ 9. ❑Building addition [No workers'comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.3 Other [N N Ici W-3 comp.insurance required.] *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. :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. 7`am an employe'-t&t is piovidUFj workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: Tr r 12 T c,(le(p ('S TASW'c.n c e. cr,m PGn,c- Policy#or Self-ins.Lic.#:^ U "B' — f ls7 `I'S-1 ^ -Expiration Date: Job Site Address: / CGte�Ut n -4- IGI S �(!� 0 a-b City/State/Zip: �t 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 cenA under the pains an p naldes of perjury that the information provided above is true and correct Si ature: Date: Phone#: Offkial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: e. i NOTICE z NOTICE TO T � TO a EMPLOYEES EMPLOYEES OEM Svc The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GKUB-477GP45-4-12) 07-12-12 TO 07-12-13 POLICY NUMBER EFFECTIVE DATES ^ MARK SYLVIA INS AGENCY 771 MAIN ST OSTERVILLE MA 02655 . ^ NAME OF INSURANCE AGENT ADDRESS PHONE# 0 0 O'NEILL, DANIEL L . DBA 1314 OLD QUEEN ANNE o DANIEL L . O'NEILL CARPENTRY CHATHAM MA 02633 EMPLOYER ADDRESS 0 EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the 'provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the j injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 000767 W20PIG02 TO BE POSTED BY EMPLOYER L! Massachusetts -De Board o f Building Re Part ent COn•�tr gulati ons a Of Public Safety uction Sup�,r�i�.or License. I SF I & -y pa and Standards mih• Ai105994 P.O BOL OINEIUI- z Cotuit ML4 p 63y J i 1 ' Commi_"'�•ssioner Expiration 10/23/2015 �� 26U� f Office of Consumer.Affairs& s�uess ego aho i HOME IMPROVEMENT CONTRACTOR Type. :t i — Registration: �168722 bBA i �. 'Expiration: 3h3.0/2013 DA L.'O'NEILL 4 DANIEL O'NEILL�x 9 CAPTAIN ISIAH'S",,,, _�_ lJ COTUIT,MA02635 ` �; >��/ Undersecretary I I YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. &-_0 =�ii:1 ln."—, �y... � Fill in please: Date: 3ZIC.,V c90 o APPLICANT'S NAME: YOUR HOME ADDRESS: Cazz:gw Tsk&N 'S �c .i.� n .�-r-i.� i i M N c7 7 ram, _ bxfi -? BUSINESS TELEPHONE # HOME TELELPHONE #: S U — / U — 3 r✓ NAME OF CORPORATION: FID # NAME OF NEW BUSINESS O " l eq TYPE OF BUSINESS IS THIS A HOME OCCUPATION? X )YIE NO ADDRESS OF BUSINESS a •Tu Sri MAP/PARCEL NUMBER Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town. 1. BUILDING CO IS ONER'S OF ICE MUST COMPLY WITH HOME OCCUPATION This indivi ual era. :f e of ny permit requirements that pertain to this-type ofk8tEMID REGULATIONS. FAILURE TO A hied Si ure** COMMEN 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: tHt r Town of Barnstable *Permit Expires onths fronr isst date Regulatory Services F. `�- BARNST,BLF, b .hq�$ 4 200� Thomas F. Ceiler, Director l-.AIEDMA'�A { V' $ BuildingDivision BAR' 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 �1J Not Valid without Red X-Press Imprint Map/parcel Number l .4 II Property P Y Address , Residential Value of Work Minimum fee of$25.00 for work u der$6000.00 Owner's Name& Address6 I �� Contractor's Name Telephone Number I Ionic Improvement Contractor License 4 (if applicable) Construction Supervisor's License# (if applicable) ❑Workman's Compensation Insurance Check one: _ ❑ I am a sole proprietor KI am 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 ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ 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 c py of the Home Improvement Contractors License is required. C 1 SIGNATURE: XkLj2�� Q:`\ PI'11.1:SU ORMS\building permi fo Ms\EXPRESS.doc Revised 100608 t f I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Le ibl Name(Business/Organization/Individual): r Address: rol City/State/Zip: / V I Phone.#: ��— 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 I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ..2:0 lam a sole proprietor or partner-' listed on the attached sheet. 7. .0 Remodeling ship and have no employees These sub-contractors have g,'❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• $ 9. �Building addition [No workers'•comp.-insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions I am a homeowner doing all work officers have exercised their I I.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.p Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] L N - *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 liave omployees,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.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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certify un a re at s an pen pe 'ury that t! *information provided above is true and correct. _ Si lure: Date: �� v Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# LIL6. uing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Issuing ntact 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 jom--enterppnse�and-m7u g-:the legal-represen-tafive-t-uf-yndemas'ed-em�piayer-� e---_--: --:-- 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, it necessary,supply sub-contractors)name(s),address(es)and.phone number(s)along with their certificate(s)of insurance. Limited Liability Comppanies"(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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple perm ittlicense 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 io 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 Investigationts 600 Washington Street Boston,MA 02111 Tel. #617-727-4400 ext-406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia y`�P�oE'THE r�� Town. of Barnstable 4. ' Regulatory Services Thomas F.Geiler,Director ui;NSTast.e. rapes. ><bs¢. •`0g Building Division �rFD A Tom Perry,Building Commissioner ........200 MainStreelt Hyannis,-M7-026,01. ........__.... ...... ..._.._. .. .. --........... . : www.town.b arnstable-ma.us Office: 508-962-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: �2,, JOB LOCATION: nu str tr )� J a village "HOMEOWNER": a l / �e L name home phone work phone# CURRENT MAILING ADDRESS: f a /. atyhown 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 faun 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"bomeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that.he/she understands the.Town of BA=- .table,Buildi.g Department minim ection procedures and requirements and that he/she will comply with said procedures and require Signature of Ho er 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 excmt from the provisions of this section(Section 109.1.1 -Liiemsing 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 homeowner: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 pennons. In this case,our Board cannot proceed against the unlicensed priori 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 helshe 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 forrn/certification.for use in your community. Q:forn ss:homecxempt z1T � Town of Barnstable Regulatory Services 9 MM,sss Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Sectio If Using A Builder I, Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aVr�izedby building permit application for.t (/l I -(Ad ss Job) 3-2,Y-05 Signatur Owner Date Print N If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:F0 RM S:0 W NE RP ERM IS S 1 ON YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates.(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to'opei•ate.) Business Certificates are•available at the Town Clerk's Office, 1st FL.; 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: O 0(o U:. Fill in please: r r OM Mho APPLICANT'S YOUR NAME: � ,ipl D AJei M.ffe n BUSINESS YOUR HOME ADDRESS: 4 GQb in TS;.A '5 two SQrv,e a5 V)OMC, Rd (_b+-u1 a- A4 , W,9 3 S TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS D.L a TYPE OF BUSINESS erutce, IS THIS A HOME OCCUPATION? Y S N.O: Have you been given apprq�val from ufldin div- ? Wv ADDRESS OF BUSINESS 7 GE.p�iui�` 1 c.4,' `did (�� A ,J MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Mas St.-(corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally olfera a&rV15ftiness in this town. F 1. .BUILDING COM NER'S OFFICE This individual h s een.i d of any permit requirements that pertain to this type of business. A ho i ignature" ' MMENT , _ i• 0 C,U- - 2.. BOARD OF HEALTH i This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature'" COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHOR . Y) This individual ha n info drof the lisiageh1trments that pertain to this type of business. Authorized Signature" COMMENTS: Town of•Bat°bstable Regulatory Services Thomas F.Geiler,Director Building Division - ins 3 m�* Tom Perry,Building Comissioner s639. p�0 . lF0 Mpt 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: / - V O G Name:Z/i %e/ L_ ( o ye-i lI Phone#: " 73 �f (�` J Address: 7 GG�J�"Grh S�G� S Rd Village: 4 _o Name of Business: D L- D- G-r, Type of Business: Cat/iUZ��/ �e r(J,Ce_ Map/Lot: DITENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. .• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have red and agree with the above restrictions for my home occupation I am registering. =t;/ Applicant: �=s Vagee' Date- L r C)r O Homeoc.doc Rev.5/30/03 and lot number_ ..... .c�.."- .�o.�?......: .. .. Sewage Permit number .. G......°...... r!Jl�iK... ........ SSFrFIC SYC . � I�V7 CO "STALLED � t BAREST LE, House number :.. ....' ... .................................... WIT;i �'1TIL. 0° G E{1I�I��t(�t'�NIIEUTAL CC 'oo,,��b Y0 a�0 0 pY TOWN OF BARNSTAB�LE BUILDING INSPECTOR .. I APPLICATION FOR PERMIT.TO aT .......................... ....................................... TYPEOF CONSTRUCTION ....... ..�1 .�..,......................................................................................... ?Q; \b 9........ �� TO THE INSPECTOR OF BUILDINGS: Of The undersigned her�yeby a�pyplies for a permit according to the following information: LocatLocation c ion ......�-�?}.-#...�D......................ef4pl.'.L3.......-1-.��.P1 J.P?.�f......h.!:,?.................. 1T.• ................. ProposedUse ......... /l .................................................................................................................................... Zoning District ....................................................Fire District ......... � ` �� cz �� Name of Owner a .............. 0 �/ I//� r Name of Builder ..... !'"....... /r� ? .......Address ........4 Qk ...................................................... Name of Architect .......bww ..../'.k�mZ ..................Address .....: M:1 C Number of Rooms W Foundation A�� v"ylr CoT Exterior .. :.....................................................Roofing .......�� 1..�'...................................... FloorseTI�cJO.�'�/..........Interior .................................................................................... Heating /`�. '�/2/C/.....................................Plumbing ...... .. ........................................................ Fireplace ..... ./................419—e.�..................................Approximate. Cost .......... lv C��®................................ Definitive Plan Approved by.Planning Board ---------------____-----------19_______. 'Area ................. .. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH QOQ52 r z I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... .. .. . ...................................... Construction Supervisor's Licensel4Qq................... 'REENLEAF INVESTMENT GROUP z 4 27655 1? Story o .....:.........:. Permit for - ^ Single Family Dwelling - -S ..... • ................................... y.......... \. , ♦ .�• �/ - J �y Lot 48, 9 Capt'n Isidh Read fj 3 Location r _ Greenleaf Investment Grp, GOwner ................:.............................�.,.........�.... TYPe;bf Ctruction ....Frame.......................... 101-1 01 ................................ v /,}(�/ •.. /�) Plot ............................ Lot v March 27 F t�Granted ' t 19 85 Permi J y ............................. Date'of;;lnspection ...!.�19 Datei Completed 4�. !Vi3AS� ' �� •v ;,� % .�;" Gar� RJ � " ,�" � � �. _ - �: `' 1 Assessor's map and lot number ...... s w� 3.R ............................ �,r-- Bpi THE TOW Sewage Permitnumber ...Q...f......`ZSG r�Jrti!_,: r, BAR35TABLE, i House number_-.,. .,1.............. ............. ................................ ro rasa 1639 'Fa MAI d\ TOWN OF BARNSTABLE � BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........ Cte �.....�. / .�. ..!� ��`i.�� ...................................... J.. .TYPE OF CONSTRUCTION ....... .,......................................................................................... �� \b 19 `� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......�-�;?�:: .... ......................G'.RP". ...!J:.....,..... 1.P? 1- .....Q.��...................�3�Z.11 .:..................... 6- �, Proposed Use .........�1..��./�......................................................................................f................................................. eF ZoningDistrict ....................................................Fire District .............................................................................. �2firzl.�.`��. 1A3J�iST nCk7� �;TMElress .................. Name of Owner--.:.... ..... .............. ............. .................................................................. T / Name of Builder .....��a........... .... ....l.,, D/YI .......Address .......4;-; '. ...................................................... Name of Architect ....... . ..................Address .....C,,.i!7r1��!/lG� ....................................:......... /� (J /Z�� C itJG2. Number of Rooms ......f�.......................................................Foundation ...........�U........��...............6.................4�.T.`:�. Exterior Cep-/ Fle.......................................................Roofing Floors C��'eT . ///�� liSJ4.U.�..........Interior ..... i�LT /�iC,��.........:................................ ............. ............................... � �G�iz/ri o2 Heating ..................................................................................Plumbing ........................................................................:......... Fireplace .................5 ��'� ..................................Approximate. Cost .......... ODD................................ . . .... Definitive Plan Approved by Planning Board -----------_______________19_______ . Area Diagram of Lot and Building with Dimensions Fee .............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH �J a y } _ y OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree do_-•conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... ... e'��... ...................... Construction Supervisor's LicensedQ..l................... GREENLEAF INVESTMENT GROUP A=38-66 No ..2.7.6�5.... Permit for ... ............... Single Dwellin .................................................�g..........."********* Location ....Lot 48 9..�Cap�'xjjaj ...Rpad ..................... ............................................ Owner ..Greenleaf Investment ..............................................!qKqup,..... Type of Construction ..Fr.dM.......... ...... ........... .............................................. ................................. Plot ............................ Lot ................................ A Permit Granted March 27, 19 85 ........................................19....................... Date of Inspection ....................................19 Date Completed ......................................19 #_0 o� TOWN OF BARNSTABLE Permit No. ---------?�655 Building Inspector Cash _$1,000.00 1129, 1039. 00CUPANCY PERMIT Bona J ' Issued to Greenleaf Investment Group Address 96 /�VJ , C076,1T 0Z63 lot #48 9 Capt'n Isiah Road, Cotuit Wiring Inspector f. ` , '�i ��c � Inspection date f � Plumbing Inspector' ` Inspection date Gas Inspector i• Inspection date Engineering Department - •,rrr �• � Inspection date Board of Health Inspection date 1 " � 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. i.3 is ............:i.... g Buildin' Inspector _ V A. 24016 � f � CEeT/�/EI> SLOT 7-1,/,47 T.-/C- SCA Z-G— p "_ 3D 1�>A TE SETBA Cfc Th4E �Loaa�G4/�f! eAXTE,es it/yE /It/C T/�/S P,C�I�v/s �voT BASE-O Dry A,r/ ,eEG/sTE,2EO l��p SU.eIiEYac /NS7-,eUi�/.�ir/T,s U,2t�E Yc T1-71'f- �sT6,21//,G 0,'�4SE'T.S IVcV7- 82--- . /C,Q/4/7��/`�`.