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HomeMy WebLinkAbout0055 CONSTANT LANE - f � . ,. .,-..:_ .. .:..� --n.�.r.pMk-vr�.w-..AI-"� .. .�; .- ...-.., - .gyp. _,✓.,,.�, _ _ ..1-,.,..,,,i f�.ru ., , a Application number... ..1......-. v� OPIUM� Fee ............................. .................................... HASS Building Inspectors Initials.... JUL 25 2019 ..................... OKIt Date Issued...... .1. ��.g..................................... Map/Parcel.......D3.. .......... ............ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: -5S , Ca �-y_ �- NUMBER STREET VILLAGE Owner's Name: J CFI Y 2 U\ -l- C.G fp 1 5 M 4 Phone Number Email Address: Cell Phone Number vie v Project cost $ 2 i ()oo Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding 0 Windows (no header change) # 0 Insulation/Weatherization 0 Doors (no header change) # Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to bo f vAS,,o b\e \fc !3 der S a} ioyA CONTRACTOR'S INFORMATION Contractor's name \\Q Home Improvement Contractors Registration (if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN - A HISTORIC DISTRICT; YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. i APPLICATION NUMBER ............................................................ *For Tents Only* Date Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am -9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/ I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: 4- Svv 0� Telephone Number Cell or Work number `1-1 y-j214 35-5 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the wn of st e. Signature Date 12n lzo I g APPLICANT'S SIGNATURE Signature Date -I I z's J ZD/ All permit applications are subject to a building official's approval prior to issuance. Town of Barnstable Regulatory Services '• BARNSTABLE, •" Richard V.Scali,Director v� MASS. `0�' Building Division RFD MO►'tA Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.townotbarnstable.us Office: 508-862-4038 Fax: 508-790-6230 Owner's Liability Insurance Waiver Owner Name: C_�t'o Owner Address: Lane , �T, 0 Telephone: E-Mail: Property Location: �JCj COK15 G��- �-Gn� 4 COVUN Permit#: I hereby certify that I am the owner of the property. I am aware that the licensee does not have the liability insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Signature of Owner Date 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 c Please Print Legibly Name (Business/Organization/Individual): e�F�l�m -J, CA-to Address: �� co<�S�a L-01Xctie City/State/Zip: (f­1C1k-J\\-\ `M' 5 Phone#: 7 " 5Z'1 —GS5 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [4 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.U 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.[1 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' under the p an nalties of perjury that the information provided above is true and correct Si ature: Date: 11251 F017 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. 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 lavestigations 600 Washington,Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia FP a 4- .> 'Town-of Barnstable p Expires 6 monftfrom issue dale Regulatory'Services Fee % aAxxgrAME INAM Thomas F.Geiler,Director Mid A 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 PERMIT APPLICATION - RESIDENTIAL,ONLY Not Valid without Red X-Press Imprint ' Map/parcel Number 039-064 Property Address 55 Constant Lane, Cotuit, MA 02635 Residential .Value of Work $2,500.00 Minimum fee of$35.00 for Trk under$6000.00 Owner's Name&Address Jeffrey and Carol Smith 55 Constant Lane, Cotuit, MA 02635 Contractor's Name N/A Telephone Number -1 y -5 Z i - 05 55 Home Improvement Contractor License ff(if applicable) N/A Construction Supervisor's,License ff(if'applicable) N/A ❑workman's Compensation Insurance Check one: I am a sole proprietor DKI am the Homeowner ❑ I"have Worker's Compensation Insurance ManInsurance Company Name Rogers & Gray Insurance Company Workman's Comp.Poficy# N/A A I In j Copy of Insurance Compliance Certificate must accompany each permit. TOWN MUU 31 2016 Permit Request(check box) OF BA RNSTgBLE ❑ 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) D<Re-side #6f doors [Replacement Windows/doors/sliders.U-Value .33 (maximum.35)#of windows 2 ❑ 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 Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollikWppData\Local\Microso indows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 Me Cannironsreallk of Massadneselts qjDepart meint of Iiatdristtial Accidents t7fce of!"vestigatiorts 600 Washington Street .Boston IVA 02111 wv ot:ntas&gmldiia Workers' Compensation Insurance davit: Builders/Contractors/El c:triciass/gtumbers Applicant Information Please Print I,e 'hl� N (iiumesvotganizi?tcmjndtviduvZ: Jeffrey and Carol Smith Address, 55 Constant Lane City/StaWZip: Cotuit, MA 02635 phone o: 508-420-4592 Act,you an employer?Check the appropriate box: T of rb'est r uirz 1.❑ I aryl a employer with 4.. Q I�a genera cont�ar�s and I _3P? ._p_.J {.?r1 _ .�= employees(full andror part-time).* have hired dte sub cosiiractors 6. ❑Naw conatr<iction 2.❑ I am a sole propristor or parfner- listed on the attacked skeet. 7. Q Remodeling ship and Have no employees These bvb-contractors have S. ❑Demolition WoNng for tale in any capacity. employees apd he workers m- ' t 4. Q Budding addition [No workers'comp.insurance comp.insusqucee.- required] 5. Q We are a corporation and its 10.Q Electrical repairs os additions 3.al am a homeowner doing alYwork officers have erbercised their 11.Q Plumbing repairs or additions myself;[No workers'comp. rig4t of exemption per`'IGL c. 152, 1 4 ,and we hune no fl�'Q hoof ins insltfaace required.)t { } 13.UOther Re—side employers.[No worker' camp.insurance required.] °Any aapiiitmit Mai checks box-I mast al;,o fal oUMi the secdon belo{T showlag infomgtim I F_omeow—mrs wbo submA Lids ofiida-di ind atig Lola'are doi ng ail work sad tiea Lire cutdda contmciars am t snbmk a new afdavit inBicaUng sari tCoatractors iha"c cb N th6s bon crust attacLed ad3iiiosai sIlaet s$o4CiDe tLe nsL*2 03 the sub cotilscmts tad state wbeier or sot Those a d&e Lave eWloYOU. Ifft sub-contraaar bsve employeas,thus must emVide chair warken'comp.poLcy number. fain art employer that ispm dhig inter ance for aty employees. Below is tho poncy and job site irtj"at'rrlaH6re~ Insurance Company Name: ' Policy-4 or Self'ins.L-ic.w: i Ex-piration Bate: Job Site Addres.7i: 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. 1.57 can lead to the imposition of criminal penalties of a fine up to$f,500.00 alndror one-year imprisonment,as Well as civil penalties in the,fom 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 n g� e verification. I do fiat2by c2rt T tender tk2pRiPts RPtll pePla O p ry fitatthe in ovrueltion prot4dod abode is Fine and correct. Simature: ate: d I �o 1 Phone;v: 5 —420-4592- Of-701 lose only. Do.not write in this area,to be minpleted 4,city or to.ow of0'iciaC City*or Tong: Permit/Lirense9r Issnf ng A�tiharity(circle aae): L Board of_Healih 3.Building Department I Cigyrloma Clerk 4,Electrical Inspector 3.>flumbinp InspectoF 6.Other C'ontarct Person: Phone 0: 'Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Tom ferry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE. 1 3\ 1 Z d `P Please Print JOB LOCATION: 55 Constant Lane Cotuit number street village °°HOMEOWNER°°: Jeffrey/Carol Smith 508-420-4592 name homep�hone# work phone# CURRENT MAILING ADDRESS: 55 Constant Lane,[ T_ Cotuit, MA 02635 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements an e/she will comply with said procedures and requirements. S of Home 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 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\MicrosoMWindows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRFSS.doc Revised 053012 i 19 �Im Town of Barnstable *Permit�0! Regulatory Services Fee date 6 months from ssue BAMMBLE, MASS Thomas F.Geiler,Director 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 PERMIT APPLICATION - RESIDENTIAL ONLY l Not Valid without Red X-Press Imprint Map/parcel Number 03CI - 0(p�-I Property Address 55 L-OO5f a o+ Lane- , Co+U 14, Ma o a635 Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 13 e 4✓e W d- Carol 5 M t'M !Z C.vr25t-ran-� Leine, C_o -ijr+, mig oa(t735 Contractor's Name_ _/L A Telephone Number Home Improvement Contractor License#(if applicable) AAA Construction Supervisor's License#(if applicable) A?I A RESSERMIT ❑Workman's Compensation Insurance U N Check one: ❑ I am a sole proprietor 7 0WN OF SRRNS T ABLE ® I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Rcp Ce G�ro-4 k�\5VfOlt1C.e 601N1QC,"-% ./ Workman's Comp. Policy# f\A Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) 2/� ® Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to 8Citrhs+abl C TIC ((G(S )e Sttt+IO►� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-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 Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is / requ-ireed. l ` C SIGNATURE: C:\Users\decollik\AppDataEocal\h&crosoft\Windows\Temporary Internet Files\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massadiuselts Department of Industrial Accidents Off ice of hwestigations 600 Washington Street Boston,MA 02111 wmt mass gm,1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leziibly Name(Bus=ss/Orpnaatiou dividual): Se fkf A Ctnd CQ y1r) l SM14-h Address:_ 5S L0t)54QY1+ La r)e City/State/Zip: 12 Phone#. Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition w for mein an capacity, employees and have workers' working Y � tY- I 9. ❑Building addition (No workers'comp.insurance comp.insurance. ME]Electrical r or additions required.] 5. ❑ Me are a corporation and its 3.® I am a homeowner doing all work officers have exercised their 1 LR Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.21 Roof repairs insurance required.]i c. 152, §1(4),and ure have no employees.[No workers' 13121 Other 0JI it - comp.insurance required.] •Any applicant that checks bog#1 ran sr also fill out the section below showing their workers'compensation policy information. 7 Homeowners wbo submit this affidavit indicating they are doing,all work and then hire outside contractors mast submit.a new affidavit indicating such. (Contractors that check this boot must attached an additional sheet showing-the name of the sub-conawton and state whether or not those entities batie employees. If the sub-contractors here employees,they must pmtide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employee Below is tine policy and job site information. Insurance Company Frame:, 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 S 1,500.00 and/or one-year imprisonment,as well as ci n1 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 ander the,pains an narjury that the information pmtdded Above is tnie and correct Si ce ture.: lties o pe Date: / / Phone#: E2�- q5?9 Official use only. Do not write in this area,to be completed bye city or town official. iCity 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#: i Y • Town of Barnstable Regulatory Services MAM ' Thomas F.Geiler,Director 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: (o/131aQ/j JOB LOCATION: 55 GO r,5 TU In t La Y)P . Lo 4 u; + number streetvillage "HOMEOWNER": Se Ff ve-u d. 6a eo l LSenl M 563—q30 -1459d names / ^ home/phone 4work phone# CURRENT MAILING ADDRESS: 53-60A54:Q,-)4 >1Q 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro ores and require ents and that he/she will comply with said procedures and requirements. AQ � Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any 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\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 072110 1 Town of Barnstable *P�t# �S-s y Expires 6 months from issue date Regulatory Services Fees. BAarsrABM vMASS. •� Thomas F.Geiler,Director V 1 �F11 MtN 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number '039-064 Property Address 55 Constant Lane, Cotuit, MA 02635 ®Residential Value of Work $2500.00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Jeffrey C. and Carol S. Smith 55 Constant Lane.- Cotuit, MA 02635 Contractor's Name N/A Telephone Number Home Improvement Contractor License#(if applicable) N/A Construction Supervisor's License#(if applicable) N/A ❑Workman's Compensation Insurance Check one: o� @YQ�T ❑ I am a sole proprietor ® lam the Homeowner MAY 2 8 2010 ❑ I have Worker's Compensation Insurance Insurance Company Name Rogers & Gray Insurance Company. TOWN OF BARNSTABLE Workman's Comp.Policy# N/A Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑x Re-roof(stripping old shingles) All construction debris will be taken to Barnstable Transfer Station ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors © 'Replacement Windows/doors/sliders.U-Value '33 (maximum.44)#of windows y "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\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 �•�+� � Town of Barnstable . Regulatory Services BARMAXX Thomas F.Geller,Director 163 6� 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: 5/27/2010 JOB LOCATION: 55 Constant Lane, Cotuit, MA 02635 number street village "HOMEOWNER": Jeffrey/Carol Smith (508) 420-4592 (508) 775-3433 (Carol) name home phone# work phone# CURRENT MAILING ADDRESS: 55 Constant Lan21 — Cotuit, MA 02635 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 dersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pr ures and a re n and tha a/she will comply with said procedures and requirements. 1,14 Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any 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 personas 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 caret amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporuy Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 i The Commonwealth of Massachusetts y Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): cL CO103 S 5M/A Address: City/State/Zip: (fo 4—Ul -7 i one M 50 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6 ❑New construction employees(full and/of part-time).* have hired the sub-contractors.. _ _._ 2.❑ I am a sole proprietor.or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers'comp. ❑ Building addition No workers' comp. insurance comp. insurance.$ /f 5. ❑ We are a corporation and its 10.0 Electrical repairs'or additions equired.] 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[4' oof repairs insurance required.] t G. 152, §1(4), and we have no 13.[�`Otber employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =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.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby cer t nder th to and penal es of perjury that the information provided abW ve is trite and correct Si nature: Date: 5 //0 Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Y1 . information and Instructions workers' compensation for their employees. Massachusetts General Laws chapter 152 requires all employers to provide 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, constriction or repair work on such dwelling house shall not because of such employment be deemed to be an employer.' OF on the grounds or building appurtenant thereto MGL chapter,152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the conunonwealth nor any of its political subdivisions shall enter into any contract for the performance of public..work until acceptable evidence of compliance with the insivance 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), addresses)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/licenserumber 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) amd under"Job Site Address" the applicant should write"all locations in (city or town).—A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. 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 Invesdgabons 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.inass.gov/dia a �twe rqi, Town of Barnstable *Pe;�Jztoqo Ll d 1 Expires 6 months from is4yadate Regulatory Services Fee Y �p 1♦ SARN9TAs1.E. 9 MASS.9. Thomas F.Geiler,Director rEA MA'S a Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 0 3 9—0 6 4 Property Address 55 Constant Lane, Cotuit, MA 02635 ®Residential Value of Work $2, 5 0 0.0 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Jeffrey C. and Carol S. Smith 55 Constant Lane, Cotuit, MA 02635 Contractor's Name N/A Telephone Number Home Improvement Contractor License#(if applicable) N/A Construction Supervisor's License#(if applicable) N/A ❑Workman's Compensation Insurance X-PRESS PERMIT Check one: AUG 2 2�09 El am a sole proprietor :B I am the Homeowner ❑ I have Worker's Compensation Insurance GOWN OF BARNSTABL. , Insurance Company Name Rogers & Gray Insurance Company Workman's Comp.Policy# N/A Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to Barnstable Transfer Station ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side �9 Replacement Windows/doors/sliders.U-Value • 3 3 (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: C:\Users\decollikWppData\L•ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\MY7NB4IL\EXPRESS.doc Revised 100608 S. c The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street I Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 120 r0 S• Srnw*44 Address: Jam- (6r)3+ari4 -LahQ. City/State/Zip: Cc i S Phone #: 5U8 -9 '-6`l Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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 g, ❑ Demolition workingfor me in an capacity. employees and have workers' y9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 require d.]] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.©Tam 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.❑ 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' under the pans Zanenalties of perjury that the information provided above is true and correct. ff Si nature: 1 Date: Z lag io? Phone#: 0 (4S I c� Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia A " Town of Barnstable Regulatory Services BtartgrABte, Thomas F.Geiler,Director ti9 ,4 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: $ I $ 1,0i JOB LOCATION: 55 CO 05-I 4-r7 + Z-0.7-e- number street village "HOMEOWNER": Cct ,5L*- name home phone# work phone# CURRENT MAILING ADDRESS: r"-e ck S a klq LI-e 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department minim inspection procedures and requirements and that he/she will comply with said procedures and requi Is. - Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any 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\homeexempt.DOC • r Town of Barnstable Regulatory Services enxivBM ns sS. Thomas F.Geiler,Director 1639. & 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 r Property Owner Must Complete and Sign This Section If Using A Builder a I, ro , ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work au orized by this building permit application for. (Addre s of Job) Signature of Owner Date Print Name If Properly Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM S:O WNERPERMIS SION OFIKE,p Town of Barnstable *Permit 4Q 0686S ! pExpires 6 months from iss date Regulatory Services Fee BAIWSW Thomas F. Geiler,Director LA ��A 1639•�.� �� ��� Building Division lED FAA't A Ju Terry,CBO, Building Commissioner L 1 1 2008 200 Main Street, Hyannis,MA 62601 roV/N 0p 8'� www.town.barnstable.ma.us Office: 508-862-4038 BAR/VS Fax: 508-790-6230 EXPRESS PER APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint MIDIumber 039-064 Property Address 55 Constant Lane, Cotuit, MA 02635 ® Residential Value of Work $2► 5 0 0. 0 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Jeffrey C, and Carol S. Smith 55 Constant Lane, Cotuit, MA 02-635 Contractor's Name N/A Telephone Number Home.Improvement Contractor License#(if applicable) N/A ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner a`""°�• ❑. I have Worker's Compensation Insurance Insurance Company Name Rogers & Gray Insurance Cb. Workman's Comp. Policy# N/A Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) . I 0 Re-roof(stripping old shingles) All construction debris will be taken to Barnstable Transfer Station ❑ Re-roof(not stripping. Going over existing,layers of roof) N Re-side t ❑x Replacement indows doors/sliders. U-Value (maximum .44) �`'/l�'[/v '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:buildingpermits/express Revisel 12807 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/Organinfion/Individual): r ff YeAA CL Address: SY) alYI P City/State/Zip: A—i CIAO Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a-sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees 'These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.-insurance comp.instuance.x 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 11.❑Plumbing repairs or additions myself.[No workers' comp. right 6f exemption per MGL 12 N Roof repairs insurance regnuEd.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Aay applicant that checks box 01 must also fill out the section below showing their workcns'corn ==fi1on polity infonvat on. t Hameowners who submit this affidavit indicating they arc doing all work and than hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box rmrat attached an additional sheet showing the name of the sub-contractors and state whether or not those critics have entployear. If the subtonbactnrs have employees,they must pravi&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.Lie.M Expiration Date: Job Site Address: City/Stat-dZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to socurz 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 statemt;rit may be forwarded to the Office of _ Investigations of the WA for insurance coverage verification. I do hereby c under the and a alties pry that the information provided above is true and correct Si afore: Date: V _ Phone# Official use only. Do not write in this area,to be completed by city or town offu:iat 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#: Town of Barnstable �0*SHE r ti o Regulatory Services Thomas F.Geiler, Director swttrtsrwarr;. 9 MASS. �p i6�q. ere Building Division Toni Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 veym.town.barnsiabl e.ma.us Office: S08-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street ``��Q (�vi'l]lage p ..HOMEOWNER": JQ `r -� �i�'C�` W l)— —0 14sst a name home phone# work phone# 3y CURRENT MAILING ADDRESS: ��'C�c�2 CSL� C� C a to l ) city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwell gs 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 strictures. 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.L 1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minim inspection procedures and requirements and that he/she will comply with said procedures and requ' ents. I'A Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 3S,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 perforating 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 aie unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.IS) 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 ii a form currently used by several towns. You may care t amend and adopt such a forin/certification for use in your community. �oF1HEt, Town .of Barnstable Regulatory.Services r B&ARNSr"s[s. ' Thomas F. Geiler,Director �$ ArEo,r,,,�a Building Division Tom Petry, Building Commissioner 200 Main Street; Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 j Property O.wner,Must Complete and Sign This Section 7 If Using A Builder r as Owner of the subject property hereby authorize to act on my behalf, in all.matters relative to work authorized by this building permit application for: (Address of Job) i Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. .�. �..�� E Assessor's map and lot*number •.•.•.•• o 0 r Sewage Permit number ..°..�� ../.1�.� .............................. Z 13lHB9TODLE, i House number ..... .............................:.................... ..............;. r rues 039• \e0 �1 am a -.TOWN OF BAB.NSTABLE 3L� BUILDING INSPECTOR- APPLICATION FOR PERMIT TO ...5. .!(,- :....... .'Y1.1.`.Y.........� 1 �1„!UC.................................►`." TYPE OF CONSTRUCTION ......CAPE.............................`.................................. i... i f. ....... . .....................19: ..... TO THE INSPECTOR OF BUILDINGS: -� The undersigned hereby applies for a permit according to the following information: p Location '()�. .© . COTU�T CC;t`(�r'(l )tvS - CONSTRh).T.....1-.tN ..: F0�2�h �2ty Ch!>yut�ii?; t�D� i ProposedUse .................................... ........ ...............................................................................:........................................... F. Zoning District .........................................................................Fire District ........ . ` ` :_f... ..,........................................ �r,� w �- „ 1�3 Name of Owner t�. —� .:.: ................Address ........... ....................'.....,....... .�.,E��...1 . t Name of Builder ..............Address ,� �� �1C1FZk����L. �N 1,.: ��lr� V► ;tti ��� .Name of Architect .._................................................................Address ........................................................................:......... Number of Rooms ...........4............... ..................................Foundation � .................................................. , Exterior C-3�.A.�....., ..tqf B/6.L.P....................................Roofing .../1 .1...I'I� I'f c7�I f IIJ�I"P. . .................... p Floors C •Yc' .......... Interior ..�.Y��..W .�.'..... ......r„�,l!q 5 ,f'I/ ........... .............................................. .... HeatingPlumbing ......................:........................................................... q Fireplace ..5.................................................................Approximate Cost y... . ........ ................. ... Definitive Plan Approved by Planning Board ---------------____-----------19--------. Area ........ .. ?..:........ Diagram of Lot and Building with Dimensions Fee 0 5_ SUBJECT TO APPROVAL OF;BOARD OF HEALTH ! r �5 7 i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... ........_:(. l ......................................... L WENGER, RdBERT J. _G No ...22...28. Permit for 1 ,1f2 Story..... Single Family Dwelling............ Location .LQ....#4.Q...5.5...C.oas.tan.t•••L•ane .................CQ t.lait............................................... Owner ...Robert J./-r'airlae nger ...................... .......................... i Type of Construction /.. ........................•• Plot ........... ........... . Lot ................................ ti Permit Granted Mayf3'0, 19 80 Date of Inspection ..................... ..............19 Date Completed ................... ..................19 p PERMIT REFUSED ......................... ... .......................... 19 ............... y,� ... ....�. �. . ......... .................................................. AA j ................. ... �. ............................ .�. ..... Approved ................................................ 19 ............................................................................... TOWN- OF BARNSTABLE Permit No.• 22228 �J e _---____—- _ l »n E Building'Inspector r$ Cash t ■.... ' [/ OCCUPANCY PERMIT , sond "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 tInspector." Issued to Robert J. Wenger 1 Address lot #40 SS Constant Lane. Cotuit l Wiring Inspector Inspection date ` Plumbing mspectoi / AI;'�,'/, Inspection date v y. Gas Inspector n C p� 1�A—'r Inspection date 1po V Engineering Department d Inspection date (3 c 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. ............... 19_ _ _..... ............. _._.�._ __ . ./,Building Inspector t. IL �9. �— Assessson's map and lot number .�. ......... .... ... ................... �oF�NETo� Sewage Permit number ... a ./.v�............................... SEPTICY SYSTEM M INSTALLED IN COMP House number ................................ ....................................... VNITH TITLE 5 °� 1639• e�0 11 MAI TAB CC>C TOWN OF BARNSTMI-EI III J, ;S BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...5J.INare........N.M..O.y....... ........... ................. TYPE OF CONSTRUCTION ...... A Re................................................................. /. .. � ..................I . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information- Location ..4.0.,.CaTU►T 5 Mx.... ProposedUse ........................� L.......,......L......J....../v.......................................................................................................................... Zoning District ..........le. .....................................Fire District ` d?� 7................ .................................................................. Name of Owner TaQ► k. .f... ....�V.1-.1�1L.�.YZ...............Address Name of Builder 013.1—ZT...........W..^ ..............Address OM .Name of Architect ....:.................. ..................................Address......... .................................................................................... Number of Rooms ....................................................Foundation .. D U ►e ({ ............. . ............... ..................................:................ pqExterior cC1>.1I'..... ...................................Roofing ... .f� .F9.1 .... 1�✓rA�..C........................... Floors CAY . ±............................................................Interior ...1)V)� ..WAJ.!. 1.....!...1.i7..�.`f..1 Y -µ Heating ' ... .�� .......::.Plumbing " Fireplace ....Y !. .................................................................Approximate Cost ................. �!�.Z.o................. s Definitive Plan Approved by Planning Board -------------------_-----------19_______. Area ........ ............ .... ........ Diagram of Lot and Building with Dimensions Fee �C SUBJECT TO APPROVAL OF BOARD OF HEALTH o I I hereby agree to conform to all the Rules and Regulations of the To of Barns4regarding the above construction. Name . WENGER, ROBERT J. 22228 1 1/2 Stor 0 ................. Permit for ............................. ...... /2 ....S",r ..... S i T.�Mi in . ...... ........... Location ...55 Const Lane n e ....................... . ................. . ............... ................................................ Owner ....Robart...J.....W.eng.er................... 7* Type of Construction ..............a Frame me........................................................................................................ Plot ............................ Lot ................................ Permit Granted ..........M&y...3.Q.,...';........19 80. Date of Inspection ................ . ....19 Date Com I t d .......... ......... ....19 0e p PERMIT REFUSED M ......... ......... ... . 19 S..... .......... .11 M > ........... A .. ............. .......... ............. .. ........ ........... rn .................................................... 4 17 Co 1 P Approv�gd!�:Zi ..................................... ........ 19 ............................:.................................................. ............................................................................... r2L . 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