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0090 SPUR LANE
90 _ .� � o o �, , .� � � � , � � w 1 � ,. . � - n ,. , � _ �� .,� �' � .. ,i �. d., .�. � .. �° ., .. � ,. - �[�� � .. �1, � � ° _ o n fir. .. � , � ,. 1 � � .� � - r .� ..�� V.� � � � c ,. _ 1�� � � � � a � a � , ,, {�„ � e ., e .. ,. , °r�y��ia. ��, ,�. a} � �� +, , ��ir , � � o r v °. :A �. M1. I n .� � .� � i � Q n .. ' - � .. .. .� .. � ,� a .. ' - �� �y _ .. a - e - ,� � ,. � a p A31 ter...++.. _.u\ r n:/'. �. � �;7.__„� �. ...,h n n.�\ , . .:,^�,..1' - ��^'� -�.. - +w„ry/a+^'G..• :,..y,.r N�.1�"�^ ,M,a..w...�..�.'r�r" "`I'� r--- j I I s �� ��� �� � . { , � ., D �a��� � ,� ;� L___- _�� q v/SOR e Town of Barnstable *Permit# j oY� �'f�� Expires 6 mom h r e d .�+ Regulatory Services Fee • antuvsTABIZ • Mass. $ Richard V.Scali,Interim Director 1639. �0 RFD MA't 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 Number0 2 7/10 9/ Property Address 90 -Spur Lane Marstons Mills X Residential Value of Work$3 0 0 0. 0 0 Minimum fee of$3.5.00 for work under$6000.00 Owner's Name&Address Wayne & Nancy Morris 58 Somerspt Road Nantucket MA, 02554 Contractor's Name Northern Colony Builders T,T.r Telephone Number 5 0 8—4 0 0—7 0 7 5 Home Improvement Contractor License#(if applicable) 16 7 7 3 9 Email: danwbcc @comcas t.net Construction Supervisor's License#(if applicable) CS—0 5 3 6 3 8 - �� u XWorkman's Compensation Insurance. nn Check one: r 0 9 2015 ❑ I am a sole proprietor 'O A'n r p . ❑ I am the Homeowner V V'U ®�DA�'VST�t n� X I have Worker's Compensation Insurance LE Insurance Company Name Southeastern Insurance Workman's Comp.Policy# WCC-500-5012280-2013 07-2015 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 New Bedford ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate'Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property.Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TA EVIN D\Building Changes\EXPRESS T\EXPRESS.doc Revised 061313 S i Offit;e of Consumer Affairs &Business Regulation- Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints z Registration # 167739 Home Improvement Contractor Registrant NORTHERN COLONY BUILDERS LLC. Registration Home Page Name DANIEL GALLAGHER Address 1694 FALMOUTH RD#135 City, State Zip CENTERVILLE, MA 02632 Expiration Date 10/25/2016 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search http://servtces.oca.state.ma.us/hic/l;<cdetails.aspx.txtSearchLN 69573 4/9/2015 THE COMMONWEALTH OF MASSACHUSETTS _- Office of Consumer_Affairs and Business Regulation Home Improvement Contractor Registration Program 10 Park Plaza —Suite 5170 Boston, MA. 02116 Deval Patrick Govemor Request For Duplicate Registration Card Tir110111y Mw'ray Lieutenant Govemor Please complete (print) this form in ink and mail it to the above address with a certified check or money order for $25, payable to: "Commonwealth of Massachusetts." REGISTRATION NUMBER(if known): 167739 REGISTRATION(COMPANY) NAME: Northern Colony Builders LLC BUSINESS ADDRESS: 180 High Street West Barnstable MA I MAILING ADDRESS(if different): P.O. Box 278 West Barstab.le MA 02668 INDIVIDUAL RESPONSIBLE FOR HOME IMPROVEMENT CONTRACTS: Daniel J Gallagher SIGANTURE OF RESPONSIBLE PERSON REQUIRE IN ORDER TO PROCESS: SIGNATURE: I4_2� TELEPHONE.NUMBER: ( 508 40'0--7075 i i LOST CARD WAS: 1 ONLY CARD ISSUED SUPPLEMENTARY CARD Never received I F SUPPLEMENTAR Y CARD: NAME OF PERSON ISSUED CARD: Daniel Gallagher SIGNATURE OF CARDHOLDER: FOR OFFICIAL USE ONLY REGISTRATION NUMBER: DUPLICATE ISSUED BY: , . � . - - o �. cCx'a ty* � �� %PPt, tfica ,U S Dollars and Cents , r�,� Yea{MonW Dey ,� e Serial Number �',� �.. ,x �� .o.t� "'_-,ter +�.�..�. r... ..KM •- .: r l �Qy15 04 07 . 026680A. 22108400728t{�; ,3 �� 90,Ste�n ltiEIAY FIVE Da1fIR8 8 OO�r - '�W - •..1'4 • .y e,F t Kr lc Clerk Pay to is L4%lc U rq PAT a ;. � d�1 Address .. c ��C1+ 3Fr00t i i , oF� • snnxsrns�. 639. Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 i Property Owner Must Complete and Sign This Section If Using A Builder I, Nancy Morris ,as Owner of the subject property hereby authorize Dan Gallagher to act on my behalf, m all matters relative to work authorized by this building permit application for: 90 Spur Lane (Address of Job) 4/4/15 tgnature of wrier Date Nancy Morris 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 Internet Files\Content.Ougook\2PIOlDNR\EXPRESS.doc Revised 040215 The Cornnionvealth of Massachuseift Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,CIA 02111 rvivivauass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi icians/Plumbers Applicant Information Please Print Legibly Name(Busmen&xhgauization/individual}: Northern Colony Builders LLC Address:180 High Street P.O. Box 278 City/State/Zip:W Barnstable Ma 02668 phone#: 508-400-7075 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with -.)— 4. ❑ I am a general contractor and 1 6. ❑New constriction 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 working for me in any capacity. employees and have workers' 9. n Building addition [No workers'comp.insurance comp.insurance.i required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself o workers' _ right of exemption per MGL n repairs insurance required.]I c. 152, §1(4),and we have no 12.,A!Roof employees.[No workers' 13.0 Other comp.insurance required.] ;Any applicant that checks boot#1 most also fill out the section below showing their workers'compensation policy information- Homeowners who submit this atfidm indicating they are doing all woA and then hue outside contractors®st submit a new affedarit indicating each. tComttactors that check this bore must attached an additional sheet showing the name of the sub-camataaors and state wheiku or not those entities have employees. Mthe subcoutractors have employees,they otst pmvide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for any employeem Below is the policy and job site information. Insurance Company Name: South Eastern Insurance co Policy#or Self--ins.Lic.#: WC C—5 0 0—5 01 2 2 8 0—2 01 3 Expiration Date: 0 7/0 8/2 01 5 7obSiteAddress: 90 Spur Lane Marstons Mills City/State/Zip:Ma 02648 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 a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisountent,as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 a Clay 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 under th pains and penalties of perjury that the information provided above is tnte and correct Si lure: Date: 4/4/1 5 Phone 508-40 7075 508-744-3362 OJjieial use only: Do not write in this area,to be completed by city or town offl" City or Town: PertmitfUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CiVrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) rM 07/28/2014 PRODUCER 508.997.6061 FAX 508.990.2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 North Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Northern Colony Building Co LLC INSURERA Arbella Protection Insurance 141360 P.O.Box 278 INSURERS: Merchants Insurance Group W. Barnstable, MA 02668 INSURERc: AEIC INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR''ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRO TYPE OF INSURANCE POLICY NUMBER /Y DATE MM/DDYYY W DATE MM/DD/YY I GENERAL LIABILITY 8500059899 07/08/2014 07/08/2015 EACHOCCURRENCE I 1,000,0001 nCOMMERCIAL GENERAL LIABILITY PREMISES Ea occurtence $_ 300,000 CLAIMS MADE FRI OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY I� jE 0 LOC AUTOMOBILE LIABILITY MCA7013965 01/05/2014 01/05/2015 COMBINED SINGLE LIMIT �I (Ea accident) $ ANY AUTO 1,000,000 nALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS I B HIRED AUTOS BODILY INJURY (Per accident) I $ I^1 NON-OWNED AUTOS I I PROPERTY DAMAGE I $ r--; (Per accidenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT I $ ANY AUTO OTHER THAN EA ACC 1 $ i I AUTO ONLY: AGG $ I � EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE i $ �I OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ - RETENTION $ I $ WORKERS COMPENSATION WCC-500-5012280-2013 07/08/2014 07/08/2015 1 TORYLIMITS I X ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y E.L.EACH ACCIDENT $ 1,000,000 C OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) Des.describe under _ E.L.DISEASE-POLICY LIMIT $ 1,000,000 SPECIAL PROVISIONS below OTHER I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Barnstable Attn: Building Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main Street REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZEDREPRESENTATIVE Karen Bernier I ACORD 25(2009/01) FAX: 508.790.6230 ©1988 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety - ` `Board of.Building Regulations end Standards G,risfructiiurSuper�isor. License: CS-053638 t ,;,? DA1vIEL J GAILLAt. B ' PO BOX 278 f West Barnstable I%A„d Expiration 10/27/2015... Commissibnet- 13�6y3. 1 . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ��/� Map na r7 Parcel l o l - p,B%J- Permit# 7 / / 7 Health Division S 1( 0 .S� . ,{�4, .� g�R Date Issued ` Conservation Division LOYIni m � �10 Application Fee 00 Tax Collector k-- L. rmit Fee Treasurer I �1 .)EPT1C SYSTEM MUST BE Planning Dept. ��TEE 5 M;ST LLED ON COMPLIANCE Date Definitive Plan Approved by Planning Board ENV' ONMENTAL CODE AND TOWN RE v��'IO��S Historic-OKH Preservation/Hyannis Project Street Address '76 Sax r k o ri f Village M ckCg'nrz V11 1 05 Owner nancd M&rrin Address ro soa r � Telephone _.S�S ��-17 /b Permit Request 1rCC210 Cie- f JCk a- e-(2S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: O Yes O No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) _ Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:Cl existing ❑new size Pool:Cl existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing O new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial O Yes O No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name U )0.yY1'P mna1S C HU5I aTelephone Number SdB-yo`fS'�y�f a. Address as Snm P.zz�R_k- / License# MCAV-"kCr k C4 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE Wlli'_ (' DATE T/oy FOR OFFICIAL USE ONLY i .. RERMIT NO. - DATE-ISSUED MAP/PARCEL NO:' + ADDRESS VILLAGE OWNER X DATE OF INSPECTION: s • FOUNDATION . FRAME _ d INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL- FINAL BUILDING o _ s' DATE CLOSED OUT ,ASSOCIATION PLAN NO. , 4 i + ;'� ` • .: :,;"•The'Comtnon�e'a�th of 1V1"assachusetts ; • ', = Department of zndustriaT'Aeeidents' xff;#ifk"S*ffffA' " 660•Washington Strdet _ • Boston;Mass. .02111 "�J • ' Wor ers9 c m ensatiolxusuranceAffidaQlt.GeneralBusinestsea �j � s� �> ';,:•,,, •yij,;'SaY+"' •:tit,...r•t+4rS;;"� � .+.• •�_ .•«'_ 'r •b!"'. • dress: •�, ,,• ,, . hone ' �a��� ; • state' ,'• address :• C Restaarant/Bai/EatYngEstablishment work sitelocafii� � dhaveno ono ' )3lzstness 'e; oce[� Sales gRt=aYEsta1e,Antos etc.)' Z atn.•a sole vroprnetor an Clnr udin working in any capacity pihe1 to er with•' etn to ee5 f1111&' art tune: ' //%%%////y/%%�//%/%%%/%%��%/ /�%%%//% n this job.. , r for my emfloyees worldn �,loyec pLOwdinrg v�rkers' cbmuensation ;• 'Ir ^ .r an. •{ F� • • '�.•_ .t.. ;! t'T:, •' / •? •)i r'":.'' }'''1f.+ :,'�;`,�',h:'r;%iil.}��:f^r ;t. r�Yy' :I • i t�T •} �Sv•t:'1'•' d'��r'l�ir'r7�S/'.t.'ril'3.\71•y,' r .II`'7.lLl• !'rr r:•, L •. �'I:': ," ' tit- C,+:\I•ti. �' ,.'.'l,ltl�1 t'���.,'.'i:\1••• I If•i?1.�1�� ,1 . .t.. .• •• 'S •'L•' L.,• i�r.•?.l':.t;i'f�r:'1'ti i:;is '7t3tvr5r SJ,;r .:ti:f::••.f': „t I��•' .r• ^ '• t :�. 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U'i1C.now :KJ l�?`rr`r,t.�':%�'^�•:s'::s,. r' a1 ena1tiesofafinelgstoS1,500,00an or insur-aud- ositign of crimfn p Fallare to secure coverage w req�ed under 6eabox,22e f f or STOP WORK 0 ands fine of$100.00 a day against me, I understand that} ent as well as cKpenalties : ' r Meyeara impruonm . copy of this statement may be for4vaE'ded to the Office of Invrstigatiom of the DlAfor coverage verification• der thepains a alt�es bf perjury that the information provided above is true and torlee� I do hereby Bert Date si�natura hone tie official use only do not pyrite in this area to be completed by city or town offlcia� ❑Building Department permit(Uceme# ❑Licensing Board city or towns []selectmen's Office ediate response is required ❑HealthDepartmen� , [�checkif imm []Other. phone#; contact person: (mvhed Sept 7Do7) __ .. . .. .. , ..by. .. r . ..: .. . • •` ' informiatioia and xiastructions• • , al L'aws chapter 152 section 25 requires au employers to provide wrorkers' eoxlZpensatidn for'tb ear. Massacl�usett$ Ge�eer ' . person in the service 6f another fiuA r an contract 1 employ is.defined as every Y �loyees; ,As gquoted,komthe `laGw', an em to se 'P ofhire;express or implied; oral or written, • a ers , association, corporation or other legal entity, or any two or rmre of An empooyer is defined as an individual,p p the foregoes gaged in a joint enfetprise,and including the legal iepresentatives of a deceased,employer, or the receiver or aroint.e i association or other legal entity, employing employees. 'Howevei.the owner of a trustee of an individual,p • p; aW g house l�v�g,'notInore than three apartments and-who resides ttierein, or fhe:occupant o`the,dwelling house bf spersbns to do mai�oteuance, constrkiction or repair work on such ewelling houk or on the grounds or another who emp1 thereto shalinotb'ecause of such e�ploymentbe*deemedtobe ari employer ,•. butiding gppurtenan •.. , t ..• lviGL chapter 152 section 25 also'states fhat'every s°tate'or legal licensing agency shah withhold the issuance or renewal elmit to operate a business or to construct buildings in the.comnnonwealth for any applicant who has of a license or p ' not produced acceptable evf dence'of compliant e wl�the ins'�a ce c�tracgfor th performan e o publictwork unt9 cob3 onwealthncr.any,ofitspolitical subdivisions sh Y acceptable eYa denee of complitoe with tie insurance requirements of this chapter have been presented:to the contract'mg•• • ' ` authority: ' Applicants Please file 4�o11C2rS'•COOP ens atifax a€Cdavit completely,by checking the box fhat applies to your situation.,Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department'of Industrial Accidents-for confirmation of insurance coverage, Also'be sufe to sign and date the affidavit• The�fiidavit should be returnedto'tlie city or town'that the application for the permit or license is being d, not the pep j-t t 6f ln.dustdal Accidents. Should you have any questions regardiri the'"Iaw"_dr if'you are requeste ,*orker�!-compensationpQficy please call theDeputment at the nimiber listed;�elo�sr. t required to obtain a , ' City or Towns . yleasebe sure that the affidavit is cbmplete andprinted legibly. The.Departrnent oupreond fhe ace li e ome f the affiilayit for you to fi17 oft in the event the Office o£Invesfigations his to contact y g• g pP ermit/liens a number which v�l b'e used as a referbn.cb number The.affidavits maybe xeturned tq b e;sure to fill ni e 1x AX unless othe'r'arrangements have b eeu made,• • ` the D epartcnent by. or, . . •. . . , ' . . •• ., .. •:,' , .•. , The of fice of Investigations would like to thank.you in advance for you cooperati6n and s4ionld you have airy questions, hate to us weal:.• ' please do nothes � . artment's address,tekephdne and fax number: TheDep w • , . . . The Commonwealth Of Massachusetts Department.of Industrial Aucadents of in of linsupftlls 600 Washington Street Boston,Ma. 02111 i fag M. (617)727-774.9 Er Town of Barnstable you °�y . o� Regulatory Services • �� $ Thomas F.Geller,Director � s63g• �� Bufl ug DiViS10I1 ''r6D MPy k • Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 office: 508-862-4038 P aimit no. Date AFMAVIT CONTRACTOR �SWPI,EIVMEMNT TO PERMIT A.PP ATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernize eo o,�cu ied ion, improvement,removal,demolition,or construction of an addition to any pre-existing owls P biding ce ltainnig at least one but not more than four dwelling units or to structures which. are adj acent to such residence or building be.done by registered contractors,with certain exceptions,along with other requirements. i� S 'type of'vo&: ep 1 Estimated Cost Address of Work: S , 'S Owner's Name. . Date of Application: �=�l I 6 I hereby certify that: Registration is not iequixed for the following reason(s): OWork excluded bylaw ❑Job Under S 1,000 []Building not owner-occupied VOwner pulling own permit Notice is hereby given that: OARS PULLING THEIR OWN PERMIT OR nelLOVEMENT WORKDO�NOT ZkYE CONTF-•CTORS FOR APPIACABLE TERED BOME ACCESS TO THE ARBITRATIOI PRO GRAM OR GUARANTY FUND UNDER MGL c,142A, SIGNED UNDBRPENALTMS OF PMUURY Ihereby aPPIY for apermit as the agent of the owner: Contractor Name Regi.strationNo. D71, OR S O Name r- e 05/11/2004 '08:48 508-325-4462 WAYNE MORRIS-MASON PAGE 02 : _ • 1. 1 r.. : - 1 , ! ' 1 • .7 : : 1 l 1 , I r _ ; Y , .i I -, 5 . 1 _-... 1 1 ., 1 , _ ... ... .. ... � ;• r ,:.• ., ��"• Poi- '�� : Y• , I • 1 ; : a 40 •.I i : . .. 6X, 771, - S� r : 1' : i : 1' , : 1� r : i i : oFIKE Town of. Barnstable Regulatory Services BARMNSrAar.E Thomas F.Geiler,Director 1639. p.0� Building Division lEc ntn+ Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstabl6.ma.us Office: 508-862-4038 Fax:.508-790-6230 HOMEOWNER,LICENSE EXEMPTION Please Print DATE:_ JOB LOCATION: T_—Aafl 5 ' Is numbei street / village "HOMEOWNER": Mri VAC m O name home phone# work phone# CURRENT MAILING ADDRESS: `1 V S p u r [o `1 �acS�'1n5i I1S ��� Cb�(101) crty/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwelling 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 and that he/she will comply with said procedures and require r Sign re of Ho caner -- -- 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 121.0 Construction Control. . - HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building pemvt 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:forms:homeexempt Assessor's map and lot number E rot ..............:...... .......... Sewage Permif"number ... �n..... 2 .. .....":........... Z BABH9TADLE, i . iNB• I"IpUSe nUmbef .......... :................r .................:............. 039, , 9 MARL YPY a\ TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... � /....:� ' TYPE OF CONSTRUCTION !..6'.P U f;?/j........................... ................................................................ TO THE INSPECTOR OF BUILDINGS: The undersigned here/by applies for a permit according to the following information: J Location ......... .. .�...........•�� ( .............................................................1 / z G/!. ....... !/,A....................................... �f ProposedUse ��?5 / i��,l ............................. .. .................................................................................................................... 1. Zoning District .......Fire District ..........1.....�921 ........ ` ................................. Name of Owner ..... 16.A1.S.i;L'7 .....✓ ,�.� ....4.1..<�.�...Address ...........,�i%vi..�......................................................... Name of Builder ......:........... .....v........................Address - r Nome of Architect ....."4t� ��........ �,.C'(/ P..:....Address 6� ��....... Number of Rooms / �/ .......:... ,...................................................Foundation ..... .. ....G..........�1j7;i�/�f�.r.1f.................... Exterior �A, GIS 4 Roofing 'sue/.. f.....J. .......................................................... Floors (��'? � ......./m./ .Interior ......./ ................................................................. Heating ....(.~.:/�.....`r/.. .:..............................................--- . Plumbing �� /% �'........... [ ......... ..v. ...... N ..*............................ Fireplace ........... ............ .......Approximate. Cost ................. . ` ............ .......... Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TKO APPROVAL OF BOARD OF HEALTH-- i I Q 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. zz Name .....1 {:t:..............%/i . / ............................... Construction Supervisor's License < ��S BAYSID.P.,', BUILDING CO. A=27-1109 f A=a 7- log 2 q534- 13-2 Story ,No .................. Permit for ..................................... Sinc[le Famil Dwelling ...................................... ...................................... Location ...L.Qt... Spur Lane . ..................... Marstons .................. Mills........................ Owner .....jA4yaide Building.. .......... . ............................. Type of Construction ...Frame........................... ............ Plot ...... of . , Permit Granted .....Sept..................1....4..............19 83 Date of Inspection ....................................19 Date Completed ......................................19 o-%A C) L( Assessor's map and lot number ....... .7.....I..d ......... THE •-ST Z "� moo`' �o Sewage Permit number .IC SYS INSTALLED IN l/hThh�� � � /�/ .� lid 4SV ��\mA?r". Z BdBB9T/lDLE, i House number...........`�............... ....... 9 WITH T raea . 1639- 1 �RAi�i�iEt�TAL TOWN OF B .. niArFALB! BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... Z. .. f.......�Fe. 9z:............................................................:.. TYPE OF CONSTRUCTION ......(�`� ... . ........ ...................................................................................... ............ .lf.. . .... �.....19.ff TO THE INSPECTOR OF BUILDINGS: The undersigned here/by applies for�a/ permit according to the following information: Location ......... ..4.1........ Y....S1. .....z/.1.cc.(v�L ...� f ............ .�........ .......... ....... ./1. ..:.................................... ProposedUse ............ofe-�I- Cep.6z ................................................................................................................................. Zoning District ................RE..............................................Fire District ..........c�. -...�5�....................... Name of Owner ...... .r4.9s1u�.....�1 ....... 0...�(�!Z�...Address ............��?1,.T.,......................................................... Nameof Builder .............. ... ...................................Address ........6".. ............................................................... Name of Architect ......�kgp#f �p WA e.......Address ..............®-?'!............................................................ Number of Rooms ..................................................................Foundation .....�I'�1 ......&r4 `47!fC!L�L° � ... . ................... Exterior ........clfk`.19d./f......................................................Roofing .......... ,qP ............................................. Floors �!''Y 1//.dJX/ .........................Interior .......L/ . Heating ..../W.14:..............................................Plumbing ........... .. .. /aY.0 .......... T Firepp W r(. .....Approximate. Cost ................. .J� �t..... lace •........... ........... ..... ....... .. ............... Pam ....... Definitive Plan Approved by Planning Board -----------___—__-----------19___ . Area .. ...J. :...... 2 Diagram of Lot and Building with Dimensions ee SUBJE•T l' APPROVAL OF BOARD OF HE z, l n . 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 Ilk construction. 1 Name .....1F�.'�./..r.2 .. . ................................ Construction Supervisor's License ................................ BAYSIDE BUILDING CO. INC 25534 12 Story No": �.......;..... Permit for .................................... Single Family Dwelling .............................. YO*"*"*'*'**"*"*'*'*",***,***I Location Lot 61, 6,1- Spur Lane ........................I ....................................... Marstons Mills ............................................................................... Owner ....:Bayside Building Co. Inc ........................................................... Frame Type of Construction .......................................... ................................................................................ Plot ........................ Lot ..................... 83 Permit Granted .......19 Date of Inspection ....................................19 Date Completed ...AO�`.Rt R......19- til I . Lv 7 G -rr / L-0 T 6 "� �v 110 C i • P L 10 ��c((I'' `rJ L 4 f ? Jo 0 0 W 3 • \� 113 . ffi ' S 5 Y" I So' F�cSnJTA�:,� L 30' f=eoN'r 5. P,• }} �� �✓ P UN-0 G{'- A-EMOC-L.E.. CERTIFIED PLOT PLAN N o�qMM act u T ! S P R L A IV6mmummomom 29874 IN 41) SUM SCALEl I =30 DATES ;r : , '"o. I CERTIFY THAT THE FocvNVAxtlon/ �' SHOWN ON �THIs PLAN IS LOCATED N : IYIL "LATO �OIaID .r-.' •/ pN THE GROUND AS MOICATED AND OONFORMS TO TNi ZOMiN• LAWS .4 0 iAltNiTA LE Aii. EXc�PT li' Iv! i 1 f0 T; w• ,1s.i#v , HYNNXts, IN° •Y: Y'�:A . GATE 8. L NO E0 OR f P esident: tfi• ( 1 i _ Member of: ROBERT BRUCE ELDREDGE.R.L.S. Ii CAPE COD SOCIETY OF PROFESSIONAL Office Manager: 1.. IN ENGINEERS AND LAND SURVEYORS JOHN R.ELLIS,R.L.S. ELDREDG Eh;� INEER it G' MASS.ASSOC.OF LAND SURVEYORS !c jl+ I AND CIVIL ENGINEERS Associates: CO PAN , C. ALBERT A.MORSE,P.E.,R.L.S. AMERICAN CONGRESS ON PHILiP WEINBERG.P.E.,R.L.S. SURVEYING AND MAPPING , AMERICAN SOCIETY FOR ! TESTING AND MATERIALS �EALS CREJJ L7 i1 tpEZeCI -fatzd �cviC 712 MAIN STREET cSuzvEyozl k, 3 �n91nEEz1 HYANNIS,MASS.02601 "' •o TEL.(617)775-2244 June 30, 1983 Board of Health .Town of Barnstable 367 Main Street Hyannis, Massachusetts 02601 SUBJECT: Request for variance from minimum well to septic system distance of 150 feet, as outlined in Town of Barnstable Board of Health instructions . REF: (1) Certified Plot Plan, Lot 61 Spur and Lauries Lane, Marstons Mills, Ma. dated 6/22/83 by Eldredge Engineering Co:, Inc. Sheets 1 and 2 of 2. (2) Septic system and well sites for "Wakeby Estates," defined on "Master Plan, file 73-012,11 dated May 1, 1973, on file at Barnstable Board of Health. Dear Sir: On behalf of Mr. Brian Dacey of Bayside Building Company, Box 95, Centerville, Ma. 02632, I hereby request he be allowed the following variances from the minimum distance of 150 feet from well to septic system: LOT DESCRIPTION DISTANCE VARIANCE REQUESTED 60 Proposed well site* to proposed L. P. 1301t 201± 60 Proposed well site* to proposed-1000 100% reserve 1301t 201± 35 Existing well** to proposed L.P. 1301t 201± 35 Existing well** to proposed 100 o reserve 1301- .20't I thank you for your consideration .in this matter. Very truly yours, ELDREDGE ENGINEERING COMPANY, INC. hn R. Ellis, R. L. S. r Office Manager * Sited per Ref (1) ** Well site per owner 6-28-83 L'oT. I wF-L-L- Si,E gc sEP- \c_ ✓Jy �J /f L.SySIEM c�cA-Mcnp"n Lr��fC K F M ASTE-C PLA,,J " Fr LE 43,SCao S. F. s ►Lcv (.o.�oE2 G�CvI A-reD MA-f I , I G-I S p 1 So' F Kp{_JTAC�` <; rgs's Q�"��� gA' z re 4'le Z' LoT ^CHrN6 0 -s I u a R, r� Lor6 0 �cl l -A- A s5wM E D P kol Ec-m,=x j u ,ocp- AP-T 1e P N . ,k O�R�s�c y m 4JZz c \c r2' rri r , +I A PT TTT �`� v ,� ; W 3 <rip pv\ _ z 0 `� D m 7 to00 I- to vir \ x � A" CATCH,_ .. I! , gn 5,�/ s 7 , f y.lo W 3 J o 'a m M v Z Il , o orb' gh 0 I~ o•J 9 9 -), c,(3.M. fib~ E,,` *�j JD 12 A.\, OF Cp to vv_ Pat QVsu L NO EXISTING SPOT EUVATION 0.0 CERTIFIED PLOT PLAN EXISTING CONTOUR ——— 0 -- - 3����t{oFM�s LoT FINISHED SPOT ELEVATION Q[�_] zN MA 1?S 7-V N� FINISHED CONTOUR 0 - --- — — MORSE INAPPROVED , BOARD OF HEALTH pNo.., 51�0 i �0c�GISTEP��y'�4. ����J`i �'�i�i ��, •1�V�i E DATE AGENT FSS10NAL a SCALE, =3v' DATE : L RD EDGE ENGINEERING CO. IN CLIENT --- I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED J08 N S3 1 >S BUILDING SHOWN ON THIS PLAN CIVIL LAND JOB CONFORMS TO THE ZONING LAWS ENGINEER SURVEYO J�• .r! OF BARNSTABLE , MASS4E =Prig _ 712 MAIN STREET CH. B /.� H YA N N I S,� M A$S. I I ' IZ -` �'�..��,..+�..� -•-- SHEE 0 BATE R�EG. LAND SURVEYOR ,� cQ A Ar` 0rR R, nC% m M' • sins 2 o �p •. ,. ,, Un v, r7o rn rn �t o fl 0 e? Sills co 0C V1 `e� y x: it c e2� Is tj yD � � 0 ,• � 1 o w 6mpIQ � � p 1 . s". o • • • •o • • �4__IIo� � �� 2 IIA aM �m n hmti ►. . . . . •� . . • � a ` 4 yy m T oRs ° off v, 3 } 3 • • r� o � � Dt. 9 9 % . y p� b N�O y .t�i� Aa� y rnrb ZCu G, tA 33 S \ 3 C C� c •011 a Lq U, \C 0 Q � F K ' TOWN OF BARNSTABLE Permit No. 25534 16 Building;Inspector's sausr f Cash _-.-.---- �r OCCUPANCY PERMIT Bond- , Issued to Bayside Building Co. -Address Lot 61, 61 Spur Lane,, Marstons Mills -Wiring Inspector V � Inspection date ( Plumbing Inspector � ^� � f� Inspection date _ras Inspector `�. Inspection date X'Engineering Department �� Inspection date/n— Board of Health !r�- ^�/ �`Inspection date 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. ``• /..............�__... _.(. ...... . ..........._.. ' �/ Building Inspector Engineering Dept. (3rd floor) Map Parcel 6 Permit# I House# r'J_S ' Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30)e3- 4-�;! Fee - Conservation Office(4th floor)(8:30-9:30/1:00-2:00) SEP-n :SYSTEM RSV 9 BE dam) INSTALLED I UA SCE VW d 19 TOWN OF BARNSTABLE Building Permit Application Project Street Address GQ P Uk LAN 1 (')ev U -*("I Village{ ANRSTDA),� /t4 i u s Owner S'-b I/ 1[\►�_- 0 L-A Address qQ S pU2 1,116A Telephone gar 1Z Permit Request,; First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ /0 d 00 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 1:�) i 5 Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type:' Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:" Existing;_ Newt I Half: Existing New No. of Bedrooms: Existing c'�, New n Total Room Count(not including baths): Existingi Newj�First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil AElectric ❑Other • Central Air S ❑Yes , EfNo Fireplaces Existing _ New Existing wood/coal stove ❑Yes XNO Garage: ❑Detached(size) Other Detached Structures ❑Pool(size) ❑Attached(size) ❑Barn(size) • �-_None Shed(size) / tx ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 1�� �- � �-l�{ DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) _ c . �6S VJ F _ l �1 V ,_ .•_ ,fie, � _ I i . i ZMIE tq� . ;The Town of Barnstable MASS � Department of Health Safety and Environmental Services r 059.�� Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME 1WROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. C?(YYI1Z' Est.Cost') �l a oo� Type of Work• NVbY�9l C-�r�l��e h@Ck� ►/ Address of Work:l !l Owner's Name Date of Permit Application:) I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied _Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME E"ROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Owner's Name Y� � D to l __ _ ... G The Commonwealth of Massachusetts Department of Industrial Accidents ` _ t 1 Office of/nyesUgat/nns :w 600 H'asitingtun Street - Boston, A1axs. 02111 Workers' Compensation Insurance Affidavit ._...._.- i._�..�.�r_. _...�....._...... __ .._._.r.�. ._-�.._.. ... r •r1.r..•�n6w�+ r:Q4�•�^�I M�iC.�.�.w.;.•�!.w!•�+•.•w..��.�w�..,.�.___. 77 �pnitryc�a/n�t�tJnlltJoJ..�►rm`altion: •_//.�� I.� • - Please PRINT'leb�]•�=,� "'� i location-1 .cit�r 0 AA A RS,V J k,jLb� nhonc{+. V g 16—� 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity .Ia:."a'�Y^!.-•ter.":•'a!^ '�??$C!m7'A+Y.Pu?'snRsi7x�'=�..;/�°a'..+•.'X'ear"�.''^R..""q"P.e.?.•!`p7".+r."wJ'/�wy�-"7!! '.n'a} ! w!!�.^•:r.,w�,•s-r-�......,.a•....,c. i..�...�;:.....:...�L._ -...."..+:���viwi....nr' Lam•• yy.s, as.r ,.� - - .�.. �:.�.�.���.._�.� I am an employer providing workers' compensation for my employees working on this_job. company,n•rne• iddrecs• cih'• phone#• insurance co. policy# ...•.. •...��.; .-a..�....,._.g:r.,•.-....,en.,.,.r......:,p�,...�.,y.,�..ry...--.•.••,.r.,.r..,r .....•�,:sr+v-o'7...r•;•!-+�.,+. .•.-..•--^-..•:-� I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city phone#• insur•nce co polio # I ^ez vrnt:. .�a��m: -�r•r:•-';�,,. _4^?:e`t^�"�.-��rr�'� ...f.—�- --F7;'fJ'`�'_n�:`.$'i''fn;T+• _ a - ':a.a+.s.:s ctimpim•name: address: city. phone#• insurance co policy# .Attar_h aJdi_tio_pal'shcet if neces_s •:�s::'_W�"'�.�"p'�•`q`.'•^1�"p.::•*°�.'�r ---,-_ e-s t;''�•,''�'ir•`.i�'''T'�y'^.'�e..".� "Jf► `."� r""iy�`�,...•".`.»•.�."�..-_. �;_._.::. .._.;.• .� •ris.,:e�h�._—^---v»�r...-..: :..:.ray-..—�.,a Failure to secure coverage as required under Section 25A of I\1GL 152 can lead to the imposition of criminal penalties of a fine up IOS1.500.00 andlor une years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herebt•certijl•/under the pains and penalties of perjury that the information provided above is true and correct. �Signatur� X ��.(,� _ Date� Z/// ' Print name I J (t'1�� Cam/ ` � �TT Phone#1 �a 0 official use onh• do not write in this area to be completed by city or town official city or town: permitAicense# riBuilding Department C3Licensing Board �.. check if immediate response is required Selectmen's Office r Health Department contact person: phone#: rjOther Irevised 3;05 P1A1' Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers* contpeivsjtion for their employees. As quoted from the "law", an emplmvee is defined as every person in the service of another under anv contract of hire, express or implied, oral or written. An empl(prer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing enuaged 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 dwellin- house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the ,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance of- renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who leas not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. -777 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits 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. 7.77 City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at tite 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to _ive 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 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE� Joe. LOCATION p . SPU Number ; Street address `Section of -towii `,"HOMEoWNER" CAA pl.� oZk 159 Name Home phoney L Work phon- _ - - PRESENT MAILING ADDRESS City town State Zip co The current exemption for "homeowners" was extended to include owner-occu, dwellings of six units or less and to allow such homeowners to engage an dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to side, on which there is, or is intended to be, a one to six family dwellii attached or detached structures accessory to such use and/or farm structu: A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner"- shall submit to the Building Of.' on a form acceptable to the Building Official, that he./she shall be respor. for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the Building Code -a-nd other applicable codes, by-laws, rules and regulations. Barnstable Building Department minimum inspection The undersigned "homeowner" certifies that he/she understands the Town of procedures and requireme: and that he/she will comply with said procedures and requirements. [OMEOWNER'S SIGNATURE ' ( � APPROVAL OF BUILDING OFFICIAL 4�2 Note: Three family dwellings 35,000 cubic feet, or larger, will be requirE to comply with State Building Code Section 127. 0, Construction Control. • i HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for_ whch ,a- build permit is re p provisions of' thsLsection p gaited shall be exempt from the (Section 109. 1.1 - Licensing of Construction Supervisors) ; provided tha Home Owner engages a person (s) for hire to do such work, that such Home shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assum the responsibilities of a supervisor (see Appendix Q, Rules and Regulat fo`r . licensi.ng Construction' Supervisors, Section 2.15) This lack of aw often results in serious problems, particularly when the Home Owner hir unlicensed persons. In this case our Board cannot proceed against the - inlicensed person as it would with licensed Supervisor. The Rome Owner as. supervisor is ultimately responsible. ... To ensure that the Home Owner is fully aware of his/her responsibili.tid. communities require, as part of the permit application, that the Home 'OT certify that he/she understands the responsibilities of a supervisor. c last page of this issue is a form currently used by several towns. You care to amend and adopt such a form/certification for use in your commur R R AUC-02-96 08:55 AM FSS 31 S749770 P.04 �QQ I go Qs V . x r �� AUG-02-96 08:5S AM FSS S1 3749770 p,02 IL I J i� �� - - AUG-02-96 03:54 AM FSS 31 3749770 P.03 Q i r �- . a s AUG-02-96 09:53 AM FSS 31 3749770 P•01 ILI IS � I S� a s 'J K III n/I I g