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HomeMy WebLinkAbout0141 TROTTERS LANE %Yi T�/rs ,G�. r 141 14 pw 0 3z —6is— r a a r { E k k t: tR f Fp R 4 i Town of Barnstable vTOW Regulatory Services ��oF4 ,' Richard V. Scali,Director l�/!/�� T4 � t: ' a"R'''AS& ` Building Division F1639. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ® �p^��041 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# 2,01Lfb—2-6S � FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less Location of shed(address) Village C-1-144 A(15e-fr2o ��09--?3 7- 10 7 (� Property owner's name Telephone number Size of Shed Map/Parcel# Signature Date / Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sign--ff li-6 for`Conservati6n 8:00=9i30 8i 3 30=4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:040914 F .y 14Vi, Y ia{ 4-z a 3 .r x :1 �` Q Z-0 0 m r.: 41 N4 -9 ISM F nx a r r •. rY, J r ? I 2 '10,0CS 5 T"T' `� \ r CERTIFIED PLOT PLrI 41 ;.CONSTRUCTION ONLY : -' IN ; FOUNDATION IS FEET aa a'S�� 'LOVE LOW POINT OF ADJACENT ���d �ASL .' ;' {- ID. SCALE / _. �;. DATE E.ENO/NEEI�ING CO.IN I CERTIFY THAT THE C1�iE�l' ' SHOWN ON THIS PLAN IS LOCH 01$7EREp REGISTERED JOB N.Q.. ; ' f ON THE GROUND AS il�OICATE�!'1 CIVIL LAND. CONFORMS TO THE YONINO LA- :.ENGINEER SURVEYOR DID OF BARNST B .E ASS. "; CH.B-Yt 712 MAIN ST. / HYANNIS� MASS. SHEET_L'OF DATE . . RES. LAND SURtl97 �� � � �- R .� � s i �� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION '."Applicatioh4r, Map Parcel on' Loo 0 "Date Issued Health Divisi 09 Conservation Division 'ITT -'�-AppliQation-F 'it F60 Dept. -r Planning, :t" Perrri Date Definitive'Plan Approved by Planning Board Historic OKH: Preservation Hyan6is Project Street Address Village Owner Address Telephone 5 0q - 73 0 Co Permit Request Square feet: 1 8t floor: existing proposed '2nd floor: existing proposed Total new Z6`n'ing District Flood Plain Groundwater Overlay nPJecN Construction Type Lot.Size Grandfathered: U Yes Q No If yes, attach supporting documentation. Dwelling Type: Single Family Y Two Family 13 Multi-Family(# units) Age of Existing Structure Historic House: U Yes Q No On Old King's Highwa Q Yes LJ No Basement Type: Ll Full L] Crawl Q Walkout Q Other Basement Finished Area(sq.ft.) Basement Unfinished Area (94,A) Number of Baths: Full: existirig: new Half: existing `—"If Lhew&; Number of Bedrooms: -3 existing —new L Total Room Count (not including baths): existing new First Floor R orn Co t Heat Type and Fuel: Vas Ll Oil Ell Electric Ll Other r M Central Air: Ll Yes aAo Fireplaces: Existing--9—( New Existing wood/coal stove: Q Yes "o Detached garage: Q existing Linew size—Pool: Q existing Linew size Barn: Llexisting Onew size Attached garage: U existing Linew size —Shed: Ll existing Ll new size Other: Zoning Board of Appeals Authorization El Appeal # Recorded Q Commercial 0 Yes Q No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �166_72© Telephone Number _5ue- 7.57- q( 7C_ -Address 7 7; '4& > Lv License# L, .115 � Home Improvement Contractor# 0X&q11 9U Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE (��l © � f FOR OFFICIAL USE ONLY A"- LICATION# DATE ISSUED. MAP/PARCEL N0: ADDRESS VILLAGE .'OWNER DATE OF INSPECTION: �t - FOUNDATION s FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:. ROUGH FINAL s GAS: ROUGH FINAL y FINAL BUILDING ���� tz `r DATE CLOSED OUT ASSOCIATION PLAN NO. of r Town of Barnstable Regulatory Services Huss , Thomas F. Geiler,Director Ar o►h 0� wilding Division Thomas Perry, CBO,Building Columssioner 200 Main Street, Hyannis,MA 02601 www.fown.barnst2ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: `t AC—r a v Map/Parcel: j O ! Project Address !yl / pre xr o,�Builder: The following iterns were noted on reviewing: C, '*4(7- /.v T¢►`�itC r ��'. �/ ,I GCE Q pflS/T/f!-,F- Oej �ETItIZ�fL/ �O S-t C d hf C K�6?"6 //Z E-� . Reviewed by: �Z Date: �o O Q:Fmw:Plnrvw T1ie Commonwealth of Massachusetts .Department of Industrial accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Ingurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leffi.bly Name Bus n ss/OrganizationAndividual): C..� /�--� 'Address• T ( ty/sta.Z p: - 41 sLL,� . ~��.-5 Phone.#: Ste- 73 �' 7� r 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/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 Bt,ildiag addition comp.insurance.t [No workers' comp,insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑Plumbing repairs or additions _3- -I'ano a homeowner doing all work myself.-[No-workers'-cormp. rigkt of exemption per MGL 12.❑Roof repai anran r tnce requizedJt I~-^x. c. 152, §1(4), and we have no employees. [No workers' 13.❑KOther comp.insurance required_] *Any applicant that checks box#1 must also M out the section below showing their workers'mmpens4on policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outsidt contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub contractors and state whcthcr or not those entities have employers. If the sub-contractors have ernployccs,they must providt their worktrs'comp.policy number. lam an employer Iltat 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 tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of _ Investigations of the bIA for insurance coverage verification. I do hereby c erfnnnthe sand penalties of perjury that the information provided above is true and correct. S e I Dater y d Phone k IOfficial 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 S.Plumbing Inspector 6. Other Contact Person. Phone#: Information and 1nS* tr°uct101aS f Massachusetts General Laws chapter 152 requires all employers to provide'workers' compensation for their.employ COS :' 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 cbapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance ar 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,' MG 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 cowpliznce Rzth 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), addresses) and phone number(s) along with their certificates) of insurance. Limited Liability Companies•(LLC) or Limited Liability Partnerships(LI2)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, n6t 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 Towp Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of tho affidavit for you to fill out in the event the Off cc 6f 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 permiVlicensc applications in any given year, need only submit onc,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.Wherc a home owner or citizen is obtaining a license or permit not related io any business or commercial venture (Le. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would hlce to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a ca1L The Department's address,tclephone•and fax number: . The Commonwf,-4 i of Massachusetts Departzmnt of Industrial A.ccidonts Office Of I1avestigatl.oas 600 Washington Street buton, ILIA 02111 TO. # 617-727-490.0 ext 4.0-6 or 1-M-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www..mass.gov/dia Town of Barnstable �oF�cHt:r . Regulatory Services : Thomas F. Geiler,Director BARNS"rABLE, t, MASS q, i679. ,' Building Division PTfD '�a Tom Perry,)3uilding Commissioner 200 Main Street, Hyannis, MA 02601 ww3y.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:;_ "/�/ IOB L-OCATIOTI ( Ll t' l�l^i Tr 't number s trect village "HOMEOWN R LtJ tl//T"I[ d 1 IC�1 U name home phone i1 work phone# DCURRE14T-MArLING ADDRESS: 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 HOAJEOWNER 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 itiio-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 pennit. (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 ecYion procedures and requirements and that he/she will comply with said procedures and req ements Signature of 1-lomebwKrr—f 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 Constriction 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 ial.1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)for-hirc 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 oCa supervisor(sec 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 Mquirc,as part of the permit application, that the homeowner certify that hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. 1 - I �opzHerOk. Town of Barnstable Regulatory Services "� ASS. Thomas F. Geiler, Director 019. reDntit,�a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.toiYn.bqrnst2ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1 , 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) Signature of Owner Date Print Narne --'e If Property Owner is applying for;p,ermrt please complete the Homeowners License Exemption Form on th'e revers 5id� { FA en- `t .14 OT .,� •5 / dill } Y r . _ • '�S.Ylf:y;1•r "Ti' h Q j l�Y�l W"_ V' r F,,1 t _ ' -70 rA SUf. 5 i e�a ry.' ,•r. .yI • CERTIFIED PLOT PL ift- CONSTRUCTION ONLY S ` F.. 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Cash ----------------- ��O •6)q. P OCCUPANCY PERMIT Bona "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department 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. _......................... _... ...___....... Building Inspector FROM TOWN OF BARNSTABLE i BUILDING DEPARTMENT Morgan Homes 367 MAIN STREET 8 Gristmill Plaza. HYANNIS, MA 02601 Southwick} MA 01077 Phone: 775-1120 SUBJECT: lot #14 Trotters Zane Marston Mills FOLD HERE Tl �. DATE ! August 25, i981 MESSAGE Please contact this office re an Occupancy Fennit for lot #14, Trotters Zane, Marston Mills. a r SIGNE i ing Commi.ssi r DATE REPLY o i SIGNED N87.RMI - RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S.A. i SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE-`�'0I-NK COPIES WITH CARBON INTACT. 4 fi 1. 'I• �' " ' - ;{F: + fa% ',;°i:' 1 �.. j 7- 1 -4 n \ N �I „� r ,• ,J M J f l.v ..gi,,nn � �T i .•Jr, lk -70 IVA ti J I vt CERTIFIED ' PLOT P t ter— t lY iK ° 1 7-/z:' 7-7-G-.2 S - 'J - 6011STRUCTION ONLY c• r1 tOp;' W FOUNDATION IS_1 FEET IN iNI40VE: LOW POINT OF ADJACENT SCALES /'_' • �1 DATE, /0�'' K , . E.E O/NEER/NQ CO.IN ''-' �' !'`` I CERTIFY THAT THE OI,.�ENT SHOWN ON THIS PLAN 18 LOCAY F „ ^� oISTERE REGISTERED fit;r. J. { CIVIL LAND JOB NQ. :_ ON THE GROUND AS INDICATED`Aq�;, .�. :SNBlNEER BURVEYOR Df.BY:= CONFORMS TO THE ZONING OF BARNS ASS - :' . 712 MAIN ST. CH-B � ✓' % jo HYANNIS, MASS. SHEET-L.,OF DATE ' REG. LAND SUR Ass%sor's-wap and lot nu ,. ...-.1 ........... �� �THEt� gage Permit number ............r SEPTIC SYSTEM MUST ............................... INSTALLED IN COMPL-i Z BAB_BSTABLE, i se number ....../.. �............................ WITH TITLE 5, 9 ; MAB6 ENVIRONMENTAL CODS 2639'a�e� TOWN 'OF BA.RNSfXhfE� nTw ,R `= . BUILDING 11SPECTOR APPLICATION FOR 'PERMIT TO .........U.....`............ ....... 5.`...:j.(�... 7 ...................... �A TYPE OF CONSTRUCTION ........................................................................................:.......::..... ?...........................: ...... ......... ...................19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit /according to the following information: l` -, Location ..........1!'!?. .....�.!............./1�1G!......... r................. ! '.? .5 ... .< ,5:.....:.................................... Proposed Use S(f=fry- t.<�/ Q�c: ? .C. .f? ............................................................................... .......... /.. .......... ZoningDistrict ........................................................................Fire District ........ :.w:........................................................... Name of Owner /'`6 �............................................Address . .... .. . .. ..... .. s7 o� Nameof Builder .....................a!-`fie....................................Address .................................................................................... Nameof Architect ..................................................................Address ................................../................................................. w�Q CY C D� Number of Rooms ..............�..............................................Foundation ........ �.............................................................. Exierior ......lrl.iv. ......... ..............................................Roofing ......!1q.5/ ,l/ S t Floors Interior .......5!...2 Heating C���r�c� i L- .......:.............:......Plumbing ......... ..................................... Fireplace .......................................................................:..........A proximate Cost .....ZS�D I.........................................n...... ...... �d �/ .1• Definitive Plan Approved by Planning Board _________ �_____19_,��. Area ..../..........CJ...... .. .......... Diagram of Lot and Building with Dimensions Fee (pZr......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH. G\1 L 10k 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ,� Az_�� Name ............s ................/...................... ........... y. MORG,xAi HOMES ;4 01 r •2.2.��.$... Permit for .Ql�.�...S. . . Y... ....... x ....S. xzl�... mx�. ..pWs�.�.a.a . .......... Location ...Lot...#14.,....1A1_..T]r•.otter.s...Lane .................Razatans..Mills........................ Owner .Aoxgaja...Home.9................................ Type of Construction ..F.rame........................... R ..••.•••••••••.•••••••.•••••••.....•.•......••.................................. .- Plot ............................ Lot ................................ Permit Granted ...,October 27.,........19 80 Date of Inspection .................�� ..19 Date Complete e.)...... ...............:..........l q PERMIT REFUSED ` S ....... V....... ........................................ 19 � f cc."� ........................................................ � ' ..... . .S. .. . .� ......................................... .. y ...................................................... 3Y'� r.. . C)����lJ•f••• h' APPiov' ................... . ........... 9 r .... .. . . . . ..�'.�l-S ... • � r S�7�• ydid r Assessor's map and lot number-,..:.I. a ..:::..%�� ........ • � „'`, I :e' P`'Of T E TOT %v Sewage Permit number .(��..—. t.>rl� ............................ Z EAMSTABLE, i �ar,�--House number .. .......................................................... °oc NAB& 0� o may a• TOWN OF BARNSTA-BLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .........................5�! ................`.�.`..". .. %'::-.... n". .....``�.. TYPE OF CONSTRUCTION. ..................... ` 4 ...... ... .......�` �� ?:- ..C............................./............................/.... e. ` ....................................19. C� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............... �...........................TT Ec f .................... Proposed Use / ZoningDistrict ........................................................................Fire District ......(:. :........................................................... _ � a Name of Owner .. ?.............................................S � �rlS7� r ���r�c 7.� ...�u ri��!-`•-�J� w= Address ..................... Nameof Builder .................5 ,;,r'e.....................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .............�„ ..............................................Foundation �. .......................................................11%^ C�LO ............. Exterior ......4 4. ,a.. " !"` Roofing '.....'�.: +.1• %a. ...j`C .:............................. Floors e�'+-119 e .................... .......Interior SA.C..�...@....�.`.v...�...�...f..C.................................................... Heating .........c; i .G �f` Plumbing // . !. .� I C dv'% c............................... .....�......�.....................................'.... .................� ............. Y Fireplace Approximate Cost ...........S...:............................................................................... ....... ............ .. Definitive Plan Approved by Planning Board --------------_-—- _____19 Area Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I CA I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...........................................<...................... ............ MORGAN HOMES X:�A=32-157 T. Permit for One Story No .226.18.... ............ Single Family Dwelling . ............................................................................... Location ..Lot,,,#.! 141 Trotter,s...Lane ....................... ................. ......................... Owner ......M9rgan..Homes Type of Construction ....F.raMe......................... Plot ............................ Lot ................................ f O�ober 27 80 Permit Granted .....!.......................►........19 Date of Inspectio .......... .................. ......19 Date Completed ............................�.......19 PERMIT REFUSED ............... 19 . ..... ..... ............ ............................................................................... a Approved .. :........� ,. ..... ........ 19 .. . ............... ...... 701*SHE Town of Barnstable * ermit# TaY HwP� ti* Expires 6 n Nis from issue dal Regulatory Services . Fee • BARNSI'ABLE, • ' v$ MASS. $ Thomas F. Geiler,Director 1639. �0 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.bunstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY - ,,pp--�� Not Valid without Red X-Press Imprint Map/parcel Number Q22 Proper Address 1Z� / �T r'l� (_/� q / r l t Residential Value of-Wort. 7 t6/1)y Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address �GC/C,tJ /� ta Contractor's Name Telephone Number I Ionic Improvement Contractor License# (if applicable) Construction Supervisor's License# (if applicable) ❑Workman's Compensation Insurance Check one: or ❑ I am the Homeowner X.PRESS PERMIT ❑ I have Worker's Compensation Insurance MAR Insurance Company Name 4 2009 Wotktnan's Comp. Policy # 'OWN OF BARNSTABLE Copy of Insurance Compliance Certificate must be on file. c.:; Permit Request(check box) -- ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) e-side Y0 CD M Replacement Windows/doors/sliders. U-Value e/�� (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 me Improvement Contractors License is required. SIGNATURE: II.kS\I 0lZMS\building permit forms\EXPRESS.doc Revised 100608 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 ,^ ,�n Please Print Legibly Name(Business/Organization/Individual): C�29 w/-7 /J )2_116 l�0 Address: //�� TU7�7���5 L.14-vt e City/State/Zip: M Ws s 0,,_(0 L/ t Phone.#: 420 ' L/3 7-3 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with . 4. ❑ I am a general contractor and I 6. El 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. r ] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. 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.❑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. 1contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a-STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certi r t ains-and penalties of perjury that the information provided above is true and correct. Si tune: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officlaL 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#: y : J 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 tlie-foregoing engag m a Jom -en rpns�e, -melt ing the legal-represen-ard-wk-uf --demased employer oirthe-. - —. --- 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-contiactor(s)name(s),address(es)andphone 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 permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all-locations in - (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related io any business or commercial venture (i.e.a dog license of 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 Investigations 600 Washington street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass gov/dia I Town of Barnstable M�"P�Of SHE Regulatory Services Thomas F. Geiler,Director BAttNsrear.e. ram& Building Division Tom Perry,Building Commissioner _.... ------ --- .......200 Mairi-Strect;--Hyamis,-MA 026-01 _............_.... ._... ..._.._.. .. .. _._.......__. . : w".town.barnstable.ma.us Office: 509-962-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 2 Q Please Print DATE: JOB LOCATION: �7-T'/�S number �street�� y9� village "HOMEOWNER': /�� R n t /�"���✓ name home phone# work phone# CURRENT MAILING ADDRESS: /Z// / //�� cityhown 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.Tpwn of Barnstable,Building Department mmunum inspectio cedures and requiremtnts and that he/she will comply with said procedures and re en 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.-Licensvtg of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exemption we unaware that they are assurning the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of aw;A=ess 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 care t amend and adopt such a fomi/certifi cation-for use in your community. Q:forms:homccxempt - sJ oFsTa,� Town of Barn-stable Regulatory Services • sAxxsr�at� • v MASEL g, Thomas F. Geiler,Director +16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.rna.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: '(Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S:o W N E RP ERMI IS S 1 ON