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0360 TURTLEBACK ROAD
��d ������� �� s � i yo`1"Eton` TOWN OF BARNSTABLE RAR 039- BSTAILL a BUILDING . INSPECTOR APPLICATION FOR -PERMIT TO .........Ohl ..............Z. ........... ........................... TYPE OF CONSTRUCTION ................. ............................................................................................... . ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... 14,1 .............. ...... .. . . . ..................................... ProposedUse ........................................................................................................................................ Zoning District ......fftp ....................................Fire District ....A..7�..�..I.s...... r.............. Name of Owner ..........................Address ........... ........................... Nameof Builder ........................Address .................................................... Name of Architect ........................Address ...RT..X..�..... ......................... c 41 Number of Rooms ..................................................................Foundation .................... ..=.............................. . .... Exterior .........c` A....Qe. .....Roofing .....a-.Sp.1141. T................................................... I vz) wP s).....Interior ...... .............................................. Floors .......0 Heating ...... ..............P I u m b i n g ........... ............ Fireplace ......... . �) ..............I..............................................Approximate Cost .......... ................... Definitive Plan Approved by Planning Board ---------------------------- Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH k3 Ll IZ6 LIJ ti r Yo.0 (D < < (5 4o I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. .. t........ .... . ........... Brooks, Robert ' No ..15817::: Permit for...:....:..two sto.......... .........single 'familyr dwelling Location .....:..... . ................. ..........................N.xS ..................... Owner R ......:................ Type of Construction ..................frame............ �t . o f_. Plot ............................ Lot ......... 64.............. January 8 73 ( Permit Granted ........:...... ........ .......:... 1 a , Date of Inspection �b �d Date Completed .. ..� .�. ..... .... PERMIT REFUSED < ..............................................................:. 19 y ................................................... ........................ , ............................................................................... ........................................................ ................... 1 Approved ................................................ 19 ............................................................................... ............................................................................... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel (� Application A Health Division Date Issued 7J Conservation Division Application Fe �6 Planning Dept. Permit Fee —7-2 c f Date Definitive Plan Approved by Planning Board O� Historic - OKH Preservation / Hyannis ' ProjectMStretress r kVillage Owner f�o RAYH 0 Z MF&40 Address. 360 Telephone q 6� Permit Request o� Z.�cxp Square feet: 1 st floor: existing d. oposed N 2nd floor: existin OTZ proposed Total new UIR Zoning District Flood Plain Groundwater Overlay Project Val l L� Construction Type � o Lot Size Grandfathered: 0 Yes ❑ No If yes, attach up`porting cLo um otation. Dwelling Type: Single Family SIA Two Family ❑ Multi-Family (# units) Age of Existing Structure l Historic House: ❑Yes a No On Old King's Highway: ❑Yes WNo y Basement Type: Full ❑ Crawl ❑Walkout ❑ Other _n Basement Finished Area(sq.ft.) WAr Basement Unfinished Area (sq.ft) 3 Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing do w Total Room Count (not including baths): existing new k IPA First Floor Room Count Heat Type and Fuel: &Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes 5(No Fireplaces: Existing New Existing wood/coal stove: 0 Yes %No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:�(existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes VNo If yes, site plan review# Current Use qTIA�'tLC.� Proposed Use APPLICANT INFORMATION `;(BUILDER OR HOMEOWNER) 2 Name \'To w LL Telephone Number 6 17 - Address 26 KO YA0 W,ise # CS -21?® 7� Home Improvement Contractor#PQ 1 ER •S l9P-a Worker's Compensation # 005�9 l f 72 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT(NILL BE TAKEN TO ( 'a ECCAV ps 7t SIGNATURE DATE 3 ).. r a r. FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. _ ADDRESS VILLAGE OWNER ` DATE OF INSPECTION: FOUNDATION _t } v FRAME r� vP INSULATION FIREPLACEzc r k ELECTRICAL: ROUGH FINAL j PLUMBING: ROUGH FINAL s GAS: ROUGH FINAL k FINAL BUILDING ® ! r DATE' CLOSED'i OUT ASSOCIATION PLAN NO' r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I' 600 Washington Street cX Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indivi dual): Address: z 6 City/State/Zip: �e�lu4e.0 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 working for me in any capacity. employees and have workers' 9 ❑ Building addition No workers' comp. insurance comp. insurance.# 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. 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 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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.M LM) DQ 1 6 7 z Expiration Date: Job Site Address: �,� � � '� City/State/Zip $'� � / &5 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cer fy tinder the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 0--' /o Phone toll FFcialonly. Do not write in this area, to be completed by city or town official n: Permit/License# ssunguhority (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 'ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: .�rtF` filz:aEk Site Address: 360 7-0�/�,,y_rC pg grin! Town: Z&_570.- 5 rktZ::711S Applicant Phone: Applicant Signature: �— r — Date of Application: 3 NEW CONSTRUC N: choose ONE of the following two o ti6ns 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE- AND TWO-FAMILY BUILDINGS MAXIMUM MINIMUM Slab Ceiling or Basement ❑ Option 1: Fenestration exposed Wall Floor Wall Perimeter AFUE HSPF SEER U-factor floors R-Value R-Value R-Value R-Value R-Value and Depth National Appliance Energy R-10, Conservation Act(NAECA)of .35 R-38 R-19 R-19 R-1 O 4 ft 1987 as amended,minimums or greater as applicable Note: This form is not required if you choose either of the two versions of REScheck as listed below. ❑ Option 2: RES check Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2) REScheckc Web which can be accessed athttp•//www energycodes.ggv/rescheck/ ADAXTIONS:OR'ALTE '' TZONS,TO EXISTING l3UZZ,DIlVGS:O VER.S YEARS OLD* *Buildings under 5 years old must use option 91 or 42 in New Construction section above. Complete the following formula to determine the % of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b - a) I ( �SF 100 x 2R� - Q _��<S--% of glazing a (b) Glazing area equals Z o ZSF b If glazing is:S 40% use the char(below. If glazing is > 40.%6 proceed to "SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM MINIMUM Ceiling arid Slab Perimeter ElJ Fenestration Exposed floors �all Floor Basement Wall R-Value U-factor R-Value R-Value R-value R-Value and Depth .39 R-37 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area(i.e. not compressed over exterior walls, and including any access openings). . SUNROOM—An addition or alteration to an existing building/dwelling unit where the total El glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form found in Appendix 120.P) OFIKE T 'Town of Barnstable Regulatory Services` �saxh�s�1E$" Thomas F. Geiler,Director �iOrEpr�'0 Building Division - Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, NQ®Nd--( 0 Zr--qNg , as Owner of the subject property hereby authorize CZE— ft-t 7t-, j l Er1L to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) i /.Jim 'al 4L/L__ Signature of Owner Date �/ �a f c� VZ lY1cL� Pnnt Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION I ! 1 Town of Barnstable m pp "o Regulatory Services si BAMSfABLE Thomas F.(seller,Director MASS. 163g. ,�� Building Division iOlEnr a 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: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING 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 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 requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings coritaining 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\FORM S\homeex empt.DOC i Massachusetts - Department of Public Safety -bat-d of Building Regulations and Stan'dards ` .4 .Gonstrucfbn Supervisor License License: CS 79074 - Restricted to: 00 JOSEPH MILLER 26 POPPLE BOTTOM RD SANDWICH, MA:02563 IA a Expiration: 9/11/2010 ('onuuisiuner Trt#: 3986 13ofYtRfl'g�; (� - Yft�orh I HOME IMPROVEMENT CONTRAC`FOR License or registration valid for individul use only f. hcfore the expiration date. If found return to: i Registration: 15208.3 Hoard of Building Regulations and.Standards t Expiration':"7/28/2010 Tr# 0 One Ashburton Place Rm 1301 -ype: Individual Boston,Ma.02108 ' JOSEPH MILLER I JOSEPH MILLER Y/ 26 POPPLEBOTTOM ROAD SANDWICH,MA 02563; AdiiliuCSrn�tri' n. Not_ valid without signature..` .: .__ ......._� ._ ture 4Y - • .L 1 O--- - - 2vas=mr —-- _ 10 I © _ ---- ORT/�NT — t11A _._ pNy CONSTRUCT�IOI THAT INCREASES LIVING SPACE FOND ON .O 'DDT ONAL EL MAY S SMOKE REQUIRE THE DETE�CTORS STALLATION . NOTE: A °EPARA PERIAIT IS REQUIRED FOR THE n c CET ECTORS-THE ELECTRICAL INSTALLATION Or SF I�K�Dc- PERMIT�F�3.t`.:—' ATiSFY THIS tcQU1R=tAEtvT. • _'�jS�IiSR7TYSQ Ll AAI .- - - , � � - a n - � �?'9Y?st"AssGfcuxw) .Il (.'t�9713LT=fir•— -. - . • li r 11 •I :, �Q�yj1!7 I I I 1 1 1 1 Fl P GT"FC'6t5fL�>��� _ '�2 w c'-TSFSI• t- N. Teu uo�l _� �2����I`1 . �j�p1P FB2YITION-� - o-r+.w�y'� �F AT EVC4Y ptHER . [R Fn I � i - I _ I f �SLL Ip..4 c a ' vKE,p�'{� 'Town of Barnstable *Permit# o Erpires 6 monilisfrom issue date Regulatory Services Fee. r • anxrtsTAaLE. Thomas F. Geiler,Director FD MA'I ' Building Division 0� 'LIAR .2 4 ? IT Perry,CBO, Building Commissioner row 010 200 Main Street,Hyannis,MA 02601 OF www.town.bamstable.ma.us Office: 508-862-40 6A��STABLE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint �} Map/parcel Number (,/ Property Address l /L [Residential Value of W Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name /YltLff_ Telephone Number Home Improvement Contractor License#(if applicable) /t Construction Supervisor's License#(if applicable) �f'S ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (� I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 0 7 l (9 7 Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to �n SE Lam//.�/ ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑' Replacement-Windows/doors/sliders. U-Value (maximum .44)#f of windows i *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: Q:\WPFILES\FO \building permit forms\EXPRESS.doc po,A-1 nonQno uo. lrYB�i"d3if1Y �fofrrt License or registration valid for individul use only HOME IMPROVEMENT CONTRt{CfOR ± before the expiration date. If found return to: Registration: 152083 B,iard of Building Regulations and-Standards Expirit ori,�.7/28/2010 Tr# 0 One Ashburton Place Rm 1301 B ston, Ma.02108 Type.=ln-dividual 14 JOSEPH MILLERt 11r i- Yf JOSEPH MILLER 26 POPPLEBOTTOM ROAD- f SANDWICH,MA 02563 r 6Not.valid without signature f _ I i B0 r r 6f�8fii o Nf Nlussachusctts- Department of Public Sat'ct� HOME IMPROVEMENT CONTRACTOR ! Bnurd of BuiWin;, Rc;�ulutions and Standard's ! st s •.Construct bn Supervisor License Registration: 152083 `License: CS 79074 Expiration:' 7/28/2010 Tr# 0 Type: Individual Restricted,to: 00 , JOSEPH MILLER JOSEPH :MILLER. JOSEPH MILLER _ 26 POPPLE.B3TOM,RD 26 POPPLEBOTTOM ROAD ��>�, � 'i`'°""= SANDWICH, 02563 SANDWICH.MA 02563 Admistl;�t�tr ' Expiration: 9/11/2010 ('onuu issioner T r#: 3986 r The Commonwealth of Massachusetts Department of Industrial Accidents 1� �r Office of Investigations I' t500 Washington Street �fIc Boston, MA 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual,�:c_.Ie 17-7z-LLO- Address: City/State/Zip: L 6 Phone 612- '229-J Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 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 sttb-contractors have g, ❑ Demolition workin for me in an capacity. employees and have workers' g Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp.insurance.t required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or addition 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or addition myself. [No workers' comp. right of exemption per MGL 12J�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 ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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 cry employees. Below is the policy andjob site information. rr Insurance Company Name: ntou Policy#or Self-ins. Lic.#: t90 5-0 '7 6 7 Z Expiration Date: l© — Zit l d Job Site Address3(00 City/State/Zip:A/1g09rg&A A'M4CL 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 fin of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder thepains andpenalties of perjccry that the information provided above is trice and correct. Signature: -v't- Date: 3-- Phone#• 6l1 - ?Z3 - L52_66 - 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: I I t rat 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the i 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 pen-nit 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 rriaiked 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 r �THErp� Town of Barnstable Regulatory Services BARNSTABLE Thomas F. Geiler,Director KA&K el) �` Building Division Tom ferry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �D OOtAH yZ , as Owner of the subject property hereby authorize S6t; /1��c �R- to act on my behalf, in all matters relative to work authorized by this building permit application f or. 360 �i/z-`u-Mctc emu( /1-1-rcc.j (Address of Job) Yn Signature of Owner Date c ra k JZ CI(1 a n n Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. I 5 i Town of Barnstable F'tt1E Tp� ' Regulatory Services t iiwxrrsrxsue Thomas F. Geiler,Director 1639. Building Division j �e PrED '�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.towii.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone fl work phone tl CURRENT MAILING 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 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 requirements. 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 dQ such work,that such Homeowner shall act as supervisor." ey are assuming the responsibilities of a supervisor(see Appendix Q, Many homeowners who use this exemption are unaware that th Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when.lhe 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 helshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a forrrJcertification for use in your community. Q:\WPFILES\FORMS\homeexempLDOC e - • w -THE Tp� •Town of F ti Non-overn; y BARNSTABLE. y MASS. Expense Rei z639• �� prED MA�p Claim C.A/a/AE Name 81z/&,DIN6_ . Lo C41- Department Select a mileage category from the rate tab and enter it here to, Itinera Date Departed from Arri ISE 1 Town of Barnstable y7 �„ BARNSTABLE. Regulatory Services MASS. Building Division prFO Mph A 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of In �/ 722F yp Inspection Location�Go �'��T�,BAtic �.� Permit Number Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: ��P z 7- Please call: 508-862-4038 for re-inspection. Inspected by Date ` / "! '� �� THE Town of Barnstable 7�0� ►O{�ti O,e BARNSTABLE. Regulatory Services MASS. 0 � Building Division p�F MP'� , 200 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection Location.?Go xr�- 4VI Permit Number Owner Builder ,t 1 One notice to remain on job site, one notice on file in Building Department. 1 The following items need correcting: J / zl")a 7- w yB Please call: 508-862-4038 for re-inspection. Inspected by Date °F tHE Tp� The Town of Harnstable STAB � Department of Health Safetyand"Environmental Services ATF01�'�A 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 IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION s 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. Type of Work: C[az� --�� Est.Cost Address of Work: 1';' d /2V 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-Budding 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 IMPROVEMENT 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 \. Date Owner's Name The Commonwealth of Massachusetts • �+_i: -_-' �;:� Department of hldunrial Accidents ,.JOffice 01109SOMMS r �,4 _ 1;: :=r;�' 600 1i'ashinrlun Street Boston, Alas. 02111 Workers' Compensation Insurance Affidavit ME c • D r c•t 12hone# 1 am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ...th,,.,,.. y :va'i.+?.". �_ P'+r.. ; v�T.?%�!qt _:^�e,T.:¢....gp ?T.•�—�;e-.a,ye-.•,-.�,...an:.sc� I am an employer providing workers' compensation for my employees working on this job. comlianv name: address: city: nhone#• insurance co. policJ # . i._...�i::- •<e.- .,r; .-sr+ •gxp•e-o�e'>,:p7�r:, •�n, rswr..y-�Fn _ _ .,w.•�......_ r.�;.-M.......,..�.,... 1 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#• insurance co. policy# i���.-0;: :,<. - - - �/7t«-_ :.71�'m:-=�•�:"1„.Y;e.e�tr-^.s,_' .-e-^-•rara2�+�^i;�-y�ita.�+ 'p�Dn;�`.:'••' ------ �t"✓:,"'r?::-.,w.-.'.:_ra.�....:_.�r_.- - -�_._'::.ilia• ...,:. - ---.:rJ�a..ai"'�atitis:f ='� u:.us:..l�or�tr•'.:araais.vs company name: address: city- Rhone#• insurance co. _ policy# :Attach addthonal sheet tf necessi .:4'' `yj`'s '.r.i�: - — ' ��.• a "�+ �i= _" = ssYt'�51t rc�c..sia. Failure to secure coverage as required under Section 25A of D1GL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one •cars'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. Zigonatur ehl ccrtifp r nder tlr Wins ntrd penn'ties ojperjuq that!!re information provided above is true and correct. e `- D::Zone e O 1(O Print name # 6& r47ofricial use univ do not write in this area to be completed by city or town official 7Department "city or tpwn: permitAicense# ritmentdcheck if immediate response is required Oice01ent 'contact person: phone#; ri 1= ' -ems.--:--:,-....-�s,�a.m��,,,. .. _.,.... r. 1, .... .,_ _. .�. . �►,r?r.-.d•.,r...�,• '•r (revised 3,95 P1A). , F Information and Instructions I ' i • Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compens�ii-ion for their employees. As quoted from the "law", an enrp/oree is defined as every person in the service of another dhber•any jcontract of hire, express or implied, oral or written. An etnp/nver is defined as an individual, partnership, association. corporation or other legal entity, or any two or more of the foregoing enga-ed 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 (,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chanter 152 section 25 also states that even, 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 commomvealth for any applicant who has 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. •,. , .. ..: r:`•,•... •?.. ..>.�• ..�a• «'4.:: <A,:J"i2,•.:j:,,,�:* air}•yr:r....«i.YX r ,.i!:., 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. -;�^�..,�-na^'.,;.n, .'�^**-- � .. ..,�.. m..•.s�rt�rr--,�..^v...e,.�l+ a 'ryti,.. y.,r,k t lr�.•[�'las:!�r t� 'sn+e .�.,ti.;✓ l ..:�. ... Citv or Towns Please be sure that the affidavit is complete and printed legibly. Tile 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. Tile affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investi(,ations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. r••touv-a•.,•�:•...,............. .a.. _. ,-rw�v .:te..' ,.+,r,-.�•'±s� ."q�'�!e..'�!'•3.`,.�°'�^ "'.""yn"t".^,•*'."';"'.rx. �''»:'r.'— Tlle Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 NVashington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 i 30751 ti SHEET 2 F 349 382L350 _ wee Sheet CAI 0 352 aot�.v,o�':PATH s« shcf 1 GRAM®LE 0� 4.7Ici . 00iE 375 383 a • , 3 5 7 a �5E o" cl 353co 374 �,3� .o y 35f fn , CN 358 a o° 354 )7 s ° Mo v in h 0 0 2 S0.3� •,o My� 3 1 �3 . . ti b ¢ o r 355 372 359 It Lb , m 4 15y� ,5�` J . ,e _• : ti, , , zG o� 3 364 i � r co `360_ o so053 .,z 2� L,• 363 •m \ A�j, 0) \,""�'� M2 \6�` .d' ' .;`y0a\0'��. o. Y �,cj1 cP ltl 370 0 o SSA ,' ,: Arkc�'> �p M,o 65 362 3 s'�%Z E p tifr / 5� r Lr �c9\rm O ao � \O• ti i� z�.tip. 385 goo ;. Z, -; �� 384 �, 386 OIL 361 V. ul ��� 1L y� ��$ N o IL @@@yyy Q,2 so 7ood �. 387 25.33 tj' l A 1 Q:ras33 R.�`5500 Vr •91.43 I .57 t 6� � s 210.00 �. 388 No fo oN 390 1 i �;y'._""" :I'Seo% of��ii p/an /Go fe•� fo n inef . • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER' LICENSE EXEMPTION Please print. . OB LOCATION Number . Street address Section of town "HOMEOWNER" Name Home phone Work phone, PRESENT MAILING 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 such homeowners to engage an in- 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 re- side, on which there is, or is intended to be, a one to six 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 acgapt*able 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 Stat Building Code -and other applicable codes, by-laws, 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 comp wit said procedures and requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. 1 HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction' Supervisors, Section 2. 15) . This lack . of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as' it would with licensed. Supervisor. The Home "Owner-`actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities,. man communities require, as part of the permit application, that the Home 'Owner 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 to amend and adopt such a form/certification for use in your community. _ I Pp P-I Nj6; �l 2 0 r ��S c� I - 2-0 / 0 C 04 ® r IWO 57\1I PW ', ► ; ®® X r, � ,ate ; �; ; �1�,�';� i� ��,� � � J�� r�® �•i. • i Engineering Dept. (3rd floor) Map 624 Parcel Permit# �0 House# Date Issued Board of Health(3rd floor)(8:15 -9:30/1"00_-4:30) I/ >,?9V Fee ,,7) Conservation Office(4th floor)(8:30- 9:30/1:�0 -2:00) ` �IKE►p; 19 �c1sTl� 6� •'BABNSTABLE. IRfAA E _ TOWN OF BARNSTABL u WIT VIRONMENTAL Building Permit Application TOWN REGULA71 roje reet Address Q Village Owner Address Telephone02� Permit Request First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 0�to Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure a0 H' oric House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl alkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing _� New No. of Bedrooms: Existing —3 New Total Room Count(no=,nclud* aths): Existing New First Floor Room Count Heat Type and Fuel: Oil ❑Electric ❑Other Central Air ❑Yes (�'N0 Fireplaces: Existing New Existing wood/coal stove ❑Yes Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) 02 ❑Barn(size) ❑None ❑Shed(size) r ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name a�!�l7 p�L_i 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 < Qr SIGNATURE - DATE ia' BUILDING PERMIT DENIED R THE LOWING REASON(S) FOR OFFICIAL USE ONLY { P L �J PERMIT NO. DATE ISSUED!, l MAP/PARCEL}NO; ADDRESS 0 VILLAGE OWNER tJ P 7 DATE OF INSPECTION: FOUNDATION I. FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FIN' L GAS: ROUGH f_- -FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO.