HomeMy WebLinkAbout0052 WILLIMANTIC DRIVE Ck) 4-L c- -C)
.� ,. Town of Barnstable Building
RAMSrA Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card.Must be Kept
163 Posted Until Final Inspection Has Been Made. , Permit
t Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made.
Permit No. B-19-3804 Applicant Name: HORRIGAN,SCOTT&SUSAN Approvals
Date Issued: 11/13/2019 Current Use: Structure
Permit Type: Building-Smoke Detector-Fire Alarm Dection Expiration Date: 05/13/2020 Foundation:
System Map/Lot: 103-054 Zoning District: RF Sheathing:
Location: 52 WILLIMANTIC DRIVE, MARSTONS MILLS
Contractor Name: Framing: 1
Owner on Record: HORRIGAN,SCOTT&SUSAN Contractor License: 2
Address: 52 WILLIMANTIC DRIVE Est. Project Cost: $0.00
Chimney:
MARSTONS MILLS, MA 02648 Permit Fee: $35.00
Description: upgrade whole house smoke detectors Fee Paid: $35.00 Insulation:
Project Review Req: Date: 11/13/2019 Final:
Plumbing/Gas
((( Rough Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced withinlsix months after issuance. Final Plumbing:
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Rough Gas:
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. J Final Gas:
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and-Fire-Officials are provided on this permit. Electrical
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing Service:
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest flue_lining_is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Health
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT p7�' Final:
ApplicationNumber................................................. .........
BARNS E94 s'
MASS. Permit Fee................. ..................Other-Fee:...........��......
%639.
0
fill"
Total Fee Paid.......................................... ... ....
TOWN OF BARNSTABLE Permit Approval by.................................On. ......j....
BUILDING PERMIT
Ivtap......... .
APPLICATION
Section 1 — Owner's Information and Project Location
Project Address �� �! ► Tr d/iUC Village
Owners Name TA Derr f1%
Owners Legal Address
City State Zip
Owners Cell # E-mail ��6A O II
Section 2 —Use of Structure
Use Group ❑ Commercial Structure over 35,000 cubic feet
❑ Commercial Structure under 35,000 cubic feet
❑ Single/Two Family Dwelling
Section 3 — Type of Permit
❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use
❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm
Rebuild ❑ Deck Apartment El Sprinkler System
❑ Addition ❑ Retaining wall ❑ . Solar
❑ Renovation ❑ Pool ❑ Insulation
Other—Specify
Section 4 - Work Description
74 AR
A)��'rL al
Tact undated- 11/15n01 R
Application Number..............................................:.....
F— Section 5—Detail
Cost of Proposed Construction Square Footage of Project
Age of Structure Dig Safe Number
# Of Bedrooms Existing Total#Of Bedrooms (proposed)
110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors
❑ Plumbing ❑ Gas ❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom
i.
Water Supply ❑ Public ❑ Private
Sewage Disposal ❑ Municipal ❑ On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: I am using a crane ❑ Yes ❑ No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq. Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yard Required Proposed
Rear Yard Required Proposed
Side Yard Required Proposed
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No
Last updated: 11/15/2018
i
Application Number...........................................
Section 9= Construction Supervisor
Name Telephone Number
Address City State Zip
License Number License Type Expiration Date
Contractors Email Cell#
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license.
Signature Date
Section 10—Home Improvement Contractor
Name Telephone Number
Address City State Zip
Registration Number Expiration Date
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C...
Signature Date
Section 11 —Home Owners License Exemption
Home Owners Name:
Telephone Number Cell or Work Number
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation req ' ed by 780 CMR and the Town of Barnstable.
LSignature Date d121A_
C.
APPLICANT SIGNATURE
Signature 7 Date l
Print Name Telephone Number.
E-mail permit to: °� ''( � Ga/�
r Act,,.,doPvi• 11 n anm a
Section 12 —Department Sign-Offs
Health Department ❑ Zoning Board(if required) ❑
Historic District ❑ Site Plan Review(if required) ❑
Fire Department ❑
Conservation ❑
For commercial work,please take your plans directly to the fire department for approval
Section 13 — Owner's Authorization
I, , 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
Last uvdated: 11/15/2018 h ,
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'_!Q11 TURES.ARE REQUIRED FOR pERMITING
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The Commonwealth of Massachusetts
Department of IndustridAccidents
Office of Invest1gations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with- 4. [2 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
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
3.❑ raj officers have exercised their 11. Plumb' repairs or additions
I am a homeowner doing all work ❑ mS eP
myself[No workers'comp. right of exemption per MGT, 12.❑Roof repairs
insurance )t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees.they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerd, un th p#ks and penalties of perjury that the information provided above is true and correct
Si 4 z
— ` Date:
Phone#: �0 `9 —✓��(
Oj)Icial use only. Do not write in this area,to be completed by city or town gfj`icia[
City or Town: Permit/License,#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person iri the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public-work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contactors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the munber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for f rtre permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax nmmmber:
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
Revised 4-2407
Fax#617-727-7749
www;maw.gov/dia
i TOWN OF BARNSTABLE
I
BUILDING DEPARTMENT .
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE /
JOB LOCATION 2,
Number Street Address y Section �Of Town
HO_-MEOW.NEp /AX, U,1 g L 5/5 Y �� �=
Name Home Phone orr:Pjhon'e
PRESENT MAILING ADDRESS
d � 6 Y �
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 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 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 acceptable to the Building Official,
that he/she shall be responsible for all such work performed under the.
bullding' riermai ..' 'Sect ii o 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the
State 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
HOMEOWNER'S SIGNATURE
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
_ t ;
I '
HOME OWNER'S EXEMPTION
The code states 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
awareness often results in serious problems, particularly when the Home
Owner hires unlicensed persons. In this case our. Board cannot proceed
against the unlicensed person as it would with licensed supervisor. The
Home Owner acting as supervisor is ultimately responsible.
To' -ensure that the Home Owner is fully aware of his/her responsibilities,
many communities require, . as part of the permit application, that the Home
Owner certify that he/s:;e 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.
r COMM ' TH OF MASSACHUSETTS
=F�R DErAXTN ENI' OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
BOSTON, MASSACHUSE'ITS 02111
fames J Camaoev
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
f
1,
(licensee/permiacc)
With a principal place of business/residence at:
(City/Stitt/Zip)
do hereby certify, under the pains and penalties of per)ur),, that:
[ J ] am an employer providing the following workers' compensation coverage: for my employees working on this
job.
lnsurancc Company Policy Numbcr
am a sole proprietor and have no one working for me.
[ ) 1 am a sole. proprietor, general contractor or homeowner (circle one) and have hired the contractors listed bcloA,
who have the following workers' compensation irsurancc politics:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Compa.ny/Policy Number
Name of Contractor Insurance Company/!Policy Number
,, �M2meowner performing all the work myself.
]VOTE: Picric be awaie that while homeowners who employ persons to do rnaintena.nee,construction or repair work on a
dwelling of not more than three units in which the bomeowner also resides or on the grounds appurtenant thereto arc not general))
considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)), application by a homeowner for a license
or permit may evidence the Icgal status of an employer under the Workers' Compensation Act.
) understand that a copy of this statement wiU be forwarded to the Department of lndustrial Accidents' Oftiee of lnsurancc for.eoveragc
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of_stiminal penalties
consisting of a fine of up to S1500.00 and/or imprLsonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against me..
Signed this day of . 19
Litesee/:Permirtce. Licensor/Permittor
t <ti
Assessor's office(1st Floor): )OS ������� oiTN[ 0
Assessors map and lot numbs
Conservation(4th Floor): " r
Board of Health(3rd floor ��R®
Sewage Permit number STOL
t ����
Engineering Department(3rd floor)::
House number I �/�, • u�� l .rgcy�'i �lt�r
Definitive Plan Approved by Planning Board 19
APPLICATIONS PROCESSED 8:30 9:30 A.M.and 1:00-2:00 P.M.only I ,
TOWN OF BARNSTABLE
'BUILDIHG ' INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION I /(/
i — ,
I '
Sew f / 3 19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according
/1to the following information: /,,�
Location ;So2 �cJi ��H .g c �l' /i iiq rt ��✓S /�1, �/S
Proposed Use C&iZ C SA(21
Zoning District Fire District 0 —In/y/
Name of Owner l`7l�i�0�� M.IA//Calms Address
Name of Builds ��- lg�� ��wH� Address
Name of Architect Address
Number of Rooms r-fC$,e U`"n,l Ate, e C Fr e 1 Foundation /o o /10 Al -po U
Exterior /V5 Roofing Sa'R'S/e frSjgoh /7e--
Floors�� /J-� J Interior �tru
Heating Plumbing d
OG
Fireplace 'yd Approximate Cost ,oO O
Area
Diagram of Lot and Building with Dimensions Fee
Ft
Z
4-
lLk)OU l 1 J
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.
Nam
b
Construction Si ipervisor's License �1a �
i
MONTCALM, HAROLD i
r
No 36273 Permit For Build Garage
Accessory to Dwelling
Location 52 Willimantic Drive
Marstons Mills f
Owner' Harold Montcalm =
. -
Type of Construction Frame
Plot Lot
Permit Granted October 2`8 . 19'_ 9'3
Date of Inspection:
Frame /- 19
?y} Insulation 19 -
Fireplace 19 -
Date Completed 3111,11W19
'v t
y..
7
'' S
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
o TOWN
0 F8 RR,Map Parcel
pyiat6r
Health Division 7013 JUL 30 Ddte�sse�i �l 3
Conservation Division Application F' ( �
Planning Dept. ermit Fee
DIVISI0r1
Date Definitive Plan Approved by Planning Board �.
Historic - OKH _ Preservation / Hyannis
Project Street Address _To9 �� l l�ia[�I' IZ n^l�12 5l 04 �'11 f �LtG9 4� y�
Village..M(m sto'h s �%N S` MA
Owner c✓t a l �, e cc(vim Address S d 4'Ayh ya-)<< 1)it 1d6,as1-1kf A11e-
Telephone
Permit Request ��� .e•-.� 0--ta-v—, . < .0 ee o
�t �A4s
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: ❑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 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: ❑ 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 ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �,, �Q lM� �fili�, Telephone Number
Address �a Z'✓i,�r f Vhn 'ram (7 L License #
I VK A IQ Home Improvement Contractor#
Workers Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO G�
SIGNATURE aAc, f 0� �/l� �/^' DATE / //J
li~
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER -
DATE OF INSPECTION:
>' i_-,FOUNDATION
FRAME
i
INSULATION
r. FIREPLACE
� w
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
g
FINAL BUILDING
' DATE CLOSED OUT
r ASSOCIATION PLAN No. .
-
i
The Commonwealth of Massachusetts
UFDepartment of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): p� inl'�fi lNt
Address: ',l C -Y( W A kv4 c t(Z
City/State/Zip: (Qh, U110 Aid Phone#: ✓r��` _�' ��
Are you an employer?Check the appropriate box: Type of project(required):
1.El am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity. employees and have workers'
# 9. ❑Building addition
[No workers' comp.insurance comp. insurance. 10. Electrical repairs or additions
re ed.] 5. ❑ We are a corporation and its ❑ P
3 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no ((,,,, �
employees. [No workers' 13. }Other`'JXX (°I
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.
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 my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,50.0.00 and/or one-year imprisonment,asmell 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
I do hereby cerWfy under
/the pains and penna-ldes of perjury that the information provided above is true and correct
Sisnature: -/ Date:
Phone#: - � C;Z 0 ' O (LO 7
Fxcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also,states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to 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
Revised 4-24-07 Fax# 617-727-7749
wwvv.mass.gov/dia
I
.y
Town of Barnstable
Regulatory Services
i A�AA7�R'1iR.£
Thomas F.Geiler,Director
6"s0. 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
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: 3 6 //--?
rr/
JOB LOCATION: f 1�l 1'H alei 5 lI J Aad 6
mnnber h,, sheet �]'
"HOMEOWNER": fM0 ! `(1�'t�C4b/t� 5��� CA S'v (J " �/
name home phone# work phone#
UCURRENT MAII.ING ADDRESS:'s�— Iv d( l"W f
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 Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
1 ign 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
Usection 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 2.1S) 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. Ou 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 m
your community.
C:\Users\decolldc\AppDataV.ocal\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\E}CPRFSS.doc
Revised 053012
�IKE l Town of Barnstable
Regulatory Services
n�g Thomas F.Geiler,Director
.163y ��
'6 39 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 Usigg 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 pernut
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORM&OVJNERPERMISSIONPOOLS 6/2012
Town of Barnstable Geographic Information System July 30,2013
#575
103053
#38
103135
#33
103054
t
a.
103062 i
#49
Sr
�u
103061 103055
#63 #64
103136
0 13 F et DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:103 Parcel: N
boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel
1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:MONTCALM, ROLD F JR Total Assessed Value:$263000
are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.47 acres Abutters W E
boundaries and do not represent accurate relationships to physical features on the map Location:52 WILLIMA IC DRIVE
such as building locations. Buffer
Aerial Photos Taken April 19,2008
�9 i3
f
C� 10—
oFtIKWE tqy,
T, of Barnstable *Permit#9
`� �� ■ �w epartment Services Expires f'omissuedate
,,, ST„ Brian Florence,CBO
HAS& cp 26 Building Commissioner
prFp Mpt���� SGr Lot eet,Hyannis,MA 02601
Office: 508-862-4TDW%o
F �� �� .barnstable.ma.us
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
G`Y Map/parcel Number Not Valid without Red X-Press Imprint
91
_ � ( (, ,,
Property Address �02 11l MBA ,C� orf,v ' `�! ��� / ![ a
R1 Residential Value of Work$ 0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address SG r a t' 1 • ✓�04 o� C—
��rf�
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑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#
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 t
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:_
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE: �52�
Q:IWPHILESTORNIMbuiiding permit formsTYPRESS.doc
11116/11
The Coamorrfvealh ofA&YsadruxdfY
Department qfrnri=trialAcdde7ds
Orke Of blysiigatians
r 600 Wash`fiWun street
_ Boston,AM 02.11
' f�vXum�grrv�iiia
Workers' CumpensaUm InmiranceAffidavit:BmIders/CuntractarsMectdcLan. bombers
�i #I�fcxrmafi Please Print fe
Name uhmi
101
CayfStabelr P'lGrs � �` O�}(y d Phaae ��� ��3 ✓�D
Are you an employer?£heckthe appropriate bo= ' Type of prof(rel e=4-
L❑ I am a employer ugh 4. ❑I am a general conbmctar and I 6. ❑New mnstiuci i
emp.1ayees(fall andfor part-ime)* 1iave hiredfhe sue•-contmotom
QZ�ta sole propZmtor orgartnw- Nsfed oathe•attached sheet;. 7. ❑Remode1mg
These sab-cofrac.tars have
sl�i and have noemployees. • 9- ❑Demolifiaa
-vorldng forme is any sty... a aployees and have waAmrs' 9. ❑B,uildmg addition
IN4 WP635 S' Comp_iacrtxatLre CotII�7_marcrarm•
I ❑ We are a cmpomfien.and its le ElRlPrfxir�rf repair or ad our
3_�regaaho officers have.x=. sedtheir 1L Phnabin r aim oradditiom
I am a bomeo�ener doing a1f Mork ❑ g eP .
Myself o woks, r=�of exempfion per MGL
� �- c.f�z 1 and L.❑Roafrepairs .
immmice required.]i ,§ ( .
employees.[No wo�ess' 1311 other
comp_iasar m inquired-I '
►gay app&®L�sc che�sha:�1�aLsa ffio�the sechoabeTaev�ntda��e¢ura$cea'mmpensaHnupoTicyiafocros`ne� .
��nmeovraersvrI�usaf�ci�os�fid�ru" xsr;,�•vt�yax�3aia�sgwar3caagtfienLeixa�caatrac�aaa�snbmitanem�a�tindi�sacF�
iCaa�adms�u.2c�ecl�fi�shmcmuststYaclu�msddi6�slsiceetshotciag&enmmeofthesab-cc�zsc.6o-s�elst�evthethesarnott"finse®tifiesha�
mnpivye&;.iftbesrm-c=tzdctsIuseempIofeas,they amstpm,6&&es wudm&camp.pdi yaumhec
lam am empIo r tJta[is prouidiiz;markers'compertsdimt hmirarwefor ruy amployees Mow is thopoiicy and job spa
€nformaliom
Insurance CongmnyName:
Policy-,A*or Self-srls-Lic-& Fxpim iouDate:
Job Tifa Address` CityfStmWZip:
Aft2ch a copy afthe workers'ca�pensationpolicy declara4ian page(showing the PoRcY au aber and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGI.a L`'-can lead to the imlposit* of criminal penalties of a
fine up to$L50D Oa amVor onL--yearim}mso as well as cif penalties m fe farm of a STOP WORK ORDERand a fine
of up to$2fO-Da a day ag ind the violafar. Be adcdsed f a copy of this sfatement.may be fatvearded fn the Office of
IwmsEigaficm ofthe DIA far iiasurance-coverage
UrfakerRby �Afftkgartdpsr�al sa,fF&jUryfMttftsbfbrma#iar�prmidedabm�ai� acidcarrmt
^�iEcaature Bate
Phone i;� 7
0j%d E use artIy. Do not ttsrrte in dds area,to be.cmupfeted by diy artown of,jfciat
City or Ta-wn: PermitlT=;cease:9
Leg Authority(trcle one):
L Board of$eaItft I Building Department 3.City-frown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 9:
formation and lastructions . . .. : ;
Magsarfiass Goal Laws 15z regoaes aII e�ploye�s to Provide wDrkem'�P °n fiir rizei=� -
pursM,Mt-to this ,an MTL*ae is defined as¢:ee�tyPeasoam$ie ser'vice of err md=amy Coact of�
express or implied'oral or writ =f
oration or other leg entdy or any tw or mare .
AIL�iployer is d�f oed as"an in�vidual,pax{n .assoca�ian,�P '
of t�f=goi ng imaged•is a Joint else,andmclndmg the Iegal Fep==a&w of a deceased=s-=31 Hyea',or the
recei�r or tros of an baVidnal,pip.associatiM or oche rlegal entity,=3p m �P� owever the
hanse having not more the tinee arhnents and wh:o resides or the occupant of the-
owner of a dweffiog repair wo&on soh dWe�haose
dweIIing hDUSe of another who employs persons to do ,construction or IEp
thereto shallnotbecanse Of elaploymmtbe d=Medto be an employe"
or on the groozlds or bm7r1mg appnr�a� •
MGL cbaptrr 152,§25C{6)also status thhat aeYery state ar local l'1=1dng agertcY Shall wiffihold the issuance or
renewal of a$cease or permtoo oper
itate a busim hess or to cons tract bwldio 5!a the commonwealth for any
appIix�ntwho has aotprodnc�d acceptable eYidemce of cdmpr=,e,with the bj r ce.coverageregnired_"
A&E&nOly,MGL.haptra I52,§25dM stafes aideiffi=tTie nar�y off political sobcfxvisi®s shall
en1er in,�any contract for the perform mco ofpnblio work ma acceptable evidence of eaznpIian cewith the mso¢'nce•
r eams ofthis chap rhavebee�prese�dfD the confra g.anthorjfy:'
Appiicatrts
Please fi�out thin worms'compensation arTdav>t compleL-ly,by chug the boxrs that apply to your situation and,if
necessary.SPPIy�s)name(s), adff=s(es)and Phone;IMM M(s) aIongw1fttbea c "cste(s)of
anies or LimitcdLiabffity`Par =ships(LLP)'w�no empIopees other than the
hastzrance. LmmitedLiabiliiY Comp LC
members or partners,are not regaied to tray workers c�ensaftan l ante If an Id�C or LLP does have
employees,apolicyisregafiuL BeadvisedtbA this affdaYit maybe snbmf tDddtotheDep-hnentOf Industrial
Accidents mr coofmaabnn of insurance coverage. Also be sore to sign and date-the affidavit: The affidavit should
bcTcb aedtojffi,ecityartownthatthesppficationforthepermitorlicenseisbeingxegn�
not the Dc-partment of
T„ A rdr=:L- 9umIdyo-a have any questions regaTmg tTie law or ifyou a=named tD obtain a wogs'
ease call the DePartme�at the mm3ber listnd below Selnnf-in ecanpanies should eater their
com pemsationpolicy;PI
s elf-insarance license nmuber on the appropriate Ime.
City ar Town Offidals -
.
Please be sore that tjie affidavit is eamplctr a3aAprided Iegffily. Zhe Depemeotl=provided a space at the bottom
You to full o�in the event the Office ofT„vr :�f*r***�has bo contactyouregardmgthe applicant_
of the affidavit for yo
Please be g=to fMin the perm>t/licrosc mMber which will be used as a=tnre:nce xrmber. In addition,an applicant
on
llaMt
at
mBsf sabn>t n�Iiiple pevmTHii c�+Ce applicsiians]a any given year,need saFmmit one affidavit indlcafing caz
policy infnnnaiian[ifnay)andender"lob 5 "the applica3t should writes aeII Iacati.ns n (may or
town):'A copy of the.affidavitthat has been.officially stamped marked by the City m bows may be provided to the
applicant as groofthat a valid affidavit is on file for f�ore'pe�zfs or licenses A new affidaVkIM t be fMcd o't each
year.'Wh=a hDme owner or c i=a is oMaming a license or pe=it not ir�ated. any bps e orp=uk to bmnIeaVM etc-)saidpmM is N0T bo complete this affidavit
(ie.a dug licens avit
or commercial Yew
The Office of Invesfigafinns wouThb--to thank youm a&a=for your cooperation and should you have nay gosliom,
please do nothesitate to g" ns a call
The Depazimex's address,telcph=and fax nmaber:
Co. �c�tt1�of�u De
Departamtc�fludro .Ac ld�nt
• - face a�X�fio�
Haan
c =I A C2111
Tt,-1.161-,F-' -4 mt4€1f w 1477 MAMUE
Fax 617 727 7749
Favised4-24-•0 7 �1Tf�
e
Town of Barnstable t
Building Department Services
Brian Florence,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
sn30rsrnBM
KAM www.town.barnstable.maus
1639.
Office: 508-862-403 8 Fax:. 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Qhn
PleasePrint
DATE• ( / ,' �1-�,—�1 /�/1/�� �p ����rn/� �I�
JOB LOCATION �� w< r�"/Gf�! (� ✓� �VL J �
/1 village:
"HOMEOWNER": numberQ l �f
name home phone# work phone#
CURRENT MAM NG ADDRESS:
city/town state up 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
proc sr dents 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 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
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.
Q.\WPFILES\FORMS\building permit forms\EXPRESS.doc
08/16/17
Town of Barnstable
Building Department Services
• ELAP.?4SM&I Brian Florence, CBO
WASEL
6 16 Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.maxs
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 behal.fy
in all matters relative to work authorized by this building permit application for.
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
I Signature of Owner Signature.of Applicant
Print Name Print Name
Date
QYORTZ:OWNERPERMISSIONPOOLS
Rev:09/16/17