Loading...
HomeMy WebLinkAbout0009 WOOD DUCK ROAD ��oo� , � �� �, Q ., - a G. �� ,:o g � S G+ ^ �r� � �� �f O Y i � (� � II 1 � � � �� �a ����— . � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map�._� Parcel 3 -;,.Application # , 0166 Health Division "Date Issued 09, Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation /Hyannis Project Street Address 9 GJ � GLlCK Village 1 �?nys /YI/GGS Owner ��� ' Da��e/ y` � � Address �' G✓Lt�A�c�Ke� Telephone L�5 `09 5-)5O Permit Request Pt-1/CX dv QnCe, Square feet: 1 st floor: existing proposed 0 2nd floor: existing proposed o Total new Zoning District Flood Plain Groundwater Overlay C= o ' Project Valuation av Construction Type c. z Lot Size ACC Grandfathered: 0 Yes ❑ No If yes, attach supporting Co ur mntation. � n Dwelling Type: Single Family : Two Family ❑ Multi-Family (# units) ; Age of Existing Structure y9 Historic House: ❑Yes I�No On Old King's Highway:ZM Y�z *0 Basement Type: G�Full ❑ Crawl ❑Walkout ❑ Other co Basement Finished Area (sq.ft.) 60040 Basement Unfinished Area (sq.ft) 0040-J m Number of Baths: Full: existing o9 new d Half: existing new O Number of Bedrooms: y existing U new Total Room Count (not including baths): existing 7 new Q First Floor Room Count Heat Type and Fuel: 140 ❑ Electric ❑ Other Central Air: ❑Yes P(No Fireplaces: Existing New Existing wood/coal stove: ❑Yes i(No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing 0 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 Old' 2 e l Telephone Number �� 9 Address o7 7 S "e57-y421rW rH 09-rJ License# es Oaf YA2r►00771 /v/4- 0,*4 7 3 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO urJ ®/� G'�5Si9L SIGNATURE DATE 1 z - FOR OFFICIAL USE ONLY - APPLICATION# DATE ISSUED �. --MAP L PARCEL N0._ e e ADDRESS, : VILLAGE OWNER s DATE OF INSPECTION: FRAME 'INSULATION.," 2' FIREPLACE 5' ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL r , j GAS: Vic` ROUGH °rid 1 - <: FINAL FINAL 130LD.1NGu.ii�GY3 DATE CLOSED-_OUT, ASSOCIATION PLAN NO. I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street . t Boston, MA 02111 �- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name (Business/Organization/I /f/�_ �_ /Individual): / '�4 W/,07�� Address: &A3f City/State/Zip: Af,mainel- 1*;ik W 473 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 • VI am a sole proprietor.or partner-employees'(full and/tirpait-time).* have'hired the sub-contractors.. _2. listed ❑on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P h'� 9. ❑ Building addition No workers' comp. insurance comp. insurance.$ required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a bomeowner doing all work officers have exercised their I I.❑ 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' I3g Other i� comp. insurance required.) 'Any applicant that checks box N) must also fill out the section below showing thcirworkers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors 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 jab site information. Insurance Company Name: Policy# or Self-ins. Lic. #: Expiration Date: Job.Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder the pa' s and penalties ofperjury that the information provided above is trice and correct. Si ature: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: Information and f nstructzoxjs i employees, Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their Pursuant to this statute, an einployee 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 mor6 of the foregoing engaged in ajoint enterprise, and including [he legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other Jega) 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, constniclion or repair work on such dwelling house or on the grounds or building appurlenaot thereto shall not because of such employmen(be deemed to be an employer." MGL chapter J52, §25C(6) also states [bat "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states "Neither the conunonwealth nor any of its political subdivisions shall enter'into any contract for theperforrnance ofpublic-4ork until acceptable evidence ofcompliancc with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out.the workers' compensation affdavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contraetor(s)name(s), address(es)and phone numbers)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 carr-y 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 lodustrial 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 Ihat•Lhe 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' companies should enter their compensation policy,please call the Department al the number listed beloW. Self-insr_rred 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 st the bottom of the affidavit for you to fill out in the event the Office of Investigations bas to contact you regarding the applicant. Please be sure to fill in the permiUlicense number which will be used as a•reference number, In addition,an applicant that must submit multiple permiUlicense 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew aftdavi l�nust be filled n>r t each year. Where a home owner or citizen is obtaining a license or permit not related to any bLls]nes sror convnerci a] venture (i,e. a dog license or permit to bum leaves etc,) said person is NOT required to complete this of davit• The Office of Investigations wou r e o -O r,.�.,,,, nnrratinr and shou➢d shave any questions, please do not hesitate to give us a call. i • The Deparlmcnt's*address, telephone and fax number: l The Commonwealth of Massachusetts Department of lndusbT al Accidents Office of Investigations 600 Washington Street Boston, MA 0211 1 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.rnass.gov/dia THE rp�y Town of Barnstable o . Regulatory Services LtA?l6TAsi.� Thomas F. Geiler,Director j6 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Dfce: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder 1, Qtc , J i►-�'W , as Owner of the sub)ect.property hereby authorize 19; C Qe l �,�e.�, f to act on my behalf, is all matters relative to work authorized by this building permit application for. (Address of Job) S. n ature of Owner Date Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form:on the reverse side. Q:FORMS:O WNERPERM1SSlON Town of Barnstable �of tt�roomy , Regulatory Services PNS'rAXLF Thomas F. Geiler,Director M.Qa =bsfl- ,�� Building Division rfv µay'' Tom Perry,Building Commissioner 200 Mairi_.Streei;_Hyannis, MA.02601 R,w•cv.to wn.b arnstab l e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 H07v4EOWNER LICENSE EXEMPTION Please Print DATE: w JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: e city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFIltMON OF EOMX0,WN`ER 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 constrycts 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 helshe shall be responsible for all such work performed under the building permit. (Section 109.1.1) 7'4e 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 roinimuin insp6ction 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 SCetion.(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 arc unaware that they an:assuming the responsibilities of a supervisor(sec Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awanmess bftcn 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 rtsponsibilitics,many communities require, as part of the permit application,, that the homeowner certify that Wshe understands the r•esponnbilities of a Supervisor. On the last page of this issue is B form currently used by severer]towns. You may care t amend and adopt such a form/certification for use in your connnunity. Q:forrrrs:hom=xcmpt JIie eom~��� a Office of Consumer Affairs and gusiness Regulation 10 Park Plaza - Suite 5170 ' Boston, Massachusetts 02116 I f� \i\ Home Improvement Contractor Registration -- Reqistration: 151639 Type: DBA i, Expiration: 6/20/2012 Tr# 298787 MICHAEL L PIMENTAL CON STRULCTI-Q.S MICHAEL PIMENTAL 1 - 275 WEST YARMOUTH RD w W. YARMOUTH, MA 02673 4 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CAI 0 50M-04/04-G101216 License or registration valid for individul use only �-\ Office of Consumer Affairs&B sines Regulation g Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:,,-Al 51639 Type: Office of Consumer Affairs and Business Regulation Expiration: �&2-012012 DBA 10 Park Plaza-Suite 5170 F_ TMIAEL _ Boston,MA 02116 L PIMENTAL"�C;QN:sTRUCTION&REMODE MICHAEL PIMENTAI i? 275 WEST YARMOUTH1� W.YARMOUTH, MA'0263 ,f�` Undersecretary Not valid with signature �''�y fie T�a�rvnwm,�,aeal� ��_ Board.of Building Regulatiods and'Sta� 'l Construction Supervisor License f License::CS 98881 Ezpiratio'n:.j'j9/2011 Tr# 98881 . s / rY M.W 3 R/estriction- 00' MICHAEL PIMENTA�L a 275 WEST YARMO10TH4RD. WEST YARMOUTH,MA -2673. Commissioner `nr �"t6 S, `^Zt A �1 Town of Bamstable Geographic Information System August 16,2010 o3oos6 8 29 iRC03ON9 040 030116 946 030080 \' 028 0=3 09 Q�G\ 030114 #10 C Y rJ O O O sti 030012 ti 128 030113 $90 0 25 Feet DISCLAIMERS:This map Is for planning purposes only. h is not adequate for legal Map:030 Parcel:013 Q N boundary determination or regulatory Interpretation. Erdargenronts beyond a scale of Owner:SMITH,DANIEL H&LAUREEN A Total Assessed Value:$337400 Selected Parcel 1'=100'mey not most established map accuracy standards. The parcel lines on this map Co-owner. Atxea a 1.08 acres Abutters W are only grab representatlons of Assessor's tax parcels. They are not true properly 8 boundaries and not represent accurate relationships to physical features on the map Lpgtjon:9 WOOD DUCK ROAD such as building locations. Bufferf,�r a.�a+v i a�wrc',tocc,�oL,r p:Lis: a moo one(tiovo ssLm a Aa iab;4c Lcr.^4vjp.wv of y.+wexuv;.n C-.Lair II)GA!La not rXC bLOW A Crj-OMLCL'. VcLf;r l6:4'0$smee � a 7.=lpQ.Uj2A uo:o.-.,e:r,.}Y;`ror,U ecMvcs,;.uc s:y JW.".s�'4 r �r ou u;r wvb (: 1001 vn'L s�L a w-rr„u a +!�u�LA u atrc: EuaLY+uuz txAaw s rc a� j 'u•L g�tiLIH't�1N1E7 F i 4 fb(alS�-Ebi V 1 ash ba�.caen2 A�In� Y33�40{T 012IY'\':,E'S2:Mrs =-G'i.otC(swLcryryu@hAthWe��'x' :dtinrxsv�:CL�wjlatjwis} �Ve 114i7 Eyg::'I Ols ^Y� 2-!Gf1sgbg1Cfi _}� i �a ,` a�csoaa C30M t f aaoota _�- WOOP? r ..r LO?A.L of Ruw2pple CGadLab}:c Iutoumspou eA2;ew bn3"2,3e`5040 Fra I S 1cl It0 G' hsc. It 9A7 �/ " Alrvq1 bblls cxsi ax8 `?T -�o sr5 i oic'. J'�11 qr,de- 4a 69 Dec K u w 3" N C'G � 9rD be 60 If bedroom bedroom master ® 3 2 bedroom 20 If bedroom ------- ------- -------- ----- ----- closet closet 4� 8 g Q1 ul A)Oj ROM hall kitchen 42 it , living , rm. �M A chimney . . (Y) Its n 20 It 1 - 1 CAW Lj con 1-,auv + Doh SCALE: P APPROVED BY: DRAWN By DATE: / 1� REVISED qcod Duck- Ln DRAWING NUMBER i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �D. ' Parcel. ��iG?�/ 3 Application # CDd "J Health Division Date Issued 1 15 0 Conservation Division Application Fee Planning Dept. Permit Fee. Date Definitive PIan;Approved by Planning Board Historic - OKH Preservation/Hyannis ' Project Street Address � i t LA / Village 1 ' I �� 1/�► 1 �J Owner� 'I' 1,-a.ur y%1 'F'1 Address 5Pr^-V-f_ Telephone 5M '4aT 5150 Permit Request e-XA*^d eXl 14 VV TaqCe eA- rn'a e r a Avl (nQ�, e1���cS��vi� L�►e�P�l/ (1°�.U� d" e,Vl�n,Vtc� Square feet: 1 st floor: existing R30 proposed 2nd floor: existing proposed Total new 5� Zoning District Flood Plain Groundwater Overlay Project Valuation e,74,000 Construction Type Lot Size I•U& +C445 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure l-{a Historic House: ❑Yes &3 No On Old King's Highway: ❑Yes ANo Basement Type: O(Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new © Half: existing O new O Number of Bedrooms: 0 existing ©new Total Room Count (not including baths): existing -7 new First Floor Room Count Heat Type and Fuel: N Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes P(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 ❑ �; r Commercial ❑Yes No If yes, site plan review # Current Use Proposed Use v APPLICANT INFORMATION j (BUILDER OR HOMEOWNER) Name g"4, 0 / Telephone Number 7 � Address d7� License # C-5 FJ 4• WeMOL47W Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��SCOcr D/S 2S�G SIGNATURE DATE &I d5 l FOR OFFICIAL USE ONLY _ APPLICATION# ' DATE ISSUED. MAP/PARCEL N0. ADDRESS VILLAGE OWNER ` DATE OF INSPECTION: `FOUNDATION -FRAME r t INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH 'FINAL FINAL BUILDING ' DATE;CLOSED OUT ASSOCIATION PLAN NO:' k � 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 600 Washington Street t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/:Electricians/Plumbers Applicant Information Please Print Lelyibly Name (Business/Organizationllndividual): Adaed Plm eWv�*"/ Address: 097.S 141eSr),0�0u77-1 -40-0 City/State/Zip: L/ yfi�41n�` ✓� 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 5A New construction * have hired the sub-contractors . _ _._._ ___.__ . .. - . . ... employees (full and/or part-time). 7, Remodelin 2.V I am a sole proprietor-or partner- listed on the attached sheet. g These sub-contractors have g, ❑ Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑ Building addition comp. insurance. NO workers' comp. insurance 10.❑ Electrical repairs or additior required.] � S. ❑ We are a corporation and its 3.❑ I a homeowner doing all work officers have exercised their 1 I.❑ Pilimbing repairs or additioi myself [No workers' comp. right of exemption per MGL 12.0 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. lContractors 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 employers,they must provide their workers'comp.policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information.. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date, Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of; 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 f 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 certify tin r the pains andpenalties ofperjury that the information provided above is trice and correct. Simature: Date' Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Q information and. hjstructions 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 ajoint enterprise, , including the legal.representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house l be an employer." or on the grounds or building appurtenant thereto shall not because of such employmentbe deemed to 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 publicwork 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-conLractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of imited•Liability Partnerships(LLP)with no employees other than the insurance, Limited Liability Companies (LLC)or L 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 lndusbr al Accidents for confirmation of insurance coverage, Also be sure to sign and date the affrdavit. 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 permiWicense 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 0 policy information(if necessary) and under"Job Site Address" the applicant should write"all locations in 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. Anew affidavit must be filled out each year, Where a home owner or citizen is obtaining e license or permit not related to any business or commerci21 venture mplete this affidavit. (i,e. a dog license or permit to burn leaves etc.) said person is NOT required to co 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'addmss, 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 1-87.7-MASSAFE Fax # 617-727-7749 RPl/1 co-A 4-24-07 ..1.,,,,, - oc, nnuldia �DFTNErOti Town of Barnstable Regulatory Services ` ushUS& a Thomas F. Geiler,Director E � Building Division Tom Perry,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 12zL ,e6-- eAJ -�� , as Owner of the subject property hereby or authize h P"M� to act on my behalf, �G in all matters relative`to work authoriz-ed by this building permit application for: 9 w Ace /00 (Address of Job) C, - a T - C� S/ nature of 0�ner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION Town of Barnstable pp THE r Regulatory Services Thomas F. Geiler,Director ` EARNSTABLF-f �qp " ASSL 9. a,�� Building ]Division TFdt�y Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 yy".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 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, thai 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 e,mpt.DOC Town of Barnstable Geographic Information System June 24,2010 O30D45 I030 030053 0300" #7164 #51 030054 #72 030063 071 #9 o3oofis 030059 #2a #40 030062 #43 030115 #46 030061 10= #29 030013 A #9 m POO { c 0304 Y ran ® c � C O 030009 W030621W 030113 017 #126 3 #90 LAKE SHORE OR 030112 #80 030027 W030020#164 030026 107 #117 (� 0#3 0028 03011 1 set 0 030018 #60 #73#147 DISCLAIMERS:This map Is for planning purposes only. It Is not adequate for legal Map:030 Parcel:013 a boundary determination or regulatory Interpretation. Enlargements beyond a scale at Otnmer.SMITH,DANIEL H 8 LAUREEN A Total Assessed Value:$337400 Selected Parcel 1'=100 may not meet established map accuracy standards. The parcel lines on this mep W E are only graphic representations of Assessoea tax parcels. They are not true property Co-Gamer. Acreage:1.08 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:9 WOOD DUCK ROAD A��f such as building locations. Buffer e i elay8l noilsrniON 3IrIq ipoe-3 sfdWarn s8 Io rrvoT — ' i r'is` LZOIX-0 (fig Q r IT WOOS C eamcG i 7 :i?GtfEb 2rtoEO rt t � i oFAt�cJ 1 relr?��t+ 1 ° c rocco ► r�x r Va Srr!t a 4 � �.. �� SrJ�Eo x-`_;){CEO "�� �•� rr.Fx OEo:cpm key;io;oowpeba ton jilt .`t�'o raa ?%rl griY.ri..'2 U►.:garn a it 2S'.z};.} Z;Q �'cKl:Gq�.5r�3E62 ;31 bsz2 io a:saz R b;vtyJ rM�nay-ia�.^+3 .iw:?:.texik�:n,�ee".xtu�ei w rx;rrlanaMb ictirluQ rn'�tEEZ'ouisil ;a.•x,�I�fe' A�.735i.1A.!:l Ff. ;M�f.,4ii'l.vf2:vemnTi rpsrn akl?txsza!sD 1eo167�t:'T .s'^.thrr.:ia tx+tn:u Gsm iwn:�Cehu 13.v!r ta:i}um•C^ram F 14 Z19NUCLA 80.t:eQsai3A :tS�tA•Ll� �nnc ve;aeRee�crlr _+ta�nrs:7xctpuiraaa'ca,wJrhrastu4�: t4ls C � 11AQA A31.10 C OCIW E:,z>h=oJ! - ir.sre m an.cse w-w"a sg4w.14exn ten c- th�ioua T f `cw Update Address and return card.Mark reason for change. DPS-CAI Co 60M-04/0u-G101216 Address Renewal Employment ❑ Lost Card ,per �le -C�anhrco�uueal� o���ac/accaetla - al\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:,151639 Type: Office of Consumer Affairs and Business Regulation Expiration: �6/20/2012 DBA 10"Park Plaza-Suite 5170 Boston MA 02116 TMIEL L PIMENTAL``C-f®Nt-T- .TION&REMODE Im _1 MICHAEL PIMENTA /" 275 WEST YARMOUTD � W.YARMOUTH, MA"0267,°3',:- - Undersecretary y Not valid with signature � fie.�omvnw7uue� . ./�aaaac�ivaella ' j Board of Building Regulations and-Standards" } Con§truction SupervisoY License !' i License:.,CS '98881• , ! Tr# 98861 � �pirati9/2011 i Restriction—--,by MICHAEL PI EN 275 WEST YARMOUTH WEST YARMOUTH,MA 02673 Commissioner �y 60 tt bedroom bedroom master 0 3 2 bedroom 20 ft bedroom 1 ------- ------ -------- ------ ----- closet closet 8 ft proposed --- proposed 1st hall kitchen fl. O 42 It new front door living rm. chimney 20 It O�0 60 fl bedroom bedroom master 3 2 bedroom CQ 20 ft bedroom ' 1 ------- ------- -------- ----- ----- closet closet closet 8 fl foyer --- exhisting 1st hall kitchen fl. 42 fl living nn. ' chimney (boob 0� f�p 20 fl L Z41 v I . 'J' oe s - ,...., ...._.__.,_,... ,.._...,. ...,� .. - a f A IR ti gg n ; - :• 4 9 1Y gg ., < p : t , a i h l .-. ., .....:..........:.. FIJI" mow. i v � kv d f z l y pp q gk l �t � '� � 1�.. s 1, � �� g �._.._._.__._.e•u.._,__. � #m � aa t q F ra f z i �3 _ v , a1:6 t x ,. .. ,.. x : •--- r t�:—...._ I � ....,.w•x..w,,,,.r_...,,,.,.-,..r..v «<.,,•.,:a,c �..,.%•m�.�`t.��,�..aR', � s.=._—» r � ,2. lG' g' j � €. � s � � '� A � t � �jo u al I s t t Ai 75A StSALE': I .APPROVED BY: vN g DRAWN 8Y OATEN REVISEp D"%MNR NUMBER IMPORTANT ANY CONSTRUCTION THAT INCREASES LIVING SPACE BEYOND 1200 SQ, FT PER LEVEL MAY REQUIRE THE INSTALLATION OF ADDITJONAL SMOKE DETECTORS. NOT?: A SEPARATE PERMIT IS REQUIRED FOR THE INST-LLAT(ON OF SMOKE DETECTORS-THE ELECTRICAL PE-IMIT DZI=SATISFY THIS REQUIREMENT. Ll I LA I - t f t ^" ti I 8 ( ! Tr SCALE:l1/4 o �YD APPROVED BY: DRAWN BY DATE: t_.-"�< -1� REVISED DRAWING NUMBER � p --- --- - -- -_.. __ __ _ _ . . b i t _ I 777 SS � y 3 t p o J -.-L L--j- ULI 0ttAj -;- Dow� ry) SCALE: .,�,, f-I n APPROVED BY: DRAWN BY -DATE: /�- ,,, 1 REVISED 1 �-T LA DRAWING NUMBER n.. ,s f q r . { a 1 J{ j t .. ' ..' '�i. 9 � i� " j �' .� � 4 ,` f ��^.-.•..w- R kt.,.w.,.�.._..�,._..� �.w.. - .. i {f �� _......., .{{ , M , i, , I _ 1 F i 71 a t f i k r E 1 t g 'a r i p fi a 1 i : F: l / 0 � y , I a : } : z F S a y p Y i , a i i , s i ' r I „ , f r � x z W �a t > _Rb" SCALE: I !/-� ,ty APPROVED BY: DRAWN:BY + DATE: REVISED Zx WA L'),tc, lv�r� s • � s � ,, DRAWING NUMBER Wo eb S-e cile-a ,r 1 /r , x Q. r � f } 4 F 4.'gg t t py _ - --� -- ,:. ! 1 rt � - � a t .., sa._„.�sr -..r=x ..•dicye�a�r*xa?, -cnw;.,�...s�,.,ec :s,e^s�c*?>'xi ,..,,, -,.....,.. ,.,.r ,,. l x,: _..,,,,,•-u«,.ti,.... I Y ! 4 { 3 ? i L h } t[ tl I 1. y42 t • wi 33 9 ti V i . 1 h F r t { 3 1 : r : , : F T 7 r •. r ( 9 7 f S'a I i r , ... . ..,, 5 4( tl i t _ SCALE': J APPROVED BY. DRAWN AY 4 DATE' REVISED .� c " '' ____ L'�..rt',•#�n ____-ti_!0 !„ 1_i� � DRAWINO NUMBER _