Loading...
HomeMy WebLinkAbout0075 SETH GOODSPEED'S WAY �I� S�-� �o,�lspe�s ��� Town of Barnstable BARN srweLe, Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Shed Posted Until Final Inspection Has Been Made. Registration �cc Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Registration Number: B-20-1235 Applicant Name: COUGHLIN, ROBERT H Approvals Date issued: 06/12/2020 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 12/12/2020 Foundation: Location: 75 SETH GOODSPEED'S WAY,OSTERVILLE Map/Lot: 122-060 Zoning District: RC Sheathing: Owner on Record: COUGHLIN, ROBERT H Contractor Name Framing: 1 Address: 75 SETH GOOD SPEED WAY Contractor License: 2 OSTERVILLE, MA 02655-1232 f �,� Est. Project Cost: $0.00 Chimney: Description: construct a 12x16 shed 192 sq ft. I i Permit Fee: $35.00 Fee Paid:[! $35.00 Insulation: Project Review Req: ` Date: 6/12/2020 Final: Plumbing/Gas ((( Rough Plumbing: _ `.,Building Official — --- Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after.issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. 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 Final Gas: work until the completion of the same. i I � ' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing 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) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-.ISSUED RECIPIENT I�� Final: S Town of Barnstable °FTHF T Building Department Services ti Brian Florence,CBO x BAMSTAHLB, Building Commissioner MASS.9� �0 200 Main Street, Hyannis,MA 02601 www_town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less Location of shed(address) Village Property owner's name LJ Telephone number Size of Shed Map/Parcel 4 E-Mail c7'6 C'� C C/f'�`!2pr) • n Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 i PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-sh*eg REV:08/6/19 R GlVG [ fl!'[V I mr-r-J, &1YV. -E?!GIINEERS & SURVEYORS P. a. BOX 434 NAME- =J v i�f✓ e�, r_�� ---- ---------- ------------------ ------------------------- WORCESTF_R, MASS. 01613 �r,,, �-�_- � ._ LOCATION---- or -'G:.- Iry PI --------------------------^-------------------_---------- 755-1285 755-1286 /; LLB -------------------------------------------------------------------------------------- REGISTRY _ E -------------- 3` J-GJ/l/f_. � ------------------------ SCAL -------------------- DATE /------------------------7--- 4y'L�. ?=•`ram. Ccii! =N•7 ila'?.rills ?"Pi'fJ..".'=p.iy Noo - 3v- �� :.✓ /oe-tea • 01 - �V to `v - t • � I 1 t I �. P3 i /4 i. N: . � I OD ! Cb 4✓^, f Town of Barnstable EVE Building Department Services°s Brian Florence,CBO BUILDING DEPT. snFwsrneLe Building Commissioner MAY 14 MASS. 039. ,0$ 200 Main Street, Hyannis,MA 02601 2020 www.town.barnstable.ma.us TOWN OF BARNSTABLE Office: 508-862-4038 SCMNED Fax: 508-790-6230 PERMIT# 07O —lo?36� FEE: $35.00 SCANNED SHED.REGISTRATION RESIDENTIAL ONLY 200 square feet or less 5' d�A GOO - -ed/ WQ a Location of shed(address) Village Property owner's name Telephone number /a x r �9a ����. / aa, - ®(o Size of Shed Map/Parcel# E-Mail 5 e) Clew 20-1 • 1) ignature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:304:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN i Q-forms-shedreg REV:08/6/17 L Kt7-Nt-- T tJKU I ttt7K,, (ir4L;. -E°IGINEERS & SURVEYORS NAME------ P. a. BOX 434 ✓ G r iY r✓J .ems - - .�. :-v,---=----------------------------------------------- -�==----- ---------;------------------------- WOR.CESTER MASS. 01613 ------------------------------------------------------------ 755-1285 755-1286 � ,-___; •: 4-4-E ------------------------------------------------------------------------------------- REGISTRY i�i �i-.'r'c. �J i T 1 ----------------------- SCALE --------------------------------- DATE ------- ---------------- Fein 3v /3y DATEQ, NoG - 0 /0/ C s�eac fj i �r I I m G C7t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1.�2`�, Parcel o 6O ' Application # 'ZD (o -t fib ( Health Division / 7 (4l/ ':_Date Issued Conservation Division Application Fee Planning Dept. Permit Fee s 3 �� Date Definitive Plan Approved by Planning Board (25 Historic - OKH Preservation / Hyannis Project Street'.Address `7 S cSe7�l GAP Village 67-le'w Ile f Owner �i • `i5�`�''- Address te"r1l �� �"""9� Telephone `J78-- C S-S-7014 4K 97S-- 60'(: D 9l6 Z Permit Request ®� Slv n 4s &4 /per I A Aw S h "V A,,4-- Square feet: 1:st floor: existing proposed 2nd floor: existing proposed Total new Zoning District r�� Flood Plain Groundwater Overlay ' Project Valuation ��-'TDB Construction Type �A10ON �"P L_ot Size 5 O'D Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure 33 Historic House: ❑Yes XNo On Old King's Highway: ❑Yes )'No Basement Type: WFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 6 7 s� Number of Baths: Full: existing new Half: existing new Number of Bedrooms: 3 existing —new _ C:=' o Total Room Count (not including baths): existing new First Floor Room Cow'0 c � Heat Type and Fuel: WGas ❑Oil ❑ Electric ❑ Other G-, Co Central Air: El Yes )ino Fireplaces: Existing New Existing wood/coal sty: FcbYes A No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing=? new size Cn Attached garage:Wexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: w Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ rn Commercial ❑Yes WNo If yes, site plan review # Current Use r _i /6&nc Proposed Use. J` 1-g-M•� �/-"` APPLICANT INFORMATION (BUILDER OR HOMEOWNER) I Name �1/�D Q,T !7 ��/I �►h Telephone Number w4c, `Address N/ 8141'%5�m License# I.,C f Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ✓(�SS� �� a3 �' ,you SIGNATUR DATE g� �� 7 1 , 1 FOR OFFICIAL USE ONLY APPLICATION# ' L DATE ISSUED _�: •�_ : ,f .MAP/PARCEL.NO _,_ ADDRESS, = a VILLAGE I' OWNER 3 I DATE OF INSPECTION: s �'%FOUNDATION C°� FRAME (-Q ci - ( ' INSULATION_!; h--I," :i r_.S FIREPLACE I ELECTRICAL: ROUGH FINAL 'y PLUMBING: ROUGH FINAL ;GAS:- r[` '- ROUGH ct9. :,a :.;�> FINAL ' — . O +fiFINAL BUILD_INGI _ DATE CLOSED:OUT ASSOCIATION PLAN NO. • 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 Applicant Information Please Print Legibly l/�����T �u�tili✓1 Name (Business/Organization/Individual): L Address: ]�(J �y+��i+lrl l 41 City/State/Zip: (AIIW I n 44-o M#- t�l Phone #: 919 C Are you an employer?•Check e appropriate box:' Type of project(required): I.ElI am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction einpltiyees­(full and/or part-time). * have'hired the sub-contractors.. _ _ _ 2.❑ I am a sole proprietor-or partner- listed on the attached sheet. 7. VRemodeling 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.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions 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' ]3.❑ Other comp. insurance requued.] *Any applicant that checks box ff l must also fill out the section below showing their workcrs'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 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 arid expiration date). Failure to secure coverage as required under Section 25A of MOL 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 eer der the par' s enalties of perjury that the information provided above is true and correct. Si ature: [� Phone M % 14 ' Official rise 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 InstrucizoDs y ,; Massachusetts Genera) 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 Iega1 entity or any two or more of the foregoing eogaged 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 lherein,.or the occupant of the dwelling house of another who employs persons to do maintenance, cons tniclion 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 stales tbat "every state or local licensing agency shall jvithhold 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•req u ire d." Additionally,MGL chapter 152, §25C(7) states "Neither.the conunnwealth nor any of its political subdivisions shall o cnter'into any contract for the performance ofpublic•-ivork until acceptable evidence of compliance with the insLuanec requirements of this chapter have been presented to the contracting authority." Applican is Please fill out.the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-conlraclor(s)name(s), addresses)and pbone number(s)along with their cerlificato(s) of insurance, Limiled 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, e 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 th-e affidavit. The affidavit should be returned to the city or lows that•the appliaalion for Lhc permit or license is.being requested,not the Department of Industrial Accidents. Should you bay,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 bas Lo contact you regarding the applicant. Please be sure to fill in the pem7iU]icense number which will be used as a.refcrence number. Ln addition,an applicant that must submit multiple permit/license applications in any given year, need only subrnil one affidavit indicating current ity or policy information(if necessary)amd under"Job Site Address" the applicant should wrile"all locations in _(c town)."-A copy of the affidavit that has been officially stamped or marked by the city or town rr�ay be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavi trust be filled out each year. Where a home owner or citizen is obtaining a licensen Orpenitnot related to any businessorcornmereial venture (i,e. a dog license of permit to burn leaves etc.) said person is NOT required to complete this aiF6davil. Tbc Office of lnv and shou➢d Youbaye any questions, please do not bcsilate to give us a call. `r • I � The Departmcnt's'address, telephone and fax number: I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Te). 4 617-727-4900 ext 406'or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia Town of Barnstable o Regulatory Services T ��,� Thomas F. Geiler,Director rtwss. >_bs� ..0g Building Division Prfv µay� Tom Perry, Building Commissioner 200 Mairi.StreetHyannis, MA.02601 vt'ww.to wn.b arnstabl e_ma.us Office: 508-962-4038 Fax: 508-790-6230 HOMEOWN-ER LICENSE EXEMPTION ' Please Print Q DATE: F / /b JOB LOCATION: �� /'` v�''"'� "s✓ �sT" v`� nu bcr �f street village (► 66 (� / "HOMEOWNER � i f� Is W � (vS� 7 lio1J � T name �i homc phone# work phone# . CURRENT MAILING ADDRESS: Vic city/town states a 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- DEFI MON OR BOMEOWNER 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 constrgcts more than one home in a two-year period shall not be considered a bome,owaer. 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 Dcpartrpent minimum inspection procedures and requirements and that he/she will comply with said procedures and re en •. I Sign rc of Homtowncr 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 scction.(Scctian 109.1.1 -Licensing of construction Supervisors);provided that if the homcogmcr engages a person(s)for bin:to do such wofk,that such HCrmcoWner shall act as supervisor." Ivi^°any homeowners who use this rxcrnption are unaware that they are assuming the responstbilitics of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness bftrn 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 honccowner acting as supervisor is ultimatt)y responsible. To ensure that the homeowner is fully aware of his/hQ rcsponnbilitics,many communities require, as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Superrisor. On the last page of this issue is a form currently used by several towns. You may cart t amend and adopt such a fon-✓certifica ion for use in your community. Q:forms:homccacmpt THEr Town of Barnstable Regulatory Services nARNSTABL- v ' MAas �. Thomas F. Geiler,Director 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 , as Owner of the subject.property hereby authorize to act on my behalf, is all matters relative to work authorized by this building permit application for. (Address of Job) I Signature of Owner Dat,- Paint Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form:on the reverse side, Q:F0RM5:0 WNERPERMIS3)oN ---- --•--- • _ � torn.o� - - L Aud ►'I T 20± ■_ °� �I O j � - I I - _cr CUD 4r LOCATIOI•.1 C),e2 °E,\1I LL1 I C.6 6a T t V=l j T 1-1 A T' T 1-1 L-1EQ 6 n1J' GQIVLPLYS W 1 TN TOG 5 i DE.LI WF— ;a Aua 'SET$AC-4 FE-401tZeMEwTS GF -r-N -TOwu OP �A'^�sr,AFL.^ Lk �� uo�1:T 1.�.� c DATE B A,XTE tZ �. E 9ZEG15"raKt-=D L.A Wr-> 6tU2Vi i IS: Ir w N Oo 0 k 33 V a J a t � 5 � V � t F ^ ' F J r1° . f S t M1 ' � t t ! ; 1• 1 s i e • off �o � � v cy ago tom. o f Q J , � o _ � fixfi Lr 1 F \� Xf t } Ao xou clt I 141 W li I 4 c� a n (V,A 60W s���� (� l ca) a LP3.-- a ,LP 3;L �43 411. 9-3/0 Qa.r d-A i x NJ bdmrl � t c� x a M � v x � a v 1 C 1 i M rl m v dr n v a } l l � � 3 Ih Jtj 0 s' x TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION,. Map a-� Parcel " 6� 6 Q -Application # (J.3 ``Date Issued Health Division Conservation Division s:Application Fee Planning Dept: .'Permit Fee L611 %- 43 Date Definitive Plan Approved by Planning Board c Co Historic - OKH Preservation/Hyannis ; Project Street Address cieA Village Owner �7 Cc,u�j1�'n Address Telephone q78-, 60((- C)U7 Permit Request I 46�?14_C4. co LY k_s 0. ,S :CM 1rut/' Square feet: 1 st floor: existing proposed 2nd floor: existing ®� proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 760 Construction Type Lot Size �� ©mod `S� Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family.. Two Family ❑ Multi-Family (# units) Age of Existing Structure 3a s Historic House: ❑ Yes *o On Old King's Highway: ❑Yes lxi�o Basement Type: Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.); Basement Unfinished Area (sq.ft) -79S Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: 3 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 )JINo . Fireplaces: Existing New Existing wood/coal stove: ❑Yes )0\10 Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:�. (existing ❑.new size _Shed: ❑ existing ❑ new size — Other: C7 1 --� ZE Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ (D Commercial ❑Yes )(No If yes, site plan review # Current Use Proposed Use r co o rn APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C 1, Telephone Number Address vd&&eW License # Prv� Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO '4S SIGNATURE ' DATE U ��� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED - MAP/PARCEL NO. ADDRESS VILLAGE` OWNER DATE OF INSPECTION: FOUNDATION FRAME } e INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL a ` PLUMBING: ROUGH FINAL, f GAS: ROUGH FINAL - FINAL BUILDING S' DATE CLOSED OUT ASSOCIATION PLAN NO: The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 i. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / r Please Print Le ibl Name (Business/Organization/Individual): Adclress: City/State/Zip: 0 /l�p y� Phone.-9: Are you an enployer? Check the appropriate box: Type of project(required): I am a employer with 4. 0 I am a general contractor and I 1.❑ 6. ❑New construction employees (full and/or part-.time).* have hired the sub-contractors listed on the'attached sheet. T. �eRamodeling 2.0 I am a sole proprietor or'partftcr- These sub-contractors have ship and have no employees 8. []Demolition working for me in any capacity. employees and Have workers' 9 Building addition [No workers'-comp.•insurance comp insurance. equLmd.] " 5. We are a corporation and its 10.0Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers compensation policy infomnation. 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 crimiti4l penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-a penalties of perjury that the information provided above is true and correct Si is ature: Date: O 0 — Phone#: /7�� d Offxcial use only. Do not write in this area, tb be completed by city or town officiaL City or Town: PermitfLicense# Issuing Authority(circle one): 1. Board of Health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Phone It: -- 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 receiver or tiustee 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 tinploys persons to do maintenance, construction or repair work on such dwelling house oron 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." AdditionaIly,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,%zth the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contiactor(s)name(s),-addresses)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 orkers'compensation insurance. If an LLC or LLP does have members or partners, are not required to carry w 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 pemaittlicense number which will be used as a reference number. Iii addition, an applicant that must submit multiple permiWicense 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 eitizen is obtaining a license or permit not related fo 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: a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Iuvestigadd.Uk 600 Washington Street Boston, MA 02111 Tel. #617-727-490.0 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Town of Barnstable TF1E Tp� " Regulatory Services o� • Thomas F. Geiler,Director =nrutsTABr.e, i639• � Building Division 9� `��` ATED 'y 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 Q �+� Please Print DATE: a O JOB LOCATION: '"� `� 5 number street village "HOMEOWNER": hone# name home phone# workP CURRENT MAILING ADDRESS: lq 9 _��� e p ,!l dl of/in 4 city/t6wn (�-- -r tate zif 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 liomeowmer shall submit to the Building Official on a form acceptable to the Building Official, that he/she sha11 be responsible for all such work performed under the building permit. (Section 109.L 1) ibility for compliance with the State Building Code and other The undersigned"homeowner"assumes respons 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 entWwnerT� Cignatwure of H 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 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\FO RMS\homeexempt.DOC f THE Town of Barnstable Regulatory Services 1ARNATABLE, ► Thomas V. Geiler,Dfrector Ah. 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 as er of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this b g permit application for, (Addres of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMIS SION � � E L AcA 'Pit ! o. 1 7 20 t r- t •4 S.M� J� -�T.l V' I 1 ' I axe t; Of 41 F '.- y x -,�.. .; ;rr ' C6EZTi'F IEb7 pl.bT �'t--•� `74D stet LOCATIO" Oe2TE .\lI LL : SCALM N- !JD I G66ZTIV=Y T"AT- TINS. Ota �`C�C�I.?511o�v�.l PLA►.1 SZ��cR.E�.1GE Wr-g r- W- COAAPLYS WIT" THE 51 Vr=.LI bJE Aua SETV AUG IZE4v11ZeAA& -ITS 6; TNT owv OP Lk PO L OueT �ZrZ2� z '�,p��.Est AEI! DATl= �'3 �! �j(.�"i�1,•P�--• L� •4 1 nJ/.�il..�....�..� t3�.XTEZZ lr*. A.1�(E 14.1G. REGIS D I..A."lC> 15ur-V6 Q�4 V3�, e� new red-, - a �P 3a- . �a� i J� x � 4 x � . M Cfs vN cb G tJ I ( I r 1 t (� M Cl Q/1 � m � v v n m a r � I M ct ro 0 s x v d ' s , i • i r t I i i , : • , a , . i , , : a , i : I i : , f i 1 t ; r r V , \ f i J , r E , r r , ( t f r e 7 1 i • 1 r ' 1 i �^ F FT�N v a 1 a o � o _ v � � JOO , 4 k , v ;4 11 � � s � ao 4111 s —h d � � 4 � 3 � i z ; x Ilk Z4- i r r ti E 6. tin _ i 1 i f r t o lOa_vc7 1 oo o 44 L- LEACA Pt T �o, c. Taw,c 17 0 "cr, ie CCO e7F OF RICHARD y A. SAMP Nil 24048 1 4pc self' LoGATIO" SGAL Ill& 7� bAT _ '3141.7-1 t CSIZTtF,f T"AT T146 �OUIJoATI(71.15u�WRF- L t4EQEts1J GoN\Pt_�(S W ITN Tt-IE SIDE_�.1►-tom AWr-> SETV�ACK VG4VtRENtr--WTS bF TNC- Lk Pt) ( voeT?oWU O>~ `25AZ�AFL.. DATE �QXT.EIZ � WEE t�1G_ REb l';-rGiMtD 'L.A WID '5U ir-V cKO V-S ' TN15 DILAf.•1 15 WOT 6A45EL7 0",4 AN ° os-rezvtt_.La o l 4S5• 0451 QCJAASWT WZVE� J TNT OPC 5ETI 'S'40WLr-> APPt_t GA�iT 1,joT 6E usEo To C)t=reetit►NF-- LO-r (_iMes E ��7�� � �• �_ ___ 77 Assessor's map and lot.number ........'.:..1.............. �1 .... 6EPTIC SYSTEM MUST BE. INSTALLED IN COMPLIANCE r, Sewage:Permit number .................. .........................'.............. 1':1�14 A`. �i%L E II STATE '%�'`'1►A"�Y CODE AND TOWN T ET°�� -TOWN OF BARNSLTA(BILE Z EARNSTADLE, "6 I) IJ11DING INSPECTOR APPLICATION FOR PERMIT TO .'.... .................................. TYPEOF CONSTRUCTION .........: . /... ... ................... ........ .............................................................. ......................... .... ...........19.7C TO THE INSPECTOR OF BUILDINGS: The undersigned a eby applies for a permit according to the following information: Location . ..... .... ........ I.... K✓... .... ...:............. ... .. .�c ..fl.�l...... ��................... ................... ^ .. ProposedUse ...... .Gam.................. ........................................................................................................... ............. .. Zoning District ....... .000 .. Fire District �!�' "�"'� ......................�.................. ............................. . ............ .. ... ..... t Name of Owner ..... .'.c"'�..... ..a,.�-��' Address ...............::. ... '�t✓i4.1 - �........ ... ................`.................................... Nameof Builder ..................... ./.........................................Address ...............:............ `................................................. Nameof Architect ..................................................................Address ................................................... ............................... Numberof Rooms ..............4 .............................................Foundation ................... ......... J.................................. 0,4e�,4 Exierior �` .........Roofing ......... Floors ..............5 ...Z/z....(tr...........................................Interior ........'1 � .......................................... f ,� � ........Plumbing / Heating ...........!:.�../,l�...`�..... �.4��./............... .................................................................................. 1... d Fireplace ...............................Approximate Cost ..................o2`5............. .................................. .. Definitive Plan Approved by Planning Board __________________-----------19________. Area 2� � / `Z ............................. ... Diagram of Lot and Building with Dimensions Fee G SUBJECT TO APPROVAL OF BOARD OF HEALTH C J i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re (ding the above construction. _ �Name ..........� .. .. . ..... .............. ................... Capewide Development No ..... Permit for ....9U.e..UbUry...... .......single...£ami.l y...dxe-1,jjmg....................... Location LO.t..#11..,SietbL.Good peeda..Way...... .........0sterville................................................ Owner .Capewid .-Development..................... Type of Construction ....wood..frame................ Plot ...:.......:................ Lot ... 11....................... e Permit Granted ....March 8....................19 77 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... Approved ................................................ 19 Assessor's map and lot number ........ .......................G......... Sew_ age,Permit number, .........: .."::................................ M TOWN OF BARNSTABLE *THE t0� a Z BARNSTABLE, "6 BUILDING 'INSPECTOR . APPLICATION FOR PERMIT TO ............................................................�� .����� ...................................... .... ....... ..... . _ • � s y TYPEOF CONSTRUCTION ............ .......... ................... ....... /............................................................ ...................... �......19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 411 Location �... ............ ..., . ....•i........... , " ............................................... Proposed Use ...... ......... ..... o�G ... Zoning District ......... `..::................ ...............................Fire District ...s ;?rl� .. Nome of Owner y � '...:.::: �. �.`. ��s � ,`y��"�� ............................... .......... ........... J .......:........Address ................... ,............ ... Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address ..................................................................................... Number of Rooms < ° .............................................Foundation ..................... ........................................... Exterior .... ... ... ...................................................Roofing ` :.. Floors ...... ...........................................Interior .......t ��% � '� .................................... Heating ....Plumbing Fireplace ..............................................Approximate Cost ...... ::.............. Definitive Plan Approved by Planning Board -------------------_-----------19________. Area o....... ............................ Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH A 1° 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Y! yo = Name ............. .. ... 2::... .......::... ...................... Capewide Deve opmen !M-1-4L9 No 1899:2...... ermit for .Q.ne...s.xQ�y,�. ......six gle..IatU 1..xel.lxmg........................ Location . .............Ds terville� .............................. Owner ..Capewide-Revel. ant................... Type of Construction ood-frame................... . ........................ ..................................................... Plot ...... Lot Permit Granted ......March 8 19 77 Date of Inspection ....... ............19 Date Completed ...:..................... ..........19 _ PERMIT REFUSED .............................. ....................... 19 Approved .............................................. 19