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Home My WebLink About0187 TOWER HILL ROAD " .7 n. r 111-7�,D ti �oFr►ur� 'own_ ofBarnstable *Permit# ti Lyires 6 mowd/rs•from issue(1nle Regulatory Services Fee r3 A uvsr�st>. : 9 IfAss. 16)9- Thomas F. Geiler, Director Building Division X-PRES PERMIT„ Tom Perry, CDO, Building Commissioner. 200 Plain Street, Hyannis;MA 02601 NOV " 41 7016 www.town.barnstable.ma.us � Office: 508-862-4038 OF 13A N T8A?4a230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY N01 Yrriid tvilhoul Red X-Press Inrprin! Map/parcel Number Property Address 1 g W e Residential Value of Work It 60 Minimum fee ofS35,00 for work underS6000.00 Owner's Name & Address w I LL I c JZ- C�� Contractor's Narne Telephone Number Home Improvement Contractor License#(if applicable) 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) C&Re-roof(1)urricane nailed) (stripping old shingles) All construction debris will be taken toEj Re-roof(hurricane nailed) (not stripping. Going over existing layers of rood Re-side • #❑ of doors Replacement Windows/doors/sliders. U Value (maximum .35) #of windows *Where required: ISSLlance or this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,ctc. ***Note: Property Owner-must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is required. • GNATUIZE: WPFILESIF0IZMSIbuil ding permit fofmslEXPRESS.doc ✓i.¢p rl 11791 10 The Commonwealth of Massachusetts t I Department of Industrial Accidents I ^x, je 'l 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): Address: City/State/Zip: �S�Ce�2�Jt l�P �� Phone #. ,>�67 r4J Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El aril a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.U-11am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and have no employees . These sub-contractors have 8. []'Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. 'El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ lam a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box NI 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 their workers'comp.policy information. 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 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. do her y rtif r the p ns d at the information provided above is true and correct Si nature: Date: V . 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#: ♦ V 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 trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have.been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should y6u 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia i The C&inmoirweallly of1lfassachitselis -- Deym7m.enl of Indus/rialAccidents --r- Ofj7ce oflrTnesligalions 600 Washinglon Street Baslort, e I4 02111 fnrtnM rnass.govldia Workers' Campeusati.on Insurance Affidavit: Builders/Con.tractorsTlechzc aus/phunbers A_ppllicant Information t� Please*hint Legibly Name. (&isioesJOrganizatiourindividclal): �� I L(� (� �0`�C City/slate/Zip:OSTe v C e Bone #: a(o 6p 3 Are you an employer?Check the appr•opHate�,+ z:bo - ,� ,f,�� Type oTproject(required): 1_❑ I am a employer with 'I/L�J'�1 am a general contractor and I employees.(full and/or part--tine).* .have hired the snb-contractors 6_ ❑.New constnrctiou 2.❑ I am a sole proprietor orpartuer- listed on.the attached sheet. 7. ❑Remodeling These smb-contractors have ship.snot have no entpla)re.es S. ❑.Deurolition working :forme in any capacity. employees and have workers 9 ❑.Building addition [No workers' comp.instrra-ace comp. insu e.ranc . re uired: 5. ❑ We are.a corporation.and,its 10.❑Electrical repairs ora.dditions 3.❑ 1 am a.homeolimer doing all work affcers have exercised their 11..❑Plumbing repairs or additions myself [No worker'comp• right of exemption per kMGL 12p Roof repairs in sasrmice:required.]t c_ 152, §1(4), and.we have no `� employees.{No wor#rers' 11❑Other comp..inmrance required.] 'Any applicant thstchecls box#1.must also 511outthe section below sbawing tbeirworken'conapensa.bon policy infonnatian. I Homeowners who submit this.affdairit hidicating they are doing all'umtc and then hire outside contructors must submit.a um affidavit indicating such- rCantractars that check this beet must attached an sdditioast whet showing the-oaane of the sub-coutracwrs so.d stare whether or not those entities-have employees. Ifthe sub-conitactors:hsve emplcgws,.lhey.must provide their workers'comp.policy number. I al/r Rn elltpio}er that is proa�r'.clirlg ttrorkers'coin ertsrlllon rixs�tm.rr.ce for!ny ertrplaJ ees. Belon,is fit policy aizd job site informatrO1L Insurance Company Name: Policy#or Self-Ins-L.ic.#: Expiration Date: Job Site Address: city/State/Zip: Attach a copy of.the 1`•oi•kers'rompeir.•sationpolicy declaration page(shoi)dng the policy number and expiration date). Failure to secure coverage as required uncles Section 25A of 1vfGL c.. 152 can lead to the imposition of criminal penalties of a fine up to S1,500..00 and/or one-year imprisonment,as well as civil penal.ti.es in the form of a STOP IVORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be.fbmarded to the Office of Investigations of the D.IA fbr insurance coverage verification. Itdo/tKreby certify trltder fhapains anrlpenath'es r7fp�rjrrry Htat t9te it forlrratfortprm ir/er! bone is rete and correct. S turret, _ jP n r Date: 1.1 1 F d Phone#: v� �P 0(icinl nse only. Do not write in this area, to be coniphrted by cih'or town of cial City or Tonm: Permit/License# Issuil g flu th m ity(circle o ne): 1.Board of Health 3.Building Department 3. City/Town Clerlc 4. Electrical Inspector 5. Plumbing Inspector 6.Other it- _ r Of THE Tp� + HARNSTAUX; Ass. Town of Barnstable �IFD MA'S a Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO 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 Owner of the subject property hereby authorize _ �b � �FZ (—I— EE- r y E to act on my behalf, in all matters relative to work authorized by this building permit application for: 1 7 `C-v Ili eV,1'kc< < (ZJ0 (Address of Job) -h Signature of Owner Date �Wtk_L Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. 1 r YDD CQQ A-- Pot r ti Town of Barnstable Regulatory Services jtsTastE'lass. Thomas F. Geiler� Director � $ '639. a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 518-862-4038 Fax: 508-790-6230 --------------------------- HOMEOWNER LICENSE EXEMPTION Please Print DATE: \ C/� eO/ /_-.,,, ,, ( f ,o y� JOB LOCATION: /, / ��'�/L �� l I �,/ � 1 ULLf— nu1mber ',D street V r� p village ,.HOMEOWNER" W I L L,O O �p\�'�'l�T�Cfi� 5U (� 'may )� —aC�b 3 name p home phone N work phone H CURRENT MAILNG ADDRESS: t) -7 dS�e��tll 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 h I comply with said procedures and requirements. Signature of hlomeown.er 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 ofconstruction 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 Ihcy are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack ofawareness open 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 bf his/her responsibilities,many communities require,as pert 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 I amend and adopt such a form/certification for use in your community. i Q:\WPFILESIFORMS\building permit forms\EXPRESS.doc En Map (Parcel 00 Permit# 33�D 3 0 • Y• House# d Date Issued i M Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) • q !� Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) yy EPTiC SY T BE Definitive Plan Approved by Planning Board O v /7 19 M STALLED NCE ' WiT ' r- TOWN OF BARNSTABUR TO NICE E�N� TOWN REG IONS r Building Permit Application Project Street Addr ss Village d G Owner 1 1-L 1 (Z, G�� E-(�'� Address a 7 .14 t Telephone 4 M—W,,,4o 3 " p� Permit Request o e C 9 k Q e l l�'C k Q D � �1�I,w e::),t X 16 'Flo First Floor 3 0 4 SQ IF T. square feet Second Floor � square feet Construction Type I-0 Q(00 e,.N) � Ann`E E. Estimated Project Cost $ �(� 060 j Zoning District CSC. Flood Plain t'V d Water Protection /Vd Lot Size Grandfathered J(Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure s Historic House ❑Yes )JkNo On Old King's Highway ❑Yes AQ No Basement Type: WFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing_ New ,— --I— Total Room Count(not including baths): Existing New .,�First Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air ❑Yes ANo Fireplaces: Existing tic) New Existing wood/coal stove ❑Yes I(No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None 4KShed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑]pYes KNo If yes, site plan review# Current Use 1\e—S t t9 ew 1 Proposed Use Builder Information Name Ce S to i-f Telephone Number Address C7 t jAt% in ueq License# �3C A I /1�s7iQt- , Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE BUILDING PERMIT DENIED FOR THE FOLLOWING.REASON(S) St- •r FOR OFFICIAL USE ONLY Y 03 PERMIT NO. 33 - i. I4ATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE ;, OWNER DATE OF INSPECTION: . FOUNDATION FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL" w m PLUMBING: OgGH FINAL GAS: &ROUGHO FINAL • - FINAL BUILDING,,_' - _ u F-vc Y�®` DATE CLOSED OUT a-- E$ ra ASSOCIATION PMA 0.Q .� .�_.... T'Iie Communwealth of Massachusetts r'F r Department of Indus&kl Accidents 011lcrallayesdAadoas 600 Washington Shed Boston,Mast 02111 Workers' Com ensation Insurance Affidavit , ,rion� 'fa� t, rhane# _ 3 ❑ I am a homeowner performing all work myself ❑ I am a sole proprietor and have no one wozIdn in any aaty ❑ I am an employer providing workers compensation for my empiovees working on this job. companv name: address: .. .. ... .- ... .... �• . ..• dtv phone#- insurance 90iicv# AM I am a sole proprietor,general contractor, homeowner circle one)and have hired the contractors listed below who the following workers' compensation polices: .... .. company TIzMe*- u,)OdO U1are,gi ..,, address• '�6C, Le � ,.. ".... .. "... . ... .n,� .• .. insvrnncecn cK ..... . tee# coin anv ieumr. address: tits- . •"crr,�jf.: ...^�.;.�Sp,:.... � .. :'n :K�:... .. ley#• .....:i�v;No•..y:':' , �,. nsaranee m Fanare to satteae coverage as rcq=red under settian 2SA of.*#IGL 152 can lead to this ingm tlon of esfmiod penalties ate floe up to SLSOLM aaaYor ens Years,lagwbomaent as well as tdwo penalties in the fora of a STOP WORK ORDER d a Oar of SIOOAO a daY ataimt uta• I tmdesatand tent a aM of this statanew my be forwarded to at Otttce of Investigations of the DIA for csvosxr verAcu m I do herby«�ify under the paint sad penalties of to jury that the informaden pavided above it trna tmd Sigollnme - PrintnMe kO k LL k E. CZ��l� e. Phoned '��-8 A"(02 ofOdal ate onir do nm writs is thib area to ba eompieeed bP d!f or town ofndal city or towea P N QBuilding Licensing Board Osel chieckifin medista responresponsepe is required O ffeeee:nm's OHeallh Department contact person: phone#; C30t`w-- 4n'wa 9l93 P1A1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires ail employers to provide workers compensation fortheir employees. As quoted from the -law",an employee is defined as every person in the service of another under am'cotter-" of hire, express or implied, oral or written. An employer is defined as an individuaL partnership, associ,rnn corporation or other legal entity, or any two or Here of tent foregoing engaged in a joint enterprise,and including the Iegal representatives of a deceased employer, or the rec..-•t'e:. 7ustee of as individual, parmership, 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 ,..a,-... ;=p1-- 's i- to do maintenance , constrtuction or repair work an such dwelling house or an the grotnnds o: auvauw � building appurtenant therein sha11 not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commomvealth nor any of its political subdivisions shall enter into any cozmtract for the performance of public work until acceptable evidence of compliance with the i*'sw'+nce requirements ofthis chapter have been presented to the contiarri�,o authority. 11 Applicants . Please fill in the workers' compensation affidavit completely, by checldng the box that applies to yoursttttatioa sad supplying company names, address and phone numbers along with a certificate of ksivaaee as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and ^ date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please=11 the Deparaneat at the number listed below. i City or Towns Please be sure that the affidavit is complete and printed legmbly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investiottinn has to contact you regarding the appficu. Please be sere to fill in the pwnit/licease number which will be us ed as a refm=cc number. The affidavits may be setumcd t^ the Department by mail Or FAX unless other,arrangements have been made. The Office of Iavesdgations would Ulm to thank you in advance for you cooperation and should you have nay questions•: please-in not hesimte to give us a call. The Dep r-=C eS address,teiephoae and fax naumbm: The Commonwealth Of Massachusetts Department of Industrial Accidents QMC8 of MV839089883 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 exL 406.) 409 or 375 The Town of Barnstable ' �g Department of Health Safety and Environmental Services Building DIVW*On 367 Main Stress,Hyannis MA=01 Raiph Crosses Off!= 308-790-6=7 Building CcmmissiOn! Fax: 108-790-Mo For oIIlce use only Permit no.____--, Date AFFMAVIT SOME DWROVEMENT'CONTRACTOR LAW suPPLEMLNT TO PERMIT APPLICATION MGL a 142A req wires that the "reconstruction, alterations, renovation, repair, modernization. conversion. improvement, removal, demolition, or construction of an addition to nay prrezistin9 - at least one but not more than four ng o or owner occupied building containing structures which are adjacent to such residence or building be done by registered s- with certain czceptions.along with other requirements. d0 Work: Est.cost Type of Address of Work: e I t Owner's Name �►)1 LL Date of Permit Appllation: I hereby certify that: Registration is not required for the following reason(s): Work ezciaded by taw Job under SI.000. Building not owner`aanpied Owner pulling own permit Notice is hereby given that PERMIT OR DEALING IV UNREGMTERED OWN OWNERS .PULLING THM IMPROVEMENT CONTRACTORS FOR�TToN P OGRAM oR GGURAf=FUN WORKD UNDDER MGLOi42AA ACCESS TO THE•� SIGNED UNDER FEVALTIES OF PERJURY I hereby apply for a.pwmit as the agent of the owner. Date Contractor Name Registration No. R Date Owners Nume TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION fPease print. y DATE C U JOB. LOCATIONCJ�I-G�� Number Street address Section of town "HOMEOWNER" U ( L-L C Name Home phone Work phone PRESENT MAILING ADDRESS Y7 9 . ( City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one 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 Officia. on a form acpeptAble to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the Sta- 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 minir.am inspec-lion procedures and requirements and that he/she will comp hh; with ¢aid procedures and requirements. HOMEOWNER'S SIGNATURE J!�`'� JV >" . APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "An Home Owner Y 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 'lf Home Owner engages a person(s) for hire to do such work, that 'such Home Owne shall act as supervisor. " Many Home Owners who use thisiexemption 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 awarene. often results in serious problems, particularly when ,the Home Owner hires unlicensed persons.; tn,this -case our Board-cannot proceed `against the inlicensed person as it would with licensed Supervisor. The Home "Owner. act�: as supervisor is ultimately responsible.. To ensure that the Home Owner is fully aware of his/fier responsibilities, ma: communities require, as part of the permit application, that the ,Home Owner certify. that he/she understands the'•responsibilities of. a supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. v R 4c, Vnat-6-L T 008 TA�� Q S� RWITEZ e e � A ws"I e e 6 / ..ram 'r <v...=TaK+nt.'tNbrKr Kv.-�Y;...�rv..�.�...Yb�.a.4C nrewi .. a .. _. `....r•. • •�.. ♦!i/Yl.:yyMAY:./)..„MYMMI•C.A•:°.1LJM.uun".a.rrr..a..:LLena.rt s.�,•.A�•....i�u.:u:^........ ,n, ,r. .>.♦ .. ' .,.i.L�.:Lr mMcro..w/•Sc.%iq.nwM"M1l%1`.t:JY.:r...wr.u.. ...i�.._.� ...�•., n. .Y.I•,fir;�:u...eY:: 1�M:+bMMW6+8v1ifYbT7.:T. .. .. .. 1 J9 4E A r , wArLLS Ito '( 6t. 0 �r To �L.#PJA ITO WL*Ar-oo,C a � � v.r,.: •` yam, � ,;. � �c�il• «� • 1. . •sue � �� j � ;�� i� , `� . ��'♦ J ,, '�� ` ►mow �� , . WNW— ♦ '� � � _-�� ► 1�" •� ►!ice �, ►�/, � � � � �� f='►s- +'�� VA 10 r� 1 "7 TO Ulf F- k kA m�4 1 60 r'T 1 d r � I t ' G Yg1� . IJ o , f NOTICE OF ASSIGNMENT 167798 IAPLOYER: MICHAEL J SMITH INC BUREAU FILE NUMBER STATUS OF EMPLOYER',' YANKEE WOOD WORKER 119098Y CORPORATION ,; �i� 209 .IYANOUGH RD ADDITIONAL INSTRUCTIONS HYANNIS MA 02601 !FII COVERAGE UNDER THIS ASS.IGNMENT!'; THE WAIVER OF OUR RIGHT TO RECOVER FROM APPLIES TO MA. OPERATIONS '1 lP i. 1 , OTHERS ENDORSEMENT IS AVAILABLE ON POOL ONLY. FOR COVERAGE OUTSIDE �Ijy POLICIES. CONTACT AGENT FOR DETAILS. OF MA., APPLY TO APPROPRIATE ;Wt POOL OR PLAN. GENT OLDIE CAPE COD INSURANCE AGENCY INC INSURANCE COMPANY: IR • 435 MAIN ST EASTERN CASUALTY INS CO RODUCER: HYANNIS MA 02601-0000 MS JOANNE STOLL-PIZZANO 325 DONALD LYNCH BOULEVARD MARLBOROUGH : MA 01752-0000 ' II . (508) 303-1000 AX IDENTIFICATION NUMBER:04-248-4325 ESTIMATED. CLASSIFICATION OF OPERATION CLASS TOTAL ANNUAL RATE ESTIMATED I CODE I'Rf_MIUM REMUNERATION SAWMILLS 2710 13.64 $ CARPENTRY-NOC 5403 Z2.82 CARPENTRY-DETACHED PRIVATE RESIDENCES 5645 10,400 15. 25 1 586 CARPENTRY-DWELLINGS-3 STORIES OR LESS 5651 15.25 SALESPERSONICOLLECTORIMESSENGER-OUTSIDE 8742 15,000 . 53 8011�::i:'j EMPLOYERS LIABILITY 100/100/500 9845 STANDARD PREMIUM 11666 EXPENSE CONSTANT 0900 .190 ESTIMATED ANNUAL PREMIUM 1 ,856 OIA ASSESSMENT 5.4% OF STANDARD PREMIUM 90 EST. ANNUAL PREMIUM PLUS ASSESSMENT $ 1,946 INSTALLMENT BAMNNUAL " REQUIRED DEPOSIT PREMIUM $ 1 7 946 ;P i COMMENTS ? COVERAGE EFFECTIVE 12.01 A.M. ON i � I•, 09/05/98 WITH ABOVE INSURANCE COMPANY. ADD ANNIVERSARY RATE DATE j 1 ENDORSEMENT EFFECTIVE ON 01/01/99. DATE OF NOTICE .09/0 8/98 PREPARED BY MARTHA STURGE I EMPLOYER COPY I MASSACHUSETTS WORKER'S COMPENSATION ASSIGNED RISK POOL ''�