HomeMy WebLinkAbout0313 TOWER HILL ROAD _72
oF'THE A Town of Barnstable *Permit#
Expires 6 months from issue doze
: RAWMAWBM Regulatory Services.. Fee
r ns�ss ' Thomas F.Geiler,Director.
Building Division .
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 X-P R E S S P,EZ
Office: 508-862-4038
Fax: 508-790-6230 AUG n 7 1003
EXPRESS PERMIT APPLICATION PERMIT APPLICATION - RESIDEl ffU r;O I, '
Not Valid without Red%Press Imprint MIS'—
Map/parcel Number
Property Address
[f R idential Value of Worker S� Q od
Owner's Name&Address S karj- 9CLM
contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
j Check one:
❑ a sole proprietor
[✓ m the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Worl man's Comp.Policy#
Permit Request(check box)
Fir' 4
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
®Re-side
[�Replacement Windows. U-Value (maximum.44)
*where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home rovlement Contractors License is required.
Signature QG�
I
Q:Forms:expmtrg
Revise053003
• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel 0 97 Permit# / g'
Health Division 2 6 Date Issued - 2
Conservation Di sion j` + FEB j j +.• `� % Application Feed
Tax Collector -VA _ Permit F e Q• C�
Treasurer YIS C,' —�" SEP S� �A�rA�;; E 01 U V
STAaLE !. W
Planning Dept. VM TITLE C; u v
Date Definitive Plan Approved by Planning Board EWROMIMENTAL COD"X4-
TOM REG �'B
Historic-OKH Preservation/Hyannis
Project Street Address .3%3 -Ta w c,- 001
U1
Village ®S fV1Ito,
Owner a Address
Telephone 505 .3(og. - 01,15(0
Permit Request .5 '1 c . Qll d -40
caL 61 eL., Ir,
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new D
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family 11"' Two Family 0 Multi-Family(#units)
Age of Existing Structure / 9S 0 `S / Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑No
Basement Type: f3 Full 0 Crawl M alkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
,. Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing 3 new 0
Total Room Count(not including baths): existing S new 0 First Floor Room Count
Heat Type and Fuel: el"Gas ❑Oil 0 Electric ❑Other
Central Air: ❑Yes 8 No Fireplaces: Existing �ef New Existing wood/coal stove: 0 Yes ❑No
Detached garage:0 existing 0 new size Ne Pool:0 existing ❑new size Barn:0 existing ❑new size
Attached garage:0 existing ❑new size 'Nd Shed:0 existing ❑new size Other:
Zoning Board of Appeals Authorization 0 Appeal# Recorded 0
Commercial 0 Yes IR(No If yes,site plan review#
Current Use S niLt �4m,lv hd"-,. Proposed Use
2� L
BUILDER INFORMATION
Name G� Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM
FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE -,, DATE allll�`
FOR OFFICIAL USE ONLY
r•
RERMIT NO. '
DATE ISSD -
'
A
MAP/PARCEL NO. -
ADDRESS - VILLAGE
OWNER
1
DATE OF INSPECTION:
FOUNDATION
r, FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
t
PLUMBING: ROUGH FINAL
`? GAS: ROUGH FINAL
FINAL BUILDING t
`T DATE CLOSED OUT '
I _ •
a
ASSOCIATION PLAN NO.:
The Commonwealth of Massachusetts
Department of IndustrialAceidents'
_ � •�16�i1�11' d�' '
600•Washington Street _
Boston,Mass. 02111 '
Workers'..Com ensation.Ansurance Affidavit-General Businesses
• � '� `����w.. �,. .-;,�er'e,tif4.r rq„" , ,y: �^•�•F,; �,:� �_;°`1't�1 i
address:
state hone
ci
wor to location full address :
[]Retail❑Restaurant/Bar/Eating
Bstablishment
I am.a sole proprietor and have no one $psiness Z�lpec 0$Ce P-jrales (including Real Estate,Antos etc.)'
working in any capacity.
I am an em to er with ein 1 ees full&' art time}. ❑tither
// ��/%% %/% ////%///////%/��%%/%%%/%///////%/%/%/////�///%/worlsin on this job.. .
I am au:employer providing Nprkers compensation for my empl y :/ : g '"
. k '}.j., .F. '�.•kp r., „t";:'. r I•'; 't.'.71;: � .l•.`li ,,7.1'�•••'.:,t^5: s�.. '.:` � ;,t;:•r•,. .i.
1:OIn"8n- Bmef_ M.n�_ j', i' /:r: �: 'i/e'o, ''^.•it' '..,' ,j .. ,r,, t� ,:i.. :� ..
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-XV
IMIx
ffrj�,m a sole proprietor and-have hired the independent contractors listed below who have the following workers'
compensation polices: ;. �li
:L
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efldtes$:. t '/v, :L' .VJ '1 5' j or'` •fr I::5,
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.:,,',•• •. •;i:� '. •.. �, .,'.., '. •,'�:.,=o,d/,c�,r 5', .Y:. •�::'�•GLIC 7f' .t.;+it2�iri Y':;Zj:�:..'f. ••,
Insurance'co. :F: t..,,, t•
�t-.r:, ..((•,��c, r•l• vT j:.,tZ. �1. •�' 'r.• '.�.�';::. ''S1�'�,r s:.r#.:''yr,9,..i•���•a::55v� t ' '.v'.��.�••�''.e.
co
Badre'$Sf
t.. ••, t~ + r. , , .,4..r .w. i'I:�' •,,': t•.'t :�:tf'^�.t"' r .:•i.t. .� :Y:. .
Cl' � ,•.i.. •.� .;h,: •'�.` iS� •n� .j.: ��::di:�t;'. •+.;Y•: �.Tyf1 t.,s: �[... r1,.,;;M:,.,;�•.1t :I.�: •t .
.�.`�i��}4': 'f, -��: ..!'• ': 'o.((• '• r ?+..•�c W
�. ti•:•:.i.'s:�' tti..j}•:":w.!•a. OtiC: '..i•, ,: 'i: '/ •�
f iSsiirsiicr° : N WIN FOR ,500.
Failure to secure coverage as required under section 25A of MGL 152 can lead to the imposition of criminal penaYtles of it fine up to$1ratan0 and/or
one years'imprisonment as well as civn penalties in the foam of a STOP WORK ORDER and a fine of$100.00 a day against ma I understand that IL
copy of this statement maybe forwarded to the Office of Investigations of the DlAfor coverage verification.
I do hereby certify under thepains and penal ' o/f perjury that the information provided above is true an4 cor
lect
!� Date
Signature S '
Phone#
print name
~official use only do not write in this area to be completed by city or town official •
permft/license ❑ m
Building Departent
#
city or town: ElLicensing Board
❑Selectmen's Office
C -checkif immediate response is required ❑Health Department
phone#; ❑Other
contact person:
(1e edSept2ao3)
Information and 14structions.
Massachusetts General Laws'cbF pter 152 section 25.requires all employers to provide workers' compensation for their•.
from the law', an employee is.defined as every person in the service of another under any contract
erriplo}+ees: As quoted- ... •
of hire; express or implied; oral or.written.
An employer is defined as an individual,partnership, association, corporation or other legal entity, or any{vo 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. 'Howevec.the owner of a
dwelling house havnag•-nonnore than three apartroents and-who resides therein, or the,occupant of the.dwelling house of
another who emplbj�spersbris to do.maintenznee, construction or repair work on such dwelling liouse ar on the grounds or
building apPurtenant thereto shall not because of such.employment.be deemedto be an p3ployer.... , .
MGL chapter 152 section 25 also'states thafeer vy. state'or local licensing-agency shall idthhold the issuance dr 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 •aired: Additionally;neither'the'
coinmonwealth nor.any.of its political subdivisions shall enter into any contract for the performance of public work until
ance with t�e insurance requirements of this chapter have been presented to the contracting .
acceptable evidence of compli
authority.
Applicants
Please%in the workers' eomPensa�a€f davit cozrpletely,by checking the box that applies to your situation.,Please
supply company name address and phone numbers along with a certificate- of insurance as all affidavits maybe submitted
to the Department•of industrial A ' 'dents•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`Tndustdal AcdaeAts. Should you have any questions regardni the"lave'or if you ale
required to obtain a.vrorkers'compensationpplicy,Please call the Department at the number listed below. ,
City or Towns .
Please be sure that the affidavit is cbmplete.andprinted legibly. The Department has provided a space at the bottom of the
affidavit for you to fjl out in the event the Office of Investigations has to contact you regarding the applicant please
be sure to fillip the pe a number�'s'h? be used as a reference number. The.afl'idavits may be.returned to,
the Department b" . or FAX unless othei•'ariangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not-hesitate to give us a call.
The Department's address,telephone and.fax number: . '
The Commonwealth Of Massachusetts-
Department.of Industrial Accidents
of in of JE WeaftWens
600 Washington Street
Boston,Ma. 02111
fag#: (617)727-7749
. i...... 4. f4lP n ?'f17_Aonn avf• dnr
F ,E r Town of Barnstable
o �y
];regulatory Services
eaxxssr,E,$ Thomas F.Geller,Director
9 1619• ,+ Building Division
�p�FD MA't k
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Fax: 508-790-6230
OfFice: 508-862-4038
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SurpuMENT TO PERMIT APPLICATION
MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernization,cu red ion,
•improvement,removal,demolition, or construction of an addition to any pre-existing own P
biding containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements. od
�,,o der, Estimated Cost ��O
Type of Work: -jn
_ Address of Work:
Owner's
Date of Application: // o
I hereby certify that:
Registration is not required for the following reason(s):
[3Work excluded by law
[]Job Under$1,000
[]B ' ding not owner-occupied
er pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIRLO ABLE HOME IMTROVEMENT WOT OR DEALING WITH ORRKDO�NOT HAVE
CONTRACTORS FOR APP
ACCESS TO THE ARBITRATION PRO GRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
Ihereby apply for apermit as the agept of the owner:
Contractor Name RegistrationNo.
Date
0
21
Date Owner's Name
Town of Barnstable
�FIHE
Regulatory Services
BARN ; Thomas F.Geiler,Director
9 MAW
�A 1639. ,0 Building Division
rED MA't A
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: iIh Ll �—, / / ! //
JOB LOCATION: 213 /V r i`ems l?i�� ��/1 `�S7Gr✓!l l _
number / street village
"HOMEOWNER": � '.5rDPi 5 2(,C-—2 �/S
name / home phone#� / work phone#
CURRENT MAILING ADDRESS: 7`f/ �r err /'f/// 12a
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
requireme
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 pemvt 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:forms:homeexempt