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HomeMy WebLinkAbout0111 CEDAR STREET t. O—Mfb-ch Is :UPC 12543 ' Ntw HASTIHOeo 88 i • i Town of Barnstable Building -�! ? Post This Card So That it is Visible From the Posted Until Final Inspection Has Been Made.Street-Approved Plans Must be Retained on Job and this Card Must be Kept NAM Permit i Md Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. i Permit No. B-20-1578 Applicant Name: THOMAS 1 LEE Approvals Date Issued: 07/15/2020 Current Use: Structure Permit Type: Building-Smoke Detector-Fire Alarm Dection Expiration Date: 01/15/2021 Foundation: System Map/Lot: 130-031 Zoning District: RF Sheathing: Location: 311 CEDAR STREET,WEST BARNSTABLE Contractor Name: THOMAS J LEE Framing: 1 Owner on Record: KOHLHEPP, RICHARD A ET AL TRS Contractor License: 172 2 Address: 111 CEDAR STREET - - - Est. Protect Cost: $0.00 Chimney: WEST BARNSTABLE, MA 02668 $35.00 Description: install (3)wireless smoke and co combination detectors and new Permit Fee: Insulation: Fee Paid: $35.00 panel. Date: 7/15/2020 Final: Project Review Req: SUPPLEMENTAL SYSTEM ONLY. EXISTING COMPLIANT p SYSTEM TO REMAIN UNCHANGED. �� 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 withink� ix months aftehssuance. 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 anj codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for ublic inspection for the entire duration of the Final Gas: work until the completion of the same. 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 Final: I - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATI r,2 M,ap_ Parcel y. J _ Application : -,alth Division Date Issued Conservation Division P p Application Fee a Planning Dept. ' �` Permit Fee Date Definitive Plan Approved by Planning Board �r�A-10- S Historic - OKH Preservation/ Hyannis Project Street Address III GI.O f�SL Village Owner QP Address.. W gA-n OM 1? Telephone Permit Request •r 05f ALL (�� wG�EIL-SS SYno('C- 4 to tom Q�,��ItoN dEI'E`'iati� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zor'fig District Flood Plain Groundwater Overlay $ ,,�;c .;ect Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If es attach su G�Fpr Y ppcfjgi c mentation. Dwelling Type: Single Family ❑ Two Family 0„ Multi-Family(# units) TO_W/v OF 20 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway R80462 , No. L� Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached.garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals uthorization ❑ Appeal # Recorded ❑ ��ornmercial ❑Yes 0-'No If yes, site plan review# Current Use gtmc- Proposed Use u +o ar,��sis,J�, �a L4;�P_YA a APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 'T-ovc , Telephone Number 7%1 -�t`�� Address License# WA L�F�A/h, �'"� ' 4 �� , Home Improvement Contractor# 1- L Email K f�/►r�SfbA� -� AA-�'. ��w Workers Compensation # Y'1 W C 31g31'149 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ~ass f_'V3i �kA5 t1TA6(AEo Gam%0h. S4C,1�w�wl SIGNATURE DATE �9I I 1'I °FI►W rqf, Town of Barnstable Building Department Services BAMSTABM ' Brian Florence,CBO 9 F1639. Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnsfable.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 E sZ6 L to act on my behalf, in all matters relative to work authorized by this building permit application for: 111 C:cc-cc S� (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signatu of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 Bradshaw, Kevin M From: Whatley, Aaron Sent: Thursday,June 11, 2020 12:55 PM To: Bradshaw, Kevin M; Brennan, Lisa Subject: Richard Kohlhepp permit r a Za_ m Life Safety Installation - Narrative Report RESIDENCE ADDRESS: 111 Cedar West Barnstable, MA 02638 INSTALLATION COMPANY: ADT Sew rity 245 Winter Strcet Wafth2m MA Contact: Aaron Wh2dey 508-360-4637 BUILDING DESCRIPTION A single-family structure with_1_ levels of living space,excluding the basement. There arc a total of_2_ bedrooms which are located on the following floors; 2 bedrooms on the fffm f3�oor and 0 bedrooms on the second floor FIRE PROTECTION SYSTEMS TO BE INSTALLED ADT, with the approval of the building owner, intends on becoming the monitoring con4my of record. The Life Safety System will be wired/wireless and the devices to be installed will included: (3) wireless combination Smoke/Carbon Monoxide Deterst The w%41 devices have a photoelectric design that will enunciate smoke and all devices arse bnercowxxud with built-in sirenstspeakers. The panel (Command/Safewitch*)includes a 2�,zy 120it encrypted design. 'The product specifications sheets for the Life Safety Devices are included with this nmrmiue submission SEQUENCE OF OPERATION The fire alarm control panel will signal two types of alarms. Supervisory alarms will be silent (tone at the panel). Another signal will be sent via wireless signal (Cell Guard)to the ADT Customer Monitoring Center. ADT will, upon receipt of a supervisory signal,notify the call list on file and dispatch the appropriate safety personal. Fire alarms, if activated eid r manually or automatically will sound audible devices(the system when triggered will notify all floors)atong with sending a signal to ADrs Monitoring Center. ADT upon receiving the fine signal, immediately contact the customer then per NFPA 72 (2013)after receiving confirmation of the alarm or getting no response from the premises,ADT will then contact the_West Barnstable Fire Dept DEVICE TESTING CRITERIA ADT will perform a complete system pre-test prior to scheduling and arranging the final test with an inspector from the West Barnstable Fire Department ADT will tree, technicians and all necessary equipment available. Upon successful completion of the acceptance test, ADT will furnish the inspector with all documentation that has not already been supplied. 1 �J Noh/n your&—Ing each dedee typo,opendon,&nd c.,.We . I eSe cx e ... °t.� Co, '-- NIP) ON i i i 41 ( � ' , 1 � r aCMPMr Kisan�Xl�"12Nat - ry LbrennanOadt.com .w i i i Note in your drawing each device type,operation,and coverage aKG c C4/do 1 1 j L; 9 I'40 { / M i MO"his si an EXl t'RN11 + lbrennan a(�adt com I i I 1 Note in your drawing each device*pa,operadon,and coverage II � � M I i I 9ti j t Icy C1ZUr[o�Cl•:`I is s"an}X1'Elt ll�L Lbrennan@adt.com / Note in your drawing each device type,operation,and coverage r.. i A, 4-c4!bo j4 i �'� ic is s an fX7ERNAf Lbrenhan@adt.com com o � bn-IYA6 - A15 -03-70 Ovq Application Number............................................................. � s UILDING DEp-f. Permit Fee.......................................Other Fee........................ s639• �� CFO MIK A BAN d 7 2079 Total Fee Paid............................................................... ...... TOWN RA , TOWN OF BARNSTA� n BL'E 1AL)LE Permit Approval by..... .............On. . ....1. BUILDINGPERNUT dD.9-1Map.......................................Parcel........ ... ........................... APPLICATION Section 1 — Owner's Information and Project Location i Project Address fit C e 8 c e, S T- Village W G�-o filza (mi l e, Owners Name So w lD O U t'Ct-e�r A . Owners Legal Address City to Eo,v vJ s7ct b 1-c- State Ko, zip Owners Cell# E-mail Section 2 -Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3 -Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ . Solar Renovation ❑ Pool ❑ Insulation Other-Specify. Section 4 - Work Description �Ja UJ C-�- 7-0 C,41 S i n) a '/z Ira tk 1 w Te-,Yt.0iy ato )q Last updated. 11/152018 Application Number..................................................... Section 5—Detail Cost of Proposed Construction 00 Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage ❑ Smoke Detectors Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom I Water Supply ❑ Public Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes WNo Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations ir 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizadon/Individual): �G Y Y-1 )2-(f c o `ri Address: C W I G 1N 1N\C4 City/State/Zip: Phone#: 7& 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.U 1 am a sole proprietor or partner- listed on the attached sheet. 7. PRemodeling ship and have no employees These sub-contractors have g. Demolition working for mein any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.i muranCe t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance rued.]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. 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.Lie.#: Expiration Date: Job Site Address: 1 I rec�n n T 16 City/State/Zip: LJ &V AO Q t j iNl Ci 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 under the pains and p alder of perjury that the information provided above is true and correct Signstore. Date: '- 1 Phone#: -7 11 — _ 6/-j O iOfficial use only. Do not write in this area,to be completed by city or town ojj`icial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants ' Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are.required to obtain a workers'. compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense 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 BostM MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSME Fax#617-727-7749 Revised 4-24-07 w .mass.gov/dia , Details http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1... The Official Website of the Executive Office of Public_safety and Security(EOPSS) Mass.Gov Home State Agencies Lic&see Details Demographic Information Full Name: BARRY M KEENE Owner Name: License Address Information City: SANDWICH State: MA ipcbde: 02563 Country: United States License Information License No: CSFA-049941 License Type: Construction Supervisor 1 &2 Family Profession: Building Licenses Date of Last Renewal: 6/28/2018 Issue Date: Expiration Date: 5/29/2020 License Status: Active Today's Date: 8/9/2018 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information loseWindow ©2011 Commonwealth of Massachusetts Site Policies Contact Us L�/ee�iomemzan� y"*p�aooa�.(�,�e�a ,Office of Consumer Affair uslness Regulation i HQMEtMPROVEMENT;CONTRACTOR TYPE Individual e r -Expiration 1 �, 06%20%2020 BARRY KEENE i BARRY M.KEENED ;ateG --� d 84 KNOTT AVENUE}/ _ k SANDWICH,MA b2563 r Undersecretary tt 1 of 1 8/9/2018,9:09 AM OFIME Tp Town of Barnstable Building Department Services $,,R,,STAB Brian Florence,CBO 1639a. `0� Building Commissioner prFD 200 Main Street,Hyannis,MA 02601 www.town.barnstabIe.ma.us Office: 508-862-403 8 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY I, �� �!/tl1�/ , Construction Supervisor License #^C U q qq , hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit# O Q 7 7, issued to (property address) I Cccta A ) 5r UJ act VvjS�-ct on Z!� — , 201,5- . The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemption form(if applicable) copy of my Home Improvement Contractor registration(if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit. Road Bond(if applicable) LICE SE HOLDER DATE q/forms/newcontrb rev:08/23/17 Town of Barnstable Building Department Services r Brian Florence,CBO UAn 16 Bailding Commissioner 200 Main Street,Hyannis,MA 02601 www.bamstablema.us Office: 508-862-4039 Fax: 508490-6234 NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR owner of property located at hereby certify that % ! is no longer Construction Supervisor listed on the application for the project under construction as authorized by building permit# ,issued on 201; I understand that the project under construction must cease until a successor licensed Construction Supervisor,is submitted on the records of the Building V-17 9 R -- DATE q�tnewconar rdzrm ce R 5 790 CMR rev:08123l17 I Application Number........................................... Section 9= Construction Supervisor Name IL e Py,e- Telephone Number `7k — Address jS k I s 19 City sG wia uu)c)h State (Y)(2( Zip C)�-S-G 3 License Number Cj V 9 0/'// License Type 1 f Z r4un Expiration Date <�-- C) Contractors Email ,m ILC A"L c w7 le%(0_�&L,6 Cell# V G r I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature 2 Date 1 — -7 -- /9 Section 10-Home Improvement Contractor Name - aY,r-X )LeC-'-1 E% Telephone Number -7 F/ -V-3 J a-C� Address 1 -7 City SCA.-(w >c(' State jr,O�Zip (0 Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your KI.C... Signature Date 1--- " 7 r' � Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature �- & 2_� Date J -7 — /9- Print Name SC4 r-r Y C Telephone Number `fjo q . E-mail permit to: j,)LA V C A L2 E_po -i- IZ`�� A U f a Cc kyi Last updated: 11/152018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13 — Owner's Authorization I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner' date Print Name Last updated. 11/152018 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I 0 Parcel d PTO/�`' S",.; 'STAB! Application #�0 Health Division Date Issued r Conservation Division Application Fee fl6 0/ O� Planning Dept. Permit Fees �6 Date Definitive Plan Approved by Planning Board _ Historic - OKH _ Preservation/ Hyannis Project Street Address Village_ CD Owner ��c���.!" ,��G N Address Telephone / — ?G 7 — % 3 S--- Permit Request cz �b Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /G,daO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new - Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: 0 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) —C � Name Telephone Number !Address 2 C_..), License # 05/ v-,.A "Z�`�� Home Improvement Contractor# Email �� o �c S�. �'�' Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �-- 'y FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED ` MAP/PARCEL NO. } . ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION } FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. . �TME Town of Barnstable Regulatory Services r WARt Richard V.Scall,Director Building Division Tom Perry,Bmldhig Commissioner 200 Main Street Hyaenas,MA 02601 www.town.barastable ma.us office: 508-862--4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I._ ����s- es•r.�.c� ,as Owner of the subject property, hereby authorize C,5.mN rc c�•+�c to act on my behalf; in all matters relative to work authorized bythis building Permit application for. ex (Address of Job) -Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted Signal 0 1 7 of App Print Name Print Name ` Date i Q:FORMs:owNIItPF.PIM&MIeoorS 'town ot-Barnstame Regulatory Services of �yy Richard Y.Sea%Director 13acling bilvision _ Tom Perry,Building Commissioner 200 Main Street Hyannis,MA 02601 ' www town.barnstablemans Office: 568-862-4038 Fax: 508-790-6230 HOMEOWNER LICEIqSE E>ETION --- -- �lPteasePtint DATE: JOB LOCATION jQ s vMW � �roMEowr>ER• - name home phone# wmk phone# Cl)RRENT MAILING ADDRESS: city/M m Oft zip code The current exemption for"homeowners"was extended to include owner-ocenpied 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_ DEFITMON OF HOMEOWNER Persons)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 sfiictiues accessory to such use and/or farm structures. A person than who constructs more one home in a two-year period shall not be consideredt a 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 understari&the Town ofBamstabIo Building Departmentnainimurn inspection procedures and requirements and that he/she will comply with said pmcedu=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 Constriction Control HOMEOWNERIS EUIION The Code states that: "Any homeowner performing work for which a building permit is required shah 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 salt Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the respoast�iIities of a supervisor (see Appendix 0,Rules&Regulations for Licensing Construction Supervisors,Section 2.1S) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed personas 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:IWPFII.EMR)dSlbmldmg pan$hons1�S.dac Revised 061313 . wev�.r�sgrrv�r� . ''��z-� 7„�Y►� aei�l���P,-�i�" �s,►��r�.-IPZiu��� - D ' Address_ V Are yEm=engAoyer?Cat&ffic sTpruprmfe bQ= Type of pl-pler:t fi red}_ 4_' I�xta ❑ L I am a employer vrlf� �—- ❑ l ccxxiiac-(ar a�I E New cunSEMCEha . apees{fizll aod�orpa�ne�* ha�'d �e sax-cuss. 7❑ I am a sole pour orparher- lis ad on the s 7- ❑ g ship anti have nG emrploy=s These sub-ccutmct=ha-m g ❑ � Ong fc rIDE m any Mpar31y ""t""J -andhxVc Wmix" [Nam comp_; sm-,m= C°=,P_kmmanml R- ❑ addition �1 5_ ❑ tie area c ogmra5cmand ifs additions 3_❑ I aZa a homwwner dnixg aII worn cis ham cm=ed fackII[]Ping xrp,=❑rajcRfi= off LRa '=33p- � c� 12-0 Rnof e sequizea.I F r-15 I(4,a ad we hnT—no -[No I3❑4tr cemp-snsuraam rare l "fsuy�F ar3e�sbmc�Iamscslmfiro s�mnhr7a�r ��cirrn�3ce�'mmn aupc3jLj-imF— #�tne>s a�sr��ic Via.::.i �y:�dnm;_III-�fz��•e o�caYmact snln�aa�sr rigd�tind�sari �r��t�bmc mgst stlsthed�3 uldifi�xl S�dmx�then�eaf�e�• a md�u oc�onttimse s�5.-� mmj4u s_ Iffthe soh-�2,xm m lutes wide b&warbea'aomg-peTi�}a�bez '.��,`�a4m` ,=ssrgflnP�thatis prm�i�ng trorkrrs'com�rz�intt�nen„�„ fo{ts�'a�n3'sss Betatr is�e Fra&cf aged job PEoFtcy 4f ar Seif-iurL lit-#- xtI}g} 1 ' Ioh�.A.da� ��� �c��vr ��` Cifg�'StairlLxp:'�✓. /�S'i''`�S� ��$ Af;tac7i 2t copy of fhe=vmrI eommpumtirrm parrET, dzclma�pzge-(4L�the P°lkT xtum er aFsd ration Este}: Fasil=to secazfi cuvcr ge as repiredumdef Sed:knSA of MGL r- 152 mm Lead to the iaposifim of-cr;minal pemafgs of a fTCI P ug to�I SOQ QD astdlor�yearimp as�aeI[as cirsl genatties iu�e fug.of a S`�'CtF�(3R�C]ItDR and s f� cd up to S250-00 a day apimt ffie violator- $e advised fbaf a coPy of ibis st mew maybe fi rwarded to the Owe of I�of the DTA fnz msamnc-e covmzge v I tia Fie ei> car* EMbU gmuffr= burp ffrrrt$t�u�DrRra�iaa pravi�aFzave" hua runt oat xsct �; - �• -�i� ems— . . Phrme ik7 asa ou£u Dv trot witrin 9ds area,err her crlatpieted by cttp m,twm of cinl Cy ar Tatru: grac e4Si` ��A�xtha�g t�7r aue�; . • - L Boyd of$caIti 3.BuffingDel=tra I af�fFawmamk 4..Blecbicallaspectpr S.Pig tar cKhm Cater-tT°essou: Ph�� • ., h!��taal Laws r I52 r�>:s aII e�iglDY�in Pie�'��n for their etaploycrs, • P=MMO±-D 4ds sf an mrpL7w is defined as a—CVsy person m ffie service of gnotber unties soy coahaCt of hie, express or flied, oral c rwiitfnn." An mnpIrtyer is defined as�mil,per,associaton,corporation or other legal cmfay,or-my two or more offfie Ercgoing e�.gaged in a joint mftrPu se,and i"n the legal rcprcseat&m of a deceased employer-or the re�eiveg or trustee of an indieithial,pmtaership,association or other legal entity,y,emPlDymg cPIDYDm However ffie owner Df a dwellmghouse havingnotmate ffian three apartment and who resides ffiemfi-4 or ffie occupant of the dwelling hD=of anoffirs who employs pecans tD do mamtman=,cons trout n or repair work on rich dwelling house " or on ffie grounds or building agputte nab thereto shall not because of such employmrn be deemed to be an employ rr." MOL chapter 152, §25C(6)also states that'every state or local licensing agency Shall wi-(hhDId 13ie issuance or renewal of a license or permit to operate a business or to constr'ircd buildings in the commonwealth for airy applicant Who has not produced acceptable evidence Df coiapfiance with-the nzs d. orance;coverage require ' . Aid#malty,MM chapter 152, §25C(7)states=Neither the commonwealth nor any of>tspolitical subdivisions shall enter jdD arty coahaet for the periie==of public woiltosIR acceptBble evidence of compliance with the fiance r-egniements of this chapter have been presented to the contracting authority' Please fm out ffie workers'compensation affidavit completely,by checking the boxes that apply to your situdDn and,if necessary, saTply sub_contactDr(s)name(s), addresses)and phone nimmber(s)along with their cerLncate(s) of insurance. Limited Liability Counter(LLC)or LimitedLiabilhy Parinerships(LLF)wi hno employees other than the members or partners,are not required tD way workers' compensation insures ce. If an LLC or LLP does have employees;a policy is required- Bc advised that this affidavitmay be submitted the Department of Industrial Accidents for confirmation Df boE=ce coverage. Also be sure to sign and date the affidavit The affidavit should be retlmmed to the city or town that the application for the permit or license is being requested,not the Departinent of Industrial Accidents. Should Yon have any questions regain the law or if you are required to obtain a'workers'compensation pDlicy,please call the Department at the number listed below.'Self-i as�companies should enter their self-m suran=license numBar on the appropriate line:. City,or Town Officials _ • . "-" Please be sure ffi4 tee affidavit is complete:and printed legxb•Iy_ Tbe:Department'has provided a spare at the boaZo o f the affidav=t for you to fill out in the event the Office of Invmtig�s has to contact Yon regmding the applicant ' Please be sure is�.in the permit/license number whim Will be used as a reference number- In addiction,an applicant that must submit multiple peimit/liceose applitations M any given year,need Daly submit one af5&-vet m0lcating current policy information(ifnecessary)and under'.TDb Site Address"the applicHat should write all locations in (city or ' town)"A cagy of the affidavit that has been officially stamped or mimed.by the city or town maybe provided b the ' applicant as proof that a valid affidavit is on file fur f itam pmmit s or lieeases Anew affidavit must be filled out each year_Where,a home owner or cibzea is obtaining a license or permit not m.Iated to any business or commercial ventrae (Le.a dog license or permit to bum leaves d r.)said person is NOT requiizd to completes this affidaiZt The Office of lhve! gations would hke to thankyon iu advance furyour cooperation and shouldyou have any.quesiibns, please do nothesitatD to givens a call. TheDepacbmemfs address,telephone and fax numben as Co= rit?f_-alth ofMassachu - .D�fiair�t ref Ian A � • • _ .. 6DO_WWda,20M Fes:*6I7-727 7749� B.evisEd 4-2"7 - � � 5/13/2015 6:36:06 AM PST (GMT-8) FROM: 100005-TO: 1b084'1fy1yu DATE(MMfDOMIYY) CERTIFICATE OF LIABIL INSURANCE 5/1312015 FERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA .OD BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNE ND, EXTE RR ACT BETWEEN THE HE ISSUING NSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT ST REPRESENTATNE OR PRODUCER,AND THE CERTIFICAT IMPORTANT: If the certificate holder is an ADDRIONI L I U e Po Icy(i m be endorsed. H SUBROGATION IS WANED,subject e the terms and conditions of the policy,certain poll require an endorse t. Gement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. VV PRODUCER PAUL PETERS AGENCY INC E° FAX PO BOX 1290 PNONE AC No MASHPEE, MA 02649 20 Wil AMM D David W. Almquist Mashpee, INSUReuS►AFFORDINGCOVERAGE NAt0 NSURERA: LM Insurance oration 3360 INSURED INSURERS: DWA CONTRACTING INC INSURERC: 20 WILANN ROAD INSURERD: MASHPEE MA 02649 INSURER E: NSUiLER F: COVERAGES CERTIFICATE NUMBER 24646983 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, S. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY Pp�CY EXP [ FF MR TYPE OF INSURANCE I OL 8R POLICY NUMBER M MMMONYYY Ll411TS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE b CLAIMS-MADE OCCUR b MED EJ�(Any one person) b PERSONAL 3 ADV INJURY b GENERAL AGGREGATE $ AGGREGATE LIMIT APPLIES PER: POLICY PRO. LOC PRODUCTS-COMPIOP AGG $ JECTb OTHER: COMBINED SINUTrior $ AUTOMOBILE UABLITY We accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per amdem) $ AUTOS AUTOS NON-OWNED P RTY OAMA $ Per amide d HIRED AUTOS AUTOS $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS�IADE AGGREGATE $ b F—FDED I I RETENTION PER TE ER q WORKERS COMPENSATION 60 N WC5-31S-3244855 4/1312015 4/1312016 AND EMPLOYERS'LIABILITY YINE.L.E EACH ACCIDENT $ 100000 ANY PROPRIETORIPARTNERIEXECUTIVE N IA OFFICERMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100000 (Mandatory in NH) If yes,describe under El.DISEASE-POLICY LIMIT S 500000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Adjoeorml Remarks Schedule,may be suarhed if more Waee is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,Only as they relate to workers'compensation coverage. CERTIFICATE HOLDER CANCELLATION MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance Corporation 01998-2014 ACORD CORPORATION. All rights reserved. h.;okd 25(2014/01) a and logo are registered marks of ACORD CERT NO.: 24640983 CLIENT CODE: 1324406 Lucy Garfield 5/13/2015 9:33:00 AN (SOT) Page 1 of 1 ,. i 1, , .L AD - -dam.= Z N 100, 00; �ry3Q 4 1 ��- L►s-7,.�c�BJ 13 ti r 7 C ; :1 ✓ f � •ram - 4— �,:--.. - a� ._ ...`::� e.:i_i ti, r . Unrestricted-.Buildings _. contain less of an use enclosed s 35,000 cubic feet grouP3�o ch Pace. et(99'r Failure to Possess a current edition State Building Code is cause f of the Massachuset� For D�Ucensin or revocation of this license. g inforrnation visit: WWW-Mass.Gov/OpS Massachusetts _ Department of Public Safety Board of B uilding Reg Construc�;on SUpen ulations and Standards •i sor License: en - VID W Q`�I'1VI 20 iST • WIj,A "g .EE MA 0649T f ¢ Commissioner• Expiration 01/01/2017 ;` e�parrvnza�zruealC/z o�� aduoe,% Office of Consumer Affairs&Business Regulation ' License'or registration valid for individul use only . WE OMEIMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: :;��:7523 Type: Office of Consumer Affairs and Business Regulation xpiration:_s 1:01:13120;16 Private Corporati .). 10 Park Plaza-Suite 5170 Boston,MA 02116. D W A CONTRACTING;INC.' i IE DAVID ,ALMQUIST 20 WILLANN RD 4vr MASHPEE,MA 02649 Undersecretar y Not valid without signature TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map , Parcel A 31 Permit# .�S/� 4 -d' I Health Division I ( u.--7 v'.� S Date Issued -7 — -':;Conservation Division /q.�r F ot: e / D.S Fee 7 ► �f � Tax Collector 7 16 O J� vv Treasurers Planning Dept. Checked in By Date Definitive Plan Approv byl?lan nin EXISTING SEPTIC SYSTEM Board ApprQY ___ OF BEDROOMS Historic-OKH I reservation/Hyannis i Project Street Address I Ce Village A Owner Address Telephone 3 6 r Permit Request n .3 I Square feet: 1st floor: existing proposed 2nd floor: existing �� proposed ��� Total n /dO Valuation "7V Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size o le� C g re> Grandfathered: 0 Yes O No If yes, attach supporting documentati rn C_ Dwelling Type: Single Family 14 Two Family O Multi-Family(#units) D Age of Existing Structure N34 45Historic House: ❑Yes ❑No On Old King's Hig-pay: O Yes O No Basement Type: 'Full ❑Crawl O Walkout O Other :n 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 3 Total Room Count(not including baths): existing 9 new First Floor Room Count Heat Type and Fuel: `f`Gas O Oil Electric ❑Other Central Air: ❑Yes #No Fireplaces: Existing ( New Existing wood/coal stove: Yes O No Detached garage:O existing ❑new size Pool:0 existing ❑new size Barn:xexisting 0 new size 3Z - a Attached garage:0 existing ❑new size Shed:`dexisting ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded O Commercial El Yes No Ifres, s'a plan review# J4E...,z Current Use Proposed Use CpS, - — — -- BUILDER INFORMATIONName . Telephone Number e © c r l Address License# Home Improvement Contractor# Worker's Compensation# ALL CO , ION DEBRIS RES. LTING FROM THIS PROJECT WILL BE TAKEN TO DATE FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/R4A- CEL-NO. E ADDRESS VILLAGE OWNER - 0 DATE OF INSPECTION: 5000 e(< FOUNDATION FRAME 4 _ -o �`j �, !" k INSULATION FIREPLACE ELECTRICAL: ROUGH FINALI ; t PLUMBING: ROUGH M FINAL GAS: ROUGH FINAL FINAL BUILDING " DATE CLOSED OUT 0 ASSOCIATION'PLAN NO. u� c The Commonwealth of Massachusetts Department of Industrial Accidents = 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 Leidbly Name (Business/Organization/Individual): 14 Address: C City/State/Zip: �� Q ,, Phone#: 2.( �_3 Are you an employer?Check the-appropriate bog:. Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ❑ ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. J�j Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions req uired.] officers have exercised their right of exe lion per MGL 11.❑ Plumbing repairs or additions 3. a homeowner doing all workexemption p [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#1 must also fill out the section below showing their workers'compensation policy information: `> t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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. M 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 a amst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of 11,e DIA for insuran coverage verification. I po hereby certify uncle a pains and pen of perjury that the information provided above is true and cec� Signature: 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#: 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-contractors)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure'to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fixture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia °Ft►+er Town of Barnstable °^ Regulatory Services Thomas F.Geiler,Director MAM 1639.�A�`� 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 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the-"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building 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. Type of Work: On G Estimated Cost 000 Address of Work: Owner's Name: Sa0k Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 (]Building not owner-occupied Vowner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE r ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A., SIGNED UNDER PENALTIES OF PERJURY I hereby apply fora permit as the agent of the owner: Date Contractor ame Registration No. Date Owner's X*ame Q:forms:homeaffidav f RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings $100.00 Residential Addition $50.00 Alterations/Renovations $50.00 Change of Contractor/Builder $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE N) square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE _square feet x$64/sq.foot= x.0041= plus from below(if applicable) . GARAGES(attached&detached) square feet x$32/sq.ft.= x.0041= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf , 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) -.Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.0 0 Relocation/Moving $150.00 (plus above if applicable) Permit Fee Proicost Rev:063004 .4 Application to kigbbiap 3aegi>onal JL)iotDrit �Bis�tritt (Committee In the Town of Barnstable (D CERTIFICATE OF APPROPRIATENESS Application is hereby made, with four complete sets,for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans,_ drawings, or photographs accompanying this application for e-- w CHECK CATEGORIES THAT APPLY: Cil dHouse co 1. Exterior building construction: ❑ New Addition ❑ AlterationIndicate type of building: ❑ Garage ❑ Commercial ❑ Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other S d\QYV- r ' TYPE OR PRINT LEGIBLY: DATE - ADDRESS OF PROPOSED WORK (viS-�kWeASSESSOR'S MAP NO. I,so - OWNER R�. � A RIQ�5G e , Q�� ASSESSOR'S LOT NO. 03 ,A 508 ► , . HOME ADDRESS �3 e S�-' �\�tsi bQ`L��� A[-Q, TELEPHONE NO. 3(v2 -5 LQU� FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any public street or way. (Attach additional sheet if necessary.) A -- f ' ST,7MT AGENT OR CONTRACTOR StVl IR nV C Vc 1+— TELEPHONE NO.-]'7q-UJ (OZ9 ADDRESS DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please include locations of proposed signs. (k+ Signed NDai-- - 0,2-ek G Contractor-Agent i For 6Com mittee-Use.Only VED 'ni � cr� ,� r Q " This Certificate is hereby Date JUN 0 2 2005 d Approv / C ee Members' Signatures: TOWN OF BARNSTABL HISTOR,C PRESERVATIO,J Town of Barnstable ✓(! �. . Old King's Highway Historic District Committee 0 2 H�STWN pF 100S SPEC SHEET FOUNDATION U C �ul� �pN SIDING TYPE �� COLOR CHIMNEY TYPE COLOR ROOF MATERIAL S COLOR mw I PITCH 1 A• �Z WINDOWS COLOR SIZE TRIM COLOR DOORS COLORS SHUTTERS COLORS GUTTERS COLORS DECKS MATERIALS GARAGE DOORS COLORS SKYLIGHTS SIZE COLORS SIGNS COLORS FENCE COLOR NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of this form are required for submittal of an application, along with Four copies of the plot plan, landscape plea and elevation plans, when applicable. SPECSHT Revised 11198 i 03/25/2003 09:18 508-992-3374 FERREIRA ENGINEERING PAGE 01 FILE#MID 30329 CENSU9 CPN 122 APPLICANT:PE 1 A g ROSALIE BELL2111 ASS MOW PLAN 130 PLOT 031 ® RTOAGE IN3FEtC ^TIOAI FLAN . OF LAN LOCATED AT l I I CEDAR STET BARNSTABLK MASSACHUSE'1TS SCALE:I"I 111F DNS r 14.1.77' March 25, 2003 3 ,IU/V 0 2 2005 PARCEL= TO N�,,\ U H/STD„/ l��s��STgB NIF WHIT. 1.�9 AL. PARCELI ER1iATi 413.00 srtt�s.�q 1 � t 04 0v) >fS/ fro a� I�4:Oo �`E�clase� -- CEDAR STREET CERTIFY TO: DUNNING KIRRAW L.L.P., SfII�RWOOD AI 4[ORT�GAGE GROUP. INC..AND TTS SURANCI~COMPANY,THAT THERE ARE NO VISIBLE ENCROACH M MS OR EASE4 mM EXCEPT'A WN AND THAT THIS PLAN WAS PREPARED UNDfiR MY I>, DLATE SUPERVISION. THE LOCATION OF THE DWELT ING'AS SHOWN HEREON IS IN COMPLIANCE WITH TM LOCAL APMCAHLE ZOMNrJ BY-LAWS WITH RESPECT TO HORIZONTAL DDENSIONAL MUIRPMENTS. THE DWELLING SHOWN MME DOES NOT FALL WITHIN �E A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A MAAP OF 00M94UNITY050001.001 ID DATED VW2 BY TIC a Kenneth L Fermirs ! p nwrrlong'im 1903 MA 02741- 61V6RAL NL Mt•9924M Per.M-3374 made as d1e oo eeeodid e�dO lbav tre m the baeb otrey knowladpq aftmsdM and balWo the wam of a e+-*w plot plan;;; ))[hie o4e sae ea awdn fa (2)DeeSeMI in Made b dw d ow drd abler o*ae cCV*dam. cff aaa�w l6r aee M propttiq 4ad er br=mnxom&(4)VwiSodow dRu"jy bee e;eNormr laAuiaa�i.b a*b e mom&hoomm eacray. ENERGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS 780 CMR Appendix J Applicant Name: S Site Address: Applicant Address: ' City/Town: Use Group: — 0 166-f- Date of Application: J Applicant Phone: 6*0 59 U,a, S 36y Applicant Signature: Compliance Path(check one): J ❑ Prescriptive Package(Limited to 1-or 2-fam(ly,wood frame buildings heated with fossil fuels only) i Package(A through KK from Table J5.2.1b): Heating Degree Days(HDD6,)from Table J5.2.Ia: (For items d.through i.,fill in all values that apply from Table J5.2.lb:) ; a. Gross Wall Area sq.ft f. Wall R-value R- b. Glazing Area' sq.ft. g. Floor R-value • R- c. Glazing%(100 X b=a) % h. Basement wall R- d. Glazing U-value U- i. Slab Perimeter R- e. Ceiling R-value R- j. Heating'AFUE - ❑'Coitiponent Perf6rmanc&"Manual Trade-Off"'.(Limited to wood+or metal framed buildings only) Climate Zone(from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14 Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet,if applicable] ❑ MAScheck Software Attach Compliance Report and Inspection Checklist printouts ❑ Home Energy Rating System Evaluation Attach Home Energy Rating Certificate(HERS rating score must be 83 or higher) ❑ Systems Analysis OR ❑ Renewable Energy Sources. Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADDITIONS ONLY: a.Gross Wall+Ceiling Area 0 sq.ft. b.Glazing Area' 10o sq.ft. c.Glazing%(100 X b=a) R% ADDITION with Glazing%(c.)up to 40%may use 780 CMR Table J1.1.2.3.1 below: MAXIMUM U-value MINIMUM R-Values Fenestration' Ceiling' Wall Floor Basement Wall Slab Perimeter Depth 1 0.39' R-37 R-13 R-19'` , R-10 R-10 4 ft I Glazing Area may be either Rough Opening or Unit dimensions. 2 Based on NFRC listing. Applies either to every unit,or to area-weighted average of all units. 3 R-30 ceiling insulation maybe used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area (i.e.-not compressed over exterior walls,and including any access openings.) ❑ "SUNROOM"addition(greater than 40%glazing-to-wall and ceiling gross area) Attach"Consumer Information Form"from 780 CMR Appendix B. Official's Name: Official's Signature:' Application Approved ❑ Denied ❑ Date of Approval/Denial: Reason(s)for Denial: (provide additional details as needed on back side) Wi WORK ASSAW 1 01 I not 4 IZZrFr�t%.ttoo h i, 7Um it I �� .,.<.... ......... '� �}•'y' sj�t•.t't..•Lt.f ., �Q..� `2 :''. _ _ t: ,i�.lr:,1. •:•i�•;,; •� Lj TAk 1 PWO, .I oymb '�V ,��•�� I' (ti Sr, +1 r•.t`1'S . .+' ,i'SIi't ,.l f WMWA many t0va VW I law, 440ty"I" VITHA .00110 A- M%A 0! W W AM; C 0 M(Y4 it 111 is,AM 1 P 30, --77 Oyu A" MACY LIW ra q ;1"iii owipA .4mm, W L"6, ad ;N!". 04 nod 1VIN2 IMI OWIMM -to Kip r t& 0100 10)"1111 U,Olt; I Town of Barnstable Regulatory Services "MSTABLB, ; Thomas F.Geiler,Director �b '3s .0� Building Division Argo��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: JOB LOCATION: Gr N v number street village (� "HOMEOWNER": w� J O 53�4 2 Q--3 name' home phone# work phone# 0 CURRENT MAILING ADDRESS: -r Q)0y, J 0 ... city/town 9tate 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 undersi 91S`ho eowner"certifies that he/she understands the Town of Barnstable Building Department minimE' e probe dunes an ents and that he/she will comply with said procedures and requir Signature of Home caner 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 fom>/certification for use in your community. Q:forms:homeexempt v Uniformly Loaded Floor Beam(2000 International Building Code(97 NDS)]Ver: 6.00.5 By: , on: 07-02-2005 : 09:32:38 AM Project: SAMPOU RESIDENCE-Location: BEDROOM ADDITION This analysis was generated by an evaluation version of StruCalc 6.0 Summary: ( 3 ) 1.75 IN x 7.25 IN x 9.5 FT /Versa-Lam 2800 Fb DF-Boise Cascade Section Adequate By: 140.1% Controlling Factor: Moment of Inertia/Depth Required 5.41 In Laminations are to be fully connected to provide uniform transfer of loads to all members Deflections: Dead Load: DLD= 0.06 IN Live Load: LLD= 0.13 IN =U864 Total Load: TLD= 0.19 IN =U590 Reactions (Each End): Live Load: LL-Rxn= 1140 LB Dead Load: DL-Rxn= 531 LB Total Load: TL-Rxn= 1671 LB Bearing Length Required (Beam only, support capacity not checked): BL= 0.35 IN Beam Data: Span: L= 9.5 FT Unbraced Lenqth-Top of Beam: Lu= 0.0 FT Live Load Deflect. Criteria: U 360 Total Load Deflect. Criteria: U 240 Floor Loading: Floor Live Load-Side One: LL1= 40.0 PSF Floor Dead Load-Side One: DL1= 15.0 PSF Tributary Width-Side One: TW1= 6.0 FT Floor Live Load-Side Two: LL2= 25.0 PSF- Floor Dead Load-Side Two: DL2= 10.0 PSF Tributary Width-Side Two: TW2= 0.0 FT Live Load Duration Factor: Cd= 1.00 Wall Load: WALL= 10 PLF Beam Loading: Beam Total Live Load: wL= 240 PLF Beam Self Weight: BSW= 12 PLF Beam Total Dead Load: wD= 112 PLF Total Maximum Load: wT= 352 PLF Properties For: Versa-Lam 2800 Fb DF-Boise Cascade Bending Stress: Fb= 2800 PSI Shear Stress: Fv= 285 PSI Modulus of Elasticity: E= 2000000 PSI Stress Perpendicular to Grain: Fc_perp= 900 PSI Adjusted Properties Fb'(Tension): Fb'= 2961 PSI Adjustment Factors: Cd=1.00 Cf=1.06 Fv': FV= 285 PSI Adjustment Factors: Cd=1.00 Design Requirements: Controlling Moment: M= 3970 FT-LB 4.75 ft from left support Critical moment created by combining all dead and live loads. Controlling Shear. V= 1471 LB At a distanced from support. Critical shear created by combining all dead and live loads. Comparisons With Required Sections: Section Modulus(Moment): Sreq= 16.09 IN3 S= 45.99 IN3 Area(Shear): Areq= 7.74 IN2 A= 38.06 IN2 Moment of Inertia(Deflection): Ireq= 69.44 IN4 1= 166.72 IN4 t , i , I I ` —I I I!Iilll I I I I i I III III I I I II I I I I I III � I • � �_ ►II!Ilil! I �� II I � ! ! I I I I D I ' I > A I I ►I I IIIIII m70 I III I I I I i I' II'I m � I,,!IIIIII I III II If II! !III! a I ® ®® rn �IL.,,I ,!,1► ► � Ii�II �!� I �' ;I!!�III _ � ' o C I �Drnr II��;I,I�II,II II,I II I I,I�I�!!'II I�II�IIiI�!IIi,•I�!�.;;!I,II;'I'I:I�,:, Q < Ill I!II Pr�yi ►�II II'I•:.:I,',1�1I�'I;, �:I,:I!II I. I�I,'I I I;I !i.�II I►Il I I II II,II II,��II' I!,n I I I•I!I!,I I;I I;; !�I !I i''I•ill � ; !I I; !'�'�i � ! I I!I � �I!, I;III�.;I — _ !III! II!Illl�lil il'IIII►��II �,I!�,I I ! I�! 'I III I IiI II I;I II;;. II ' � i � i�ij! i IIII Iilllillll!jll � :!IIII:. II II IIIIiI I j li i I!II II ill !LI, �,I; I IIIIIII II I IIII!IIIII'II„II� � �(I I I I i I II III ;III I ,!i:Il IIII I ! II�I,IIII IIII � I III I �� I III � III IIII' 1IIIIII'� . ® I I III II mi , Ii IIIII l Il�;l ; _ 1 ;j U) ' Ill III r m I ! I m r A i I, II III: a e_ I •,I,i,i III ,_ � rn ► I r rn I Ili ! < > IT J I ' D PROJECT: -+ yy SAMPOU- RESIDENCE ' ' LIT { AL �t 111 CEDAR STREET, W BARNSTAHLE 110 SEABOARD LANE HY' ANNIS, 02001 �•. AS-BUILT ELEVATIONS p ���: �08o5=0031 } , jt I -u �pi j m i I ! m { D I I I f I I I I II III I l� it lli� a o ® �® ill I , 'o ! I I I LI LII;I ,I I a i 111111HOMI � �i , f , III„I,II D � � Y !. II II 1.1 ' T•. v d II `U 0LO y !! Hal - o � d .r D PROJECT: f. 1, ..�5AMPOU AE51DENGE �'of>=" "G�'��E�ksARGHlTE(-,TURAL GRAPHICS J✓� -� Ill CEDAR 5TREE7, N 5ARN5TAI3LE ►� .. i! PROP05ED ELEVATIONS AZID ON IS ITI 24'-8° 0 2A O 2442 ANDERSFIJ FWN AWING F- 606E 111SSS11Y"� a 5ATH I �q NOTF: . I' REF.. -TARE 4g FAMaI-Y o AND�1 400 SERIES WINDOWS. a BEDRQOM ®1-FLO n CONTRACTOR SWALL.VERIFY q 2'-0° An L= ONS 0 DIMENSIONS PRIOR . TO WINDOW ORDER A INSTALLATION Li 100 NEW WALL N_PL _IL . !I 49 ppp --- IL BI-fw - KITCHEN Re'tOVF� WALLC===-=___� 2A /L o Q� I: RN i! IxISTING raAL1 II II DN o � �(y''•�7' :.I I Po �C/ g:UTE 29 O � !I 2442 2442rtp ' '`''AI� I I d LEI' irI I I 4'-2a 3'-2° 3'-2' 4'_2° r Wul `�11 II . - .AD'DITION ""� II up I I I �-- --- ---- ----- -- ADDITION ' w�-- --- 2s-W I < FIRST FLOOR PLAN r - - - -- w z SCALE: 1/4' 1'=0" ` . I -- — I I I Z I I w I I A 3 I w Z I I W_ lu I OL BEDROOM L--- 0 t- Q w _ U DN SHEET 3 OF 4 J� SECOND FLOOR PLAN G' J, SCALE: 1/4" m V—O" Li I .I I�I�1—1 JOB: 0508 DRAWN BY: KW DATE: 6/12/OS 8°X46°CONCRETE WALL 111444YYY/// 10lxW CONTINUOUS FOOTING If—t 1 1 .VEr"T GRAINL SPACE 1 = I VAPOR BIER Z 2°CONC. DUST CAP I 1 z 1 REMOVE WINDOW AND nnp .'. ENLARGE OPEMNG FOR lla>..e CRAWL SPACE.ACCESS r+ r CCU cl • FULL ri BASEMENT k w ' EXISTING f— MATCH LDOSTINGt2 ITCH SECOND FLOG Z Ass�IALT sµl�G�gg n/ 5/9' PLY SHEATHING 4� � li! �• U Q R90 F.G. IN^..1-JL. z to. T FOUNDATION PLAN nATCN EXISTING TRIM _ _ eevo�-- '°°01s (� 3 Q ALUM. GLTfERB/ Dw SPOUTS _. i RESM�OpVpEp�W�ALL (� a SCALE: I/40 1'-O° LVL BEAM �. Lu �. F �. NEW WALL .. R13 F.G.TI IN w. v t4UL. Lu D i i • 2M EXT. STUDS i 10 O.G. I t 1/2° PLTWOOD SHEATHING EXISTING CL W.C�SFN WRAP �661 w FIRST FLOOR ' II II R14 F.G. 1NSUL_ lfUtftt yc, yac mmar°m-vvm W r,IM U B5r46° GONCR_TE WALL• ' TOW COwr.,fw=MG I''u EXISTING•va,cec dmM 5ASEMENT SHEET 4 OF 4 ZA MALL SECTION SCALE: 1/4° = 1'-0' _108: 0508 . DRAWN 57: KW DATE: b/12/OS 1. IMPORTANT ANY CONSTRUCTION THAT INCREASES LIVING SPACE BEYOND 1200 SQ. FT. PER LEVEL MAY REQUIRE THE INSTALLATION OF ADDITIONAL SMOKE DETECTORS. NOTE: A SEPARATE.PERMIT IS REQUIRED FOR THE INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL PERMIT DOES NOT SATISFY THIS REQUIREMENT. SMOKE DETECTORS REVIEWED c� 7- s�, BARN TABLE BUILDING DEPT. DATE FIRE DEPARTMENT DATE BOTH SIGNATURES ARE REQUIRED FOR PERMITTING Town of Barnstable Permit# 3�� Expires 6 mom om issue date Regulatory Services Fee z ewxrtsrnsM M` 0 Thomas F.Geller,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY r O 1 Not Valid without Red X-Press Imprint Map/parcel Number \ FI Property Address ao'L-f W � �N,4J (�Residential Value of Work$ 1 I Minimum fee of$35.00 for work under$6000.00 Owner's Name&AddressP� t Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: i Construction Supervisor's License#(if applicable) _--�-PRESS PERMIT ❑Workman's Compensation Insurance AUG _ 8 2013 Check one: ❑ I am a sole proprietor j I am the Homeowner TOWN OF BARNS 1TAE3LE 'C7 Lhave Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑s Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop t sign Property Owner Letter of Permission. A of the Home provement Contractors License&Construction Supervisors License is requir SIGNATURE: Q:\WPFILES\FORMS\building permit forms Revised 060513 The ColmrmrnsedA of Massachusetts Deparbuenf offadas&ial Accidents Office qflnmfigadons 600 Warkingion&reetf Boston,MA 02_111 tvKtry mamgorldia Workers' Compensation Insurance Affidavit BuilderslConfracttors/Eiectncians/Rumbers Applicant Information Please Print L 'bly Name(B am/lndivitlual): Address: C*/State/zip: 40A4hone i 0Y 3o- Are you an employer?Check the appropriate box: Type of project(required): >!_❑ I am a employer with 4. ❑I am a general contractor and 1 6. ❑New oons5nsctioa employees(full and/or part-time).* have hired the subactozs 2-❑ I am a sole proprietor or partner- listed on the attached sheet 7- ❑Remodeiiag ship and hate no employees These sab-ooatractCrs have 8. ❑Demolition working forme in any capacity. employees and have wodcets' 9. F]Building addition [No workers' comp.inmx c- ane comp.insurance-1 re 5. ❑ We area corporatitffiand its 10.❑Electrical repairs or additions 3_ a a bomec wn�r doing all worse officers have exercised their 1 L[j Plumbing repairs or additions rmayset£[No worloers'Comp- right of exemption per MGL 1-���{{hoof repairs insurance r' ]I c.152,§1(4),and we hn a na- . I employees.[No worTons' 13:❑Other comp"insurance required.] ;Efny appluautt that dec ks boa#1 t>ms'also fM out the secdon below showmg f�vradeee rnmpe_nsa oa paHu iafnemadicm Snmeawnera arho sabmd this affidavit mffc mtg tfiey ate doing aU vrade and @lea hire oatside cont=tms toast submit a new afftdmM meTcating sarlL ZCanftRctoa mat checY this boot mast attached as addition sheet abaaring the nee of tfte sa6�e ode and state uhetLer txnot t3xtse Mies hsv� amplayees. If the soh-coat mctats pace employees,they tmest provide their work-e comp.policy nvmaber. I am an employer that isproviding ttrorkera'compensirrlian irtsunatrce for aiy atrrpinyeaL Below is the policy atzd job site information. Insurance CompanyName: Policy g or Self-ins-Lit g: Expiration Date: Job Site Address. City/Statelzip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to swore 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 maybe forwarded to the Office of Ins estigations of ffie DIA for insurance coverage verification. I do here carhfy ri dhepai ndponatties ofpedwy thatthe information provided abov is true and r ct tore: Date: Phone#: O,&ial use only. Do not writs in this area,to ba completed by city or town oficiat City or Town: PermitUcense it Issuing Authority(circle one): L Board of Health 2.Binding Department 3.CitpToRn Cleric 4.EIectrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 i Information and Instructions , Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 15.2, §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 ins�ce requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and;if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have i 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 lime. 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 permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lie 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 Deparlmmt of Industrial Accidents Office of lavestigations 600 Washington Street Boston,MA 02111 Ta A 617�-727-4900 at 406 or 1-877 MASSAFE Revised 4-24-07 Fax##617-727-7749 www.massgov/dia I Town of Barnstable Regulatory Services ♦ A�R�'�yA{R Thomas F.Geiler,Director �E 659. ►`0� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 f HOMEOWNER LICENSE EXEMPTION DATE: /z . Please Print L 2 JOB LOCATION: cc_A"d ��I 1�. b �v 3 k b street village 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. DEFINITTON 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 under r ' ` omeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection ro d requ ements and that he/she will comply with said procedures and requirements. SGgnatrire of eowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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. C:\Users\decoDik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBNIE)TRESS.doc Revised 053012 Town of Barnstable Regulatory Services .� 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building petit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPEPMISSIONPOOLS 62012 r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map r c-) Parcel ( Permit# Health Division Date Issued o2 / Conservation Division _ �2 Feed. Q u Tax Collector Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH '3 Preservation/Hyannis Project Street Address Ll C:25-DA-L S T Village UJ BMS70ct U Owner 44THC_&G-AS' %tf6-kJ Address et►-P Telephone SD 1?'3G D—aY(a a a 14 cectoo Permit equest P��r�o zetrDhc�/a� Square feet: 1 st floor:existing `ADO proposed 2nd floor:existing %OD proposed Total new e---Estimated Project Cost Af 00 Zoning District Flood Plain Groundwater Overlay Construction Type Wend-enm�^,P 1 40L S� /,a* .2a x /� I. 64.r-jt, ^adfm 30 A 'is— Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family 81-<wo Fa mily ❑ Multi-Family(#units) Age of Existing Structure 5? Y— Historic House: El Yes ❑No On Old King's Highway: El Yes El No Basement Type: O�Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 6 010 Number of Baths: Full: existing / new Half:existing new Number of Bedrooms: existing }L new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: Q'Gas ❑Oil aElectric ❑Other Central Air: ❑Yes 21 o Fireplaces: Existing _I New Existing wood/coal stove: a<s ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:existing ❑new size Attached garage:❑existing ❑new size Shed:2,6x'i4sting ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes Ygo If yes,site plan review# Current Used Proposed Use Sa-M 4 BUILDER INFORMATION Name Telephone Number -73(02 2-1/C� Address 1//. L� ,� License# A4 A.)VR Home Improvement Contractor# A 4 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 00h Y6-- 6& lOCa2c{ OA sl -eo r ,Vi5,o z_ or- DE3?1 S IGNATURE DATE FOR OFFICIAL USE ONLY a. PERMIT NO. , - DATE ISSUED JF. MAP/PARCEL NO. ' - y lip ADDRESS VILLAGE P i OWNER � .;,� - - '� - •_, ' -.. DATE OF INSPEC 1 , FOUNDATION - FRAME ` INSULATION 'l FIREPLACE - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL - FINAL BUILDING - j A o DATE CLOSED OUT y ASSOCIATION PLAN NO. ' .' Application to E� Old K>Ing s Highway Regional Historic District Committee U 54 in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, id triplicate, for the issuance of a Certificate bf Appropriateness under Section 6 of Chapter 470. Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: > 1. Exterior Building Construction: [Q New Building ❑ Addition [[Alteration -� Indicate type of building: ('House Q Garage ❑ Commercial ❑ Other 2. Exterior Painting: -1 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign IU 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other ��— (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK /it ASSESSORS MAP NO. OWNER (v��� lIl y �CRTNCL=E7t' A+ TiH�� ASSESSORS LOT NO. 31 HOME ADDRESS W)t&-'3. LJ 813W 57' t-F TEL. NO. FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). Ak Paj fz%," Tio�I«ong V M&trkesm Ave,, Rocky Oil[,Cr 06067 AGENT OR CONTRACTOR S-� TEL. NO. 8 1-942 0 k-2— ADDRESS DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No.8,other side), including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). genoelm& pRON-' tooF ar �tDuS�s y X,---Pk4e1416- C�DR'k J IVA!' .,FS ivt I H �l°i4l�� R.�STRiN qS dS. Q� MOOLA- - F, V'r r�,y� �vo c.����• O Signed Owner-Contractor-Agent Space below line for Committe use. S e e Certificate is hereby Date pNSTA81.� . Approved ❑ IMPORTANT: If Certificate Is approved,approva s subject tot a 10 day`appeal period s provided in the Act. Disapproved ❑ - e t ADDITIONAL INFORMATION FOR MAKING AND FILING AN APPLICATION FOR' A CERTIFICATE OF APPROPRIATENESS The four categories for which a Certificate of Appropriateness is required are: (application for demolition or removal is a separate form). 1. EXTERIOR BUILDING CONSTRUCTION (new or existing buildings): An application is required for any exterior of a building to be erected or altered including windows, doors, siding, roof, light etc., that will be visible from any public street, way or public place. The following scale drawings are required in duplicate with application: plot plan (if addition - show existing buildings in outline), floor plan and elevations. Also required are snap shots of existing buildings, where additions or alterations are to be made. No plot plan is required for addition or alteration which does not touch the ground. 2. EXTERIOR PAINTING: An application is required for any portion of a building, structure or sign to be painted that is _ visible from a public street, way or public place. Color samples must be attached to these applications. An application is not requi red when repainting existing colors, changing to white, or using colors approved by the Town Historic District Committee. 3. SIGNS OR BILLBOARDS: An application is required for any sign or billboard to be erected within the District, with the following exceptions: a. Existing signs or billboards on November 27. 1974 shall have until November 27, 1977 to secure an.approved Certificate of Appropriateness. b. Temporary signs for use in connection.with any official celebration or parade or any charitable drive as long as they are removed within three days of the,event.. Certain other temporary signs that the Committee feels does not detract from the Act may be allowed,,with the prior permission of.the Committee. C. Real, Estate-signs of not more than J square feet in area advertising the sale or rental of°the premises on which they are erected or displayed. d. aA single sign of-not more than.I-square; foot in area showing the name, occupation or address of the occupant of the premises on which they are erected or displayed in a residential zone. 4. STRUCTURE: An application is required to build or alter any structure within the District which is defined by the Act as a combination of materials other than a building, sign or billboard, but including stone walls,flagpoles,hedges,gates, fences, etc. GENERAL REQUIREMENTS 5. Work on projects requiring approval shall not be started until the Certificate of Appropriateness has been filed with the Town. Clerk by the Committee. Approval is subject to the 10 day appeal period provided in the Act. 6. No changes shall be made .from the original approved specifications without advance approval of the Commission on an amended application filed with the Committee. 7. A separate application must be filed with.each project requiring a Certificate of Appropriateness. 8. Under heading of "Detailed Description of Proposed Work" give:detailed data on such!architectural features as: foundation, chimney, siding, roofing, roof pitch, sash and doors, window and door;frAes,"trim';4jutters'—leaders, roofing and paint color. 9. Unless application is complete and legible and all material required is supplied, application willIrio. 'br aM. PtWWILacted upon. Copies of the Act establishing the Regional Historic District may be obtained a own A -� ' ; &.JRAT2ImpAft 1,) u:. t S - - C e© e`rUx-o - MAP 130zP14 R.c67L. 031 P3S- ,P_ccrigel ,► ��tf Lz" 110�5, 1(�b �e�av'Sf 8arr�stab u9 Fs Pa3 - John Secres�� Po So gm, s+-d6 --- f C4i OTown of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION SIDING TYPE COLOR CHIMNEY TYPE COLOR ROOF MATERIAL A S PO ALL 5 f#iN&LE5 COLOR k-�P C)ST A3 L ND6 R D SEt L -4416- 3 0 PITCH WINDOWS COLOR SIZE TRIM COLOR DOORS COLORS SHUTTERS COLORS GUTTERS COLORS F AP LORS M, ■ - vAPPROVED, dale/colors to be used. Four copies of this g with Four copies of the plot plan, landscape I - ' i v � cn•131-11� TOW�OF AR 90 8 MASSA\HUS�TTS (M-131-u) /19SESSORd"MAPS Lao Eo64p F H 1 fit` Ae b 4 s ''a �? 0 10 C. • oC c; s ' P a ao lk 30 ?s A e 410 ?� °C Y 20-1 •� Y C `; J Z.O•L C L�• . PP q�J ,3C t e COW KEO CARYWAY M00A sto-s • q ` ae�. - — — -&AC+so.&&W.25 Z 108 islas SCAIL 1"-100' . ((''�� .. ,.�. l9 107 130 IN 3 108 1>tP 16i I S' ?' T S King nese-AidSe t �u •u-.a��'-1�r ' rt 1,�E�{jS��yFy����,�,.D.g a�,D�0 `►'�"r�,i�'!?•1 iK Ll ,rl t��t D t• 1 D �tt • D y r,�}�J'�dr�. :t t•{t• tN i' ,y�` •l.� �a.��`�� : l L h4ft ' x �_ J � �� � '�k� ,pt.,_-MLncu❑��i�k �lkYtl.L�sS`*""t '�•rF•m_ Yy �3'►'!t- 'x. c, h .t *a ',;l a cis t '" •�� �k''� a Mkt-. T '�r i � c�r .:,"�Y S? ° r.:."• � �.�w'J'C�J,aw; � L4',Tj� r• .11 ,l ¢F r>+?'a��r,_ ��_ ,�.���•+�s. .�'� 1:s�:i�y� �. s, r 7c a X.�.Y`'+ ''3�" .r� "Y' - 3 f .�z. ✓ `. ��_ t�X"ti$ � .I � , t'• i Color show❑tst.Ch:si❑ut Brown,,-' • • 1 I .4a��C� '0 I > •s .S� 1�� �• ^I�t. K�y�jdf o y�.• • '. As•- c i 1. ti 1Ts y,.. .- :J� S �cy ` .�,4`Lj) fity�i. �[� S a•-./'tr. ��'. < �� ,r{. 1`,`� 3�: •3 �CA k'i.* I�t •"S+ � C ti F _ 45, r >.r rya d� '.c �t°Y9; .ziY.... _ '�'; 'b}!s'�e�"��k.-ta72>-.'`•'�..K+�`t��N ktr �� -i e; � ��1 � �{��R,l +, St y��G�ri� •Tr�F.pp,���'" �t6 t 7.S .r��,•N r • �1��},�1/1"'}� d! "I�t ^�l•e _ ��0 1 L.'1.1.:{h..d'1.�1;�yh -'3s..(�M,, ,�t; V qh' � ��..7 r°{� s ,: 3S � `,�,•� ,�K } .r 1,' , ^�''I��S�,rJ��.� 1� „ ► Ml •„ ,V y `� 9N. e rpp �c,�"' � r d C� - J -it+ �a '�•S2 ty1 trn�1+,;,�T t+ >�,P .�. vJ� r � �f•�F`Ya ���y��.k5;�`tav�.��.'� � ..+uw'�'a !� T '� ' r' �Ys� ' 1 S '� .� '•� - fri �� 1i4fi`I SaI" nZ .-'bM ��.,:t£: e x a ;a 1Tt,,y r 7>'t �r 1 i•5�`+. � Yp. 1s'r S�k `�:L, �d3..gt'*�f< •? �- ,Jl,.. }y,h n- -r.5 ,F,`� 3•"`�'t,§�f 3=r°..>t-d�t�"�-�^�.; '1"� ' hi �s�'-i .iT,•� a ;r '^14.. �c• �' � _ s.c -�,.,r<.r .w.. -.•Y3' aJJyy,,,,.t F r� a-��,, t.,�+� 1�{,�.�1 ` �� R � ¢�' v i1I 1 1 r L, S Y�.t.tr 1 lYrti x u1 r. t 14�"��{. y`,..r-. r.•Vie`+ 3' rqn P'i'F,1 �� �,r••�►y „••�►�; ' ► ttv t�k �`r�s � ;,L, ham. .,r.lr��l'S°+:'it•....f",.'".'+�:t•.I �',a1 ;�. i The Town of Barnstable • nssrerw�. _ 9eMAM Department of Health Safety and Environmental Services - Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit.no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building 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. Type of Work: e�-� nrl r n-4 Estimated Cost Address of Work: //l �Qi/^ 9t /V Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law OJob Under$1,000 [:]Bu ing not owner-occupied ElOwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. O � _ Date Owner's Name q:forms:Affidav The Commonwealth of Massachusetts + = �. Department of Industrial Accidents _T- . :--- ONCe 011flyesaffaffofns = � 600 Washington Street i Boston Mass. 02111 Workers' 11 Com,pensation insurance Affidavit name: bV- location: City S�15t!9- hone �(0� �/ � D 3Kam a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers compensation for my employees working on this job. companv name address: :::.... :: .. .....•. ::.. ::: city: phone#• insurance co. Po1icV# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the follmi ing workers' compensation polices: company name- address:... city phone#• ................ msarnnce co. :.:;:•;;:.;:.;;;;:>.:;.... company name: address: city ....:. phone#, insurance co. ::..:. .::::::::. .:.. olicv# . :::; >.: » Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S 1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of S 100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby cenijy under the pains anJ p�enaltiyesnojperjury that the injornration provided above is tru,-and correct Signature ate Print name �, f%2�LG�N L-- rTw 6-14—r Phone# �15 —Czy official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check it immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other .............::::::.. . (rmuo 9/95 P1A1 I / , Information and Instructions v.: •. Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any conza- , 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 c: 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renews; 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,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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance 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 call the Department at the number listed below. City or Towns 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. The affidavits may be returned io the Department by mail or FAX unless other arrangements 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. j The Commonwealth Of Massachusetts j Department of Industrial Accidents Office of Invesugatfons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 I Department of Health Safety and Environmental Services B11,10ding Division 367 Main 3teM HYIMnis MA M601 Office: 508462-4038 Ralph Crossm Fax: 508-790-MO Building C�c: HOMEOWNER IZC== � pteasalPsl� DAB JOB t=nC)N: �l r � d��Jf9 &A jeV S7-1-A CE aaa>ber s� vi� • -WhEOWNM!- . oar � � wodcphoae s CU"MFrMAtLuaaa�Ri�s: SM The current exemption for was cried to incW'I ied dweffimg of sin units or less and to allow homeowner to engage as individual far him who does not possess a fie, a��t�SQL DEFIINTION OFSOMEOWNEQ pawn(s)who owns a pucel of land an which h lshe insides ar iz=ds to reside,an which there is,or is intended to be,acne err two-faanly dwdb&attached or deumW susa=cwMtO such use andrar farm=cmr= A �M vvho more than MC home in a two-year period shall not be cansidet:d a hmneowner. Such A�•/ci,�email bt' . ....._ ."hameownce shall submit to the Budding Official an a foam txtioonft Bing offitdal, Mw assumes fit,sIW for compitaaee whh the State Budding Code and other applicable codes,bylaws,tales and rt;gniatrons. Min tmdesigned"homeowne"certifies that hershe=dam the Town of Barnstable Bug ogn Department minims motion procedures and requirements and that helshe will comply with said procedures and �j y A� i.D - r.0' /t later I' f pamIIe of Konwwww Approval of BZgM O�aai Note: 1ltree4=ily dwellings cowaining 35.000 cubic fees err iat'Ber will be to comply with the State Building Code Section 127.0 Camaction CaROMEO 's EMNrrMN MO Cods sues that "Any homeowner peefotmiag wodc forabieh a braiding�is tetj,,W I abaci be=czoptpvnlbm feom the offt mdon(Sa:ma 109 Ll-Umodngof 1,11 M I 50PwwbM);PwdOdtbUffdw bamemroeratgtBes apaso*$)for Um to do s o*vwit.tbat taeh liomw masbad m u sapavboe Mmy bozo MM=whoated ds c m tioaateuoawtsedmt.y mo tongd mn==dM ofasopavitor(see �Appa Q. Riles B R for Ltoca ft Camaeadlen Snpawisom.sad=210 nh Ldcof swan is oAea temps in serious proble= pxdmd dy wbm the bomeswoer bj==U==dV==. lu d!s eats.oar Bomd cmm;v r l"d apimtho=&rased pain os it woold 'IU 6omeowwacdng m Sn awbwis8W0W*mP=ML with a licensed Snpa+rimr. tet�as Pw of the permit z*'cadO°• To aametbatthalmmeowarsis8>1ly aware ofbis/ba�, thatthe howwwon an*that� the Hof asapavisw. Ontba impap oftbis issue is afro===Iiy used by soverai towns. Yon mar care to--ad and adopt mch a fmWoadfiadn fin itss in yota may.