HomeMy WebLinkAbout0074 COACHMAN LANE I
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The CamwomveaUh ofMassachusetts
Department of Ind Accidents
- Offwe of Investigations
600 Washington Street
- Boston,MA 02111
wwoc nras&govldia
Workers' Compensation Insurance Affi&vit: B:uiMers/Contractors/Eiect icians/Plumbers
Applicant Information Please Print LM'bly
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Are you an employer?Check the appropriate box: T of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full andlor part-time)-
# have hired the subcontractors [6-7[]New construct on
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- EVemodeling
ship and have no employees These sub-contractors ha-,re g_ ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp_insurance comp_insurance.1 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10_❑Electrical repairs or additions
n-Eli am a homeowner doing all wofk officers have exercised their 11.❑Plumbing repairs or additions
myself o worleers' right of exemption per MGL
my � c�P- 12.,❑Roof repairs.
insurance rewired.]i c. 152,§1(4),and we have no
employees.[No workers' 13_❑Other
comp.insurance required.]'
•'Any applicant @ut checks box ml umst also fill out the section below showing their woakere compensation policy infmm can.
T Homeowners who submit this affidavit indicating they are doing all woalt and then hire outside contractors mast submit a new off davit indicating such
tCantrsstors that'check this box must attached au additional sheet shoring the name of the sub-com actors and state whether ornat(hose entities ham
employees.lithe stub-contractors have employees,they must provide their worker'comp.policy number-
lam art employer tliat is'providing tnorkers'coniperrsation insrurance for my employees. Below is the palicy curd job site
information.
Insurance Company Nance:
Policy it or Self-ins.Lie.4: Expiration Date:
Job Site Address: City/StatelZip:
Attach a copy of the workers'compensation policy declaration page(shaming the policy number and expiration date).
Failure to secure:coverage as requiredunder 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 imprisonments as well as civil penalties in the form of a STOP STORK ORDER and a fine
of 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 cerft,under clue pair nalties ofpe�rrrry tltatthe information prmided above is tnw and correct
/I7ate-f _2�S' API214-
of
Official use only. Do not mite in this area,to be completed by city or town official,
City or ToNtm: PermitUcense 4
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CiVrown Cleric d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Town of Barnstable --~
Regulatory Services
oFq ,p Richard V.Scali,Director
Building Division
saarisz LYs Tom Perry,Building Commissioner
Mass.
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
-- -- Please Print
DATE:,.. Z P 21 L_ 7 01 �{
JOB LOCATION: ? A�"J L A I.,N r— w_ BA M&I 7rA tit C ^&A a 2 6C2 8
number street village
°°HOG l,;EowNER" €. _ S `D Z kK F_ 7 7 Ll 81411 /24
--name--- home phone# work phone#
"CURRENT MAILING ADDRESS: -7`-/ C. AC- V-.kN L a_`J E
W. >A,RNa STABLC alti#V O 2 ad
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit: (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
proce ores an uireme an�tht e/she will comply with said procedures and requirements.
attire of m
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit formS\EXPRESS.doc
Revised 061313
anxrrsrnsr.E.
MASS. ,.� Town of Barnstable
Regulatory Services
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Sectio
If Using A Builder
I __ s O er of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this b g permit a lication for:
(Address of b)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exem Lion Form on the
reverse side.
Q;\WHFILESTORMS\building permit formsEXPRESS.doc
Revised 061313
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and not Included in the price. Although we do try to ensure that the information in this program is correct, we apologise for any
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a► rtQ Town of Barnstable *Permit#
T EYpires n 11 ssire date
Regulatory Services Fee 171.11
.
M" Thomas F. Geiler,Director
`b 1p i 39' RNSTASLE
�l
T® Building Division g �
Tom Perry, CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number �2 CUTS
Property Address ^I y (I i7Q C /'1 lral CLV1 Llf) . l✓U 13c(v'Y-) S Q?,�LeCi S/ .
�Lt3 vv
esidential Value of Work
Minimum fee of$25.00/for work under$6000.00
Owner's Name&Address
Contractor's Name Telephone Number -
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's C mpensation Insurance
Che- one:
I am a sole proprietor
1 ain th"e-Homeowner -
ave orker's ompensation Insurance
Insurance Comfy Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
Ve-side
4 � #of doors
Dil teplacement-Windows/doors/sliders. U-Value vi (maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License & Construction Supervisors License is
required.
SIGNATURE:
Q:\WPFILES\FORMS\buil �geLit forms EXPRESS.doc
Revised 090809
a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
• I I
Map_ Parcel Application
Health Division Date Issued CA I
Conservation Division Application Fee
Planning Dept. Permit Fee , ► '
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
C—project-Street Address -1 N ca A �+�• •,, g�.E
�Village�w s f Q i\e_+.4 STIN,ti t-
COS '�'L� �a S g �2A K� Address S�•.N,..�. 4--Z o.,�s--� ��
�-
Pe *Request--i 2e- C COrfz K�
k
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project-Valuation— a 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 4 new Half: existing new
�f o o �
Number of Bedrooms: 1" existing � X__ C)
Total Room Count (not including baths): existing new First Floor Room Count_3 o
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove❑es ❑ No
11J '
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ el isting O new;�ize_
_ m
Attached garage: ❑ 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
i, (BUILDER OR HOMEOWNER-),
Larne L__t,o,& Telephone Number f7 Y
dress - CQA<<A "�N '—' �A,—e_ License #
Vr_ `S 4R*i *3TgQ_ r (v a Home Improvement Contractor#
Email Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE --DATE 2 s L�Ir CZ I i g o r y
.r
r
s
FOR OFFICIAL USE ONLY
APPLICATION#
DATE,ISSUED
MAR/PARCEL NO.
e
ADDRESS VILLAGE
'- OWNER
DATE OF INSPECTION:
5
' FOUNDATION
ff r
FRAME Y.
INSULATION6i� �
f
FIREPLACE
ELECTRICAL: ROUGH I FINAL
I .
PLUMBING: ROUGH FINAL
GAS: ROUGH- FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
!� t Office of Investigations
' 600 Washington Street
Boston, MA 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Tef r-p u L-14�Q
Address: Cyy1�A ►'1 �,�,V�
City/State/Zip: r Phone #: 57:�9 'V-� ' yy
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with .4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New constriction
listed on the attached sheet. 77 ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
re d.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. I a n a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 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 andjob site
information.
Insurance Company Name:
Policy# or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK.ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the p ins and enalties ofperjury that the information provided above is trite and correct
Signature: Date: 3 _3 — 0
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone#:
i\
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."
i
i MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public�work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should 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 permi0license 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 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
i
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
Town of Barnstable
_
" Regulatory Services
0
Thomas F. Geiler,Director
BA_6rtSrwBL.E,
t,tass.
9� 1
639. � Building Division
PTfD eta 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: —) SY ACC C "msi y_-x
number ) street village /
„HOMEOWNER": � � Q c I 1 ^�1 n bl Y U _b uU ��( �7�� -7Go01
name \ home phone# work phone#
CURRENT MAILING ADDRESS: 9
city/town state zip ebde
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned "homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
gnature of Homeowner
-Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages.a person(s)for hire to dp 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.lhe 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 hdshe 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:\WPF.ILFS\FORMS\homee-xempLDOC
THE Town of Barnstable
Tp� -
ti
Regulatory Services
STABLE, ' Thomas F. Geiler,Director
buss.
fn; -c 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
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 permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
n:FORMS:OWNERPERM1SS10N
I
1 `
Parcel FJf Permit# /5 -
';Conservation Office(4th floor)(8:30-9:30/1:00 2:00) t-, � 'SW-+rllate Issued* .15' /Is- 96
Board of Health(3rd floor)(8:15 - 9:30/'1:00-4:45) Z Fee
Engineering De t.(3rd floor) House# ' IMF -
a�
• BARNSTABLE. -
roved by P a 19 T 1639.
TOWN OF BARNSTABLE
Building Permit Ap lication
Pr 'ect S t ddress 2 'CPAC ev Low 4 S
Village &S�? i�A Ns i�t��V--
Owner �i-f$TAK Lf£ i Li_ 5A e.7-a us r L U49�uAddress �
Telephone p
"Permit Request A-P-P -Pae-K
First Floor 49� 9 SZ0 square feet
Second Floor square feet
Estimated Project Cost $ _1 t-,crp8 .
Zoning District R F Flood Plain Water Protection
Lot Size I V A- A . Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use -P 1-74 c-iz- Proposed Use Z�s I r,>r,r e a
Construction Type_ U yDp
Commercial Residential
Dwelling Type: Single Family V Two Family Multi-Family
Age of Existing Structure Basement Type: Finished
Historic House N o Unfinished
Old King's Highway -/9 ; PO�
Number of Baths No. of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
Name C, K.Qjr Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE S/S7�s�� �1/� DATE 5 t ��L
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. t L
D TE ISSUED 1
f
MAP/PARCEL NO:I ,
DRESS ) VILLAGE
ON6ER
DATE OF INSPECTION: ,
T i
FOUNDATION ^
FRAME
INSULATION
' f
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING 19 2 -1�
DATE CLOSED OUT
r
r
ASSOCIATION PLAN NO. , 4
M
50 ANCIENT WAY
\ & UTILITY EASEMENT
x
c
.�� 4
60
9111
0
LOT 5'
sr� 0
s
LOT 6
NOTE. IT APPEARS THE ANCIENT WAY
RUNS THROUGH LOT 5 AS
OPPOSED TO THE LOCATION ON
PLAN 384156.
RES. ZONE.- 'RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C"
TOWN-: JffZiT ,4' Bank Use Only
— _ REGISTRY OWNER: --T1'-JtAS.SA 1i!V-FffZ7-F- 0—INC— ——
DEED REF: -&` 7Z /-271— —— — — -BUYER: SQNSTBN�SALTEB Br�O�'EL� SALTEIt�J$
DATE: —,91-1 .l�4— — — —— — — _ PLAN REF: A84 _ _ _ __
SCALE:1"= 50 _FT.
I HEREBY CERTIFY TO —_ �N-»�•-,�. YANKEE SURVEY
---THAT THE BUILDING pt --
SHOWN' ON THIS PLAN IS LOCATED ON THE GROUND AS CONSULTANTS
SHOWN AND THAT ITS POSITION DOES CONFORM � ' �.
TO THE ZONING LAW SEPBACK REQUIREMENTS OF THE h1ERiTa'HE SC 40B (SUITE i)
I ..
TOWN OF p9A��T9, __ AND THAT No. 3209
8 ���' INDUSTRY ROAD
IT DOES NOT_ LIE WITHIN THE SPECIAL .FLOOD HAZARD MARSTONS MILTS, MA 02648
AREA. AS SHOWN ON THE H.U.D. MAP DATED $/t,Q,A85 TEL 428-0055
250001 0015 C FAx 420-5553
-
_ a THIS PLAN NOT MADE FROM AN INSTRUMENT VA-UL A MENITHEW. PLS SURVEY NOT TO BE USED FOR FENCES ETC: 15649 BJS
A '
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: The Ci minutnft'ealth of 4fassachusetts
Department of Industrial Accidents
i 1 #MCCOfIM9Wgd7 loan
600 Street
4i•��`.:::::4 Boston,Mass. 02111
Workers' Compensation insurance AlMdavit
AjT
location-
phnne P
I am a homeowner performing all work myself.
0 rI
I
sole proprietor and have no one working in any capacity
am an emp�oyerl providing workers' compensation for my employees wori:rng on this fob.
com^pint nnmc I`1 F�a�tz.i �•�iI ab►-f .
aSl_SI_rs_cs• 3� y-T�r--1 t s
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city: C, r[7 0 eVi\)t 1 i.E phone#• 77.5- 4,q d'`#'•
incur nice co CIL az ��' Y 13+ policy# -
I a sole proprietor,general contractor, r homeowne circle one)and have hired the contractors listed below who ha
e following workers' compensation polices:
COmIlIny n
re
cih phone#•
curnncc ce Roliev# -
-- -c:. .,...�.. --- ,,•«.zr.+,�..semis.-n-er+►•r—�-.z-nsnr��.av-zs•--•...•.•.�a�r.—�A.•7�4t,�41�'�►�'•�C7+►!. +1�15i*R++----
m •tnv name*
r
t itt phone#s
Relic!#
:Attach addiH6nal'sheei if'aeeeisa ''"'
Failure to secure coverage as required under Section.SA of A1GL ISZ can an f c
d to the imposition oriminal penalties of a fine uP tO S1300.00 aod/u
one Veers'imprisonment as%veil as civil Penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day apatinst mt» 1 understand that
eoff of this statement may be forwarded to the Office of investigations of the DIA for coverage verification.
1 do hereby cent' nrler re pal sand P.Tftltio ojpet furs that the information pm-ided above is nut and eoffeee
Signature / Date
Print name
a R SR i�i �i�f lfo2�/ Phone#
official.use oniv do not write in this area to be completed by city or town aMcial
citt•or town: permitfileease# n8uilding Department
(3Ucensint;Board
17 check if immediate response is required 05electmen's Office
C31icaith Department
phone tY: nOther
contact person: -
' F ,
information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the
employees. As quoted from the "lay+", an emplirnee is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An emplarer is defined as an individual, partnership, association. corporation or other legal entity, or any two or mo
the foreaoin�; engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
rccciver or trustee of an individual , partnership, association or other legal entity, employing employees. However tl
wtvner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwclling house of another who employs persons to do maintenance , construction or repair work on such dwelling he
or on the ;grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
rene��-if 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 in 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
been presented to the contracting authority.
Applicants
Please `"I in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers 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 require.
to obtain a workers' compensation policy, please call the Department at the number listed below.
... •. .; .. _ ' '•ate•.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned
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 questio
please do not hesitate to `=lye us a call. ,
�r
The Department's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washinaton Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
n d�
The Town of Barnstable
NAM $ Department of Health Safety and Environmental Services
2"9. Building Division
367 Main Street,Hyannis MA 02601
Ralph
Offroe: 508 7 Building 90-6227 Builldd
FaFax508 775-3344 ing Commis
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,•renovation,repair,modaaizadM 00IIverston'
improvement,.remomai, demolition, or consauc ion of an addition to any Pm"cKisoag owner occupied
building containing at least one but not more than four dwelling units or to sMuctures which are adjacent
to such residence or building be done by registered contractors,with certain cwTdOus, along with other
requirements.
Type of Work: Est-cost—L2,, (°I�—
Address of Work: .,
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work cocluded by law
Job under S1,000
Building not owner-occupied
_x .._ =ping aim pam4
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WIT'SUNREGIST'ERED CONTRACTORS
FOR APPLICABLE HOME 1MPROVEi&'NT WORK DO NOT HAVE ACCESS M 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.
OR
12-A /
O(vner's name
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
lease print.
DATE
JOB. LOCATION Ll e9a s4a i, L o h e h9Af A le—
Number Street address Section of town
"HOMEOWNE
RLa well_ s &g JR qa8-50
�o� Sumer %LL Sq,Lfe2 . Home phone Work phone
PRESENT MAILING ADDRESS 2 S0 wfA 6 9'j'aam dA A ve
Sti.e� 9, u . /
C y town State Zip code
The current exemption for "homeowners" was extended to include owner-occuDiE
dwellings. of six units or less and to allow such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person (sj who owns a parcel of land on which he/she resides or intends to re
side, on which there is , or is intended to be, a one to six 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 Offic
on a form acceptable to the Building Official, that he/she shall be responsi
for all such work performed under the building permit. (Section 109. 1. 1)
The undersigned "homeowner" assumes responsibility for compliance with the S
Building Code and other applicable codes, by-laws , rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requirement:
and that he/she will comp with said procedures ad requ 'r ments.
HOMEOWNER'S SIGNATURE f /:�a
' APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
r r�
-, ;.- HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner 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
Home Owner engages a person (s) for hire to do such work, that such Home Owne
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the-responsibilities-of a supervisor (see Appendix Q, Rules and Regulations
for . licensing Construction Supervisors, Section 2. 15) . This lack of awarene
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home 'bwner acti
as supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities, ma
communities require, as part of the permit application, that the Home Owner
certify that he/she understands the responsibilities of a supervisor. On th: ;
last page of this issue is a form currently used by several towns. You may
care to amend and adopt such a form/certification for use in your community.
y
7
FF ,ZINC TOWN OF BARNSTABLE Permit No. ................
BUILDING DEPARTMENT
{ I TOWN OFFICE BUILDING Cash
�ouv HYANNIS,MASS.02601 Bond
CERTIFICATE OF USE AND OCCUPANCY
Issued to
Address
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
.......................... . 19................. ...........................................
Building Inspector
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
_ NARNSTAU TOWN OFFICE BUILDING
out
HYANNIS, MASS. 02601
�o r�r►•
MEMO TO: Town Clerk
FROM: Building Department
DATE: 2 -.2- �
An Occupancy Permit has been issued for the building authorized by
Building Permit `..... .. .--- - ........ ..._..:.......»....:.... »»....»»......._ . .......»»_.
issued to r�..... � „v]�/ .........�.�.��...»... _......»
' ...._......
Please release the performance bond.
i
BUILDING
TOWN OF BARNSTABLE, MASSACHUSETTS PERMIT
JOB WEATHER CARD
DATE 19 PERMIT NO.
APPLICANT ADDRESS
(NO.) (STREET) (CONTR'S LICENSE)
NUMBER OF
PERMIT TO I_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
ZONING
AT (LOCATION) DISTRICT
(NO.) (STREET) "
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS:
AREA OR PERMIT
VOLUME ESTIMATED COST $ FEE
(CUBIC/SQUARE FEET)
OWNER
BUILDING DEPT.
ADDRESS BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET. ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR
PERMANENTLY. ENCROACHMENTS ON PUBLIC. PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE"DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS-PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SURDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND
I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MI NAL INSPECTION
TI TO BEFORE
FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION BEFORE
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVO.,LS
2 2 2
3 I(,u:AlLjHEAT:NG ENSPEC7ING APPROVALS REFRI RATION INSPECTION APPROVALS
I1 1 '
l 11,9
ri'�I�GYLC'1'►Zr `�, YVl G �B d/Vl
'�CRx 3nAL•_ r;C? onq_F_�:.. .I>,�:I. - - PERMIT W!LL BECOME NULL AND-VOID IF CONSTRUCTION ;NSFECTiONS ;NOICATED ON TH!S CARO T
Ng?EC' R -.AS �RCv_D IE CGS WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CAN SE ARRANGED FOR By TELEPHONE
SAGES JF CONSTRUC7;0N. - 1-PERMIT IS ISSUED AS NOTED ABOVE, —OR WRITTEN NOTIFICATION.
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1977
• "
TO THE BEST OF MY INFORMATION, AS GUILT" PLOT PLAN MASS.
KNOWLEDGE AND BELIEF THE �-
D v�/�/�T/ate✓ WN ON THIS
PLAN HAS B �`jH of ON THE Rd OkEARN //VC
o ��op�t{ yG1 SWAN RIVER PLAYA
GROUND AS CAff B. 35 ROUTE 134, UNIT 2
WILCOX y SOUTH DENNIS,.MASS. 02660
O. 41 r
GIST �° �� DATE: SCALE:
JOB NO.-L?99 - os CLIENT':
DATE REGISTER Dj LAND SURVEYOR DR. BY: SHEET OF
I
Assessors map and lot number .... , 1� ..CZ.......'7
r a 10*THE TO
Sewage Permit number .......... ......
?�C ' "V_L_�D IN- =V6+1111FLIA�
House number �j �y] WITH TITLE 5 = BA"STADLE,
............./LJ�.. .l�.l.........1.!.............................. ""L 0
!` ENVIRONMENTAL CODE o 39.
ViR
TOWN- OF .BARNSTw1XIONs
f 1 "" ALLIED
SYSTEM M P
BUILDING INSPECTOR Ta``EDINCoM N
NViRp Tire 5
E
NMENTAL
I1 CC, E A
APPLICATION FOR PERMIT TO ...:............/'..t.�nl. .. .......... ,�E?>.w . . .......................T.� �
TYPE OF CONSTRUCTION ................(A)q. �. ... Rr( !!ti ...........................................���L`...... f����
........ ... . ..................
............................ . . ..........19.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the followin informati-A•
Location ......./LD .., ...... .Ry✓.'....,f�/�. ...... .. ..Jrl .. .. ..............
ProposedUse ... I.M. . +l/�!}!1s✓. ..... 6%.. ...........................................................................................................
ZoningDistrict ........... .... .... . ..r.. ...........................Fire District ..............................................................................
Name of Owner .ra.(.;.kt. .... E.rn./....Rr9• . .?�r1: Address ...
Name of Builder l�1 y...P,.4 .1.� '.d�.✓................Address ..y3.� .l.r!?rN f�iv�s .......S,Jj INd
Nameof Architect ................./ .........................................Address .....................................................................................
Numberof Rooms .......'.....................................................Foundation ......14.................................................................
Exterior ..5,.. �IZ......... ;��,� .C� ........zX'��V�T �oofing ......... �,
. ..................................................
.
Floors ......� ..m.0 Gt/..o� ...c.........................:.......................Interior .......c.�. p,,c�/.Z-UPI. .........................................
r
n Heat Plumbing
ing ........�-%tS........ .�..:.�%� '.
'-.Plumbing ............ .........................................
Fireplace .........../..................................................................Approximate. Cost ........XQl. ........`......./......................
Definitive Plan Approved by Planning Board e �� /1�.�_ -----t9 -. Area ......... .... :..!..
Diagram of Lot and Building with Dimensions Fee ......... . .. . ...L......
SUBJECT TO APPROVAL OF BOARD OF HEALTH
q 9� _�_ //?E. S�
�l� r 4AL-01
}
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
i
I hereby agree to conform to all the Rules and Regulations of the Town rnstable r rdin t bove
construction.
me .... ... ..... .........
9
Construction Supervisor's License ..�./q.6 G. .....
STERLING TERN REALTY TRUST'
�o ..................29663 Permit for ....................................One S tor y
.g ,
Single Family Dwelling
..............................................................................
Location
Lot #5, 74 Coachman Lane
................................................................
West Barnstable
...............................................................................
Owner; ......Sterling Tern Realty Trust
........................................ ....................
Type of Construction .....Frame..........................
...............................................................................
Plot ............................ Lot ................................
Permit Granted ......J.ujy....16.....................19 86
Date of Inspection ................. . . .................. .
-19
Date Completed ..../Z:7
Ass_essor's map and lot number ...., ...... ..... THE
Sewage Permit number ..........� �Q
Z EA"STODLE, i
House number ............;V:4... .....� y p...:"..�................ ` 9p� P 9
p Mix a'
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ................. .).., ..........(..R... :1.4v........................................................
`TYPE OF CONSTRUCTION .oa:;� . ...............
........................... / ....19Q„
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies f�or'a permit according to/the following
informati.o
Location .rS•..0 ..�. .4..r�i!4��,/I!i!3it�..... .,f� �. l!1. .. � /�;z,27a,Z.. ...............
.j.
c,
ProposedUse ... .�?.:.+_z11. ....... ...........:.........................................................................................................
Zoning District ........... .............._.............................Fire District .............................
Name of Owner R;�4.1'tf'3?PfNjAddress . .. .. ........1...............
/Z/L �ic X /z--S0,e1 ...........Address ...`./3.. .......� 7ti:�....._..r/�
Name of Builder .... .........y.................................. 7 � 1`/
Nameof Architect ................./e IA.....................................Address ....................................................................................
Numberof Rooms ......../.........................................................Foundation ....../10.................................................................
Exterior L�jllf�/2 �� X /�/yr'Roofin h.. .....................................
......
........ .................... i g ......... ,l
Floors .................................................Interior '`—
HeatingG ........#cll ..........................Plumbing ............ ......?. ...!... .........................................
Fireplace ............,1...................:.................................................Approximate. Cost (�Q, d4 C2........................ ........ .............................
;fUDefinitive Plan Approved by Planning Board ° tt_R• __1A_?__. Area ..........................................
Diagram of. Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
4
S
�Lep- r
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulafions-o0fhe Town "Barnstable rega din• t e above
construction.
Name i4 .�. /!/I .. ,v... ��... .........................
Consruction Supervisor's License � 9
f........
STERLING TERN REALTY TRUST A=152-43
ji
No'..2.9.663..... Permit for AP!e.AtR.0.. .... ......
Single Family Dwelling 14.....................
Location ......Lot...#.5 7.4..Coachman Lane....
West Barnstable
...............................................................................
Owner ......Sterling Tern Realty Trust
...........................................................
Type of Construction Frame..............................
..................................................................
..............
Plot ............................ Lot ...........................
Permit Granted 16,
y......Jul................................. 19 8 6.".
Date of Inspection ....................................19
Date Completed .....................................19
/.0 1111e17
TOWN OF BARNSTABLE 29.663
Permit No. ................
BUILDING DEPARTMENT
Cash
TOWN OFFICE BUILDING
t6,9• X
enr HYANNIS,MASS.02601 Bond ................
I
CERTIFICATE OF USE AND OCCUPANCY
Issued to STERLING TERN REALTY TRUST
Address lot #5 74 Coachamn Lane, West Barnstable
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
December 2 86
........................... 19................. ...
Building Inspector