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HomeMy WebLinkAbout0035 CURRYCOMB CIRCLE DJ."j jo 15 2 113 0 R A 1 o✓a W y d' � V TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map S Parcel Application # Health Division Date Issued 10 . a Conservation Division Application Fe O. Planning Dept. Permit Fee- Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis V� Project Street Address 3 C"i co"n)p C`'' Village o r n Owner G W(y /YA ejctrm a Address' so-*y-9— Telephone Permit Request rn o.� 1 Square feet: 1.st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain - Groundwater Overlay j� Project Valuation 161 Construction Type D °° Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. Two Family ❑ Multi-Family(# units) Age of Existing Structure 2 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 cy ZEI Total Room Count (not including baths): existing new First Floor U90m Count' Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other No Central Air: )&II Yes ❑ No Fireplaces: Existing X New Existing wood coal stove: ❑M- s ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ xisting Q new size_ Attached garage:] existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: � rn Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name y �y A k�n� Telephone Number i Address '� �"��7 C°`'��' C`r License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO gav `'3� ,�k FJ\\ vl� SIGNATURE DATE I I 1 I; z 1 FOR OFFICIAL USE ONLY APPLICATION# R .DATE ISSUED .:: g . -- -MAP:/PARCEL NO ADDRESS . VILLAGE OWNER, e r, i' } DATE OF INSPECTION: 4 _.FOUNDATION: ' FRAME l6//tz1/ra 216tc 6t � .-?`INSULATION' FIREPLACE ELECTRICAL: ROUGH FINAL z PLUMBING: ROUGH FINAL r GAS ,rA ! ROUGH FINAL 1 k DATE.CLOSED OUT ASSOCIATION PLAN NO, r I The Commonwealth of Massachusetts Department of Industrial Accidents Offt.ce of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contra ctors/Electricians/Plu m bers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): ��J (arZ nZ lQ Address: C„rry Corn C,lcUL City/State/Zip: W't 43 a.-r,�,�c,Lka /M Phone #: S O� —y Zo 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 I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2,❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ® Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL 1 LEJ Plumbing repairs or additions LL myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp, insurance required.] Any applicant that checks box#I 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 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. #: 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 pains and penalties ofperjury that the information provided above is true and correct. Signature: lz�' Date: Phone#: .�o `� s�y C)7 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): L.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other. Contact Person: Phone M 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." I 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 numbers) 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 future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license.or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia Town of Barnstable �OFSHE Tp�� y�P Regulatory Services + BARNSTABLE, = Thomas F.Geiler,Director 9 MASS. g,A 1639• Building Division rE0 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: 1 A JOB LOCATION: Gvrr y V%am�) C,r�_�Q_ t Rv TS� b\D_ �(1Z number street village „HOMEOWNER": ccil fv1 1 ',/►)A C.�C� t,� i b V 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. 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 requirerr�¢s-�,q Signature of/Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control ROMEOWNER'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 super�visor(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 writh 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:forms:homeexempt 'ppUtNEroy, Town of Barnstable » » Regulatory Services 8"" MASS. E$» Thomas F.Geiler,Director �A 039. 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. Q:FORMS:O WNERPERM ISSION r l R :TOL 'Z 1 ��l/lr-Q✓ VV a a� i Town of Barnstable erm4t�`�z�� Regulatory Services Expires 6 nro is from 'ss a date Fee —/] '' BgRV57ABGE, 1619. ,1b Thomas F. Geiler, Director �ArE7 MAC A Building Division a 1� Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www,town,barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid tvithoul Red X-Press Imprint Map/parcel Number Property Address S/ Curry comb PArn�) "ks MA � DOo , Residential Value of Work �e oO Minimum fee of$35.00 for work under S6000.00 Owner's Nam e & Address G kzJ 1 ' 19 C�--z n Z L'Q 3 Curjr Lbmb C,fL\J)_ Contractor's Name o wr\.ar' O�—y ZO — �y 07 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) , -PRESS PERT ❑Workman's Compensation Insurance AUG 18 2010 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABLE 12 I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) ❑ 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 5 r�A RT SUN #of doors Replacement Windows/doors/sliders. U-Valtte rO w — (maximum .35)# 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, iIGNATURE: )AWPFILESVORMSIbuilding permit formslEXPRESS.doc revised 072110 t 1 The Car nroirivealth of ilfassachusetts Department of Industrial Accidents �-- - Office of Investig,ations 600 Washing ton Street t� Boston, z'�Ll 02111 fvstnv.mass govJdin Workers' Compensation Insurance Affida,,it: Builders/Con:tl:3ctors/Elechzcians/Plumbers Applicant Information Please Ri- nt Legibly Name (Business/Organization.q.ndividnal): G A fL_1 fyl'A CIC9.YJZ-A Address: 3 C,� lam , \J A.4yxl:> City/State/Zip W t t^'try� ���c M A Phone#: S6 — y 10 Are you nn employer? Check the appropriate box: T f (required): 4. I.am a general contractor and I }Pe o project : .Ject(r � 1.❑ I am a employer with ❑ I g 6_ ❑.New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprielor or partner- listed on the attached sheet_ 7. (g Remodeling ship-and have no employees These sub-coutractors have S. ❑.Demolition working :for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.. I 9. ❑.Building addition required-] 5. ❑ We are.a corporation..and its 10.❑Lec.trical repairs or additions 3.] :I.am a homed-tAmer doing all work officers have exercised their 11..❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 17❑Roof repairs insurance required.]T c- 152, §1(4),and.we have no employees. [No workers' 11❑ Other comp.insurance required.] •Any appticavt that checls'box#1.must also fill out the section below showing their wozkers'compensation policy infornmtian. t Homeowners;who submit this affidavit indicating they are doing all work and then hire outsidecont—fors must submit a new.affidavit indicating suctL ICoutractors that check this bacc must attached as sdditiDwd:she.et sboieing the nsme of the sub-contractors sad stare whether or not those entities have employees. If the sub•-contractom,'hsve employees,they.nmst provide their workers'comp.policy number. I ant an enrplo}ar that is pravidirtg ttrorkers'conrper:tsalion iarsrrrarrce for nay entpioyeas. Below is the policy and job site inform atiam Insurance Company Name: Policy#or Self-ins.Uc. Expiration Date: Jab Site Address: City/Stat&Z : Attach a copy of the workers' compeirsation policy declaration page(shot iving the policy number and expu-ation 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 thepains and penalties ofpediin,that the information protdded above is true and correct. VJWL— Signature.: ) Date. Phone M �_6 — '416 — 5-4'0? Official►ise only. Do not write in this area,to be completed by,city or town.official City or Torn: Permit/License# Issuing Autlrorit}'(circle one): 1.Board of Health 2.Building Department 3.City/rORn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 6 Y KKE Town of Barnstable ' 0: Regulatory Services >an�JASS. - Thomas F. Geiler, Director �A A39 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnsta ble.ma.us Office: 518-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: Cvr� I omj C,ec� number street village "HOMEOWNER" GA 2y J119 CAL nZIP 9Z6- Sy07 T2 S-7O name home phone N work phone N CURRENT MAILNG ADDRESS: S� C ©Z C'(e6 7 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 procedure d requirements and that he/she will comply with said procedures 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 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing ofconstruction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that 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/cerlification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 of THE rp� aaRNSTABLE, , MASS. Town of Barnstable �lFD MA'S� Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnsta ble.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and-Sign This Section If Using A Builder L , 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. QAWPFELESIFORMSIbuilding permit forms EXPRESS.doc .Revised 072110 ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map/,_� y. Parcel 3 Application HealtK'Division Date Issued �1 1 O 9 Conservation Division Application Fee Planning Dept. Permit Fee L9�' cb Date Definitive Plan Approved by Planning Board OHistoric OKH Preservation / Hyannis Project Street:Address Village Owner G 5%,sho 01A L2r1ZCk Address" Telephone 110 — S 4 o-) Permit Request �efP�G csZ -ex u�any c��c k Z.- Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation A(o 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 �jrS Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 0 Full ❑Crawly 1 ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 4%Q Basement Unfinished Area(sq.ft) l i Number of Baths: Full: existing aC 1"2. new Half: existing new Number of Bedrooms: 3 existing _new n Total Room Count (not including baths): existing 3 new First Floor Ro m CoL Heat Type and Fuel: )d Gas ❑ Oil . ❑ Electric ❑ Other co Central Air: X Yes ❑ No Fireplaces: Existing New Existing wo coal stT.e: 0 Yes L IN o Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ xistin&..'❑ n4 size_ ._ r- Attached garage:� existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: `D M Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name G Amy r)A a.n7J 1Q'1 Telephone Number Address 3 S C"rr`(���`^� Ce License # r^A Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO _rO w n LanQP d , II SIGNATURE �'`�� DATE G) I 0 FOR OFFICIAL USE ONLY APPLICATION# _ DATE ISSUED MAP/PARCEL N0. `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.. T Town of Barnstable • �' Regulatory Services'RAR _ ,U.M Thomas F.GeiJer,Director Building Division Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: Map/Parcel: Project Address 3�Lt+�rryEm Ar Builder: The following items were noted on reviewing: �nrAe' Reviewed by: Date: 7 �( C� — Q:Forms:Plnrvw •J 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 Aunlicant Information Please Print Legibly Name(Business/Organizationdndividual): (9 A4" IY)ACJCQY1Z� Address: �'5- C,,, r i City/State/Zip: , 6s n>D\ Phone.#: S� y Zd 'S q O 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 employees(hill and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ,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.# ❑ We area corporation and its 10.❑Electrical repairs or additions required.] 5. 3. I am a homeowner doing all work officers have exercised their HE Plumbing repairs or additions myself.[No workers' comp. rigbt of exemption per MGL 12.❑Roof repairs insurance re t c. 152, §1(4),and we have no �Lk 4ed] tsL employees. [No workers' 13.❑ Other QeR 1a 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. t-_Mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: . Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimirial penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of _ Investigations of the WA for insurance coverage verification. I do hereby certi&under the pains•and penalties of perjury that the information provided ov is true and correct Si store: "_ Date: ©� — Phone Official use only. Do not write in this area,to be completed by city or town offWaL 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(o 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 fori 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 fo any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. t The Office of Investigations would like to than 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 Dopy i ment of Industrial Accidents Office of Investigations i 600 Washington Street Boston, MA 02111 Tel. #617-727-490.0 ext 406 or 1-977-MASSAFE Fax# 617-727-7749 . Revised 11-22-06 www.mass.gov/dia r Town of Barnstable �pFSHE tp�� Regulatory Services BAMSTABt.ti Thomas F.Geiler,Director 9 MASS. i6J9• �� Building Division �1E0 MA't t► " 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 llPlease Print DATE: '' 11 " JOB LOCATION: "� t`o m p Ci/C� t�.J t �� s}�6, number street village "HOMEOWNER": Gfl2y 'sLs t1ZUi �OFS—�IZo - b� �{26—N�Z`► name home phone# work phone# CURRENT MAILING ADDRESS: S 0`r^A city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on'which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"-certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requir ts1.w n Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic.feet or larger will be required to.comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that'if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors;Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the 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. OFIKErp�L Town of Barnstable , Regulatory Services EMWGTAB1E Thomas F. Geiler,Director ArFo �A Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.ba rnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This-Section If Using A Bu der as Owne o the,subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this buildin permit applicatio 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. fl•F(1RMC•f1WAfFRPFRMi.CCIf1U IN i Applicant: 51WlZenzle locatfm of-�� : 73 arnsWIZ /51 O�e< Lc>+ 3V !� I.ot 37 1G9,69 - 38 � N Area-: 110Z � o Sol z.5t'ory dwellinn d V [ot 39 ON. ref Toro 199 *od{saner:250001 001.5 C flood .ion.¢: C IA OF 4(4,p c ? PAUL'T. �N herefy certify tua thin '-m�orCtg�ajgle inspecti/o ��n was-prwarec�-For GROVER . itt ani l2•14aml/at v� 1.1 z�� WrP *,110 31311 40 J71weU.i shown. hereon, do¢s `tot��aL1 in.c�specialEk-�Ooc� ��/ o "J �1 ST.E�+ hazar& aria with am efFective date o f 8-19-95 and.,die locabbry op q�S.u�E twdwe[Ung does conf arm rto th e local,eon.iz -laws tnm C t' attht oFcotutruaion with, respect:to hortz tta[ di ionaf set-back. re uirem.e�nts or is ex�nvr' rortl, v1olatiom enForeetlu scale: 1 = q, Date: 6-/5-95 Q=om under Mass. Geri,eraL laws Chdpter4oA-SectLory 7. File No. 05-15S7 PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a precise determination of the building location and encroachments, if any exist, either way across property lines. This plan must not be used for recording purposes or for use in preparing deed descriptions and must not be used .for variance or building plan purposes. This plan must not he used to locate property lines. Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE PURPOSES ONLY". COLONIAL LAND SURVEYING COMPANY , INC. 269 Hanover Street , Hanover, Mass. 02339 - Phone: 617-82677186 - Fax: 617-826-4823 , -� --- 3 � � 3 _ _ t {I 2. y i 'i ��..... ��.. . Y t , t � _ ..:. ... C 1 �� f� ... :��-� n � _ t 7 - �'- - Cam. ,k... . {.. E _ �->:•:.`� � �.�� 7 �..... - LA . i n� � a f , fi 1 I s { p , E w . f 44 i aloy t T a� 77 k17, x `9 Page 1 of 1 1- r�o � _3s NHS` F,HS �3i4R; RAS BMT l� 1'4 \� a c e �l rl C c,)(, L^j ©t��S �w �c.�t n I�e� a�C � � 1-f � n S�m� Q11`r1�ri51>,N) Gs -ex 154) n http://www.town.barnstable.ma.us/sketches08/10206-10591.jpg 6/18/2008 i t Town of]Barnstable *Permit# Co7 Expires 6 months from issue date Regulatory Services Fee � 5� Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner ( �-- 200 Main Street,Hyannis,MA 02601 t/ www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press rinprint Map/parcel Number r,S-/ (D G S Property Address .3!�- Curry COM L C`fr-4 Q i (S"'J_A M X Residential Value of Work /S-i DSO Minimum fee.of$25.00 for work under$6000.00 Owner's Name&Address G A iz�y M Ache n L Q Contractor's Name ! Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance �p�®��� PERMIT Check one: T� I am a sole proprietor I am the Homeowner AUG 16 2007 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance.Compliance Certificate must be on file. 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) A Re-side G/` Replacement Windows/doors/sliders. U-Value maximurn.44) *Where required: Issuance of this permit does not exempt compliance with other town department regu a H§tiE;Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required?t `^ - 1 nor SIGNATURE: ti.� Q:Forms:expmtrg Revise061306 THE. Town of Barnstable CF )p� . „Pe Regulatory Services Thomas F.Geiler,Director BAANSfABM * f MASS. g 4iA 1639• e,0 Building Division TED � 'Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508490-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: -61 6 I cr? JOB LOCATION: 3� C�.Yry t -b C�r•c� v�l �U6n ski. p number street village "HOMEOWNER!': (;SA6" MACAC ..02S2 Sak- 4zi�, -S`16--) Zf Za- yY Zy name home phone# work phone# CURRENT MAILING ADDRESS: me e 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 sfructures. 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. minimum inspection procedures and requirements and that he/she will comply with said procedures and require \^ Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1•Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the pemrit 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:fomu:bomeexempt The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers" Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . G Ate( rn AC 14kn 2 LA Address: ' City/State/Zip:G-) -&Ir46-b6 TIA Phone-#: 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. El New construction . . employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity.acitY employees and have workers' $. 9. Building addition [No workers' comp.insurance coin.insurance. required] 5. 7 We are a corporation and its ME]Electrical repairs or additions 3.4 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 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. $Contractors 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 providt:their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required trader 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 WA for insurance coverage verification. I do hereby ce nder the pains-and penalties of perjury that the information provided above is true and correct 7 Si ature: C _� . Date: g �� Phone k S0 R"y o_ Official use only. Do not write in this area,tb 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( )states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract fm 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,it necessary,supply sub-conti:actor(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 penmittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all-locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit. .The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-49QO ext 406 or 1-977-MASSAFE Revised 11-22-06 Fax 4 617-727-7749 www.mass.gov/dia i Town of Barnstable *Permit# 03 GO ,4 p� Expires 6 months from is "7—d5—(3 , ,y-r„B�, : Regulatory Services .Fe o Thomas F.Geiler,Director 9cbp s6�q. ��0 � Building Division Tom Perry, Building CommissioYPRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 JUL 2 4 2003 Fax: 508-790-6230 gg STABLE MI EXPRESS PERT APPLICATION - RE�ALY Not Valid without Red X Press Imprint Map/parcel Number Property Address J Curry c orn 6 Cl r W &rr7>1N G_ moo Residential Value of Work Owner's Name&Address G Amy S U5 0.Y7 M a`C-k0 z 01 3 S C.v r rr c,Z f"4 G r A"ns I-Q, Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken toq__S0e=J ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. `A Home Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise053003 Town of Barnstable Dp"E Tp� Regulatory Services BMWS.,mM ; Thomas F.Geiler,Director 16f `0�' Building Division �Eo �a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: —7 �/++ ] j- JOB LOCATION:. 3S �vr(�j co M� Cie- number I a�r1s T t4 street village village "HOMEOWNER": � 1 W � ' I yy� 1 ACtk yl-L 7 Z� — S yd� q zo -y`l Z name home phone# work phone# CURRENT MAILING ADDRESS: CA-.)r rn/ C VM Ci rz -L W , &,fAA. 6 (Y'h city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and require Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger.will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the 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:forms:homeexempt Engiagering Dept.(3rd floor) Map /� Parcel (� �rmit# House# Date Issu Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) -7_9 / r Fee / floor)(8:30-9:30/1:00-2:00) ool Admin. Bldg.) ; UST BE ng Board 19 INSTALL LANCE ---� ' 5 6"l G TOWN OF BARNSTABLEENV1R0N C ND �' Building Permit Application TOWN REGULATIO NS Project Street ress �� CUegY_C_ Village ffS-/-r �'L,,�Q �� Owner . y .�IJSA-N /"{�FLll EAlZ/j6r - Address sx/16 Telephone �� Permit Request /G/A//5t/ e/¢S,611, /1/T First Floor /��� square feet Second Floor 91 D square feet Construction Type YVOD� Estimated Project Cost $ 5� Zoning District Flood Plain Water Protection Lot Size_)4,39a sa Pr Grandfathered ❑Yes ❑No Dwelling Type: Single Family )d Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes 1.JJ(No On Old King's Highway ❑Yes OeNo Basement Type: 15Tull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) �8 Number of Baths: Full: Existing New Half: Existing /' New No. of Bedrooms: Existing—_New Total Room Count(not including baths): Existing_ New First Floor Room Count Heat Type and Fuel: 1N(Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes JA No Fireplaces: Existing New Existing wood/coal stove ❑Yes `�WNo - `Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) S1 n4)e Aug ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes )(No If yes, site plan review# - Current Use 661 be; AL- Proposed Use /DEA/TzAL // Builder Information Name-_�6L�, �� y-Z z�'� Telephone Number �/Z O — %1-1A y Address 1r. License# z9 2.2— 4/3 Home Improvement Contractor# //V01'e, 7 Worker's Compensation# 4JG1-3/0-7-3 SSS`O—off NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION D�E/B)RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE `//G �� DATE BUILDING PERMIT DENIED F R FOLLOWING REASON(S) av i FOR OFFICIAL USE ONLY J PERMIT NO.,,- DATE ISSUED a MAP/PARCEL NO. It ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:', ROUGH _ FINAL GAS: ROUGH I' %; FINAL FINAL BUILDING t DATE CLOSED OUT e! ASSOCIATION PLA O. U4 4 aS Qa, t THE The Town- of Barnstable 9 UAM Department of Health Safety and Environmental Services BuiIding Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Building Comr. Fax: 508-790-6230 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, 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 arebadjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. zl�Type of Work: `!f� �1 ;B Est.Cost 5M /Address of Work: C. U� ^� OMIT (.i 'LE b)'64'RJg_ GE: Owner's Name=_ 1� Su SAW AA CAME z f C ate of Permit Application: �/ 7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner 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-. Da a Contractor Name Registration No. The Common wealth of Massach usetts : 2 Department of Industrial Accidents y ` J efte it1AVesdpslliis - 600 Washington Street . . P 4r ' Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Applicant intoifialhon- name: 41 ti an ... /1-744 /I 4ta .` //s` 4 .sz, t A6r0,04 C-iS Y location: /.�"14 Ott t�>L� p�C—v �i�/� 0�L�..� phone a S_J 69 o 1 am a homeowner performing all work myself. I am a sole proprietor and have no Qne working in any capacity I am an employer providing workets compensation for my emmpfogees working on this job. company ame: address: ' 0 17 / v/4/ iLh•' ( phone#• / 7 insurance co. 2.�J zv�y �v�vt/ policy# G�'G�'3�.Z—�J�✓�S�'O/�� O 1 am a sole proprietor. general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: I address: cit.y: phone#• insurance co. policy# ... .. -...... ...r....�. .• ..r .. i._._ yr' ...�. t^. • .- I comfy name: address• cry: phone#• insurance co. policy# Failure to secure coverage as required under Section 25A of MGL 152 no lead to the imposition of criminal penalties of a not up to 51.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a floe of S100.00 a day against me 1 understand that a copy of this statement may be forwarded to the Oftice of Investigations of the DtA for coverage verification. t do hereby certify under th pains and penalties of perjury that the information provided above is true and correct Signature Date ��/' e960" Print name �!=n h /,/4 C-A 07 Z't L Phone N Cchck do not write in this area to be completed by city or town official - _ _ permiVlicense# LOOS ildiag Department ensingrdate response is requiredectmennce alth Department phone p;_ __ er Devised 3195 P)A) F 6771 UEPAiTMElIT OF PUB lc SA? E Y �n5�.700 ONE ASHBURTON PLACE , RM 1301 BOSTON, MA 02108-1618 CONSTRUCTION SUPERVISOR LICENSE - NurnbYr: Expires: Restricted To: GLENN S MACKENZIE IR Detach bottom n on 3 M L N N I C v... ':�", 'u': },;'moo::`,` r fold sign s CENTEkViLLE , acJ:'`, and laminate license card. MA 02632 Keep top for receipt and change ,of address notification. I ' � fie -�anv�,00uueez� o��,/G'�aa�c�u�ae� • HOME IMPROVEMENT CONTRACTORS REGISTRATION °Board of Building Regulations and Standards One Ashburto.n Place - Room 1301 , Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 114607 Expiration 1O/06/0 Type — PARTNERSHIP MACKENZIE BROTHERS GLENN S . MACKENZIE. 3821 FALMOUTH RD 8B MARSTON MILLS MA 02632 : 0 9 k r t ♦ \ x o'. ► cr ra h��a� c �►'�\ � 61 s � a_- l!" C 1n I oe f` r' 3 •� ' O r G 'f MA CA 70 rCOOa T 6- IA9 q bc < I'T d �. T y j 1 --- -__ _-- --- aye -- -- -- - ' s, X Z I N T7- Y- Vrnr�es o c P � � N � w N U A Z ' � 3 C, C � A 3 . � 9 • A— t p n 3 Q eL-- cl p 0- t ' c J>(DTp — 1 CA N 9 V\ Q I WCl t i L X _ c40 cr CA G �9,. c y 1 1 O P r tr G 70 r c rbc ox 1 T; d � � I � I � T mom V(A�+es o` o ri w � c � r► 3 � 9 A � P � A ey- r� o• �> TOWN OF BARNSTABLE Permit No. __--_28845_ i Bnilrling Inspector Cash -----_-----___-- • OCCUPANCY PERMIT Bond -----X Issued to S L S Trust Address ��lot #38 35 Currycomb Circle, West Barnstable Wiring Inspe'ctor`` Inspection date Plumbing Inspector Inspection date Gas Inspector �__ Inspection date Engineering Department Insspectionn date Board of Health Inspection date 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. .....................................................1 19...... .............................................._........................_.... _._......_._.� Building Inspector HU •! J PERMIT . '"-.TOWN OF BARNSTABLE, MASSACHUSETTS JOB WEATHER CARD as 4 • J.l;tl:_-y 14 19 u'6 PERMIT NO. E` K aDATE L)t -S,,I lov T;:tel:':_ ADDRESS J 1� a1G'� -' - ;APPLICANT (N0.) (STREET) (CONTR'S LICEd NSE) NUMe , . !.LS:L:L. L• :a :..: ' ( Ste) STORY _ J`' i �:'•:I:o i�li Il �lij DWEBL LING UNITS PERMIT TO (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) iC'C Ju ?_, CTS_` .CC li. :.•.' ia:,C Si.?I^:'L .11.L 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: VAREA OR OLUME ••�i• - ESTIMATED COST � ,, 000 FEEMIT $ -�'•7 J (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 7EMPOPARILY 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 FROP.: THE CONDITIONS OF ANY APPLICABLE SUBDIVISION 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: ELECTRIC,.L, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHAN!CAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM `-'TREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 2 Dec:- ' HEAT:NG 'NSPECTING APPROVALS REFRIGERATION INSPECTION APPROVALS , ry I -K SSA. NC' �aO=EE U ? L TN_ PERMIT W;LL BECOME NULL AND VOID IF CONSTRUCTION NSFECTIONS iNDICATED ON THIS CARD 11CTCF. AS .?=4CVcD 74E V.-cus WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CAN BE .RANGED -0R B� TELEPHONE `TALE_ JF '-OV 5TR UC7,0N. PERMIT 15 ISSUED AS NOTED ABOVE. OR WRITTEN NO IF ICAT!ON. :A�:.,"";.v;; '• .. _ •L -'a.M i� -,;'�,"' i 3':r:>�;,y3"' a"i "'�"` %G'�4 '4Xy� o• Q TOWN OF BARNSTABLE Permit No. 28845 ----------- — n 4 Building Inspector Cash .�o R '"' OCCUPANCY PERMIT Bond Issued to S L S Trust Address ��kot #38 35 Currycomb Circle, West Barnstable Wiring Inspector--_ Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date 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. - " .......... z4. .....«.2 19 2'4 ................................................ ...�` .'.._.«---- _«.«._ Buildin Inspector a'�y�•�'. TOWN OF BARNSTABLE _ BUILDING DEPARTMENT seams TOWN OFFICE BUILDING rua HYANNIS, MASS. 02601 �0 reY M. MEMO TO: Town .Clerk ; FROM: Building Department DATE: SA 9 An Occupancy"Permit. has `•been issued for the building authorized by R t / Building Permit #...... - _.».».................._......._.................. issuedto ................» .. .... --- .....».................... f.�Please release the gerformanee /—# bond. � y 1 _ -rz- PCL a • J � -�c.�ric�. 0' • t9 P 5P -* 85-215 C�ieT/F/E'D BLOT 0=L/4A6/ , PREPAReE-D FOR: / ocg7-iov. :.W EST SAP-"% ABLE, MASS. L E 8E L E SOL LOW S JAN. e3, ►9s� SCgL E: D/4TL�. .e EFE.eccicE: HVNTE� 2 �./E.eEBY CEBT/FY T!-/FaT T.�•/E BlJ/LD/.t/�r PL.U.V /S LOCATED OA1 T.UE y.eoc%vn AS 3"NOW.V f-/EBEc.V. /lH Oi Ma�� ARNE i down came er�9�rreer�r,9 ' '� � n' N Lf7.�/D Sc/eV6YOB3 /� 'p¢/ �ouTE• 6�4^-Y�.eMOc.JTs-�, MA53, a�r�rQ1�/ ��. ��_�� _ ,/►- �: Assessor's r?fap and lot number . .. .... . THE w� pi tp f SEPTIC SYSTEM MUST Sewage Permit number r� ... "' "......" INSTALLED IN COMPLIA 3S ' WITH TITLE 5 l Bafi NILSTABLE, Housenumber .................................,....................................... ENVIRONMENTAL CODE &e39.9 0 gar a TOWN OF . BARN11- BEEMI IONS BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....®7.v/ � I ............ .................................................:. TYPE OF CONSTRUCTION ..............li.�. ...............................................................................................;................. .......:.... f...L......�.�.3..t9........ — TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies fora N�eremit acc��ng o,�a foil /wii/ng information: Location ..rr�C?. ....#.. . � c_!/ •.:.......... ....................... S�:"�.F.Q,................................ ProposedUse ......�............ ........................................................................................................................................................................................................................................ Zoning. District .......... .. .................................................Fire District ......................... .................................................. Name of Owner .........' S �T/LCJS .........................Address zU/9 � e I.3 Name of Builder �P62/- �—S Z .......Address ........... Name of Architect ..........Address . ....` •• (' 0���U?` � ••i Number of Rooms / ..........Foundation . 0114e ..... -- Exterior ......�/Z/h9/'S.............................................:.......Roofing ...............G. ZL: ..................................................... Floors ( Co Interior ..........�l22 C �. ................. ............................... ........ Heating ............ .... ....................Plumbing .....�r.. CC��2`�.......a.. ....... ....... S .......... ..... � Fireplace .............�.e..............................................................Approximate. Cost ......'�..�� 60Q ..................... .... Definitive Plan Approved by Planning Board -------___________-----------19_______. Area ...... id.........1°....... Diagram of Lot and Building with Dimensions Fee .� ....................d.... UBJECT TO APPROVAL OF BOARD OF HEALTH �• ��. V OVUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnsto le r rdin above construction. Name ......... .. . . . ........... .. .. ........................ Construction Supervisor's License i -_ I -S L S TRUST 28845 11 Stb t*Nq ................. Permit for .................................... Single Family Dwelling .................. Location Lot 38, 35 Currycomb Circle West, Barnstable ............................................................ ................... Owner ...............................S L S Trust.................................... Type of Construction ....Frame....................................... . ...........................I...............:...................................... Plot ............................ Lot ................................ Permit Granted ......JanuarX 14,..........1 9 - 86 Date of lnspection,�:/�:.SJO.................19 Dated Completed .......................................19 Ass e's1o `map and lot number - .. THE Sewage Permit number � � 5` Z B9BMAS& House number B, i ..................L�............................... . . .. 90 M6 a \\ . .. .................... O 39• �0 • �'0 YpY a' TOWN OF BARNSTABLE BUILDING INSPECTOR .. ��-� '��. fU i2 APPLICATION FOR PERMIT TO ..��v�...............................................�...............................................:.......:.. TYPEOF CONSTRUCTION ..............................................:...................................................................................... z S7Z 19�-- ............... ....... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a ppermit according the the following information: Location ........ ..........za. =�Gc/Zh 5����Q.................................. ProposedUse .....e�-vP� .N.,? ........................................................................................................................................ ZoningDistrict .......... ...C,.................................................Fire District ............C�...`.C2.................................................. Name of Owner S! 5 � f.....•.••••..•.••••......Address .... Nameof Builder .............. .......... ...........................Address ........... .................................................... .. /��� Name of Architect ., !�1 !�1.5% �:n.�..r. ...... Address «� U�;Jul f Number of Rooms ............. !,................................................Foundation .. 1�Q.�i P ...... li1�GlZP.,: ......................... Exterior ....... ./i>���, �5.....................................................Roofing ....:.................. j...................................................... Floors /J,/,�( UO� ...................................Interior �/�e��vG/C �....� .... ..................... //..//........... Heating ................. s ................................. ...Plumbing 92 rS..? .. 5 .... Fireplace ........... !PS..........................................................Approximate. Cost .............SU;: UC� ...................... Definitive Plan Approved by Planning Board ____________ Area ......O . . Diagram of Lot and Building with Dimensions yCe, ;� •••••.•••••......•... Fee .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnsta•'le regardin above construction. , 1G°' Name ..�.. .. ...................... Construction Supervisor's License ..................... ..:....... . . 0l3 . S L S TRUST A~151- ^ 28845 lj Story ' ' No -----.. Permh {or --..---------. . ' ' � Single Family Dwelling . . --------------------------. ' tot 38, 35 Currycomb Circle iocohon --------------`------.. . ' ^ ^^ West Barnstable . -----------------.--^------ ' ' ` ` S L S Trust � Owner --------___,—_________. . . , . Frame TypeofCono�uchon ----------�---.. ' . --------------------------. . ' P�� �� � ---------. ................................ ^ . - - � Permit Granted ..........JqAiAarI.l4x--lP 86 ' Date of |nxp6ction ------------lq Dote Completed --�----------.]9 ' . ` . . . . . . . ' . . . . . . ' . ' . . ^ ' ' ^ '