HomeMy WebLinkAbout0868 OAK STREET (CENT./W.BARN) /y ~•- 1"•+. ��,f '� �ilk -p ���
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O�brdNO. 152 113 ORA
ESSEME o°�o
w........_.. . _ .._,�
WOW
MIT Town of Barnstable *P�;� t 105 CO
ti Expires 6 months from issue date
i 1 2011 Regulatory Services Fee 56-411-0
• BARNMBLE, ■
• f�� �° Thomas F. Geiler,Director
Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.barnstable.ma.us
Offic 508-862-4038 Fax: 508-790-6230
EXPRESS PER UT APPLICATION - RESIDENTIAL ONLY
,,Not Valid without Red X-Press Imprint
Map/parcel Number 0
Property Address c)C_
� t
Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address_ �J b GL ,n S fv� u i E ri
I
Contractor's Name 1. Telephone Number —5 QF—3 qk
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor-
0-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(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
Re-side
#of doors
❑ Replacement Windows/doors/sliders. U-Value (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 Horne Improvement Contractors License& Construction Supervisors License is
required.
SIGNATURE: x v
):1WPFILESIFOPMSIbuildin permit forms\EXPRESS.doc
revised 070110
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
�� licant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #: 573 02 �d �eL
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
employees(full 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'
[No workers' comp. insurance comp.insurance.# 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.X 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 t9e 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 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 criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
-Si ature: Date:
Phone#: 9z—
ol
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
DF1HE Town of Barnstable
Regulatory Services
BAMSTABLE, Z Thomas F. Geiler,Director
y HASS.
n 39. a � 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
HOMEOWNER LICENSE EXEMPTION
DATE: Please Print
— •%!��� �y.,�/
JOB LOCATION:
number street
r village
"HOMEOWNER':_ u U C2'ooVe. /}�� !'/✓11ejL TD,5
name / home phone# work phone#
CURRENT MAILING ADDRESS:
/ors &1/e o �Z4 4 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 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.
Si re 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
}
�1HE h, Town of Barnstable
R Regulatory Services
�sz,��. l
�.+es Thomas F. Geiler,Director
i6Jp. �
a►wAy' Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
a!
Office: 508-862-403 8
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
(Address of Job)
---------------
**Pool fences and alarms are the responsib' ' of the applicant. Pools
are not to be filled before fence is installed and pools are not to be
utilized until all final inspections are berformed and accepted.
Sign e of Owner Signature of Applicant
1.
Print Name Print Name
Date
Q:FORM&OWNERPER MISSIONPOOLS
•� / /
US
Asses.^ ^U-so(- a'A )—M^^- Parcel J Permit#
9- Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) S� d� .
Engineering Dept.(3rd floor) House# IG iSS
- INSTALLED 1 ^T BE
IF
g NCE
oar 19 ENVIRONME $
'° E AND
TOWN DREG C �.
TOWN OF BARNSTABLE n
NG9tr' O tc— TO
Building Permit Application - fLav)o AA% �
Project Street Address
Village
:Owner `u V\ Address
-Telephone 2( — 014
r
Permit Request .2
L, .
02Lh
mot!
First Floor square feet .
Second Floor square feet
Estimated Project Cost $ /�z1
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Commercial Residential
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure Basement Type: Finished
Historic House Unfinished
9 �L
Old King's Highware__1q)
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
Namely��}-72��_ 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 DATE
BUILDING PE DENIED FO THE FOLLOWING REASON(S)
T '
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MP/ ARCEL NO. { -
ADDRESS VILLAGE "
OWNER + < s
DATE OF INSPECTION:
FOUNDATION + "'
FRAME '
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL "
PLUMBING-, I f'ROU ., FINAL
cr
GAS: FINAL
fn
FINAL BUILDING= M 2,
2mof:+ i
DATE CLOSED OUT,
ASSOCIATION PLAN NO.` ;
i
�/"" /�F�jam.
Assessor's map, and lot number � .t;44'........ vvl/ A — C V VIEEPTtCgySTEi� }sT
INSTALLED IN COMPLIANCE~
WITH ARTICLE fl STATE
n
t< Sewage Permit umber ../y �...... ...............:..\� /c% �
SAPQ1TARyY com AW-
f; ..
�o*TNer,�� TOWN OF BARNS` .
tt
i EAMSTADLS, i
• 9O�,o,r0
9 �•� BUILDING. IN-SPECTOR
'Ep 11pY a• ,
v
v APPLICATION FOR PERMIT TO ...:........ .. . ............ R................... `..............................
TYPE OF CONSTRUCTION ......................( ..............
.�..t�0-te...................................................
:.� ................../ ... �►.......19. ..!.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
4
C�.a.1�....... T'. 5` .............3 �a.> t„ ........ L�.�a...........................
Location ........... .
Proposed Use .ptkt ��L `. 6e.&V0.0.%AA.........�.�.J................................................................
........... ....... ..... .......
Zoning District s �. — ��p n 0
.................` .... .................................Fire District ......��S.t.......:-�a1�51�.!5 .��
Name of Owner . .* ... D�A. ... .:....Address .......j(�( .... ..�,�....... ..: .�2 .............. .........
Name of Builder ........."1.....PIZ!�l G�L.......... Address ....... . . .. .......
Nameof Architect ..................... .O UV ......................Address ....................................................................................
. C `jam
Number of Rooms ..............I.................................................Foundation ...��'��.�......".....�`e..�.........`.J!;�Ok,
Exterior .......tzop.k......... !S.O�I".......................Roofing .................. 4� ................................
Floors .......... I0._.. .......QP. ........................Interior ........\. �S�a►.� `� .... .. ��.�.�.....
Heating ..... ... .o1e� .......... ..............Plumbing ............
Fireplace ..........:....y ........................................................Approximate Cost ...................�® .....-r...................
Definitive Plan Approved by Planning Board ---------------__-------------19--------. Area ..........................................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
4e I
6
OR/L :
I hereby agree to conform to all the Rules and Regulations of the of Barnstable regarding the above
construction.
Name ............ ,f.. ...............
Mullin, Daniel J. & Joan M. ;
No
...1........719
. ... Permit for ......dQXPAK................. .
...............................................................................
i
Location .......Aak..S.trest.............
......................WRsX..asxuat,able........................ - --•
i Owner .........PAIR191...J.-.&..JQazx.M...Mullin
Type of Construction" ..............frame.................
� V
1 1 ,
Plot '``. . 'j ''2' � R
............................ Lot ................................ �y7
47
Permit Gra Jl 9 74d Y ...
•• "'t S '
p ...... ........-19 Date of Inspection .................. ...�
C;
Date Completed 19 �^
PERMIT REFUSED -
............................................................................... `
tea.
,` ..�...... .... ...................................................... Vj 11 r�• ,ll
............
1z
,'-/PProved .!............................................ 19 IIL
�J
. ^ .................... '..................................................... S1 _1 �..•�' ~
Assessor's map and lot{ number .................:...7.. ..............
i
Sewage Permit number ..... f !'... .C..�.. .......
..... `_��t��
P��FtHETO�y TOWN OF BARNSTABLE
Z 33AUSTADLE, i
"b9- BUILDING INSPECTOR
�o waY°'•
APPLICATION FOR'PERMIT TO ...........� : .......... -c,u r.0.....................�r..�............................
TYPE OF CONSTRUCTION .....................1 ............. :=.....
..................................................
.................. .......19. .
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a p'er-miit according to the following information:
Location ......... ........�� .1. .......t'.- \...............:.�?.. ..��L� .�.. :..... ."-`.> ...........................�..
Proposed Use ...I........................................►UP 'vC Li n..........US, P
Zoning District .......................�.............,..................................Fire District .............'......1.:�
Name of Owner ',)A -..�1.:ac DA�...�.:....Address .......D�IC.....cam . w.'..
..
Name of Builder ....... .A.Q - `� .I l- Tt �t...Address ......<........!�1 c �.} . moo
Nameof Architect ..................... O Ul)�......................Address ...............`....................`.................................................
Number of Rooms ...............!..................................................Foundation ...-f"..1'2.1 ......\1�C�1��... .......,`. `,oC��>.
(.
Exierior ��l�C .........��^�!l.U4 r. I° Roofing ................. � �lekut. -
...................fl'.qp.o.........................Interior ........!:...`... \...` '`."....�...... ....1 t� .!.`.....`Floors ?1 \ ` ,
l � •e
Heating .. ' . ........... . ... ........ ...-.-..'Plumbing':.............I 1 .y ' .......:...............:...:..:........
v
Fireplace � ..........................Approximate Cost <kg
. ................................... o..................... ....................
V
Definitive Plan Approved by Planning Board ________________________________19________ . Area ..........................................
Diagram of Lot and Building with Dimensions Fee .............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
� � Z
v
Oak. Ste:
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. �i
Name �! /yi�tln �/. � !'�!.�/.. ...............
Mullin, Daniel J. & Joan M.
o2� � S
17193 dormer
No ........... r:.. Permit for ....................................
...............................................................................
Location Z 4.3...Oak Street
.............................................
...........................West Barnstable
.............................................
Owner .........Daniel J. & Joan M. -Mullin
......................................................
Type of Construction .................frame.........................
................................................................................
Plot ............................ Lot ................................
Permit Granted .............J.uly..9.............19 74
Date of Inspection ....................................19
Date Completed ......................................19
t
PERMIT REFUSED
................................................................ 19
...............................................................................
................................................................................
...............................................................................
...............................................................................
Approved ................................................ 19
...............................................................................
...............................................................................
r
The Cunrnionivealth of Massachusetts
Department of Industrial Accidents
. �-� . '_• �:1 OJflfceol/oYest/gat/oas
600 Ei ashbiglon Street
. :��:►:
Burton.A1ass 02111
Workers' Compensation Insurance AfAdayit
A,nnlica�n nformaion-� Please PRINT�,e jj�y�,�,�,�_� •
name,
L11,6 lot-S
fl� G� �aS
c13L��. ,C ,? i �u� phone .2 F—F3
I am a homeowner performing all work myself.
�am a sole proprietor and have no one working in any capacity
i....MKT••-ti..,.�,�,=_R..�--.?;,,-.,�.,.:.,, .. .. .. -�.. _ •..-.,
(....r iiV.•..r
0 1 am an employer providing workers' compensation for my employees working on this job.
company name.
11 c
citya phone#•
insurance co policy#
I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
companyn
iddresse
phone#•
tncurnnce co policy# � _�
.� .• — vcir�-• �o ,n.�ey"�s '�+vrnwr.r"a+ 'g`j��s'J�e '"'
tin an•nn c:
citti phone#:
policy#
j cur•tnee co —�
:Atiach addItionaI'sheei it'neeess_—_� a `` �°O
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,SOU.UO and/or d/ur
une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
cope of this statement ma% be forwarded to the Office of Investigations of the DIA for coverage verification.
I d lterebr certify under the ai s and penalties of peduty that the information provided above is true and correct /
Signature
Date• /� "9 , 9 G
Print nam Phone#
official use only do not write in this area to be completed by city or town ofrcial
cih or town.
permit/license# riBuilding Department
�Liceming f3uard
0 check if immediate response is required �S' i tmen's Otrce
�11calth Department '•�
contact person phone#• r�Other
(reared 3.95 PJA)
The Town of Barnstable
er g Department of Health Safety and Environmental Services
Building Division
367 Main Strut,Hyannis MA 02601
Ralph Crosses
Office: 508 790-6227 Building Commissioner
F= 508 775-33"
For office use only
Permit no.
Date
AFFIDAVIT
HOME BeROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,•renovation,repair,modernization,eonvetston
improvement,removal, demolition, or construction of an addition to any pm_cds owner,
occupied
building containing at least one but not more than four dwelling units or to stru s
adjacot
to such residence or building be done by registered contractors,with certain exceptions, along with other
requiremm-
Type of Work:L.2da-�',
Est Cost t/ d?1
Address of Work: D l O � ��'�` `
Owner.Name. /
Date of Permit licatiC /a 9 9 6
I hereby certify that:
Registration is not required for the following rcason(s):
Work cmduded by law
Job under 51,000
guilding not mmeroccupied.
Owner pulling own permit
Notice is hereby given that: CONTRACTORS
OWNERS FULLING THEIR OWN vIpPERMIT OR ROVEMENT WORK WrM DO NOT
ACCESS TO TFiE
FOR APPLICABLE HOME
ARBTIRATION 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 '
94
Date Owia,s name
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB. LOCATION
Number Street address Section of town
"HOMEOWNER"
Name Home phone Work phone
PRESENT 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 such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Persons) who owns a parcel of land on which he/she resides or intends to re-
side, on which there is, or is intended to be, a one or two family dwelling,
attached or detached structures accessory to such use and/or farm structures.
A person who constructs more than one home in a two-year period shall not be
considered a homeowner. Such "homeowner"- shall submit to the Building 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 Stat
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 requirements
and that he/she will compl with said rocedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING 0 �cIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
HOME OWNER'S EXEMPTION
The code state that: "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 Owner
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 awareneE
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- actir.as supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities, . mar.communities require, as part of the permit application, that the Home Owner
certify that he/she understands the responsibilities of a supervisor. On the
last page of this issue is a form currently used by several towns. You may
care to amend and adopt such a form/certification for use in your community.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map! I Q Parcel > o S Permit# 736 6-6
Health Division Date Issued eC boo
Conservation Division 2 G U 3 Application Fee
Tax Collector Permit Fe
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address
4 �
Village 0-�wi'YI • !�oZ l�
Owner J o cL', Address 0011 (C• S GLJ r /
Telephone CK a
Permit Request
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District ale Flood Plain -Ale) Groundwater Overlay
Project Valuation Construction Type
Lot Size 91 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 ZM6
Basement Type: mull EY rawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) O Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas arOil ❑ Electric ❑Other
` Central Air: ❑Yes R o Fireplaces: Existing v' New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing Cl new size Pool:❑existing ❑new size Barn:2'*existing ❑new size
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_ h 0 n �e_ Proposed Use
BUILDER INFORMATION
Name �o o,�,., S f'1�1 j Telephone Number 5 z _ 3 6,c;1 - z
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
t FOR OFFICIAL USE ONLY
C 4
Al
.•` •PERI�IT.NO.
-r DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
` DATE OF INSPECTION:
FOUNDATION
FRAME
F INSULATION
FIREPLACE
} ELECTRICAL: ROUGH FINAL
?° PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
r
-DATE CLOSED OUT
a
ASSOCIATIONPLAN:NO.
�y
The Commonwealth of Massachusetts
Department of Industrial Accidents
F 600 Washington Street _
y Boston,Mass. 02111
Workers' Compensation Insurance Affidavit-General Businesses
�ii i i • is �/�//O/O///O�O/
name: �po c yt
address' 8� c� OIL S f
city W 6ct rY S tom,b state: t///7 ZjR:6a QIQSl_phone# S 34 oZ —o741t��
work site location(full address): �,6 :g- C-o" �< P5' a 66s-,
❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment
working in any capacity. ❑Office❑Sales(including Real Estate,Autos etc.)
❑I am an
e%mplo er%it loyees(full& art time). [Otherw �i/�i /il %%%%%%/%%/%
U I am an employer providing workers' compensation for my employees working on this job.
company name:
address:• ..:. ....: :......:.�r.: . .•.
city: phone#: .
insurance.cb:-:'..::; .;":. > of e. #.:
I am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices:
coin any name: .<• " . : - " ;. ; -
address:
city:. .." phone# ' "
insurance co.
/ /// / //, "" / ME / / %%/%��////%%//
company
address
city:" :" :• :. ". phone# ..
:.,
illSnraDCeSO.:':`.•:..-;":.:.'.:::::'.•:.:.:" .;• .;" .:.OIICV•#:"::
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that 0
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certi der the pains and penalties otf p r'iry that the information provided above is true and correct
Signature ®7 /V Date -3
Print name J o Q n S ✓ It e-h Phone#
Official aye only do not write in this area to be completed by city or town official
city or town: permittlicense# ❑Building Department
❑check if immediate response is required ❑Licensing Board
p q ❑Selectmen's Office �
❑Health Department .
contact person: phone#; ❑Other
(mveed Sept 2003) 'e
I
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is defined as every person in the service of another under any 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 bean employer.
MGL chapter 152 section 25 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,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted
to the Department of Industrial Accidents for confnnation 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 pernrit or license is being
requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are
required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the pem-nit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made. T
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
BMW of Imsdgmens
600 Washington Street
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406
i
oFTME,�. Town of Barnstable
Regulatory Services
snxxsTeet. Thomas F. Geller,Director
16.19. �`0� Building Division
�fD µP't •
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
• Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME MROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which -are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of
Work: �P�n v vzL�"/ �'► Estimated Cost
Address of Work
Owner's Name: C, v S
Date of Application: ;9-
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
DI ob Under$1,000
[]B g not owner-occupied
wner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME Il12ROVE1SENT WORK DO NOT RkVE
ACCESS TO TEE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agept of the owner:
Date Contractor Name RegistrationNo.
OR
Date Owner's Name
Town of Barnstable
CF T?1E Tpt�
Regulatory Services
sARxsz.ASI : Thomas F.Geller,Director
Building Division
prED MAC s Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
ice: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE IMIPTION
Please Print
DATE: O
JOB LOCATION:. S f
number street village
�lol�owl��Ex^: c�ao�v� s h1 u fly s7>S- 3Ga- a�Sz
name home phone# work phone#
CURRENTMAMG ADDRESS: e,5—
/?,
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-&'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,structuies: 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 Buildhig Official on a form acceptable to the Building Official,that he/she shall be
resgon'sible for all such work 1ierformed 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— i
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Sign& ofliomeownei
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 EXMWTION
•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 i supervisor(see Appendix Q,
Ruses&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 pernit 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. Iron may care t amend and adopt such a form/catification for use in your community.