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HomeMy WebLinkAbout0157 SADDLER LANE f i rj 3 UPC 12543 4 Now r CnN,r�`�� HASi1NGS. MN .9 �; �: �:; i�. ;: ��, G �� �� :r ��� ,� << S. P, _ . �. + , � 3 . . 1 s v r' Y � �. i I -- — — ,�.� i 16 �p1HE Tqy, Town of Barnstable *Permit# ,per Q Expires 6 mont .from ue date Regulatory Services Fee g BARNSTABLE, « 9� 1639. �0� Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner p" .200 Main Street,Hyannis,MA 02601 h www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 151 0 Property Address IS-7 &cl,&6,j Ln IJJ��ffia�ti ,� []Residential Value of Work 1146v0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Ginn �c,�J��M \'3-7 SN-td leii (, .I, '12; .'; r Contractor's Name_ D C) Telephone Number (Sue) -2 3'1 —9W Home Improvement Contractor License#(if applicable) I N636-1 Construction Supervisor's License#(if applicable) 5 7y ❑Workman's Compensation Insurance X-PRESS PERMIT Check one: ❑ I am a sole proprietor JUN Q 2010 ❑ I am the Homeowner 0_I have Worker's Compensation Insurance `TOWN OF BARNSTABL.E Insurance Company Name ,R cc-,e<S /� c'J�, 1 hS•, Workman's Comp. Policy# WC IN 0'2 ( ►Q t-Iq l 2 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 .3`Z (maximum .44)#of windows I *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 Co .tfactors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit fomu\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial'Aecidents Office of Investigations �a 600 Washington Street i Boston, NIA 02111 p rvfvw.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C c4, T� hC - Address: i S-1 S�dd \w Ln City/State/Zip: '0 t-vs-b6L IVA Phone #: 08 — 2 3 -- 2 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 hued 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions right of exemption per MGL _. myself,..[Noworlce�s.'_eort?P...... ._.. ..._........._..._.........__...... _..-..__.._..._ _ ......12.O Roof.repairs........... . .. ... ........ '^ insurance required.] t c. 152, §1(4),and we have no ' l3.❑ Other employees. [No workers' 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 provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. _ Insurance Company Name:��cJ COS, ,_I K.S Policy #or Self-ins. Lic.#: Cwcq Ca I 1 5? ki l 2 : Expiration Date Job Site Address: t 51 J�44[cc f LA City/State/Zip: 11 t 4- 1 t�� 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 Lip 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: Date. Phone#: �� Z-,s 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 Information and -Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for.their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair.work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s) of . _ insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the - ' members or partners,are not regiiirecl to'carry workers'compe`nsafioii insurance If an LLC oi'lLP'cloes have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Induistrial 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 permiUlicense number which will be used as a reference nuunber. In addition, an applicant That must submit multiple permitflicense 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. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 4-24-07 wwtiv.mass.gov/dia i i h pFIKE7 Town of Barnstable Regulatory Services BARNSTABLF, ' Thomas F. Geiler,Director MASK. fo_19�., Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 wwtiy.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-b230 Property Owner Must Complete and Sign This Section If Using ABuilder I, J► M P o P h G nn , as Owner of the sub)ect property hereby authorize' c v)ear CovNtA v A 4-"0 n to act on my behalf, in all matters relative to work authorized by this building permit application for: 5 7 S 01011 eY �� t RAJ .�► o,vv�.S �1P, MA (Address of Job) Aatiure r Date J Gw,eS POP haW Print Name If Property, Owner is applying for permit please complete the Homeowners License Exemption Form on the.reverse side. Q:FOFJYIS:OWN ERPERM ISS ION ' Town of Barnstable P�0F'[HE TO�'l� o Regulatory Services, " 4 BARNSTABLE, Thomas F. Geiler,Director ' MASK. 9� 1679. ��� Building Division pTfD 'y a Tom Perry,Building Commissioner. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 10B LOCATION: number street .village "HOMEOWNER": name home phone t! 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 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 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 !j when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC Client#:44075 UNECON ACQRD- CERTIFICATE OF LIABILITY INSURANCE 03/03110 "YY" PRODS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8:Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Acadia Insurance 31325 Lineal Construction,Inc. INSURER B: ! P.O.Box 111 S INSURER c: Barnstable,MA 02630 INSURER o: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS'AND'CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' UCL� TYPE OF INSURANCE POLICY NUMBER DATE I EFFECTIVE POLICY MMIDDEXPIR M UNITS A GENERAL LIABIIJTY CLA017561113 03/29/09 03/29/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 5250 OOO CLAIMS MADE 51 OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $2 000 000 POLICY PRa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (P-Pe—) $ HIND AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peracciderd) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY CUA028696610 02/20/10 03/29/10 EACH OCCURRENCE s1 000 000 X OCCUR ❑CLAIMS MADE AGGREGATE $1 O00 000 s DEDUCTIBLE $ RETENTION S $ A WORKERS COMPENSATION AND WCA021184912 03/29/09 03/29/10 X We sTATu 2 EMPLOYERS'WIBILITY E.L.EACH ACCIDENT $1 O00 OOO ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-FA EMPLOYEE $1 000 000 If yes des- under SPECIAL PROVISIONS Eelm E.L.DISEASE-POLICY LIMIT $1 00O 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS russo Dev Group Inc&162-167 Naushon Trust as addl insureds on a primary&non contributory basis for general liability,per form AICG65(0306)and GU206L(0692). waiver of subrogation applies.10 day notice of cancellation for non-payment-,30 days for material changes. Project:Lot 167 in the Cliffs of North Falmouth,MA (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Russo Development Group,Inc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL IR. DAYS WRITTEN Attn: Robert Russo NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 378 Page St IMPOSE NO OBLIGATION OR LJABILTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Stoughton,MA 02072 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 3 #S49590/M49589 AMP ®ACORD CORPORATION 1988 L— { .-.�-- �-^.h-----• —��- ��;"d�fan aids �. ra '� }F Construction Supervisor License License! CS 87579 ar, i- e is Birthdate g51111978 T 13513 �w 3 Expiration m BENJAMIN G LAMOR/a PO BOX 1:737 Commissioner BREWSTER,MA 02631� '�`e Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License N 87579 Restriction 1 G Name Benjamin G Lamora City,State,Zip Brewster,MA,02631 Expiration Date 5/1/2011 Status Current No complaints found for this Licensee. Back To Search http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL87579 6/1/2010 f HIC Registration Complaints Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home> Consumer> Housing Information > Home Improvement Contractor Program> HIC Registration Complaints e Registration# 146367 Registrant LINEAL CONSTRUCTION INC. Name BENJAMIN LAMORA Address P.O.BOX 1737 City,State,Zip BREWSTER,MA,02631 Expiration Date 4/14/2011 Status Current No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2010 Commonwealth of Massachusetts http://db.state.ma.us/homeimprovement/licdetails.asp?txtSearchLN=47005 6/1/2010 ` � I Town of Barnstable lgermi#�JGY�a.3`-I Expires 6 nto �s fi�{� 'sue date Regulatory Services Fee d sez;rvsreare, Thomas F.Geiler,Director Mass. ��prF0:59. 0� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 62601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230;/ EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ZPrope Address — �` }t.... j�� Wi cl � C% Uc2_63� Residential Value of Work 4 72 1U. �y Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name "�.V_v VC'1 _ � Telephone Number Home Improvement Contractor License#(if applicable) ` , S 0,1 Workman's Compensation Insurance X-PRESS PERMIT Check one: ❑ I 'sole proprietor �qN 2 1 2009 am the Homeowner I have Worker's Compensation Insurance �� TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# �J S - �`0 1 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) C=3 CD ❑ Re-side `a 7x ❑ Replacement Windows/doors/sliders.U-Value (maximum.44) N . rn *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Hi c,Cons erY on,eta s- ***Note: Prop rty Owner must sign Property Owner Letter of Permission. N P. CV co y of the Home Improvement Contractors License is required. O M SIGNATURE. Q:\WPFILESWORMS\building permit fonns\EXPRESS.doc Revise020108 rtt r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual . �AI > r f_ Address: CZ— Q� � City/State/Zip: � t Phone.#: ', - 2 22C� 60 2A 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 mployees(full and/or part-tim.e). * 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. required_] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ME]Plumbing repairs or additions myself. [No workers' comp. right 6f exemption per MGL 12. oof 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 subcontractors and state whether or not those entities have employees. If the sub-contractors have mployees,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: ^F �p/l-L Policy#or Self-ins.Lic.#: ' ��2 - ?j �� ' ?� �2- 0�7 � Expiration Date: Job Site Address: I�� t � City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure fo secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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.ag t the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of the DIA or insurance coverage verification. I do hereby certify und e pains and penalties of perjury that the information provided above is true and correct. Date: A2 _ t r�zq7� Phone#: '-2 (7 z jo -l Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more - of the forego ing-engagedm a Iom--en r`pnse-anca mclu0din`g=tlie leg represen-ative-t�f --demased mpiuyerorrthe-==-- -- receiver or trustee of an individual,partnership,association or other legal entity,employing employees.-However the owner of a dwelling house having not.more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies•(LLC)or Limited Liability Partnerships(LLP)with no employees,other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly..The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 of permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext-406 or 1-977-MASSAFE Revised l 1-22-06 Fax#617-727-7749 www rnass_gov/dia .j Town of Barnstable ° Regulatory Services ys g, Thomas F.Geiler,Director E16 L 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 5087862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder 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) <J'D . Signature of Owffer Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNER-PERMISSION Town of Barnstable 'P Regutatory Services Thomas F.Geiler,Director KAes � �63¢ .•� Building Division pIED a Tom Perry,Building Commissioner ........... ......._. - ............. _....200 Main=Street Hyatmis;-M7k 02601. . . -....----...._ ..:_. www.town.barnstable-ma.us Office: 508-86274038 Fax: 508-790-6230 - H01% EOW ER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMF.OWNFR': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state kip code The current exemption for"homeowners"was extended to include owner-occupied dwellinlZs 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. DEFUGTION 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.."homeownee'certifies that.he/she understands the.Town of Barpstable,Building Depar went minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatirm 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 assurning 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 responnbilities 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. I Q:fonns:hoin=xcmpt Massachusetts- Dcp.u-tmcnt of Public Safer Board of Building Regulations and Standards Construction Supervisor License License: CS 80591 Restricted to: 00 r RICHARD A.PRCHLIK PO BOX 895 BARNSTABLE, MA 02630 Expiration: 6/28/2009 . ('ummissioncr Tr#: 14591 Board'ofBuilling Re gulations and Standards " HOME IMPROVEMENT CONT "� License or registration valid for individul use onl RACTOR .before the expiration date. Registreto - � y 135897 #. Board of Build If-found return.to:.; Expirat�o� 5�17/2010 g Regulations and:Standaids l � �i Tr# 270402 One Ashburton Place Rm 1301: i T00 Individual Boston s "RICHARDANDREW p Ma.02108 CHLK a' RICHARD P L"� 26 HANSON B ARNSTABLE, MA 02630' v f Not alid without signature , p� a TOWN OF BARNSTABLE 30005 a�YMe�` Permit No. ..... .......... BUILDING DEPARTMENT DAM I TOWN OFFICE BUILDING Cash 7 t639 �O�1,Y►� HYANNIS,MASS.02601 Bond ........X..4.(.I� g CERTIFICATE OF USE AND OCCUPANCY Issued to S L S Trust Address lot #72 157 Saddler Lane, West Barnstable USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. April14 19.....a�........ ............. . ..................... Building Inspector i ��r f a'�y ••�. TOWN OF BARNSTABLE BUILDING DEPARTMENT t �a]azss : TOWN OFFICE BUILDING � rua ti .639. HYANNIS, MASS. 02601 r MEMO TO: Town Clerk FROM: Building Department ` DATE: Y An Occupancy Permit .has ,been issued for the building authorized by BuildingPermit #�_ _ ... U' ... ................._................................_..._.......... issuedto ......_........... ................................................... Please release the performance bond. I +� TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING. PERMIT" i_5l.-OU4 An DATE `)C�'�O` ' �� 19 36 PERMIT APPLICANT :,..17t1—;;L%:,J.U:.'.., !i ' .iI?fi'li� ;Ql�3f• 1 ' ADDRESS J` 1rL.,ti��. J (NO.) (STREET) ICONTR'S LICENSE) PERMIT TO ', r�L41i< JWI:�. � 1 , '' r'CI1:111.j :JWL<.li ','r NUMBER OF (=) STORY DWELLING UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) ZONING AT (LOCATION) ''`)t" i'%" . li%+ �'•-iL:.".:c1"i ,.._..,., ., ..; 1'�;.:iL:aJl.l' DISTRICT— (NO.) (STREET) Z. :S BETWEEN AND ' (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT _BLOCK SIZE `� .. BUILDING IS`T FT. WIDE BY. FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS UR•.FOUNDATION j{+ (TYPE) REMARKS:•`+a�`. ilbU":.i 1Jd IS�i4 I,!Ll ?, AREA OR"i 1 .� c>C. t(:. `�j, ,t ,..,t.,•) PE VOLUME ESTIMATED COST RMIT ) ''''t� ' ' FEE ' 14 Uii ..JL (CUBIC/SQUARE FEET) w"•`� i OWNER , 1.Mti• '' cdk BUILDING DEPT. ADDRESS J/��.I 1 ''•,:"% '✓�[ �' BY THIS PERMIT CONVEYS NO-RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANYr PART THEREOF. EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED-"UNDER'.THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY, OBTAINED FROM THE DEPARTMENT OF. PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL INSPECTIONS REQUIRED FOR APPROVED PLANS MUST BE RETAINED ON JOB AND THIS )WHERE APPLICABLE SEPARATE ••�ir4 ) •.PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: CARD CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN 'ELECTRICAL, PLUMBING AND ). FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS 'RE- MECHANICAL INSTALLATIONS. Z. PRIOR TO COVERING STRUCTURAL QUIREO,,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 .STREET BUILDING INSPECTION APPROVALS PLUMBING INSPE TION APPROVALS ELEC RI(:AL INSPECTION APPROVALS 2. � G oXQ ' nY 3 `"? Cj HEATING INSPECTION PPROVAI.S ENGINEERING DEPARTMENT if /rw aj,z 4 It OTHER Z Q./)_ /�. ���� BOARD OF HEALTH WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. I PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. • 111 P ., ' 9z.s1. q N P 2q• l7U . N�l ~ 4 FouHp, cv n 00 mn D v e aI I�ZCo� -SF3 V ' . L_off' 1 Jos # 85-309 CEPTIFIED PLOT ' PLAN PREPARED FOR: LOCATION. L-72 SADDLER LN . BARN . i SCALE: 1=40 DATE: 9/27/86 PEFEPENCE: PB 420 PG 97 LEBEL / SOLL.OWS I HEREBY CEPTIFY THAT THE BUILDINGS SHOWN ON THIS PLAN IS LOCATED ON THE GPOUND 'AS SHOWN HEPEON. BUILDINGS CONFORM TO SETBACK REQUIREMENTS OF THE TOWN WHEN CONSTRUCTED. ARNE down cape engineering o ALA026348 H� CIVIL ENGINEERSEo LAND SURVEYORS 274/0 f I E ROUTE '6A' tiYARMOUTH MA .DATE u , „ °' =r P D SUPVEYOFR j TOWN OF 15AAA1�1rA&EA55E55OR5 MAP' LOT 70P OF I0' 20'MIN. ZONING ; �r FOUND. 101MiN• I I 5ETBACKS: FRONT: 7Jr 51OE5= 75 REAR=7,5 SEPTIC TANt4�4fDI�,T. BO,�—T LEACyING FACILI"fY 6ROUNOcOVEQ I �• J. oLr� :T JQD SECTION- 5514AGE 37. 44 TEST HOLE L065 DESIG r - I N FOR I�/ ::,.• 74 - 1D ci,�2i r'� 1 LN TE5T 6YJ u�+'• PERC.RATE 3 MIN.//N. �� DATE : 12'I �f - FLOW RATE I�0 GAL./OAYJBD 3'30 rNE5 �! L w .5 \ r1'S SEPTIC TANK 33O (1-5) W 4 I \ �! ep V — —REQ'D. SEPTIC TANK . I COOD El.• - LEACHING / � � ,�-t�oX . � �N �. . \ . . •, "� II �.-, FAC LITY WALL ,� �G2�)=4Z4•I G/D O/ VC borro � St' I; e5/0E � l�l Cola Tt'_ �Q,.S (.q2 ); �2,3GID i I _ TOTAL -- - ® f ad _2Cp-T•O 5F. =4°Ilo•4GIo; D US LIEA HIND x W ,i i t •� "COD ,` , � g — NOTES I. DATUM(H5L)t TAKEN FROM 1.At Ql6 QUADRANGLE MAP � 7� 2. MUNICIPAL ,WATER I 1�7 AVAILABLE 1 , 3. DESIGN LOAWNG FOR ALL PRECAST U91r5:AA6140-E4 -44. H n Q. PIPE ✓ H OINTS SHALL BE/4A.DE {JA7ER T1GT• IJo Ii.�A'1'�r�i �P�rp J-��, D .5. CONSTRUCTION DETAILS TO BE IN ACCORDANCE W/TN I COMM.OF MA55. STATE ENVIRONMENTAL CODE TJTLE 7L P2fAKpUT X t S(� ,�'1s� 16, rHl5 PLAN FOR PROPOSED 14ORK ONLY AND.SHOULD NOT ar EZ2' O �AVNI El'r BE USED FoR PROPERTY•. LN. STAKING. j �H OF M� �\ �j S;C H/i p `•yLA i ARNE GT.. ra liii FA ii 3.4fy!{ of H. ' CD SITE.-.A.ND_:6EJ4AGE . PLAN. ,- �`` o�acL,n ca e eh lneerin PLAN.'— IL _ LOCUS : LOT�" 9 9 ' l.0''( 72-�QDP`�,� i��l ��.JT�v l.I.1 Y: _ - r�O'�',t LA, g� / CIVIL ENGIIJEERS COHT0Ue5 (EX/5T. . (/' --- -- I I (PROP,)— REFERENCE:PREPARED FO_ _—_--__-- LANID SURVEYORSCONG.60UND h' DA E g2cv Main St.Yarmou�h Ma ® .ce � -� «d+az Z�Ai t3atillk P F ' TEST HOLE board of health SCALE : III `qo� DATE ,JOB'NO. APPROVED DAYE.: B�•R _�TAFi! ,MA � 6P6 S/ 16186 ak �S Assessor's offioe (1st floor): l 5�! QOi- d y OF T H E .. L Assessor's map and lot number .....�.t �.. . : � �S ` Board of Health (3rd floor) bp, EPTIC SYSTEM MUST Sewage Permit number .:......:....... �......... .•�. INSTALLED IN COMP LIAN 8H39'f4DLE, Engineering'Department (3rd floor): �� �)S� WITH TITLE 5 °°.�t6 q'a e� House number ........................:........... �I�NIIRI®NMENTAL CODE �+�,v 0 YAV APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only �q�L��i I� •�. TOWN 'OF- BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..:...Build .1 1/2 �StorX.................... ..... .. ....................... TYPE OF' CONSTRUCTION .........W..Q.Qd...f r'.dMe................................................................................................. ...............August..11.........19.8 6 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............1{A. .�.....'... ..F�.. ....... . ...............W..... /.`f. .�.. U/��.......... �. ... ProposedUse ........Wellillg. ................................................................................................................................................ Zoning District ........R.. ................................:....................Fire District ..... �...................................................... Name of Owner ....SLS...T..rUS.t..............................:...........Address ...Ey.annis.,...MA..................................................... Name of Builder ................................Address ...Hy.anniz.,...MA................................................... Name of Architect ..Noxthside...Des.ign.....................Address ....Ya.rmouthport.,....ILIA..................................... Number of Rooms ........5......................................................:.Foundation ...P.Oured..Concrete.................................... Exterior .....e.ddr'...S.hilagleS:..........................................Roofing Asphalt................................................................. Floors ....31..4....T'.&.G...P.IyWood..........................................Interior .S.hee.track............................................................ Heating ..Gas........................................................................Plumbing ....P-TJC...and...Co•ppe.r...B-a:th.s.................... ..... Fireplace .....Masao.nry........................................ ................Approximate Cost ...6O.,.D.O.()..... �f.. :,�.............. — Definitive Plan Approved by Planning Board ____ ___ L' Q______19_% . Area ............... . Diagram of Lot and Building with Dimensions Fee A , _ SUBJECT TO APPROVAL OF BOARD OF HEALTH / C�a 0 0 ) L// , / (/ r 14 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstab a regarding the above construction. Name . ...... .. .... ... . ... . .......................:.............. Construction Supervisor's License .......04.3.41.5.............. -L-9" TRUST 30005 Sto No ................. Permit for .................................... �.�milv Dwelling ...... .... ....... ....................................... Location Lot 4�72, 157 Saddle�r Lane ........................................... West Barnstable ............................................................................... Owner .........S...L.....S.....Trust.......................................... Type of Construction .....Frame........................... ............................................................................... Plot ............ ............... Lot ................................ Permit Granted ......October...3, 19 86 Date of Inspection ....................................19 Date C iplete ......19 i.. ..................... 17�� h2 ofTMSTo� TOWN OF BARNSTABLE Permit No. .....30005 BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash ................ NAN& ouv► HYANNIS,MASS.02601 Bond 1 CERTIFICATE OF USE AND OCCUPANCY Issued to S L S Trust Address lot #72 157 S.-Adler Lane, West Barnstable- USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS�AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. 10, Ap r i 1 14 $7 %%��-r �- -. 19................. ............. ........ r' 4� Building Inspector Assessors offioe Ost floor): Fti+eT Assessor's map. and lot number .... .f�........... /:....0U ""rev cp � �o off` Q Board"of Health Ord floor) Sewage' Permit number ................... ......... .........`.(........ .......... Z BAB39TULE, ! Engineering Department (3rd floor): ice- , �J S '° �1639• e� House 'number ................'. ......................./... .7..................... `; "�oyp�d` APPLICATIONS PROCESSED 8:30-9:30 A.M. and. 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUItDIHG INSPECTOR APPLICATION FOR PERMIT TO .. Build 1 1/2 ;Story ........ ................. :. ......................... ........................................... TYPE OF CONSTRUCTION ..........Wood...kxame.................................................................................................. August .1•i--••---- 19.86.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / Location LOt ...( 0.6 �/v /�/`� t. .................. .. .......... ProposedUse .......DWe l]-.?:ng................................................................................................................................................ Zoning District ........R.r- Fire District ...... �� Name of Owner ...SLS...Trust............................................Address i...Ryan n..i.s.;n...MA.................................................... Name of Builder .S................................Address '...T.IITA T).nh*-p...MA.................................................... Name of Architect ..NoxhsdP..i??s.i ......................Address ....Ya.?tY!auth. ? Yt.,:...M_A.<..................................... Number of Rooms .......5........................................................Foundation ...P.0u.re.d.....C_o ane..te.................................... Exterior ....Cedar...Shoxlg.�e.M...........................................Roofing .A..Gnh.al.t...........................................I Floors ....VA...T&G...PlvwPg.d...........................................Interior .SheP..tr..ock................. ...�... ............................ Heating ..G4.S........':............:..:...........:..:...:r.......:..:....,...........Plumbing p� r` a hc� r "I" ...... ........1. :..a.:r...............Oe:r...R....a......,..... ........ Fireplace ....Tr .CaO.P.ry................................ r ........... Approximate Cost .....6. 0.0.0............................r::................. Definitive Plan Approved by Planning Board _— �_ -----19_8b_ . Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 1� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name r �' ..... ..................................................... Construction Supervisor's License .......0.4.34.3..5............... S L-S TRUST A=151-004, \ 30005 1# Storyu No ................. Permit for ...................I................. __Single Family Dwelling Location Lot #72, 157 Sgddler Lane West Barnstable ............................................................................... Owner S L S Trust .................................................................. Type of Construction Frame ......................................... ............................................................................... Plot ............: .............. Lot ............................... Permit Granted ........October. 3...........19 86 Date of Inspection ....................................19 Date Completed ......................................19 y i a