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HomeMy WebLinkAbout0127 WHITE BIRCH WAY Ci 4 Oidbrde V No. i52 im ORA MADE M U.SA i$P ESSUR • s o • x 4' i K a �� � i � � y �� i I F a G I t t t' t t t�p k Town of Barnstable *Permit p Regulatory Services FFxpeieres6mon edate R&MSTABLE. I Thomas F.Geiler,Director -X0P. ,►a Building Division Tom Perry,CBO, Building Commissioner �(i �Y ZOO 200 Main Street,Hyannis,MA 02601 V 2, www.town.barnstable.ma.us Fax: 508-790- j0 SS PERMIT APPLICATION - RESIDENTIAL ONLY Not!Valid without Red X-Press Imprint Map/parcel Number Property Address ,11 4�; ' j 11 �Dl v Lou Residential Value of Work Zcc GD Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address S 1� ` Contractor's Nam �� ���� �'� Telephone Number 75 Home Improvement Contractor License#(if applicable)_ (`���1A�_) 'ti ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 'RI have Worker's Compensation Insurance Insurance Company Name `c�l_�� ��a1L Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value .__(maximum.44) *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. V SIGNATURE: Q:Forms:bui Idingperm its/express Revised 123107- a s ` ✓�xe 'tOo�n��uynu�ea`�c a�✓vGaaea�u�eeaa L. Board of Building Regulations and Standards License or registration validfor individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Reglstr41jpp{ 100740 One Ashburton Place Rm 1301 _pine ixoflz 23/2010 -tom _ _=() Boston,Ma. 02108 pplement Card CAPIZZI HOME,_ _F2T/: — - ll�ti tARY GUSTAFSOIy: 1645 Newton Rd. __..._. Cotuit, MA 02635 Administrator No vali itho• ' nature �Ias.�aeluisetts- l)�partm�ut of Public tial'el% -- -- — IFBoard of Buildin , Re!ulatit�tas and Stand:u'cl�' , Construction Supervisor License License: CS 74M �jt r Restricted to: Oq b;ft ai, ,t tr• :- GARY GU$TAFSON: t 8 SHORT Ay SANDWICH, MA02563 Expiration: 11/29/2010 Tr': 7755 Client#:47298 CAPIHOM FPRIDUER D- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYI) 12/30/08 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION y Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE F D NAIC# Capizzi Home Improvement, Inc. INSURER A: NGM Insurance Company Capizzi Enterprises,Inc. INSURER B: American Home Assurance 1645 Newtown Road INSURER C: Cotuit,MA 02635 INSURER D: 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 S POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY MPB1075H 06/08/08 06/08/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE EREMISESO RENTED(Ea occurroace) $SO OOO CLAIMS MADE a OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $2 00O OOO GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JE O- LOC PRODUCTS-COMP/OP AGG $2 000 000 A AUTOMOBILE LIABILITY M1 M28044 06/08/08 06/08/09 ANY AUTO COMBINED SINGLE LIMIT $SOO,000 (Ea accident) ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY $ X Drive Other Car _ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN ACC A EXCESS/UMBRELLA LIABILITY AGG $ CUB1076H � 06/08/08 06/08/09 EACH OCCURRENCE $5 000 000 X OCCUR �CLAIMS MADE AGGREGATE $5 OOO OOO DEDUCTIBLE X RETENTION $10000 $ B WORKERS COMPENSATION AND WC6957000 12/25/08 12/25/09 X WC sTATu- oTH- $ EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OQO OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT $SOO,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 200 Mai Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 00 n Street --IO_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S40650/M40647 KW © ACORD CORPORATION 1988 - CAPIZZI HOME UVIPROVEMENT INC. Page 7 of 7 SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, SHANNON FITZSIMMONS, OWN THE PROPERTY LOCATED AT 127 WHITE BIRCH WAY IN WEST BARNSTABLE, MASSACHUSETTS. 6- � I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: -;� - OWNER'S ADDRESS: 127 WHITE BIRCH WAY, WEST BARNSTABLE, MA 02668 OWNER'S TELEPHONE: 508-420-4416/774-238-0687 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: 4 +i to 'i:i.3 r— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations: 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Led ly Name(Business/Organization/Individual) Address: V�� ' City/State/Zip. Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 14 I am a employer with/Q11 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the stab-contractors 2:❑ I am a'sole proprietor or partner-• listed on the attached sheet 7. &e..liti emodeling ship and have no employees These sub-contractors have g.' on workingfor me in an capacity. employees and have workers' Y P tY• $ 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.❑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 ng employees.[No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have amployces,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, b. \b \Ml, w) Y— O LQNQQ — Policy#or Self-ins.Lic.#:W 0�02:_ n Expiration Date: ' Job Site Address: (�� a) \VI��V\ �9���7 City/State/Zip: 01 (' 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 crimuial penalties of a find 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 D�IA for insurance coverage verification. I do hereby certify der 14 ' ins.and penalties of perjury that the information provided above is true and correct Signature: Date: \\A 0 1 Phone# Official use only. Do not write in this area,to be completed by city or town offu:iaL .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 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." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoingg-engag in a)om--en rpns�e, —n =1aiZu- mgfihe leal-repre'sehTa-livet'UfT.dL-c;a'seri'eu�pio3�er, —:_- 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-contiactor(s)name(s),addresses)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-inenranr,e 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 (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit I . 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: i The C6mmonwealth of Massachusetts Departaaent of Industrial Accidents Office of lavestigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext-406 or 1-877-MASSAFE Revised 11-22-06 Fax# 617-727-7749 . www.mass_gov(dia TOWN OF BARNSTABLE =CERTIFICATE OF OCCUPANCY PARCEL ID 128 031 G90BASE ID 35417 ADDRESS 127 WHITE BIRCH WAY PHONE W BARNSTABLE ZIP - LOT 7 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT WB PERMIT 61661 DESCRIPTION SINGLE FAMILY DWELLING - BLDG PMT 08857 PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: De artment of Health Safety ARCHITECTS: P y and Environmental Services TOTAL FEES: BOND $_00 ptr THE CONSTRUCTION COSTS $.00 756 CERTIFICATE OF OCCUPANCY 1 PRIVATE F'* W * BARNMBM MASS. ��639• A�O� ED Ml►� BUILDIlNG' IVISION�) 1 BY DATE ISSUED' 06/07/2002 EXPIRATION DATE (f ti TOWN OF BARNSTABL'E ~� ` BUILDING PERMIT PARCEL ID 128 031 GEOBASE ID 35417 ADDRESS 127 WHITE BIRCH WAY PHONE W BARNSTABLE ZIP — LOT.' 7 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT WB PERMIT 8857 DESCRIPTION CONSTRUCT NEW DWELLING PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT CONTRACTORS: PROPERTY OWNER Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL- FEES: $312.30 Tt1E BOND CONSTRUCTION COSTS $135,000.00 101 SINGLE FAM HOME DETACHED 1 PRIVATE c P + * BARNSTABM + MASS. BUI DIVISION BY DATE ISSUED 07/13/1995 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED 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 OFTHIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. �mLo:l N nff���R k a I.-STJ RM g njej m&I d an g:* 'BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS X/10 2 2 c- �� ✓.,a�.u�C 2 3 1 HEATING ASPECTION APPROVALS ENGINEERING DEPARTMENT ? 1 O !� 2 n�/`4 D BOARD OF HEALTH II`OTHER:.✓,�.5�PSTA7 YF�4�C lY� SITE'PLAh REVIEW APPROVAL Tr WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. I I I ly i 1 � I[a r r _J A .OF1HE, � The Town of Barnstable NP �� BARNSTABLE. Department of Health Safety and Environmental Services 9 MASS. m 1639.PfE�MP 8'. Building Division 367 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection L� Location_` 2b� Permit Number Owner 1'-J (4l -P Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: / c 0 4 w w 1 UYL 40 l,ku � v ------------------------------ Please call: 508-862-4038 -for re-inspection. Inspected by ✓S �7i��s � t x Date I,�' L J ✓ U , AIs, gor's Office(1st ) Map ,2� Lot 0 / 19,V1 Permit# Conservation Office(4th�floor) ' -L-t. - _ 5��,i, Date Issued '/3 9� �$ Board of Health 3r4 floor)(8:30-9:30/1:00- 2:00) cf, Fee .�A-2, 36 V - ✓5ngineering Dept.(3rd floor) Hou4 1 (a? JiPW Manning Dept.(1st floor/School Admin.Bldg.) ®oq°�� 9�d t �, �� ap U� "` �-BARNSTABIE. Definitive Plan Approved by Planning Board A —7 19 �•�.� �0 �°'� �° b� TOWN OFt BARNT�BL ® � Building Permit Application Project Street Address T '7 - 2. wy Village !�. 3 A-r ./a 47 Owner o fit- �', w�� I T A dres �v�,c+� � l.�_ , J Telephone — Permit Reques s. • LLTotal 1 Story Area(include 1 story garages&decks) ��j square feet V/l otal 2 Story Area(total of 1st& 2nd stories) square feet ,/f-stimated Project Cost $ 1 /zoning District Flood Plain Water Protection Lot Size 0,00 Grandfathered ? Zoning Board of Appeals Authoriza ion Recorded Current Use Proposed Use Construction Type - Commercial Residential z Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure mac,(} Basement Type: Finished Historic House /�/� Unfinished Old King's Highway �Af �! Number of Baths R No.of Bedrooms �J Total Room Count(not including baths) 6 First Floor Heat Type and Fuel_C�/� Central Air Fireplaces ) Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds Other �E Builder Information i y ame a/5 , /e.,77— r 141�_4�5 Telephone Numbe d-A4- 1 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 SIGNA RE r` DATE BUILDIN ' DENIED FOR THE FOLLO , ING REASON(S) FOR OFFICIAL USE ONLY I PERMIT NO. #8857 DATE ISSUED July 13, 1995 ° MAP/PARCEL NO.,.' 128.031 a ADDRESS 127 White Birch Way VILLAGE W•Barnstable, MA 02668 OWNER Robert T. & Louise White - f DATE OF INSPECTION: ' FOUNDATION ' FRAME INSULATION nn FIREPLACE-,- ELECTRICAL: ROUGH FINAL I PLUMBING: <;ROUGH FINAL GAS: ROUGH', FINAL c FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i if, ,6 V 5' LOT 6 tt' �3 00 Q.% LOT 744,688 SF ` 1.03 ACRES I o�' r y •A ry LOT 8 l j I JOB # 93-013 CERTIFIED ' PL 0 T PLAN LOCATION : 127 WHITE BIRCH WAY W. BARNSTABLE, MA SCALE 1" 50' DATE 8-10-95 REFERENCE LOT 7 PP 406 PG 9 PREPARED FOR: I HEREBY CERTIFY THAT THE STRUCTURE R OBER T WHITE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. Of ft M�z � AIWE down cape engineering, ine. OJALA CIVIL ENGINEERS N0.2634�8 �Q LAND SURVEYORS — --� ---- ------------ fCis—it QJ use main st. parmouth, ma DATE REG. LAND SURVEY �oy� ialloso f TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. ., . DATE JOB. LOCATION /v� / �✓�Q �57/���2/�/�p-A,BZ,c -Number Street addres Section of down IIHOMEOWNER" /l�U•B _ NameHome phone PRESENT MAILING ADDRESS . 2, 4DL C4tyTtown State ip 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 to six family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered 'a homeowner. Such "homeowner"- shall submit to the Building Official on a form acCeptaable 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 com /with said procedures and requirements. HOMEOWNER'S SIGNATURE o APPROVAL OF BUILDING 0 IAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. I 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 a 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' Supea;visors, Section 2. 15) . This lack of iwarehes 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"dwner-'-"actin as supervisor is ultimately responsible. To ensure that the Home Owner. is fully aware `of his/her responsibil .ties,'',man communities require, ' as pact of the permit'' application, that the Home Owner certify that he/she understands the responsibilities of a. supervisor... . Oj 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. ;x t I l r Ej O-Y.- �D =W __QP.T'L ASPHALT ROOF. ol�, OT62 70 FELT : T �0 I LEI I ..tee AW30 AW31 - 1 ' F 20N'T.E L E VA.'TI Ot j 5CALE 4=1FT �ulM•GEMENT CAS' ' ,o FEE H 7-11. �i -- 1 QIGHT ZIOE ELEVATION — -- — -- --�— -- ,�� - - �--—•-' - _.__._.. ..5CALE 4-.1 FT. ----- ------'-•' J PLAN 8ZZ8 ZU�YGI�GtL'4 C&ftCC SHEET N4 Z OF S ,,FZHF_-ET - .A. i . .' Ze�z I - --•----- -_--�--_-� zees _ , IF M3 i �S C24 1f. SD�2 14 -- Doolz • u 1 eu�l G.cG P.T. REAR C-•LEVATION. \ =GAL/4''1 FT ` ALUM.LQUVE04F . 12 Iz ' Trt R Rp/aL-r..•' ASFNCIJT'- 9 .. ;:.�, -V Tay j. _ 6••75HEST5 i ;!�12KC r -L _�- j 1 As) 31 Li i I I DECI.AFZLA 0 WALK • LOCAL�oDE � i 9AZ COtJCI¢.FLOOr- 6u5-tomto 7Tt6L&lCSH Jtl DtaIf ,jet iLI�1 I U1JFIul=HEO _ 1• — , pA5EMEtJr 1 I— — — — g'C+co� I F I - GA2AGE ! Q , 1 UNCXCAVi�TC-D to-,1 2L-t ToIyEIL y CL (Zp.WEt-L —r�I wI •' CONC2:FLOOR I I I � to.c6 l0 10'Sr£EL ME:FI � _ _ - --_ - � � 1 0�L 1 FAMILY 1200M I -i OesVA2 T— �. lo.t 20 I Fil, e1i AW]I tO'COUCP. ALL- -O HI -I i— T •e a:p — --- 0 0 POQCH O 0 SA#JV FILL. I . — I ' 1 � --_:-F�i1NDA710W..E LW2 FLQQR'_P.LAN ' ' . I FT. 62"t 3.F:LIJ.A2a-A • . . . .. .. _-PCnN:822d . -Yi,(.z,G/LP.OGGLEK.C'.� • - ..:' - -- :5'HEET.:1J4.5 OF. .S-SHEETS 1 'SCALE %w 1 FT_' IF ! 2 Q-'o r V v7.:�• I•^. O I i cc A f1L �FR I I =cnl o r At14 col 10 }I. 11", ..pN 6 :h'IS ' Z fl A U tl n i I ^ s:a• ' p t j J ' r IW ! Iz • A 4 N. N O 0 r r > �' I I_' - I ! - �Aie® 0• i Z � 1 I XID N I I 0 . 7. tit k 0 ab `I b m X • � •;Z i I I III ! 14 11 74 I L I i ; o ' di i N �j0 p t �! Iw A'M In n E Y a n JN f �Flw.ccll_ ce�c i A I I it I � xr v o > fr• E. r O I UjjUI i c� z0-7 J 1 A � j � �•A IL�o • A xm 1 I 0 �. ---- a1 r r I ' —� —� RAIL on £ za ^^ �- 4•c I r•s 'z � � - I A gn I � 1 N Lr=L--� prop � J r N l' rr��o lu r- > '11�� - uM- III . 1 _• � .•�f V �\ / ^ —--I m �� 1•I•a ^� I I __ p> _ � - c I4 N I ; O r li d0 i OL IirT I: N ' u 1 nr•rn- Z ! f 'W _I Iq:p _•_•__• a I x Z (c I i p Q > _ > I c:o �. / h I� u I t V^ 75 i/ �mlo IO I db 0p 17— N i 8•c I I 1 ^i 'h • _Q I I I R I i " z N :lira 1 'p co e T � ii 10 •Itl E r �8 The Town of Barnstable NAB& �eE' Department of Health Safety and Environmental Services 1659.A� Building Division 367 Main Street,Hyannis MA 02601 Office: 508 790-6227 Ralph Crossen Fax: 508-775-3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME E"ROVEMENT 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-eadsting 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. r Type of Work: � � � Est.CogAJ— O 1TZ Address of Work /A Owner.Name:, Date of Permit Application: I hereby certifv that: Registration is not required for the follcming reason(s): Work excluded by law Job under S1,000 Building not owner-oocupied _ 0%ner 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 n I hereby apply for a permit as the agent of the owner: Date Contractor name Registration No. OR Date Owners name f 11•%0:'94 17:02 $`6177277122 DEPT IND ACCID ems., CortunonwPa&L o/ &Ijach"4etti ' ..L.)apartmerst o����ca[✓tfcccdsnti 600 WU.Yton sl., E James J.Campbell &Ion, „/aaeacL a to 02f f f Commissioner Workers' Compensation insurance Affidavit (aomsoelpam�a) " . with a principal place of Gbudmoss an (lily/StatelZEp) J do hereby certify under the pains and penalties of perjury, that: () I am an employer provid'mg workers' compensation coverage for my employees working on this job. Insurance Company Policy Number () l am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor o omeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: /Co ctor insurance Company/Policy Plumber Contractor Ansurance Comp ny/Policy NtmlbW J�P c99zo*- ontractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. I understand that a copy of t1his stste.-nent will be fo-r:arded to du Office of Investigations of cite DIA for coverage verification and that failure to Seto. cove-age as rec.,i ed under Section ZSA of MGL 152 can lead to the imposition of criminal penatties eotnisdn¢of a fine of up to S 1,500.00 and/or yes:s' imprisorm.ent as well as civil penalties in the tom:of a STOP WORK ORDER and a fine of S 100.00 a day against me- day this v L day of '�UL.. 191,5 Li enseelPermitte Building Department Licensing Board Selectmens Office Health Department TO VITRIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375 y 6 _ DATE(MM/SD/YY) AMOUVI CERTIFICATE-OF INSURANCE 06 29 95 [ PRODUCER ' „' "•THIS CERTIFICATE IS'ISSUED AS A MATTER OF INFORMATION McAlpine Insurance Agency ONLY. AND CONFERS NO RIGHTS UPON THE CERTIFICATE One Center Place _- --HOLDER. THIS CERTIFICATE DOES-NOT AMEND, EXTEND'OR 'ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1550 Route 28 COMPANIES AFFORDING COVERAGE Centerville, Ma. 02632 / co"PANY Camierce Insurance Canpany INSURED � COMPANY Travelers Insurance Canpany Bay Colony Concrete Forms 32 Third Ave. COMPANY , C Osterville,Ma. 02655 COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED.OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER -.DATE(MM/DD/YY) DATE(MM/DD/YY) - LIMITS GENERAL LIABILITY GENERAL AGGREGATE $1Mil. A COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE ® OCCUR SBP C38207 03/30/95 03/30/96 PERSONAL&ADV INJURY $ OWNER'S&CONT PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ 5 MED EXP(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM _ AGGREGATE $ OTHER THAN UMBRELLA FORM R $ WORKERS COMPENSATION AND STATUTORY LIMITS EMPLOYERS'LIABILITY EACH ACCIDENT $ 100,000. B 6EE-154K4250-95 03/31/95 3/31/96 THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ V%jv. OTHER A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Concrete 'foundations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Mr. Bob 'WhiteEli{RATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL White Birch Way �! DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE.SHALL IMPOSE NO OBLIGATION OR LIABILITY B3rnstable,fia. 02630 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25-S-(3/93) � ©ACORD CORPORATION 1993 r. r ` �,.,11TfJG��J` J' �Ot� lrOw.l �P�n►-1� �< , \.,. r I ! see �• i s.,� 34.5 a - - ,, - ;r�Ec.. co►1: . F e> � I � �� � III --------— --'—'— � `' � } CpTUM r.<,-:.,.�✓t�Gi C�0�-'1 `-a,.i O►.1��.1 �.strc: L Z�%� 11•\ -- � ao _go_ ; Za o 2 Mu�:iGtcat_l�ia,?t✓2 I'V POT-3 �Jare'J /y •/ (,,�. � / =✓�� i I c.,o 1_ t 3_.o I ( 4 C.Z.'S (N -'! ! - �� ,,,," / �. X ����,�• � ; S. PtPr— S4ALL. E145 MACS C'E Pc 1►.4 T}4 v� �` t z ��� ' I i h-1 o ATE►� �.!rJ� �.+�. �rl !i t2L�1�!F N��l_ l..�C%�. 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