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HomeMy WebLinkAbout0006 WIINIKAINEN ROAD JaaF.�YC(po�y a 1pj,Q,(il�p _2 UPC 12543 %g No. °OST.CON'J HASTINGS, MN . ° ƒ } / � \ ] . . d \ \ . \ d , \ § . . \ { M. COMMONWEALTH OF MA..S CHUS ITZ =E� DEl Aj;1TN E OF 1ND USTRIAL ACCIDFIIIS Goo WASHINGTON STTZ�= Ga-toDei° 130STON, bQ SSACHUSETTS 02111 -sames c^^':ss�one WORKERS COMPENSATION INSURANCE AFFIDAVIT (l;cc n scc/perm i ctcc) with a print; al placc of busincss/rtsidcncc at: W/Z��- (Ciry/st2tclzip) do hcrcby ccrtify, undcr the pains and pcnalacs of perjur)�% that: j ] i am an cmploycr providing ncc follo•.ving workcrs' compcnsation covcragc for my cmployccs,•orl:ing on this Job. Insurancc Company Policy Numbcr l J I am a solc proprictor and havc no onc working for mc. j J 1 am a solc proprictor,gcncrzl conuaaor or homcowncr (cirdc onc) and havc hircd the conttaaors listcd bcloµ• who havc the following workcrs'compcnsation insurancc polices: Namc of Contractor Insurancc Company/Policy Number Nzmc of Contraaor Insurance Company/Policy Numbcr Namc of Contraaor insurance Company/Poiicy:iurnb:r 0 1 am a homeowner performing all the work myself NO'I- Plcasc be awarc tbat while bcracowacrs who employ pers.00s to do raaiatca mcc,coottruaioo or repair wodc on a e—Cll;ng of not snort than three units in wbicb ut c bomcowncr also resides or on the grounds appumnaot tbcrcto arc not gcocraB)' considered to be employers undcr the Worl-cri Compeasat;on Act(GL C.152,seez 1(5)).appliutioa by a boraeowoer for a Iieeasc or pern;t nsy cvidcacc the Icgal surus of=cr_ploycr undcr the Wor)ccrs'Corapcosauon Act i unccrscanc that a copy of iris st:tcmcnt w;u ix forv.-ardcd to the Dcpa:.-mcnt of Industrial Acadcnu*Ofiicc of Insrancc for.covcntc verification and that failure to secure coverage a rcqu;rcd undcr Sccc;on 25A of MGL 152 can kad to the impomion of ujminal pcna c;cs consisdng of a fine of up to S)500.00 andfor irnprisonment of up to onc year and civil penalties in the form of:Stop work Ordcr and a I finc of S 100.00 a day against mc. /vo / / Signc i day of �/ 19 Liccnscc/P irtcc Licensor/Pcrmirzor Assessor's office(1st Floor):,-, ` rr 7 / Assessor's map and lot number!_/W: "� 3� Conservation(4th Floor): { `• Board of Health(3rd floor): I "i • Sewage Permit number ' ` # �� t ssa»rant. � rua Engineering Department or):(3rd flo s670 ON r, House number Definitive Plan Approved by Planning Board < 19' -APPLICATIONS PROCESSED•8:30 9:30 A.M.and 1-:00-2-00 P.M.only TOWN . OF BARNSTABLE 3 SUILDI_HGnn11 INSPECT0 I APPLICATIONIFORtPERMIT TO V O D I TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for as permit according o the following information• Location Proposed Use �- Zoning District Fire District Name of Owner C7_5 /w s t Address ROz �X O 1%-, C S(o'0 2 Name of Builder�t�Cl� w�/°`0��i� y 7 Address 6��Orj� Rio glQ 1 z/V 01>1 Name of Architect .Xeld me Z' Address Number of Rooms Foundation C Exterior Roofings64C Floors Q Interior Heating Plumbing Fireplace �— Approximate Cost • Area d Diagram of Lot and Building with Dimensions Fee Ito. I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable ing the above co ruction. c Name 11-1"55 A s6_ /1 0, I 0 co Construction Si ipervisor's License 0 0 0 (� �L— DONAGNY, FRANCES M. i No 36311 Permit For Re-Roof Single Family Dwelling �. Location 6 Wiinikainen Road r West Rarngtable , Owner Frances M. Donagny Type of Construction Frame ' Plot Lot " Permit Granted November 10, 9 9 3 f Date of Inspection: Frame 19 Insulation 19 Fireplace / "19 Date Completed 19 9. f y l I � " i COMMONWEALTH OF DEPARTMENT OF PUBLIC SAFETY j ONE ASHBORTON PLACE .� MASSACHUSETTS BOSTON,MA 02108 S t h4susaaedGRatem stgt,o lduN�ing Colo Isowrea for ro"s4tlov EXPIRATION DATE ci'=� LII-'ENS='E vlra�tt�tc®a,s, TF:. ;=;I_IF'E F;;V I I:ih CAUTION ' RESTRICTIONS EFFECTIVE DATE FOR PROTECTION AGAINST Ni 1NE LIC-NO. • t 6/;_;t i•/1.=�.=�_; 16 92 Li Li(-)99;=: THEFT, PUT RIGHT THUMBPRINT IN APPROPRIATE o DoBOX ON LICENSE. ' 1fi C)1./_.—::c.ca—'=�:=''�,�. VI CI _I WI TNT.I'-'::AINEN _ B TING O I F'I] FtliX / INCL FRATO 1 !PPIO10 OPR QNLV) W& ( 1 FEE: W ElAR 'TABLE I Lit_i. t_iti d r . �� ..•` _ . NnT VALID UNTIL SIGNEU BY LICENSEE J HEIGHT: STAMPED UE sE SAND OFFICIALLY E AI V y STAMPED.OR y ••: :? c.. DOB: SIGNATURE OF THE CJl,ihtl$$IONER tit ` $ ' THIS .e•w+.u+v�•� e �•1.-+...�� DOCUMENT MUST gE 4 � �"] ., ;•��\ AI`� •�\.t�=ti CARRIED ON THE PERSON OF r I • • L.T=' THE NO SIGNATURE OF LICENSEE D.P.S. J '011i THIS WHEN EN" �ril•�. _ ....:.• V ._ry.• �__^ �!1 GAGED THIS OCCUPATION. �. �.1 ER .�� f C ,�o 6 Town of Barnstable *Permit# Fxpir 6 months sue date s Regulatory Services Fe ' • anatasTnsra. • MAES'1639. Richard V.Scali,Director�0� Building Division � *OENMI �ti, Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 MAR 18 2016 www.town.barnstable.ma.us Office: 508-862-4038 9fq 0WWN 0 &P' 0E MI EXPRESS PERT APPLICATION - RESIDENTIAL ONLY Map/parcel Number,�/J� a S Not Valid without Red X-Press Imprint Property Address 6 W1 Lk"4,!.t ,W . err d (joIza)C-Q�. Residential Value of Work$ 3, ycvo �S'/ - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address t S 4 Q e7/ C,9.f a e77 Contractor's Name % Telephone Number So g- 3 4a - Home Improvement Contractor License#(if applicable) Email: CN,00e Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: P9 I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ® Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is require SIGNAT Q:\WPFILES\FORMS\building p a forms\EXPRESS.doc Revised 040215 I ?lie Comrtromavealfh of Massadiusetts Department ofIndushial Acciderds Offwe oflmaestigadens 600 Washiigion Street _ Boston,M 02111 wivi masmgov/ilia Workers' Compensation Insurance Affidavit:Buiilders/Contractors/EIectricianslPlumbers Applicant Infarmafian Please Print legibly Name{Busmesf0zganizz ionM dMdnal /e Q R k. /].4 k Rao Address: 4 00. d/Y c Citg/Stater �.g Rocs/�/g�e /V,- o g6.3 O Phone i Are you an employer?Check the appropriate box: T of project r 4. I am a general contractor and I Ply P ] (required): 1.❑ I am a employer with ❑ g 6. ❑New construction employees(fu11 andfor part-time).* have hired the sub-contractors 2.K I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sob-contractors have 8. ❑Demolition wo dng for me in any capacity. employees aad have wodws' 9. ❑Building addition [No tv-orlaers'comp.insurance Comp-rnsuranmi required-] 5. ❑ We are a corpomfion and its 10_®Electrical repairs or additions 3.❑ I am a homeoumer doing all work officers have exercised their I L❑Plumbing repairs or'additions myself[No workers'comp_ r of exemption per MGL 12_❑Roofrepairs immnanre required]Y c.152, §1(4h and we have no employees-[No workers' 13.❑Other comp.insurance required.) •Any appticsat that checks box PI tense also fill out the section below showing their worker'compensatian polies innrmafim- Homeowners Who submit this affidavit nuffcxt ing they&m dGmg all wal and then bim outside contractors rant subnut a new affidavit indicating such. rCasaactors that check this boa mast attached%a additiansl stet showing the nave of the sub-cantrwum.and state Whether or not those entities bav emplayen.If the.sub-caatramrshave employees,they=1stpmuide their workers'comp.policy number. lam are employer fliat is pm dirtg vt�orkers'congrerc i art insnratrce for my dnrpli4,ees. Below is flee poll y aced job site it formadom Insurance Company Name: Policy 4*'or Self-in s.1.ic_# Expiration Date: Job Site Address: CityfStatd27 p: Attach a copy of the workers'compensationpolicy 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$I,SOU 00 andlor one-year imprisonment,as well as cixil peaalties.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 Iavest gations of the DIA for insuramce coverage imrification_ I do hereby csrfFfj�riatd a priers and shies of Fedury thatthe irfornu firm ptmriiW above fs byre and correct Sio nture: Date: Phone ik G d 6 16 OfiTcial use.only. Do not write in this area,to be calnpleted by taty ortotrn o f j'iciat City or.own: PertmtMicense# Issuing Authority(tdncle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4_.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions ` Massachusetts G;Teamnd Laws chapter 152 requiies all employers to provide workers'compensation for their employees. Pm jaatto this stye,aa.m ployne is defined as.--every person in the service of another under any contract of bire, express or implied,oral or wrfthm" An erVloyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is a Joint enterprise,and mclndmg the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employers. However the owner of a dwelling horse having not more than three apadmeufs and who resides therein,or the occapzmt of the - dwelling house of another who employs persons to do mablEziance,construction or repair work on such dwelling house or on the grounds or building apputenazt thereto shaIl not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also stains that"every state or local licensing agency shall withhold the issaa.ace or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for rap applicant who has not produced acceptable evidence of compliance witlm the insurance"coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any coairart for the performance ofpubho work until acceptable evidence of compliance with the inw=cd: requirements:of this chapter have Been presented to the contracting amthoi*_" Applicants Please till out the workers'compensation affidavit completely,by checIdag the boxes that apply to your situation and,if necessary,supply sub-mntract0r(s)name(s), address(es)and phone ntrmber(s)along with their certificates) of hisirrarice. Limited Liability Companies(LLC)or Limited Liability Pmtaerships(LLP)with no employees other than the members or partners,are not rtquiled to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidayit maybe submitted to the Department of Industrial Accidents for conf rmation of insurance coverage. Also be sure to sign and date the affidavit- The affidavit should be retomed to the city or town that the application fur the permit or license is being requested,not the Department:of Industrial Accidents. Should you have any questions regarding the law or ifyou are regcdmd to obtain a workers' compensation policy,please call the Department at the number limed below, Self-ins.mred.companies should eater_tbeir self-insurance,license number on the appropriate line. City or Town OfFacials . Please be sdre that the affidavit is complete and primed legibly. The Department has provided a space at the bottom of the affidavit for you in fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the peuniUlicense nrnnber which will be used as a reference number. In addition, an applicant that must submit multiple pemit/liceuse applications in any given year,need only subunit one affidavit indiraf ing 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 mmimd by time city or town may be provided to the " applicant as proof that a valid affidavit is on file for future permits or licenses A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i..e. a dog license or permit to bum leaves etm;.)said person is NOT required to complete this affidavit The Office of Investigations would Imke to than you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Departmenfs address,telephone and fax number �e Comma wealth-of Massa.chusa is , Depai xment Gf 1adusirial Accidents Office of livegt�gatiow 600,washivGa Sizt B� �E1�11f Tf,,L 4 617-727-4900 Qxt 4-06 or I4M MASSAFE Fax 617-727-7M Revised 424-07 gQvfdia Town of Barnstable Regulatory Services UARNi MM&�' Richard V.Scali,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, iJ A djy w Gt/i" -217C !� , as Owner of the subject property hereby authorize T to act on my behalf, in all matters relative to work authorized by this building permit application for: �1/ ct i!J 'v CD• GUt J 4s/JJ�� (Address of Job) **Pool-fences and alarms are the responsibility of the applicant. Pools. v are not to be filled or utilized before fence is installed and all final ms.P5,ctions are performed and accepted. S* 'ature of Owner Signature of Applicant Print Name , : Print Name. r,:....:_...�.... eel s ATTENTION: MASSACHUSETTS LAW REQ IRhg- _ CARBON MONOXIDE DETECTORS 1 S�v� ALL RESIDENTIAL DWELLINGS. -e I � 7 IN ADDITION TO THE FIRE ALARM c.� INSPECTION,THE INSTALLATION OF . CO DETECTORS, IN ACCORDANCE WITH 527 CMR 31.00 WILL BE VERIFIED PRIOR TO SIGNING THE BUILDING PERMIT pl�i.,ls i f/C��� P S,o S/YK sMc')KE DETECTORS R.aVIEV1IED c. • �v�d ,ARN�T ALE Bi ILDING D ATE_ L(i�S ��N S✓9 �-¢ FI EPARTMEPIl DA E BOTH SIGNATURES ARE REQUIRED FOR PERMITTING r >� n v lTt P�DFIKE r, Town of Barnstable *Permit# F-rpires 6 monthsjrom issue dote O Regulatory Services Fee BARNSTABL& v� ib `0$ Thomas F. Geiler,Director �lFl)19. Building Division � Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 -vvww.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 1 ©� ` )Property Address 1g6)9r lyasl:lAwa;:5o_CIA�ekl i t 3 `� l Minimum:fee of 525.00 for work under S6000.00 Residential Value of Work Owner's Name& Address FAA/Yc i S I�L AAA Q Alm - 1 s. b 3`1, © 2. ly cs 1/�� PdEI ' i' Contractor's Name���� �l y � �1 /�l;'F� Telephone Number$ 3102 T O 1C� Home Improvement Contractor License#(if applicable)1/00 O Construction Supervisor's License# (if applicable) 7 ❑Workman's Compensation Insurance ,. -PRESS PERMIT Check one: e' ZlTlam a sole proprietor J U L 14 ?.010 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE, 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 Rep cement Windows/doors/sliders. Value �� (maximum .44)# of windows f *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is, required. SIGNATURE: Q:\1'YPFILES\F0FLY4S\building permit forms\EXPRESS.doc RP„;cPrt nonxno The Commonwealth of Massachusetts Department of IndustrialAccidenis Office of Investigations 600 TYashirrgton Street Ic Boston, MA 02111 sy www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �� Please Print Legibly Name (Business/Organization/[ndividual):� J a e ^ 1*1/�f N AddressFD C�p� . 41 /y� City/State/Zip 6 to D Phone #: 5 ?$ 1 D Are you an employer?Check the appropriate box: Type of project (required): 4. I am a general contractor and I 1.❑ I am a employer with � 6. ❑ New construction have hired the sub-contractors.. empl6yees'(full and/of'part-time). * _ _ 2-�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 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 l LE] Pltimbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t C. 152, §1(4), and we have no e0 L�C e employees. [No workers' 13•IJ Uther 6g_ comp.insurance requued.] ' 'Any applicant that checks box fl1 must also till out the section below showing their workcrs'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 jab 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 impositiba of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of In of the DIA for insurance coverage verification. I do hereby c under t pains and penalties ofperjury that the information provided above is trite and correct. Si nature: Date: 0 r� Phone# '�v$ 3 7?0 Official use only. Do not write in this area, to be completed by city or town official . I City or Town: Per # Issuing Authority (circle one): 1.Board or Health 2. Building Department 3. City/Town Clerk 4• Electrical Inspector 5.Plumbing Inspector j 6. Other Contact Person: Phone#: n for their Massachusetts General Laws chapter 152 requires all employers toinrlhe,servioce�of another ennderoany contract of hire, Pursuant to this statute, an el ployee is defined as "...every person express or implied, oral or written:" er An em loyer is defined as "an individual, partnership, association, rpo�aho liven or s of aedece deceased employergal entity, or any ;ootheore P of the foregoing engaged in ajoint enleipnse, and including the legalF rig employees ees. However the n or other legal entity, receiver or lriistee of an Indi dalnot morehhanalhroee1aparlments and who res des theroei'n, or the occupant el the owner of a dwelling house haying dwelling house of another who employs persons to do maintenance 'c sucth employment be deemed to be aneempl Ye se or on the grounds or building appurtenant theretair WOT o shall not beca L_ the MGL chapter 152, §25C(6)also slates that "every state orolo al liven ingildgngs fn the nq lcommonavealthsfor any r renewal of a license or permit to operate a business orre applicant who has not produced acceptable evidence othe omrnonwear compliance 'Ith nor any ofth the nts political gsubdausioas shall Additiorially,MG chapter 152, §25C(7) slates"Neither enter into any contract for the performance of public wo ont atiltiac acceptable ev]dence of compliance with the ins�uance requirements of this chapter have been presented to the o Applicants lease fill out.the workers' compensation affidavit completely, by checking t alongs [bat their apl erlificcale(s)y to your S, ,of ation and, if P ( ) g necessary,supply sub-contraetor(s) name(s), address(es)and phone numb in surance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not requoes have ired to carry workers'is affidavit maynsatlbe,submitted to the D partment oon insurance. If an LLC or LLP f Industrial employees,a policy is required. Be advised thate the Accidents for confirmation ofinsurance coverage. Also be sure to sign and d2t requesledYntot the Departmenhofld be returned to the city or [own that the application for the penn�t or tic g Industrial Accidents. Should you have any questions regarding the law or if ySelf_?nsOq are u ed compaquired to nies Should enter their compensation policy,please call the Department at the number listed below.. self-insurance license number on the appropriate line. City or Town Officials applicant. Please be sure that the affidavit is complete and printed of Irbives4gatihe onsh sr toncontact yoiaregarding the app a space at the bottom of the affidavit for you to fill out in the event the Of an applicant usePP Please be sure to fill in the.permit/license applications coons in anber which, y l be year, need only submibone affidavit indicating current that must,submit in permiUlicen pp (city policy information (if necessary)and under"Job Site Address" the narked by sthe city or townmay beprovided to the or P y town)•'?-A copy of the affidavit that has been officially stamped or m Yout cach applicant as proof that a valid affidavit is on file for future permits o en A or commerc FP trnoi related lonany busew iness al venlu e year. Where a home owner or citizen is obtaining a license or pei. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. (i.e. ueslions, The Office of lavestigalions would like to thank you in advance for your cooperation and should you have any q Please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax *1 f 17-727-7749 I OF THE Tp� Town of Barnstable Regulatory Services uxxsr{siF Thomas F. Geiler, Director MAS& 1639. ��� Building Division Tom Perry, Building Commissioner 200 Main Street;Hyannis,MA 02601 www.t own.b arnsta bi e.ma.us Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign Tlli.s Section if Us ing A Builder as Owner of the subject property "' 70— � to act on mybehalf, hereby authorize in all matters relative to work authorized by this building permit application for: (Address of]o ) 1 Signature t0wner ate PR19/Ve,I Print Name if Prope Owner is applying for permit please complete the Homeowners License Exemption Form on tbe. reverse side. Town of Barnstable P 0 . Regulatory Services Thomas F. Geiler,Director EAAN5TABL£, . h' Building Division s639• PTFD h`A�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 myw.town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 _ B OMEOWNER Ll CENSE EXEMPT]ON Please Print DATE: JOB LOCATION: village number street. "HOM EOYMER": ' home phone 4 work phone I1 name CURRENT MAILING ADDRESS: city/town stale zip code for"homeowners"was extended to include owner-occupied dwellings of six units or less and The current exemption 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 be/she shall be responsible for all such work-Performed under the building permit. (Section 109.1.1) omeowner"assumes responsibility for compliance with the State Building Co The undersigned "h de 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 12TO Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which i 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 J-lomcowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc assurrung the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often resuhs in serious problcrits,.particularly when the homeowner hires unlicensed persons. In this east,ou Would with a licensed r Board cannot proceed against the unlicensed person as it 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 m curpermi ntly used b 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. v�Iiaa•a•„taa aa, • la•i a,t Jlltl• • Board of Buildin�� Rc!�ul:Uiuns and Standards Office of`�o-nes nie'A?fair"Es bB' sine�eguta ion Construction Supervisor License HOME IMPROVEMENT CONTRACTOR License: CS 998 UR Registration: ,. 100053 Type: Restricted to: .00 Expiration: �6($2012 Individual VICTOR J WIINIKAINEN PO BOX 69 .WIINIKAINEN , ;1 W BARNSTABLE, MA 02668 Victor Wiinikainen�b 58 CAPE COD LN BARNSTABLE, MA 02630t= ;" Undersecretary Expiration: 9/29/2011 ('ununissiuncr Tr#: 2294 1 ; License,or�registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 - c N' lid without signature 7 Town of Barnstable *Permit# o?DOYh q� Expires 6 months from issue date . Regulatory Services Fee �S , d 6 X-PRESS PERMIT , Thomas F.Geiler,Director APR 2 9 2008 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF BARNSTABLE 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 NumberClT�s Property Address / �S71 4R/r"111-?4 � Ob Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address r6k cCS twx G!t 13�?C) &.C,961' 0 F ZAtze cf"V ACA 0, Contractor's Name 4 W;1 6 �'t" `V Telephone Number- Home Improvement Contractor License#(if applicable) f 0 g Cgnstruction Supervisor's License#(if applicable) 91 MI Workman's Compensation ance r+' Check one: ETI am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Ze-side /-q SL CAB� E ❑ 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: roperty Owner must sign Property Owner Letter of Permission. A cop of the Home Improvement Contractors License is required. SIGNATURE: — `//�" ` Q:Forms:expmtrg Revise061306 ' o£9z0 dNJ`3�9d1SN?!d9 4' ,�3ndaQ. NlAO�3dd4.85 ao3��3slulwp 10301A uaule�Ilul1M t f-31 N3N Id>11NIIM T 2i01�1� �[ eripl`n'ipu► ` 800ZI819� oil xf... A P �C ' Ply '�'� •,YJ 1, : ._S T , I.. �}3.`....��`��PBS ' lyi .. _ ...- .. .�. •. i f�y't 1 i . b s 3. Q 8 License or registra4ion valid for individul use only before the expirat►on date If found return to:, A-{ ' Board.of Building Regulations and Standards I... One Ashburton Place,Rm 1301 Boston,Ma.02108 i Not alid without signature The Commonwealth of Massachusetts Department of Industrial Accidents € Office of Investigations d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers"Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): . V, Address: �� �/� Ca 0� � 3d _ City/State/Zip:�3��11r°�!%��� + Phone.#: ©� e, 2, 7' 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 Z.- mployees(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 workingfor me in an capacity. employees and have workers' Y P tY• $. 9. (]Building addition [No workers' comp.insurance comp.insurance. 10. . Electrical repairs or additions required.] 5. We are a corporation and its ❑ P officers have exercised their 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself: [No workers' comp. right of exemption per MG 12.❑Roof repairs insurance required,] t c. 152, §1(4),and we have no employees. [No workers' .13.❑ Other.t�j�lf� comp. insurance required] . �`� CA3.4 4 r *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. 1C6ntractors that check this box must attached an additional sheet showing the name of the sub-contractars 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 isfhe policy and,job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date),.. Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of the DIA for ins nce coverage verification. I do hereby ce nde4" r the ns-a [ties of perjur}'that the information provided above is true and correct C � 1 Sienature: Date: _ Phone #: Official use only. Do not write in this area,tb be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: °FtNZE r Town of Barnstable Regulatory Services BAr1NSrABMASS,U%� Thomas F..Geiler,Director ��,r,�,�► Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,Na 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize yl i" V w to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) J =�r�!�ttre wn 6ate /V f (P Print Name i I i pFt 1p,,, Town of Barnstable *Permit# uzga P� tip Expires 6 monthsfrom issue date snxxsrnei.a Regulatory Services Fee tZ -06 MAW9cb T, Thomas F.Geiler,Director ED'A° a Building Division Tom Perry, Building Commissioner .PRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 - JUN 2 Q 2002 Fax: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIUDENTLATMABF BARNSTABLE Not Valid without Red X-Press Imprint Ap/parcel Number Address 6 W 1. :operty lYr; /! esidential Value of Work wner's Name&Address 1( ',0ed0,V S / I c /,:5 WX611 "54 ontractor'sName Telephone Number 1j gw.���>S/d ome Improvement Contractor License#(if applicable) �� 0 '� onstruction Supervisor's License#(if applicable) �0 U © ]Workman's Compensation Insurance Check one: 0-1 am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance surance Company Name orkman's Comp.Policy# ;rmit Request(check box) �� e-roof(stripping old shingles) All construction debris will be taken to X2n, ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) Other(specify) �� �� G 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. gnature ` Forms:expmtrg `vised121901