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HomeMy WebLinkAbout0389 WOODSIDE ROAD OxfordNO. 152 1/3 ORA ESS>ELTE 10% _ m o ... .. - r, .,,. ,.... _...v...._. ,. --,..rn_.^.v..�:~.�-• �--^.�.�.....-"W�'.!�!�"`�.�. .-`�• /,._.�. .fly-..Jwa .n.�--\ r.. ��� n Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee • a Z BARKSMULK i MASS A ► �e� Richard V.Scali,Interim Director `iV• O V Building Division Tom Perry,CBO,Building Commissioner hj 200 Main Street,Hyannis,MA 02601� ttAY 19 Z416 tvww.town.bamstable.ma.us o IV OF �8, ax 08-5 90-6230 Office: 508-862-4038 W EXPRESS PER UT APPLICATION - RESIDENTIAL"ONI,Y �� Not Valid without Red X-Press Imprint Map/parcel Number ZS L 0 3 Z II Property=Address ,�g-I mat) S,d e Ef Residential Value of Work S 5 i O Z fs Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address fA;(e,n Iyiao0 u k E(enemakeleyc. 3 ff�l �aod �o�e trap( D Z 6 Contractor's Name io tn,v r W /SOtd Telephone Number Qd/-ILA—�'8t�ld Home Improvement Contractor License#(if applicablea7__ Y__'/ Email: Construction Supervisor's License it(if applicable) 07S7,07 AWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name A0A)f tAq_ l/(JS M b&U Workman's Comp.Policy# W�iQa g'Q5 S 9 y- 4 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.35) `of w ows of d rs:___i ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspection tred. 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 required. SIGNATURE: QAWPFILESIFORMSIbuilding permit formslEXPRESS.doc Revised 061313 o Renewal -Agreement Document and Payment Terms byAndeml1t 46ji BatmwA By Mijan rv.bnov and Ruva kholay-A d teml Name:Soump.New 6haWdWotAs ILC 389 Ymdside 0 1. R1 036019,MA 91,73245,CY 00634 555, Lead finis 11231 West tarns0b`�-,MA 02600. 611ituffiff4i) Wive- MHOn Iv a anav nd,Elena Zheievo r,41111:610: ljqie. 6 Addfmaq-189,Woods Ide Rd, West MA 02668 �508�241-02.83- Number nniliFn QqnialL(Orn turual: Buy-0(s) lined Id inly and myer.6jt AjYOQj M li%Jfeljl'1s0 the.j5foCluctj wul/of&-mvicess New Eli g-laiLd Wljtdww LLC dAda Ralf.1wal By Andusten of S"thent New Eil III WEQF'1lfjJlke tYldb t1te 4efliks aikill condkioliks deserlbed hit t p r,S 6\4 r,0 f v.4 n jky 111)F Pm pt-1 t,1�1.11 rj N-P.C,At v t 1116 r M PQ F I-s W r pd F C.-r.,s o n d,C i�i i t I i t i f)i i s-0 f$a 1c, HIV V,, C-tl ii IL-2 Y!ng,,�q P rel g ru in (S CS P)i U-mi d Al e ivi (C-1 7& MA r-t it#t r 1�tnj _Td@;l _LCjjtL&Ct. a -, d. alild any Othk Lit ighCd t� witt, the terns or which me L&I "d. by L R P"�CN,2111 Infarl . - U.I I I I s Age,:eamt t,Mounu I UV to' I koyt 00.1.-w4 lwttln by CtOunce,(;:01 19COdivi Oil"Agm t`)�Rkly00 1kcrOy figlus to sip k�".F fripkab"ftroMewe Owe Comm-ror 615 110-al fill Wiwk tin.4.'f, - t. " P By 11 ping 411 kik Tiilpljob Amount: mW 46 A- Rionced lum In, lila*bv PO-movoij dwck,billk chea,Oollf cw.4,or Mih- Depimit. $2,514 Balanct-DUC: $24514 EnLirinted-start: EILWIZU'd C-WUPktUHk: Alubufm 10-12 Weeks 10.12 weeks Mutkod td Payment: Cred It Card 10*-,SCIMdult WSALl Itations 6 led'o,I) t6c dut or the Apod vontrim mrid woridatily on Financing the date I-PI %A- flelt Vve Otilitiple'le the tedinkal T wo w la'stAllAd tL td 416at -we Are providing ot this tiiffe L4 Oddy IM4 Csaimcitc,)*- .will 40ninturOute an offitchd date Nota: 28.00 cc-figoolit and 0 lite At I later datc. Puderand-ex4mmuc Weadlev ape 41le''fl3cm.Cornflion Cniij for Z50040 dapWtl paid, by &q)& Green Sky 2500,00 balanct due to be pOW by Gmon Sky BijyvO)agrees&id undemnit4b time t1lb tjlC-efttlft, botween the pufi.cq,rffLd fliAt HbeN tiliv tilf)m6f Unilamindiflo cloll ift-OdIrybitany o0f tlku livins ofthilgAgmenimi. No afternCtow rf)or devlad011is from this Agmer-unt k-411 bt�*JLJ - C - quo -;tn: Conquemor. Awyof(4 ho* ktj� WiC6,141.4 thi�ilp W4 kv I M 9 it ktr -itiml --p At 11 1 trig. -tor6mlitheq WO k! 0 ­k wyer(q fgad Aikemy-wi%tifiderswidi the terit! ifthiiii Cirwit,and hr-iq wirlwd a Complewdt 01gLud ond.dawd trap Celt-r i Ag-Wittent Incl i d!-- the mA attlated Nodw of C'atudlaflon,on 4 kc da re fmqt,"h�irib:dxwe,Amd wa�r-4.111Y hirkirlitied or UWYOL�taut46 CAVICA, t"M N- Apument. NOTICKJO OWN R! l ki not Apt Y-bil al-e-entlitlad [Olt Copy of the 6611trutt.1.1 tho 611C r* ("111, P OYM Of V- N A T ANY'.171 MENOT LATE R THAIN W.Micst-11 WT... P W-MCIRUM.WTUANUCT TIO HUMM DAY.AFTER THE DKIet OF T-H-Q-S T 0 C N' 1"jvarncts of CAwai '—W WN - ,!,S LATORP$EE,TO d FOR AN -WOR &Lin: (phAtkire ol Irl M-3 I I Chils Hutson Milen lvanev Von Zholeva Mitt Mimic Kim Namc-o(Salo Pcriuml Kim Mune { Southern New England Windows d.b.a Renewal by Andersen of S E i I Massachusetts-Department of Pubiit-Safety Board of Building Re_ui2bons and Standards i ;ons-ticdon Supervisor !icerse: j { M41I D DENN WON - T i 71LAFVM POND , Charlton KA 91W } J� s'afson � Co�rc-ussioTer i 1 Office of Consumer Affairs ind Business Regulation 10 Park Plaza-.Suite 5 170 Boston;Massachusetts 02116 Home Improvement Contractor Registration ReglsItation: irw is Type: Supplement Card F-Viration: g/19 MS SOUTHERN NEW ENGLAND WINDOWS LL DENNISON BRIAN 26 ALBION RD LINCOLN,RI 02865 Update Addren and return card.Mark reason for Cbao9e. r Address I::Renewal !�l Employment r!tut Card sa-Q 204+r �/.r't`Car.,Ac�4Ul+.cf'f•�a�uyapS�.•• *n1in'E':xpIrj!JIon: of Coammc AMIZZ&�a'i'Retulat= License or reg-Is>rotioa vntid for indMdul me only E QdPROYEMH�tbNTRALi'OR before the erptratiom data Iffaond return to* affi¢of Comm ter Affairs sad amines Aegototivo isV&otr. ,73245 TYGe 10 Park Pinm-Suite 5170 9t79=16 SuWlenerd-ard Bastuo,. A OZ116 SOUTHERN NEW ENGLAND WP=WS ULC. RENEWAL By ANDERSON DENNISON BRIAN a-� \ 2E ALBION RD a UNCOLN.RI C2865 lladeraereur+ ^fot valid without signature i The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: ]builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl-Y Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 phone#:401-228-9800 Are you an employer? Check the appropriate box: I am general contractor and I Type of project(required): 20+ 4_ . 1.0 I an a employer with ❑ a g employees (full and/or part-time).*. have hired the sub-contractogs 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 8. ❑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 l0-❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] c. 152, §1(4),and we have no Door Replacement employees. (Io workers' 13.0 Other p comp. insurance required.] *Any applicant thatchecks box#1 must also fill out the section below showing their workers compensation policy information- ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers-comp.policy number. ram an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lic.#:WC 928058352394 fI Expiration Date:8/21/2016 Job Site Address: 38.9 0o'oc�S.-de- 0 • City/State/Zip: W, 6eccnsla6te, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date): Failure to secure coverage as required under Section 25A-of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a-copy of this statement may be forwarded to the Office of Investigations of the DIA fo insurance coverage verification. I do hereby certify under th sins and penalties ofperjury that the information provided above is true and correct. t Si afore. Date: Phone#: 4012289800 Official use only. Do not write in this area,to be completed by city or town ofjiciaL City or Town: Permit/License# Issuing Authority(circle one): I.-Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i is SOUTNEW-01 SHETTYSHT DATE(MMIDDIYYYY) CERTtt°tCATE OF LIABILITY INSURANCE 8/19/2015 IS THIS CERTIFICATE IS ISSUED NATI MATTER OF VELY OR NEGATIVELY LYTAAAEND,LEXTEND OR ALTER THE COVERAGE AFFORDED BY THY AND CONFERS NO RIGHTS UPON THE CERTIFICATE E POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY IZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S),AUTHOR REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT d Iif the e Certificate f the policyr certain polic esNmzyAL INSURED, requRre an endorse the ment A statem nt on thies)must be endorse - s certificate does Nnot WAIVED, rights t the ho the terms an certificate holder in lieu of such endorsement{s). ccI-cT Willis Certificate Center PRODUCER PHONE 888 467-2378 Willis of New Jersey,Inc. A,G No.EXt:(877)945-7378 arc.No_( ) C/o 26 Century Blvd w�Dss:certicates@wiollis.com P.O.Box 305191 NAIc Nashville,TN 37234-5191 INSURERS AFFORDING COVERAGE INSURER A:Selective insurance Company of Southeast 39926 99 U INSURED INSURER B:OneBeacon Insurance Company 21970 19801 Southern New England Windows LLC INSURER c:Argonaut Insurance Company DIBIA Renewal by Andersen INSURER D: 26 Albion Road INSURER E ••ii. Lincoln,RI 02865 INSURER F REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: RESPECT TO WHICH THIS ED To INS ED ABOVE IN DICATED IS NOTTWIT THAT CE LISTED BELCHSTAI THE POLICIES OF INSURAN NDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTORU E0-1 HER DOCUMENT WITH FOR THE POLICY PERIOD CERTIFICA MAY BE CONDITIONS OR OF SUCH POLICIES.LIMITS SHOWN MAYHAOV BEEN REDUCED BY PAID CLAIMS.By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS _ POLICY EFF POLICY EXP LIMITS ILNSRA I TYPE OF INSURANCE NSD WVD POLICY NUMBER MMIOD MIDONYYY V S 1,000,000 EACH OCCURRENCE A COMMERCIAL GENERAL LIABILITY Ea bcplrrencel S 2029459 0811012015 03/1012016 = S 110,000 CLAIidS-MADE 00,090 ® PREMISES OCCUR I MED EXP(Any one person) I S i,000,400 PERSONAL-8 ADV INJURY S 404,000 GENERAL.AGGREGATE IS • GEN•L AGGREGATE LIMIT APPLIES PER I7 PRODUCTS-COMPoO ,000,0001 PAGG I S 3 POLICY®PEG LOC I I S OTHER 1 ,E�Fauid [SINGIJ LIMIT S 1,000,000, AUTOMOBILE LIABILITY S 2029459 08/1012015 08/10/2016 BODILY INJURY(P A X ANY Auroe;psson) �5 SCHEDULED I BODILY INJURY(Per accident)I S ALL OWNED AUTOS PROPERTY DAMAGE i S AUTOS AUTOS IPer accident` X HIRED AUTOS X AUTOS I I S I I EACH OCCURRENCE I S 5,400,000 X UMBRELLA LIAR OCCUR 5,000,000 S 2029 os/1o/2415 08/10/2016 AGGREGATE IS A EXCESS LIAR CLAIMS-MADE 459 ;5 I oeo RETENTIONS X ER rE WORKERS COMPENSATION I s 1,000,00 AND EMPLOYERS LIABILIT YIN p( 1 Y YN 000006IB028 08/2112015 08/2112016 E-L EACH ACCIDENT 1,000,000 B ANY PROPRIETORlPARTNER/EXECUTIVE NIA E L DISEASE-EA EMPLO 5 OFFICERIMEMBER EXCLUDED? I'` I 1,000,00 (Mandatory in NH) EJ_DISEASE-POUCv LIMrT I S I(yes,descMe under, DESCRIPTION OF OPERATIONS below C928458352394 08121/2015 08/21/2016 See Attached C Workers Compensation DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is required) CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, tLQ310E WILL BE DELIVERED IN ACCORDANCE:WITH THE POLICY PROVLd10NS. AUTHORLEDDREPRESENTATIVE A14 Evidence of Insurance p 1988-2014 ACORD CORPORATION. Ali rights reserved. ACORD 25(2014101} The ACORD name and logo are registered marks of ACORD OCR p "�L4 va BIKE TOWN OF BARNSTABLE BuIlding Application Ref: 200905476 * sARxsTASI.E, Issue Date: 11/20/09 Permit y MASS. �ArFG 3�A� Applicant: SWANSON, ANITA L Permit Number: B 20092279 Proposed Use: SINGLE FAMILY HOME Expiration Date: 05/20/10 Location 389 WOODSIDE ROAD Zoning District RF Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 152032 Permit Fee$ 25.00 Contractor PROPERTY OWNER Village WEST BARNSTABLE App Fee$ 50.00 License Num Est Construction Cost$ 1,000 Remarks ROVED PLANS UST BE RETAINED ON JOB AND CHANGE A 1/2 BATHROOM TO A FULL ONE CARD MUST KEPT POSTED UNTIL FINAL J INSPE ION HAS EN MADE. WHERE A RTIFI TE O CCUPANCY IS REQUIRED,SUCH Owner on Record: SWANSON, ANITA L ZINSIPEC ILZ NOT BE OCCUPIED UNTIL A FINAL Address: 389 WOODSIDE RD N S BEEN MADE. W BARNSTABLE,MA 02668Application Entered by: RM Building Pe t ue �v, THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALL R DEVDERTH ART THEREOF,EITHER TEMPORARILY OR PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECI ALLY PE EDILDING CODE,MUST BE APPROVED BY THE JURISDICTION. STREET ORALLY GRADES AS WELL AS DEPTH AND LOC IONOFP OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT REL E THE LICANT FR S OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS RE I FOR A CONTSTR CTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED A HE HROAT LE L BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE 0 LETED PRIO TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBE ADY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE O UPANCY. WHERE APPLICABLE,SEPARATE P MITS ARE D FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL HE INSPECTOR APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BE NUL OID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF- DATE THE PE IS ISSUED A OTEI ABOVE. PERSONS CONTR TING WIT UNREGIS RED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). O � ' O • �, .... .� , ,0 * , s try_A f'�t. BUILDING INSP N APPR ALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health ^ t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ./ Parcel , Application #/Xo 0 1 b J� Health Division Date Issued % ( 70 lU� Conservation Division Application Fee , Planning Dept. Permit Fee a Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project ,S,tr/eet Address 38 9 W J©D S I DE j2D u`�Village E5 I f�AP_fJ'_1_7A--b LE Owner M I LEN IVA N V V Address 3?9 (A10005i)t w Telephone 50 P Zy 42 3 Permit Request G h A &E A .fi.,4 Lr• gAL77*_10 0 A( TO A- FQ L L 0 N6 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1000, dQ Construction Type Lot Size 0, 9 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure S6 �Q,S Historic House: ❑Yes XNo On Old King's Highway: ❑Yes ❑ No Basement Type: f9 Full ❑ Crawl W'Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: .3 existing —new Total Room Count (not including baths): existing new First Floor Room Count 3 Heat Type and Fuel: ❑ Gas XOil ❑ Electric ❑ Other Central Air: ❑Yes XNo Fireplaces: Existing New Existing wood/coal stove: N Yes ❑ No Detached garage• 'existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: existing ❑ new size _Shed:Xexisting ❑ new size _ Other: 0 Zoning Board of Appeals Authorization ❑ .Appeal # Recorded ❑ ` " I „' N Commercial ❑Yes ❑ No If yes, site plan review# C.n Current Use Proposed Use r NO r-- rn APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name AlIL5W ZJAAto-V Telephone Number S'02 24/19223 Address 38`� I�lOoDSlp Ap License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �� D� -a 1 7 " ` r, FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. - ADDRESS VILLAGE OWNER .DATE OF INSPECTION: " t - - FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL :. GAS: ROUGH FINAL - FINAL BUILDING DATE CLOSED OUT a ASSOCIATION PLAN NO.,--:, L 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 Legibly CName_(Business/Organization/Individual): /"l/f�ItC-Il -TV p'/U/J t--CityLS_tate%Zip:--UL-6( Phone #: 3O Y Are you an employer? Check the appropriate.box: Type of project(required): C4. � I am a general contractor and I 1.El I am a employer with r� r . 6. ❑ New construction employees(full and/or part-time).* V have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any,capacity. employees and have workers' 9 ❑ Building addition [No workers' comp.insurance comp. insurance.$ p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions B I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi , der a pains and penalties of perjury that the information provided above is true and correct. Signature T D te: f 2 0 POfhone#: OfficialIc 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 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 required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit.. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia Town of Barnstable 0 Regulatory Services aASTABLF- Thomas F. Geiler,Director 1659. Building Division orEo Tom Perry,Building Commissioner 200 Maio-Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 HOMEOWNER LICENSE EXEMPTION L— i Please Print 2-0 11 9 CoB-l_ocArlorl: ��I (/ V(9 Q S l0C P-1� j/✓c�T ,13A2NS77�I�L� -----.Jnumba street villa'gc _ FioMP�OWNER /1/1(L t N 7 508 Z.IY( yr 2Y3 5'�� }i ' 00 y _�-narrie home phone# work_pbonc# CURRENT"MAILINGADDRESS: I/10001//fit !� cityhown state ap eodc The current exemption for"homeowners" was extended to include owner-occupied dwellinys of six units or less and to allow hQlneowners to engage an individual 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 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 bomeowner. Such %Qm*eowner"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) 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 minirnum inspec ' n procedures and requirements and that he/she will comply with said procedures and requirements. 5ignatinc 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 pernvt is required shall be cxcmpt from the provisions of this scction.(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homcownt:r engages a persons)for hire to do such worms that such Homeowner shall act as supervisor." Many hofncowners 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 bftm 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 ultirnatc)y responsible. To ensure that the homcowncir is fully aware of his/her resptmnbilitics,many communities require,&s part of the permit application, that the homcowmer certify that helshe 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/ccr-6ficat.ion for use in your community. Q:fornu:homw cmpt IRKS ` `own' of Barnstable ` Regulatory Services s.�xrrsrAst� • g, Thomas F_Geiler,Director fn196. '`I Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,MA 02601 1VWW.tow n.b arns tabl e.ma.u s Office: 508-862-4038 Fax: 508-790-6231 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) Signature of=er Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. gLp(zoo M v v 14-1 M NIr Y 51 n�lc LI U I NG kom bAL CONY f171LEr hA--r�f-9,DOM (RAC F) CLOS&T 5TA-( 2 (,A s E EN 7RA-N CE IVG S CO Al CALF ) t�oo/� i I I I P 0M I I 3 i J I • I P�ED2 �d M / I &- K 15T I NG w j-L,(Z o v T j�A Sam F-lV T G-E i FA-M��Y SASE i Jf I (�VL � P D�-0o M DEC c H-( M tlf& �c ( TCHEn/ VICE S! lv(G l,( V( A "o SNvw�2 S fiAl2CA-SE C-9MAWGG �Qypf?NEt��y� TOWN OF BARNSTABLE i BJSBSTAXFB i 039. oe BUILDING INSPECTOR / � aY a' --, APPLICATION FOR PERMIT TO ....."_/,'4ele l..a...w.u.. .� D✓`. ... I U � (aIP_l/<Gt TYPE OF CONSTRUCTION v.l . ...... .'e-..................... ..................... : 6.......19 7 TO THE INSPECTOR OF BUILDINGS:g,5; 9 The undersigned hereby applies for a permit according to' the following information: • Location o�.t?./..... e ...-..L/�lOu�tiJlcal ..��9. �. . . . .. . .. .. .......,sJ. .��f ProposedUse ...... /............................................................................................................................. ZoningDistrict ...................:....................................................Fire District .............................................................................. Name of Owner . JriVX31 t�.. .........Address (JCT Name of Builder ................................Address ......:........... �... Nameof Architect .......... ..........................I................Address .................................................................................... Number of Rooms ........... ..............................................Foundation .:1�4....... ....4�.r.......................................:....... Exterior .............w d..Q.. .....................................Roofing ........... ........................................... FloorsC ...... ..........................................Interior .................... ................................................................ Heating 0 L...................................:.....:........................................Plumbing 4..�.C1,�.1,.7(a�.......... Fireplace ......... ........... Qh.`e ..........................Approximate Cost .o �J.u..�. Definitive Plan Approved by Planning Board -----------____—-----------19______. O , �:Diagram of Lot and Building with Dimensions l_ ON 6 Z a - < = �m / SUBJECT TO APPROVAL OF BOARD OF HEALTH (n N }� 4 z 0 LU> LU Ct Cl 0 Lo o M cL LU O C� "N o (n Z �` y 0 Ix c0 V , � j- W`j Lu i z 0 c2/ :e W Q� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .................. .................s.�.� | `` . �vmuoaoo^ Robert ^ ` . I5078 - I � /2 atoz�/ No ..�..�.--.'Perm� ---for ..'----.'-^-` ---'' ' ! aiumIa family dwelling .| -'---`-~^-'-------------`----' ` ' � Woodside Road 7 Loco/on ------------.--^^-----' � / ( | West Barnstable . ` . ---^-------'~r`-^~---------''' � . - Robert Swanson Owner ----.--------_-'-'------ � � � ^ frame [ Type of Construction -------------- � | ' ----.~--.-..---,.--^----.----- �nn | Plot �� ................................^~~ ^~ ^'7-------- � � — ��y ST.AIM ' . x -_- of ..-r-^ .~. CompletedDate . � . PERMIT REFUSED . x ----''.-----.----------.. lV � . ----.---.-----.. . - . ----.-------- -.~---.-.---..-.----.,....------ ' � - ~^~---'-^-~----'^'^^~^^---`'-^-^'`--' . . ' .-----------.-.-_......--.-.--.-. \ | ^ . � , ^ ( Approved lQ ,--------------- ! . .............. / ' - -------'-----------~-.---..... i 1 .