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Home My WebLink About0017 ARBETA ROAD �7 ��,��. �� z __ a �� IG��ii� G�� A ' ,� i I i I � i I i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map u Parcel" pp (� A lication Health Division Date Issued IZ `13 T Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 1-1 A( h,9� Village vt n i J c Owner(.e C.y v�{M � ,�' Address � — .Telephone Sy 3 (o Y_U $®ef Permit Request 0 PkAQ SR t'cm " CJOrirs �� Ci clr i2 p s 1c I P i� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay :Project.Valuation 1, a e Construction Type 0 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting dr9cume station. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) _ ' ' Q Age of Existing Structure Historic House: ❑Yes ❑ No On Old King Highway: ❑Yes; LJ No .T? =° Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) � r-- Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION - - - - (BUILDER OR HOMEOWNER) Name ti Telephone Number �� 3��i'0 �o Address 1-7 c�. License# Q 2Ca0 ( Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Dv c rcln SIGNATURE DATE 1 ��Z— ti. 1 �1, y FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED MAP/PARCEL NO. fi r f a ADDRESS VILLAGE OWNER DATE OF INSPECTION: r.' ,r z FRAME { '�;INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH- FINAL FINAL BUILDING ' 4 DATE CLOSED OUT ASSOCIATION:PLAN NO. } L� Hie Comrmompeakx of Massachusetts Departtertt a,f)Tirkstrur Accidents - Office of fil sttgatrons 600 T3'itshrrigton St`ta'eet -� A Boston,MA 02111 wn Pv.ynasmgoVdi a Workers' Campensafion Insurance Affidavit:Builders/❑onhuctors/E ecfriciansfNumbers Alrpliamt Infarmation Please Print Legibly Dame(BnsmeaslO�anizationitndividnaq: ��C1L �✓(•wt'�'`-1°'�-Q1 S Address:— /'7 Ir 434kcL CitylStat&Zip: W gLv S (J'1 kQQj Phone 4-7 O e-01 Are you an employer?Check the appropriate box.: Tylre of project(rewired)_ I-❑ I am a employer with' 4. ❑ I am a general contractor and I` employees(full and/or part-time). * have hired.the sub�ontractars 6- ❑New.construction. 2..❑ I am a sole proprietor or partner- listed on the attached sheet 7- slip and have no employees These sob-oontractors have g_ ❑Demolition d have wo�dcers'an employees wo>jcing forme in any capacity. 9. ❑Building addition workers. comp.insurance comp-nnsurari $ 19b" ed.] 5. ❑ Clue are a corporation and its 10-❑Electrical repairs or additions I am r hameawner cuing all ward officers have exercised their l I_❑Plumbing repairs or additions 3.9myself[No worloei8'camp- right of exemption per IVIGL 12_.❑Roof repairs insurance rewired.]T c.152,§1(4),and we have no employees-[No worlaers' 13_.❑Other comp.insurance require i_]- *Any appti taut that checks boa#1 mast also fill out the section below showing their woosew compensation policy information T Homeowners wha mbmit this affidanif inducting they are doing aII trod[and rhea hire outside contractors nmst submit a new affidavit ind"icsting mch- lCoutractors that check this bmc must attached as additional sheet showing the name of the sab-colors and state whether or not those entitks have employees. If the soh-conta tans bate employees,they must provide their workers'Comp.policy number I am an employer chef is prodding tt,orkers'compensation ir[srcrance for icy emp7nyetts. Below is Ste policy and job sits informadgm Insurance Company Name- Policy*V or Self ins.Lic_A�. FXpintionDate: Job Site Address: CityfState/2tp. Af#ach a Capy of the workers'compensation policy declaratiou page(shoiwing the policy number and expiration date). Failure to secure coverage as requireduuder Section.25A of MGL c. 152 can lead to the imposition ofrrirninal penalties of a fine up to$1,500.00 and/or one-year imprison,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Imestigations of the DIA for insa rar,ce coverage wrification. I do Hereby certify under the rdiis andpenatlies afpedary that the information pro-tided abmw is hue and.correct Si tie: Date_ Phone#- IyQj,'�3�p O Off Ecial use only. Do not write in this area,to be completed by city or town oficiaL City or Town: PermitUceuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing.Inspector 6.Other Contact Person: Phone 9- 6 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 IocaI 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 airy applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage._ Also be sure to sign and date the affidavit The affidavit should be retumed 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 affida-vit 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 tilled 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 hike 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 ofkvcswgafimis Goo Washington Street Boston=MA 02111 Tel.#617-727-4900 ext 406 or 1-9 MASWE Fax# 617-727-7749 Revised 4-24-07 - Wew.mass gov/dia l V VV 1t v i L..a Regulatory Services �i%E Richard V.Scali,Interim Director Building Division Tom Perry,Building Commissioner ="MMBM ` annis;MA 02601 M $' 200 Main Street, Hy �n�" www.tovcti.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 HOMEOWNER LICENSE EXEMPTION ' f Please Print DATE:' 112i/.1 X / 1 n 1 JOB LOCATION. i" street ` village number �w 1/✓iA i' I— work phone# ®�a "HOMEOWNER": home phone# Cl- name CURRENT MAILING ADDRESS: 5•-� l — state zip code city/town possess a license,provided that the owner acts as supervisor. 'The current exemption for'home_ owners"was extended to include owner-occupied dwellings of six units or less an to allow homeowners to engage an individual for hire who d nEFINITION OF HOMEOWNER who owns a parcel of land on which he/she resides or intends to reside,o farm strucmhuech tsheA person whore is,or is constructs�mo e-than one two- person(s) in family dwelling, attached or detached structures accessory to such use shall in a two-year period shall not be considered a homeowner. e foSucrall such work' erformed under der the lld Ogrmltl (Section homeY acceptable to the Building Official,that he/she shall be res onsib - 109.1.1) dersi ed"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, The un gn bylaws,rules and regulations. able Building Department minimum inspection The undersi gned ed"homeowner" certifies that he/she understands the Town of Barnst ; procedures and r cuts and that he/she will comply with said procedures and requirements. J Sign e f e r ' �I' Approval of Building Official Code Note: 'Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Section 127.0 Construction Control. HOMEOWNER'S MMPTION shall be exempt The Code states that: "Any homeowner performing of construction Supervi ork for which a building ors);provided that if the homeowner eowner shall.act as supervisor.." from the provisions of this section(Section 109.1.1-Licehsmg engages a person(s)for hire to do such work,that such Hot, es of a ervisor he responsibiliti Many hom eowners who.:use this exemption are unaware that they or assuming 2t15) This la k of a`vareness often . (see Appendix Q,Rules�&Regulations for Licensing Construction hires unlitSuper i. , suits in serious problems,.particularly when the homeowne licensed Supervisor The homeowner acting s Supervisor Board is t re proceed.against the unlicensed person as it would with a licen P ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, responsibilities* ties o a Supervisor. On the last mmunities require,as part of p age permit application,that the homeowner certify that he/she and of thi s issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use n your community.. Q:\wPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313. ,„ oFTME Town of Barnstable Regulatory Services w t L+xrrsrwa�g, MASS. � Richard V.Scali,Interim Director 1639. ♦0 o " 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, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:F0RMS:0WNERPERMISSI0NP00LS 10l13 . Q' N CC 37 Ll 1 � l 5 a 4 C-) 00 L1 F Q Jj N ISIAIO z C. W d z 1 'IJO IIGZ a cl� o s� F f M M Jtld 'Jig 110 I istyM 310 NMO1-