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HomeMy WebLinkAbout0178 ARROWHEAD DRIVE 17b' Jr. Town of Barnstable tiilCl1ilg r , �. ,.,., ..�'', - .. -$ Post This.CardySo T.hatit,�s;Uisible,From,tFe Street-:Approved Plans;Must.be°Reta�ned onJ,ob and this Card Mustfibe Kept ; M'� �Posted�Until FinaI�InSpection Has Been Matle � �� � ;� � Wh"ere a Certificate: Occu,pancy is Requ�retl;sach Building shall Not be Oceu`pied until a Final lnspection:hasbeen made Permit ro-3,, Permit No. B-19-573 Applicant Name: Lloyd R Smith Vivint Solar LLC Approvals Date Issued: 03/11/2019 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 09/11/2019 Foundation: Location: -178 ARROWHEAD DRIVE, HYANNIS Map/Lot: 270 149 Zoning District: RB Sheathing: Contractor Na LANGILL Framing: 1me BRIEN Owner on Record: COELHO,ROSIMEIRE D � .� Contractor License'GCS,106675 Address: 88 FRANKLIN AVENUE 'g 2 HYANNIS,MA 02601 ., 3 EstProle jr, ct Cost: $`9,548.00 Chimney: x Description: Installation of roof mounted photovoltaic solar sys, s 4 34kw 14 Permit Free: $98.69 ' Insulation: Panels Fee Paid $98.69 Project Review_Req: ate Final: D 3/11/2019 Plumbing/Gas Rough Plumbing in iaa This permit shall be deemed abandoned and invalid unless the work authorized,by th�is permit is commenced within six months after issuan Final Plumbing: All work authorized by this permit shall conform to the approved application and ttie.'approved construction documents for wtiich'this permit has been granted. All construction,alterations and changes of use of any building and structures shall'e in compliance with the local zoning bylaws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or oadland shall be maintained open for public inspection for the entire duration of the work until the completion of the same. 3 Final Gas: i, The Certificate of Occupancy will not be issued until all applicable signatures by theEBwldmg and Fire Officials aresprovided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: �> Service: 1.Foundation or Footing b 2.Sheathing Inspection y Y {�•''° Rough: 3.All Fireplaces must be inspected at the throat level before firest fluelmmgs nstalleda g 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Pers ns tracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Buildingplans are to be available on site p Fire Department c All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: DIME Shed grAB . * TOWN OF BARNSTABLE Permit BARNLE MASS. iOTFD A Permit Number: Application Ref: 201404144 20141610 Issue Date: 06/26/14 Applicant: PENNA, RUTH A& JEROME Proposed Use: Accessory Structure Permit Type: SHEDS 200 SQ FT &UNDER Permit Fee $ 35.00 -Location 178 ARROWHEAD DRIVE Map Parcel 270149 µ Town HYANNIS Zoning District - RB ` Contractor PROPERTY OWNER Remarks INSTALL AN 8X10 SHED Owner: PENNA, RUTH A & JEROME Address: 63 ELLSWORTH AVENUE SPRINGFIELD, MA 01118-2102 .w Issued By: PF d ` POST THIS CARD SO THAT IS VISIBLE FROM THE STREET J., Town of Barnstable Regulatory Services TO _r�. Richard V.Scali,Interim Director a Pp r r ELAMSTABIA ` Building Division 7rri, RN 3 39. Tom Perry,Building Commissioner 1` ; 200 Main Street, Hyannis,MA 02601 www.town.bgrnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# a61/ 7l � FEE::$ SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less Location of shed(address) Village I } " Pan& Property owner's name Telephone number Size of Shed Map/Parcel*'y *igginature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? 0� If over 120 square feet,you must file with Old King's Highway Conservation Commission si nature is required) % . � g Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JfJRISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY-A PLOT PLAN ; Q46nns-shedreg REV:110413 T�. +r • . ... � t I. t 11 ] ' !, h.� ?.i�'••Et.t; - ..re f r,.. t ' Ito �_ .': • i�a ;i1+�itb 'irt. t:_. .s ar !�'b ! •�.. '�,., 7�.-, .. .. . ,s its .. : ii (. �• '�� tl�a �•/r: rf"} .�i.'!' :r FFr .Pi .f ..i` .. :T 1`. �i• P .,''C�. .�i PP 1� j +'.J:n" 1•`� �•,�� ! bt ,. ti. .v"� rfay'i�+fP, ya � � /'/^/ Y i ,.,,;Map f Page 1 of 1 Town of Barnstable Geographic Information System New sear Parcel Custom Map Abutters Map Size 13 ❑❑ Zoom out Y Q fl l 1111 tin ,,..L1FF11viewer JPG 270184 270151 p IBA - pL /f. 01� f 270101032 047 270081 2N*172 70150 175 72 270101033 N41 r 19� 2701a9 270101035 ' 270080 ®181 0178 - tl21 E A Turn map layers on/off by selecting check boxes below 0 270101 034 Town Boundaries 929 FA Road Names 270079 - �� ❑ Voter Precincts ' q 180 1701% 13�- 0186 ' © Map&Parcel Numbers © Parcels _ 270101D3B 473 ❑ FEMA Q3 Flood Zones(Current Maps) 270101037 Not for official flood hazard determ rq ® N 17 AE(100 yr flood) 2q'00798 270084 1 5 13 AO(100 yr Flood) Q 4 Feet .0 VE(100 yr flood w/wave action) 13 X500(500 yr flood) ❑ FEMA Preliminary May 2013 Zones(su Set scale 1"=44 July 19-9 6 Coastal v i MAP DISCLAIMER Expected Adoption Summer 2014 — —----�-- -- -- 0 AE-100 year flood Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GI 13 VE-Velocity Zone BarnstableMA v1.2.5122[Production] - 0 0.2%Annual Chance Flood ❑Open Water - - © Neighboring Towns to ❑ Water ❑ Streams ❑ Jetties El • ❑ Edge of Water ❑ Marsh e r ❑ Drainage Ditches Water Bodies ❑ Transportation © Major Road Centerlines http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=270149 6/17/2014 Engineering Dept. (3rd floor) Map Paicel ' l</9 Permit# House#.. l'7 t Date I sued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) T Fee- c Conservation Office(4th floor)(8:30-9:30/1:00=2:00) Planning Dept. (1st floor/School Admin. Bldg.) + ANCE W,"* ETBE Definitive Plan Approved by Planning Board 19 _ ��� AND TOWN OF�BARNSTABLENvIRON UL.AT Building Permit Application T®WN REGIONS Project Street Address 17 J (d,0110 y1/917P 7,, ,_ VillageA�yiv%s �, Owner �i 6,�./��rrGs� - Address s,�✓�1 _Telephone SG .7-//- 1,41 - , o Permit Request �e ArG9 Iq a-4 roy,- bQ� �ly7o c�'s. �l� �i�Oti f ` ���e �r�sr.�,ey J5�Vrr , First Floor square feet Second Floor �/�� square feet Construction Type w a r �- Estimated Project Cost $ !v'�7'70,d Zoning District s Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 9 yZ s Historic House ❑Yes 21C On Old King's Highway ❑Yes EJ1Ko Basement Type: U'Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) ,t/U�, Basement Unfinished Area(sq.ft) Number of Baths: Full: - Existing New Half: Existing New No.of Bedrooms: Existing a-, New Total Room Count(not including baths): Existing -7f _New First Floor Room Count `f Heat Type and Fuel: ❑Gas ErOil ❑Electric ❑Other Central Air ❑Yes ❑'ffo Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) ,/�L� Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use // Builder Information Name-_ �`/f, �� �,gt,l�f �,/ Telephone Number ?5;'�0- D Pad. Address _ (� 41 7ti� License# G 0 9 C �'S� Home Improvement Contractor# 1166 019 Worker's Compensation# L(-V1r4) 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 gjg4iJ�V-e/9 71 c5&S d SIGNATURE �ff DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY ♦.r, -_ .. - . v. ~. }� ` ., e' - y y •,i tl f .. � a' ... t, AT-, + y� j 4 - a ~r PERMIT NO, - DATE ISSUED' MAP/PARCEL NO. - ,_ � . ' .- +j .. .� '� •� ... ! # fig: � t 4a� , ADDRESS VILLAGE OWNER r 4 L i Q yea DATE OF INSPECTION: ° t FOUNDATION FRAME INSULATION FIREPLACE o _ {'� � '+ � ' . • ` t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH s> + FINAL GAS. ROUGH FINAL FINAL'BUILDING -�• - j. -DATE CLOSED OUT m ri r + " ASSOCIATION PLAN�'N0.! # } t The ""'own ®f Barnstable M .�' Department of Health Safety and Environmental Services BuiIding Division 367 Main Street,Hyannis MA 02601 Ralph Crosse.^ Office: 508=90-6227 BuiIding Co=—;, Fax: 508 790-6230 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernizntion. conversion, improvement, removal, demolition,et one bolt not maref than fourn to any dwelling nnr�oring to owner occupied building containing structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements QQ Type of Work: . �� . gtl -�h..) L_tLl R el�Est. Cost a?GN U !1� S� y' >y --- � ee - Address of Work: Owner's Name &;`4k Date of Permit Application: �/aa/ gam I hereby certify that: Registration is not required for the following renson(s): Work excluded by law _Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: PERMIT OR OWNERS PULLING Tim O CABLE HOME MORO MENTG WORK D WITH ORNOT HAVE CONTRACTORS FOR APPLI ACCESS TO THE ARBITRATION PROGRAM OR GuARANTl'FUND UNDER MGL c- 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: �D g� Ca tractor Name Registration No. Date TI�c• Cunrrrronll•calt/r of.1fassuchusern pepurtnrcrrt of ludusrrial.4ccidemts -:\1=ci {:_.� :,• 600 Waslurr,�ru,r Strcct Bt,srom Muss 0111 Workers' Compensation Insurance Affidavit `1(ililirint�nformatinn _ PicTs.e ORTNT. iM ^ me �✓��l. �,t4/1 /��J Inc-rinn ��o l7e`� L`-�• ` r I am a homeowner performing all wort:myself am a sole proprietor and have no one working, in an-, capacity I am an empiover providing wori;crs' compensation for m% employees working on this job. cnm inns• nnmc- !`L k7- rl�fL��✓. �• c�. 4 K2--vCr ��� -v .if Idrr<c 4 (D in<mrnnrr ^n. LlC/ 1 am a soic rroorie•or. general contractor, or homeowner(circle oee) and have hired the contractors listed below u•he ::z the �ollowin= woke.rn compensation polices: cmmn•rnA• n1mr• :ftirlrr«• cir nhnnc a• in<nrnnrr rn nMier# _ cnnrr.In% narnr atittrr«• rirs•• nitnnc ir' incmr-nrc rn nniic�•# �- _ AIMCII additional sheet if nrce_s.Iry - .,•L. ._... -�. •.<.YW - •� ..- _r.... ••.... -. -... ....r....._... -.. —c- F:uiurr to secure cus•crncc ns required under tectton-25A of I%IGL 152 can lead to the tmpostnon of criminal penalties 01*a line up to SI.S00.U0 anuiur uric scars' imprisonment:t. %s ell as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. 1 understand that- caps of this statemcut may be funs•arded to the OlTce of Investigations of the DIA for coverage verifteation. I do hercnr ccrriir untier the pains avid penalties ofperjurt•that the information provided above is true arrd correct. Date Si^n�turc G( _ Print name l l �� `" C��-c/ Phone~ �Rciai rue unh do not write in this area to be completed by tiny or town ofTciai f city or trigs n• permiUliccnsc ti mtsuilding Department ❑Licensing !ward [. t '- checi:if immediate response is required ❑Scicctmcn s Ufftcc 1. (�'iticalth Ucpartment c phone it• r-"Utltcr gander ncrson: Information and Instructions Mcssaclwsctts General Laws chapter 15: section _5 requires all employers to provide workers' ctunpensattt N etnnioYces. As quoted from the "1a��". an e•»rphomc is defined as every person in the scrVice 01 :tttt►tlicr undo- ::::. co►:tmact of hire, e%press or implied. oral or-written. An emplewer is defined as an individual. partnership. association, corporation or other local entity. or an}' lWo or the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employe-. or:1;c recciVer or tntstee of an individual , partnership. association or other lecal entity. employing employees. Hmvev- o"ITICr of a dweilin:u house having not more than three apartments and who resides therein. or the occupant of dwelling house of another Nvlio employs persons to do maintenance ;construction or repair work: on such dweliin or on the _rounds or 1iuildinL appurtenant thereto shall not because of such employment be deemed to be ::n e.- MG;_ banter !5? section :5 also states that eti•ery state or local licensing ngency shall withhold the issuance o; of a license or hermit to operate a business or to construct buildings in the conimunivealth Car uny icant i ho has not Produced acceptable evidence of compliance with the insurance covcmac required. .tau. ionnily. neither the commonwealth nor any of its political subdivisions shall enter into any contract for :11e pc::'6-ntz::ce of public work until acceptable evidence of compliance with the insurance requirements of this hc= aresc::tcd to the contracting authority. A i::�nts P!::::se +ill in the %vorkers' compensation affidavit completely, by checking the box that applies to your situatio,, c:'. suc::i\•in_ cotnt;anv names. address and phone numbers as all affidavits may be submitted to the Department of 'nc tri ti \Ccideats for confirmation of insurance coverage. Also be sure to siDa and date the afiidnvit• The should be returned to the city or town that the application for the permit or license is being requester. :he Departnte::t of industrial accidents. Should you have anv questions retarding the "law" or if you are rec�: .o ubt:::n a workcrs' compensation policy. ple=se =11 the Department at the number listed below. City or Towns Me_" �e Aurc that the -ffidavlt is complete and printed legibly. The Department has provided a space at the 5orc the for %•ou to fill out itt tite event the Office of Investigations has to contact you regarding the applicant. P be _ : :o fill in the permit/license number which will be used as a reference number. Tire affidavits may be -e:urne -ae DL=rtme:.t by mail or FAX unless other arrangements have been made. The Off:ce of IttN,esticstioils would like to thank you in advance for you cooperation and should you have any ques:: pierse do not hesitate to _give us a c::Il. The Department's address. teiepitone and fax number. TIte Commonwealth Of Massachusetts Department of Industrial Accidents 1wa r stt ; Office of investigations 600 Washington Street Boston. Ma. 02111 fax T: (617) 7/27-7,749 nhone =. `6 i'1 -:7-4900 e::j. 406. 409 or - . �..r Elie �o�rv�reoouuealllr c�,:�ac�zuu(tee%�i 4 r , w DEPARTMENT OF PUBLIC SAFETY c CONSTRUCTION,,SUPERVISOP LICENSE :. Nunber - Expires: Rest€ic_-y�,eclJ6 00 r B 11l-Y `CAUTHEN A 86 BETH{N HYANN I S, CIA 02601 - `eta E�H �oN �, 4 • �, �9. - " ANrn v ti' 2 � Town of Barnstable *Permit# D!/ Tl� RegulExpires 6 months from issue date atory Services Fe=� 9 1639. Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main,Street,Hyannis, MA 02601 FYI www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY 1 Not Valid without Red X-Press Imprint Map/parcel Number 00 Property Address 1 7 1� 17 f residential Value of Work / l' f 0 ® Minimum_fee of$35.00 for work under$6000.00 Owner's Name& Address Rt !f/ ,6_1"rPO r- 1 1 zyp Contractor's Name f !��; 16:--, O 1 Telephone Number Ire-d' ;FY0'- FIP6� Home Improvement Contractor License#(if applicable) G A�/'�� Construction Supervisor's License#(if applicable) C4 S 7,r ❑Workman's Compensation.Insurance Check one: X-PRESS PERMIT El am a sole proprietor ❑) am the Homeowner [✓]'I have Worker's Compensation Insurance Insurance Company Name 4 Z'1,eIC hf - ,Llf�r n(r �✓1 c,4-4, 7L5 6�/PPt�0F BARNSTABLE Workman's Comp. Policy.# Z U �t-3,9S-P7rj /P Copy of Insurance Compliance Certificate must accompany each permit: Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction:debris will be to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side #of doors replacement Windows/doors/sliders. U-Value. (maximum .44)#of windows / *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: e - v Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 f - The Commonwealth of Massachusetts ' Department of Industrial Accidents f Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t! n Please Print Legibly Name (Business/Organization/Individual): �y-0 Address: City/State/Zip: ,v IS d1A 0 9 W Phone #: 2 PG 3P4 — Are you an employer?theck the appropriate box: Type of project(required): 1.©I am a employer with 1 4. ❑ I am a general contractor and I employees(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 shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, employees and have workers' l. 9. ❑Building addition o workers' comp. - [N . insurance comp.insurance. P 5. 10. Electrical re required.]. ❑ We are a corporation and its ❑ pairs or additions 3.❑ I 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.]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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: L=idle tcw Policy#or Self-ins.Lic.#: Z y 3 - q 3- 9 P`2"V- !—/Li Expiration Date: «//�f% Job Site Address:_/. 7P City/State/Zip: A691_4� ,, yk/ C 2e rl 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 certify Under the pains aan�dpenalties ofperjury that the information provided above is true and correct. Si ature: '�� r ` <C�-� � Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: f ' oFTHEra,, Town of Barnstable Regulatory Services • BARNSTABLE, y MASS. Thomas F.Geiler,Director 1639. 1 i. A� 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 as Owner of the subject property hereby authorize e4 1-9htWr1Z/ to act on my behalf, in all matters relative to work authorized by this building permit application for. 7e Pe (Address of Job) Signature of Owner Date Print Name If Property Owner 1s applying for permit please complete the Homeowners License Exemption Form on the reverse side. QTORM&O WNERPERM ISSION r- SHE Town of Barnstable OF Tp� Regulatory Services + BARNSTABLE, +` Thomas F.Geiler,Director v MASS. �,,, �b39• Building Division rfOy Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: ,14A/A/ f number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department nunimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner .Approval of Building Official Note: Three-family dwellings containing 35,000 cubic.feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do.such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used-by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt NOTICE N NOTICE TO A a TO EMPLOYEES EMPLOYEES del The Commonwealth of Massachusetts . DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston,Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MA 02344-1450 ADDRESS OF INSURANCE COMPANY C -10) 10-01 -10 T 10-01 -11 EFFE DATESINC BA P 0 BOX 1990HYANNIS MA 02601 ao NAME OF INSURANCE AGENT ADDRESS PHONE# CAUTHEN, BILLY E . 86 BETH LANE o� HYANNIS o= MA 02601 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE o= 0 MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy-of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •� connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 003849 W20PIG02 Town of Barnstable *Permit#,_a�e5 RF.zpi ns 6 mon from issue date Reg Services - ,.•A,SS. , Fee 1639 Thomas F. Geller,Director 1 Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to wn.b arras tab l e.ma us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDENTIAL.ONLY Nof Yalid without Red X--Press Imprint Map/parcel Number � � 1 Property Address / 7,9 4,ezo 17 E/]Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address � irf1 i A 4^Al- .11)U Tele :ontractor'sName ��114 �q�,�{f�-rJ hone Number p �cfJO—AJ&—.3,P6 ; come Improvement Contractor License#(if applicabl U•rf :onstruction Supervisor's License#(if applicable) C s 'F C7? ]Workman's Compensation Insurance Check one: ❑ Iama sole proprietor -PRESS PERMIT i;I am the Homeowner have Worker's Compensation Insurance J U L _ 9 2011 3urance Company Name 2u11tCt/- *b�eiCz,.r1 �'.r�t✓/ .�� � L; ,;OWN OF BARNSTABLE. :)rkman's Comp. Policy# _�,- Z Z U3/ py of Insurance Compliance Certificate must accompany each permit. mit 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) Eff""Re-side ❑ Replacement Windows/doors/sliders, U-Value #of doors (maximum .44)#of windows *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. IATURE: FILESTORMS\building permit forms\EXPRESS.doe -d 070110 i '7 The Commonwealth ofMassachuseits Department oflndustrialAccidents Office of.1nve5tagatMns ti 1:?; 600 Washington Street Boston, ALL 02111 t 2 www.massgvv/riia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi icians/PIumbers Applicant Information Please Print LetTibly Name (Business/Organization/IndiviaLw): Address:_ Y-ra o-7 If 1-4.v City/State/Zip: 4,- A.y st/ 5 fi'M O d(b U I Phone #: EED1 an employer?Check the appropriate boa:' Type of project(required): a employer with / 4. ❑ I am a general contractor and I loyees (full and/or part-time). have hired the sub-contractors 6• EJ New construction a sole proprietor orpartner- listed on the attached sheet. 1 ?•. [J Remodeling andhave no employees These sub-contractors have 8. []-Demolition ing forme in any capacity. workers comp. insurance. 9. ❑Building additionworkers' comp. insurance 5. ❑ We are a corporation and itsired.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions lf.[No workers'camp. c. 152, §](4), and we have no 12.❑ Roof repairsance required] t employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box f 1 must also fill out the section below showing theirworkers'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 mast attached an additional sheet showing the name of the sub-contracton and their workers'comp,policy information. I arn.an anployer that isproviding workers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Ewa y .Policy#or Self-ins.Lic.#: Z Z tJ j� — t�3�' 7 ��l Expiation Date; Job Site Address: / T P? &zy lle�j,i�) -2 City/State/Zip; �l s ,,4 0 6(f J 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 flue up to$1,500.00 and/orr 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 maybe forwarded to the Office of'. Investigations of the DIA for.insurance coverage verification. I do her ehy c27, under the pains and penalties of perjury that the information provided above is true and correct. 3i ature: �`�v Date: )hone o 3, Official use only. Do not write in this area;to he completed by city or town offw&L" 'City or Town- - PermitlLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other J 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 Iegal 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 I52, §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()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." PP A licants . . 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 certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 m the event the Office of Investigations has to contact yod regarding the applicant Please be sure to fill in the pen-nit/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 hid icating current policy information(if necessary) and under"Job Site Address"the applicant should write"a I locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to.the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. . The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,-MA 021I I Tel. # 617-727-4900 ext 406 or 1-877-MA.SSAFE r— .9 47'7 '7'1'7 '7'7 e n NOTICE ' z NOTICE H W � F TO 9 O TO � 1 � .1 EMPLOYEES �� EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-7274900 — http://www.mass-gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21, 22&30,this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6ZZUB-4395P74-9-10) 10-01-10 TO 10-01-11 ._ POLICY NUMBER EFFECTIVE DATES MILLER MCCARTIN INC DBA P 0 BOX 1990 HYANNIS MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# CAUTHEN, BILLY E . 86 BETH LANE HYANNIS MA 02601 �= EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE o— MEDICAL TREATMENT ^^ The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 003840 W20P1G02 TO BE POSTED BY EMPLOYER Tom,; Town of Barnstable 0 Regulatory 5em"ces Thomas F. Gefler,Director Building Division Tom Perry,Building Commissioner 200 Main Strcct Hyam3is,MA 02601 wwwaawn.barnstab le.ma.us Office: 508-862-4 03 8 Fax: 508-790--6230 Property O:wner'Must Complete and Sigh This Section If Using A Builder as Owner'of the s ub.ect, ro l p PeY hereby aIlf-horize !'JI ��ei' (�,Qt f�¢fG�,r/ to act on beh�f in aII matters reItive to'wpLk autlioriwd by this binding permit appjicatiori for. 17 (•Add=ss of Job) S4„e of Owner , ate - Print Name , ,. • If Property P1,0perty Owner is applying for p ermit please c ora le te.the Homeowners License Exemption Form 0n :the reverse side. THE Town of Barnstable Replatory [Services Thomas F. Geiler,Director ;J6 Building Division Tom Petry,Building Commissioner 200 Maid-Stracf,_Ay.anpis,MA 02601 wwwJDwnab arnstab Ie_ma.us 015cc: 508-862-4038 Fax.- 508-790-5230 HOMEOWNER LICENSE Ex A=ON Please Print DATE: JOB LDCAnON: numbs street village -HOMEOWNER"*___ name borne phone f work phone# CL1R UENT),L L Q ADDRESS: city/town states rip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF E%dFgowI,�mR Person(s)who owns a parcel ofland on which hehhe resides or intends to reside, on which-tE=c is, or is intended to- be, a one or two-tamely dwelling, attached or dctarhed sfructures accessory to such use and/or fame structtacs. A person who constrr}cts mart than bne home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building OfEcW.on a form acceptable to 6c Building Official, that he/she shaD be responsible for all such wOIk performed'imderthe building permit: (Section 109.1.1) Tb,c tmdcrsigacd`homeowner"as=cs resp=srbrlity for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The imdersigned"homeowners'ccrtifics that.l e/she,understands the Town ofBamstable BuldingDepartment _ TTTriRT in p6ction proecdtn-cs an4 rez ir==h;and that he/she wall comply with said procedures and . rcz Ircmcnts. Signat E=of Hrmuawncr Approval ofBuilding,Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be rcgtrirad to comply with tha ' State Building Code Section 127.0 Construction Control. #OAMOWMMI8 EXEMPTIDN -The Code stairs that: 'Airy hrmreawoer pafommng work for which a building perrmt is mqui rd shall be ceumpt from the provisions f this s cd=.(Section l D9.1.1-I icrnciag of canstruetion Supervisors);provided that if the homccwncr engages a p aa(s)for his to do such pork,that such Hamaiwaer shall act as supervisor.,• k say homeowners wha use this.ex tics are unaware that they arc xmnTsng the respm=bnlitfes of a sups-visor(see Appendix Q ulcs&Regulations for Ljccas ,g Conshuctim Supervisers,Section 2.15) This lack ofawaralcss Men t=uln in serious I cul ien the homeowner hires unlic=-d moons. in this our Board==at eccd a -P� 1 ed P. : fie, Pro a i*+[t the ualieasse�pasoo as it would with s licensed pervisar. The ham mmer acting is Supayisor is uhi mtely responsible To cruvre that the bomccwncr is fully away=of his/hcresponsibtlides,many eorrmwnitics regsm-e,as part of the peirsut ippIiadon, i the homeow cr certify that bckhe understands the responsibilities of a Supervisor. On the last page of this issue is a,form currently used by —1 V__.__..__..--_A—A.A--....-'6.!I-.mod R--.._ ' Nlassachutietts Department of Public SafetA Board of Building Revelations and Standards Construction Supervisor License License: CS 9975 Restricted to: 00 � BILLY E CALITHEN , 86 BETH LN ; HYANNIS, MA 02601 Expiration: 8/13/2011 Commissioner Tr#: 2150 Office of 1A mer airs Viness egu AMP HOME IMPROVEMENT CONTRACTOR Registration: _116609 Type: Expiration: 6L29l2012 Individual EZ B E CAUTHEN BILLY CAUTHEN' #� 86 BETH LANE HYANNIS, MA 02601 ;, Undersecretary I 5 Massachusetts- Department of Public Safety Board of Building Re!ulations and Standards Construction Supervisor License License: CS 9975 Restricted to: 00 w� $'5 'BILLY E CALITHEN 86 BETH LN '� ` HYANNIS, MA 02601 Expiration:,8/13/2011 Commissioner Tr'#: 2150 a e ..License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation l ' 10 Park Plaza-Suite 5170 Boston,MA 02116 I i4 of valid.without signature ..