HomeMy WebLinkAbout0183 BARNSTABLE ROAD � � 3 ���-���� �i
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5 Town of Barnstable *Permit#f::>
fires 6 mon rom issue date
Regulatory Services ;I.; thsf ee
lAIuvsrnac E,
Mass. Richard V.Scali,Director&
Building Division _%S
Paul Roma,Building Commissioner at
200 Main Street,Hyannis MA 026d
www.town.barnstaX^. }�s 2Q��
Office: 508-862-4038 J�I� Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDEl W LY
�' o I Not Valid without Red X-Press Imprint
Map/parcel Number. `
A)J)
PromP r o e 'Address
CP �.
TV
❑Residential jQue of Work$_ Minimum fee of$35.00 for work under$6000.00
�Qwner's Name&Address"--�
--�I n
Ala kz�ezGr C N
Contractor's Name Telephone Number Cr`o� .(
140me Improvement Contractor License#(if applicable) Email: e/ Q
Construction Supervisor's License#(if applicable)
❑Workman'_ Compensation Insurance
C k one:
E�I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name F
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
`P� i5j t Request_(check l )
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows/doors/sliders.U-Value y�amum.32)#of windows
#of doors:
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Pro a Owner Letter of Permission.
copy of the Home Impro met ont tors License&Construction Supervisors License is
quired.
SI _TUR_ E
Q:\WPFILESTORMS\building rmit forms\EXPRESS.doc
01/25/17
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27m C'ommomreaWr-43&rsachusetts
Deparaneut af Ind strialAcciriats
— Office-00M gatEafrts
690 WashfiWon Skreet
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Bastan a AIA 0211I
• '` • ttaFVIM1LTl1t7SS�,�#7P�l1�iQ
wi orkere LVmpensatr=Insarance AffidAvit$uRdersdCanfractarsMecfi "ins hers
APPHCMtIUfMMI2ffiM Please Pkinf
a
C ifgf Patel i Phano '
Are you an employer?Qseckthe appropriate bay ' Tyke of project(rerllired}:
❑
I ant a general contractor and I ❑emlloyees(fish andfOr part-time)-* ❑�e,hired the MIP-coatcact zs 6. Newccns5�cixa�x
2.0 I am a sale proprietor orpartnes Tined on.the,attached sheet. "F..0 R.emodeHng
sh p and fiave no employees These sob-conftac4=hat ve 8-,Q Demolition.
w a forme in a employees andhave wadmrs'
rynany t3`- 9.;,❑Building mica .
IN4 UpdrOE& comp.Tta manse codup.ksuran{l—
r -I �. ❑ We are a rmporafimand its 1 0 Ele ical repairs or a des
I am a humm er doing an w� off cers have exercised fiv=ir: 1 L❑Plumbiagrepairs ar aa3rlitiams ,
rigbtf fi o esempou per MGL 7
� rapsel€No vas'caffiF- L.❑Roadrepairs ,
incntance ret;red]i w c.15Z§1(4�aadwe have no
employees.[NOwo&ers' L3_❑€7ther
comp.inslxcar m required.
•A.nyapg&�Cdatciae�sboa#1 Rho fMcmttbeswd=beLmr�ins&jrworlEWcomp-safinupeTV-giafa€ma`arm
fi Snaeoaraersvrbo submit dm rdB6mk they am alarm agvra&anttbnahim Outside cout 2cb=amct.submit anew srTdOZIt indicabea s W5-
�CaaaacQots tcheckrbFsbanmustatt ch sasddi6nnsl shed shoniagtbenaneoftheX&-<c �aadstiftwhadmarnotftseeal¢drsbxm
emp9vyees.Iftbes¢b-caatradoesbase®.Piafers,t�'mIIstgms'idetbeir urorlEea'lump.gaTi�awabeL '
I am Orr e�nplaFsr Sea[ispra�aririx�u�vrkets'contpensrdiart nzsrirancs yr err Pfe3�ees Scroov is t7tepo cy and jah zFte
Fnformatfau
Insurance Company Name: � F --
,.
Pnficy-,IkL or Self-i m l ic,¢ nDafe:
Job Tite Addre= CityfStawZip:
Attach a copy of the warlmrsa conxpensation.poli'crdecaratian page(showing the poficy,nanther and expiration dame).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the i mpositiaa of climiaal penalises of a
fine up to$1,54a OU awYor one-year impfis=ent,as wcA as dvil penalties is the farm of a STOP WORK ORDER and a ime
of up to$25A a Av against the violafor. Be ado' d that a copy of this statement.may be Rmarded to the Office of
Irrsrestigafa�ans of DIA i�susanc�coverage � .
I rl`o hereby nsrd ttrs errs per f re ar�ar matim�r-p-r-mz—rE-ed a �E carrect
_
Of aL rly. Do uat wr&r in Sds area,tit be cwnpfeted by city artan.-a niftict
Cityar'Iawu• _ PermitUcense
Issuing.Anthor€ty(cum one):
L Board of Health I Ruing Ilepartmeeat 3.citjgown Qerk 4 nechical Impector S.Plumbmg Inspector..
r
6:Other
Ca act'Person: ' MOIL,P.
-- 6
ormation and flastructions
M-asmcIm cft Geheaal Laws dmptcr M regnn-es an=Ploy=' Pie 'co33p=MtIon for fheir employees. �
PM:S�f3ig Istafntq,an eaqrkyae is defined as.`�—cMYPcm6n ia.$3.e seavice of anoacr MdM aay co,grad ofhfim.
express or implied,oral or wrab ."
An is defied as'-an indiinffiA par[nezabT,association,axnporafion or afh=Iegal M±±Y,Cr say two or MU=
of file foregoing=Pgea is aJoint ,and mclodmg idle legal xc:FwerrFaii of a deceased employrx,or fiie
receiver or frastee of an incfividnaL p ,association ar Otherlegal cadty,employes employe9- B:Owevcr the
owner of a dwell og l Dwa having not more Bran it rte apa dmeats and who resides herein,ar thD occopant ofthe-
dwelImg house of anon who esuploys pegsans t D do mahtenance,crost-�or repair wolk on such dwel mg haw"
urii=antth=t[)shannotbecaase ofsoch�ploymedbe deemedtn be an e�loyr 7
or on the mounds or b�7dmg agp
MGL daepter 152,§25C(6)also states that"every staff-or loeal se m�ageacy shall wIffihold ffie issuance ar
renewal of a Ticense or pert t to operate a hm-mess or to construct bmldiogs k the commonwealth for any
applicantwbo bas notprodtrced acceptable evidellm of comprance wn tIM 4r=ranM.coverage re�
Additionaiby MGL chapter 152,§25C(7)gfatns-Ncifizer the nor airy ofifs political snbEVI!5ions shall
ester mtn any contract far the performance ofpnblio work mmI acceptable evidf-nce of camplian cewifll a msm-ana:e.
regn CMfs ofaiS d1u2teahavebeen presea�:din the CQnhactnzg.�oilly."
A.ppHcaats
Please fa Out the wori='compensation affidavit completely,`by chug-aLo boxes ffiat apply to pour situation and,if
necessary,supply sub-contcacEnr(s)name(s), addresses)and phonemanb=Cs)alongwi hf cir cerftfrcatc`CS)of
Tsrrr-ice_ rz=tedLiabmjy Compmnes(MC)or LiomtedLiabiilifyParb=:sEps aj2)•withno employees otTierffimthe
members or partnea_4 are not rbquired to carry warke re campensatioa i i7ora nce. If an LLC or LLP does have
rmpIoyees,apolicyisrequirc& Be advised- atthisaffidayitmaybesuimftt:dtatlieDepaitmentofrndnstrial
Accidents for conrnMaiion of msurao ce coverage ATso be sure to sigh and date#dre affidavit The affidavit should ,
beet 3m d to-.e city or town tip the applic Hm foi fhe putt or license is being rrgws�ted,no t the D ep artme of
r
Ir asirial A_ccid�ts- Monldyon h M any gnMffons regarding the II or ifyon are regret ed to obtain a workeas'
compensation policy,please cza the Department at the m=Lbm listed below- Self-fimir'd.o03Mgsanies&hovld eatrr .their
self-msr¢ance Hcmse number on the appropriate line.
City or Town-Officials -
Please be sm�tiaat the aifrdavif is camp Iete axui prime IegrhIy. The Department has provided a space of ffie bottom
of tTie affidavkfor youth fill out inthe event the Office oflnycs-d aas has to contact yoaregardingam applicant
Please be sure to fill is the permit/license munber which.wM be used as a reface=mbe r. In addition,an applicant
that must suhmit multiple pcxmWHcense appli-cafions m aay give.year,need only sabmit ane affidavit indicating cusent
policy inforunation(ifnecessary)and under°Tob Ad es"tie applicant should wrhe-all locations in (CiY or
town)-"A copy of-(he-affidavitfdlathas been officiaIIy Stmxped or mardced by tb.D cry or town may be provided to fire
applicant as prooff3iat a valid affidavit is on file for ft1<nre`pezmifs or 1ieeuses A new a$davitmust be fiI1ed out each
year."niece a home owns or citizen is obtibaing a license or permit not related in any burin=or commercial vie
(if-.a dog license or permit to bom.Icavm etc-)said pmsm is NOT re gpitEd to aampleb flus affidavit
TbzOf 000fTnyc:sfgad wouldlflce-tothaakyotimadrm=for yo=coopmatim=Asbouldyon.haveanyquestions,
please do noth.esif it to give us a call
The Deparfinezifs ate,tnlepl=and tfax number
B.evised4-24-07
I
Town of Barnstable
Regulatory Services
Richard V.Scali,Director
4 Building Division
s�vsrest.E. : Paul Roma,Building Commissioner
5 �� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
JOB LOCATION:__ .( vi age
- t
oMEowNE—
�.�
name home p e# work phone#
- r (sz
CURRENT h A I:NG ADDRESS:
I
iry wn 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 hermit. (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 ders' ed"homeown a th she understands the Town of Barnstable Building Department minimum inspection_
pro dare d requir en / will comply with said procedures and requirements.
r Homeown
t proval-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
this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in
your community.
Q:IWPFILESTORWbuilding permit formsTYPRES$.doc
06/20/16
Town of Barnstable
Regulatory Services
s MAW ' Richard V. Scab,Director.
Building Division.
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
wwwAown.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
r ,as Owner of the subject property
hereby authorize to act on.my behalf
in all matters relative to work authorized by this building peat application for.
(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
QYORMS:OWNERPERMISSIONPOOL S
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Official Website of The Town of Barnstable - Property Lookup Page 1 of 4
Select Language
Assessing Division Property Lookup Results - 2016
367 Main Street,Hyannis,MA.02601
<<BACK TO SEARCH<< APrint Friendly
Owner Information-Map/Block/Lot:310/153/-Use Code:1010
Owner
Owner Name as of A15 IE MAE Map/Block/Lot GIS MAPS
1/1115 49 WEST HYANNISPORT 10/153/ VJ
CIRCLE Property Address
183 BARNSTABLE ROAD l
F YANNi .02601
Co-Owner N me %DALEY,JOHN F. o�
Vi age:Hyannis
own Sewer At Address:Yes
GIS Zoning Value:HG
Assessed Values 2016-Map/Block/Lot:31011531-Use Code:1010,
2016 Appraised Value2016 Assessed Value Past Comparisons CC �/
Building $76,300 $76,300 Year Total Assessed \
Value, Value
Extra $26,000 $26,000 - 2015-$185,400 �
Features: 2014-$185,500
2013-$185,600
Outbuildings:$6,700 $6,700 2012-$183,400 a
2011-$197,860"
Land Value: $67,100 $67,100 t/
2010-$231,200
2009-$300,200
2008-$289,200
2016 Totals $176,100 $176,100 2007-$288,600
Tax Information 2016-Map/Block/Lot:310 1 153/-Use Code:1010 bG/
Taxes
Hyannis FD Tax $426.16 ( '► `�'J
{ (Residential) _Ie�,�,
'Fiscal Year 2016 TAX RATES HERE
Community Preservation $49.18 4'-S Cat P !0-4-
Act Tax
Town Tax(Residential) $
1,639.49
2,114.83
Sales History-Map/Block/Lot:310/153/-Use Code:1010
http://www.townofbamstable.us/Assessing/propertydisplayscreen 16.asp?ap=0&searchpar... 11/15/2016.
Official Website of The Town of Barnstable -Property Lookup Page 2 of 4
_..._ __..._.__._,._.........._.........__..__..____.._...._._......._.....__.____..._............._______....___.__.._______________________.___._..._ ..._ .
History:
Owner: Sale Date Book/Page: Sale Price:
FANNIE MAE 2015-07-09 29000/231 $173000
KNOBLAUCH,ANNALIESE 1980-01-01 3160/21 $0
DALEY,JOHN F 2016-08-12 29858/151 $155000
Photos 310/1531-Use Code:1010
There are not any photos for this parcel
Sketches-Map/Block/Lot:310 I'll 53/-Use Code:1010
t
AsBuilt Card N/A
Constructions Details-Map/Block/Lot:310/153/-Use Code:1010
Building Details Land,
Building value $76,300 Bedrooms 5 Bedrooms USE CODE 1010
Replacement Cost $127,238 Bathrooms 1 Full-0 Half Lot Size(Acres) 0.13
Model Residential Total Rooms 7 Rooms Appraised $67,100
Value
Style' Conventional Heat Fuel Oil _ Assessed Value $
c 67,100
Grade Average Heat Type Hot Water
Year Built 1930 AC Type None
Effective 40 Interior Floors Hardwood
depreciation
Stories Interior Walls Drywall
Living Area sq/ft 1,167 Exterior Walls Wood Shingle
Gross Area sglft 3,283 Roof Gable/Hip
Structure
Roof Cover Asph/F
GIs/Crop
Outbuildings&Extra Features-Map/Block/Lot:3101153/-Use Code:1010
Code Description Units/SQ ft Appraised Value Assessed Value
http://www.townofbamstable.us/Assessing/propertydisplayscreen 16.asp?ap=0&searchpar... 11/15/2016
Official Website of The Town of Barnstable - Property Lookup Page 3 of 4
FEP Enclosed porch- 208 $7,200 $7,200
roof,ceiling
FPL1 Fireplace 1 story 1 $2,700 $2,700
FGR2 Garage-Avg-Wd 280 $6,700 $6,700
Shingle
BMT Basement- 936 $16,100 $16,100
Unfinished
Sketch Legend
_......................._............................._........_........................................................__._............................._...............................:....__......_..................,.............:.............................................................................
....._...
Property Sketch Legend
B2N Bam-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only
BAS First Floor,Living Area FTS Third Story Living Area(Finished) SOL Solarium
BMT. Basement Area(Unfinished)FUS Second Story Living Area SPE Pool Enclosure
(Finished) .
BRN Barn GAR Garage TOS Three Quarters Story(Finished)
CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished)
CLP Loading Platform GRN Greenhouse UHS Half.Story(Unfinished)
FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished)
FCP Carport KEN Kennel UTQ Three Quarters Story
(Unfinished)
FEP Enclosed Porch MZ1 Mezzanine,Unfinished UUA Unfinished Utility Attic
FHS Half Story(Finished) PRG Pergola UUS Full Upper 2nd Story
(Unfinished)
FOP Open or Screened in Porch PRT Portico WDK Wood Deck
PTO Patio
Print Friendly
Contact
Director of Assessing
Jeffrey Rudziak
E
�P 508-862-4022
f F 50&862-4722
I
'8:30a.m.to 4:30p.m.
'Helpful Links to
` !Downloads
Abatements
SALES LISTINGS
Barnstable FD
Residential
http://www.townofbamstable.us/Assessing/propertydisplaysoreen 16.asp?ap=O&searchpar... 11/15/2016
Official Website of The Town of Barnstable - Property Lookup , Page 4 of 4
C.O.M.M FD Residential
Commercial-Industrial-
Mixed Use
Cotuit FD Residential
Hyannis FD Residential
Townwide Condominium
W.Barnstable FD
Residential
lu <'
Department of Revenue
` i
_ 4
Exemptions
Parcel Consolidation
Questions about values
Town Tax Rates
Town Land Use Codes
;Helpful Maps
All Town Maps
Flood Insurance Maps
Property Maps
FY16 Tax Maps
Owned and Operated by The Town of Barnstable-Information Technology
Home I Departments&Services I Boards&Committees I Residents&Visitors I Doing Business Town
Calendar I Phone Directory I Employment I Email Town Hall
•
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http://www.townofbamstable.us/Assessing/propertydisplayscreenl6.asp.ap 0&searehpar... 11/15/2016
Gallant, Therese
From: Gallant, Therese[gallantt@barnstablepolice.com]
Sent: Tuesday, November 15, 2016 8:07 AM
To: Gallant, Therese
Subject: FW: 179 Barnstable Rd
-----Original Message-----
From: St. Onge, Nathan
Sent: Monday, November 14, 2016 9:47 AM
To: Gallant, Therese
Subject: 179 Barnstable Rd
I meant to email you his yesterday but we had an unarmed robbery and some drug activity at
179 Barnstable Rd. It's a house right across from Cromwell courts down the driveway in
the back.
Michael O'Dea told us it is his grandfathers property and he lets them stay there for free
in exchange for " working on the house.
When we entered the house it is in complete construction and is a total "disaster. They
sleep in the rooms with just a mattress on the floor and I'm unsure if there is running
water or heat. I'm. sure it is not up to fire code. The women who lives next door said
there are people in and and out all day and I suspect they are using it as a trap house
for drugs. Not sure if there is anything you could do or if it was on your radar.
Feel free to call me 508-221-8116 with any questions or email me. I just wanted to give
you a heads up.
Thanks
Ptl Nathan St.Onge
Barnstable Police Department
Sent from my iPhone
Confidentiality Notice I This email message, including any ,attachments, is for the sole
use of the intended recipient(s) and may contain confidential, proprietary, legally
privileged and/or CORI information. Any unauthorized review, use, disclosure or
distribution is prohibited. If you are not the intended recipient or have received this
email in error, immediately contact the sender by reply e-mail and destroy all copies of
the original message. This email message may be monitored by the Barnstable Police
Department.
1
..i
Ettigineering Dept.(3rd floor) Map ParcelPermit#
r w House# 3C Date Issued ► �271`I 6
d of Health(3rd floor)(8:15 -9:30/�1:00-4 ) - Fee ,��,cyConservation 0 1 floor)(8:30- 1:00-2:00)
Planning Dept. (1st floo ool Bldg.) �T11E
yoject
n Approved by Planning Board �19
BARNSTABLE. °
�FD MAC a,�
059.
TOWN OF BARNSTABLE
Building Permit Application
et Address
Village �^ /
Owner �^G¢ N2h A�'r'1) Address IJ4V?�-Cx-�6
Telephone �f 7 j
Permit Request s /N ®cam / ,A 0,J .9AV11 011Je C-¢/
3N
First Floor square feet Second Floor square feet
Construction Type )r,4 4V—
Estimated Project Cost $ ;!M-0 a
( Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Q 4 Historic House ❑Yes p'<o On Old King's Highway ❑Yes f3l 1vo
Basement Type: ❑Full ❑Crawl ❑Walkout Other �yI
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No. 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
jGarage: ❑Detached(size) 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
Q / r `Builder Information /
Names J-JLM� cf , Telephone Number
Address 9�3 /� 5� License# a(o S Q Y q
y ,
�J � f �7 I Home Improvement Contractor#
((��
c�f)-JI)k `14-(Ato U4 � � 1 1 Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE 1 DATE
BUILDING PERMIT DENIED 6R THE FOLLOWING REASON(S)
•
FOR OFFICIAL USE ONLY
i 4
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
1
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL'BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
r
g
J .�"ene th'AO`rig;
7
ye `r k e s rS�3 �y �er��ts nik �z
4'
fi 'x'pSrg4 ,t4
NOME�IMPROVEMENT,CONTRACTOR A' _,
x r Re91s Tation :117515 ,£ r
Type a ARIVATE CORPORATION r 4
Expirationx:10/13%98 s y'
PAUL DAVIS SYST OF_CAPE COD '
:4nw;DAVID J:,ROME : n:
�CQ7j� �R 421/, 973 Main Street
+ ADMINISTRATOR ,�
k, SOUTH 02664
YARMOUTNr MA n `"
r -
The Commonwealth of Alassachusetts
Deparmient of Industrial Accidents
F Office Of inYestigations
\ `,:. Ih;
^\_J'�' 600 Washitt;;toiz Street
` Boston, Ma.v.Y. 02111
Workers' Compensation Insurance Affidavit
Appltcant information• Please PRINT le�ii��!; -
name:
location:
city Phone#
1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
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'I'am an employer providing workers' compensation for my employees working on this job.
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I am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the followin;workers' compensation polices:
company name•
address:
cirv: phone#•
insurance co policy#
company nnine•
addres-s•.
city. Phone#:
insurance co policy#
Attach additional sheet if
Failure to secure coverage as required under Section 25A of i11GL 152 can lead to the imposition of criminal penalties of a line up to S1.500.00 andior
one years'imprisonment as%%ell as civil penalties in the form of a STOP 1vORK ORDER and a fine of S100.00 a day against me. 1 understand that a
cope of this statement may be forncarded to the Office of investigations of the DIA for coverage verification.
I do herehr certify under the pains and penalties of perjure•that the information provided above is true and correct.
-1)Sicnature �� �� � �- Date 4L�
Print name '' Phone#
T waYL'iY!
(11:'o'Mcinl use onh do nut write in this area to be completed by city or town official
city or to-.vn: permit/license# Miluilding Department
CLicensing hoard
rl check if immediate response is required C3Scicctmen's Office
C3I1calth Department
contact person: phone#; rjOlhcr E:
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information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide Nvorkers' compensation for their
employees. As quoted from the "law", an e►►►p/oree is defined as every person in the service of another under anv
contract of hire, express or implied. oral or written.
An en►plo'Ver is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foreuoino en,,a,,cd 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
dwellin- house of another who employs persons to do maintenance , construction or repair work on such dwelling, house
or on the ,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency small withhold the issuance or
reneival of a license or permit to operate a business of- to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance-with the insurance coverage required.
Additionally. 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
Phase fill in the workers compensation affidavit completely, by checking the box that applies to your situation and
Supplying company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
afdavit should be returned to the city or town that the application for the permit or license is being requested, i
not the Department of Industrial Accidents. Should you have anv questions regarding the "law" or if you are required
to obtain a workers compensation policy, please call the Department at tite number listed below.
City or rowns
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 leas to contact you regarding the applicant. Please
be sure to fill in tite permit/license number which will be used as a reference number. Tile affidavits may be returned to
th,_ Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
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The Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 «'ashington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
The Town of Barnstable
BAMSTABIA
Department of Health Safety and Environmental Services
ArEOMA�A Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
Permit no.
Date
i
AFFIDAVIT ,
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building'containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: i-C _h 1, Est.Cost SQ0
Address of Work: /?y
\\\ Owner's Name rik v-�
Date of Permit Application: u b )
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit the a Jentthe owner:
50
Date Contra for Name Registration No.
OR
Date Owner's Name