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Home My WebLink About0059 BETTY'S POND ROAD �� i7` s- ��ne� ��. �- INSULATION Iq ❑ NgSROLAS' SSAMLSSS SPRAT F0- SYSPSNR{R &ATTI GYlTigi INSYlAl10N CIILINOi 1-800-696-68!- TVIS: _ PF Z - rS"-r3 1'own of Barnstable Regulatory Services Building Division 200 Main St Hyannis, NIA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed completed the insulation and weatherization work at the property listed below. Cape.God Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Vil �la�e Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes Floors ( ) (X) Walls ( ) 06 1) Sincerely He y E C sidy J , President Cape Cod nsulation, Inc. I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map pp� Parcel A lication # �. u Health Division Date issued. ` << Conservation Division Application Fee Planning Dept. Permit Fee S k Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis ' Project Street Address Village Owner Z6 /af��,s�'` Address Telephone 72 Z Z !�!� Permit Request ,1�11.f„I�t� l' �5� �A` .�� j/��Qi� ,r�/�✓� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation. 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family a---" Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 4frNo On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing r.3 I new i Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room�', ount Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other ' %q m 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# �. CurrenLUse-.--= 4; w a; :. - - Proposed Use - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name / ��d c�� / Telephone Number Address icense# , a Y Home Improvement Contractor# Worker's Compensation # kz, 1411 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �T t �r 's FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r • y 4 r DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE } ELECTRICAL: ROUGH FINAL k PLUMBING: ROUGH FINAL z GAS: ROUGH FINAL .t FINAL BUILDING I DATE CLOSED OUT ` ASSOCIATION PLAN NO. L 12/01/2012 08:3 FA% HILLARY PECK 0 004 OWNER AUTHORIZATION FORM er's Name) owner of the property located at (P operty Address) (Prdperty Address) hereby authorize C (Subcontracto an authorized subcontractor for RISE Enginaering, to act on mybehalf to obtain a building permit and to perform work on my property. XOwne s $g t �a� I Date D EG- 3 2012 o�V z 1 . Nlwssachusetts - Department of Public Safety Board of Building Regulations an(] Standards Construction Supervisor License a:�' Licen CSC 100988 r HENRY CASSIDY 8 SHED ROW r - WES,T jARMOUTH, MA 02673 " Expiration: 11/11/2013 <',uuni,viuui r Trg: 7620 Office of Consumer Affairs and Business Regulation - 10 Park Plaza.- Suite 5170 -e.g. •: .. Boston, Massachusetts 02116 Home Improvement Contractor Registration ' = Registration:. 153567 Type: Private Corporation Expiration: 12/15/2b14 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE -=--- --- ----"-- - - SO. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. SC,41 Co2UM-05;1 1 .Address E.] Renewal n Employment Lost Card . . � - - - • CrrJJacf meerJ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only _ IOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: » egistration: 163567 'Type: Office of Consumer Affairs and Business Regulation xpiration 121 5/2014 Private Corporation 10 Park Plaza-Suite 5170 r c®w f Boston,MA 02116 CAPE COD INS ULATION!I NC: . HENRY CASSIDY 18 REARDON CIRCLE SO.YARMOUTH, MA 02664 Undersecretary- 4thho t nat re I No. :r CllentW:4597, ACO \D,,. CCINSUL'_ --- LABILITY INSURANCEUA,1 N-NIfUUIY„'yl THIS CERTIFICATE.IS tSU CERTIFICATE OF LE.p AB q q MATTE OF INFORMA"I ILIrI 01vLY AND CONFERS NO RIGHTS UPUN TMG GEt;TIFICATE HLOLpC'Q�i20y? CERTIFICATE Dql_;;N(')-I"ApFIRMATWELY(JR NEGATIVELY AIVU NI],EXTEND OR ALTER THE COVERACI:AFF'ORDCD-A THL Lrj1: IES F.ikL.UW.')HIS Ckl�'I'1F1CAT6 OF INSURANCE DOES NQl'CONS I I I lI tE A GUNI"RACY BEl'WEEN 1'HE t$$CIING IN iUlil:[t(iJ,AU CI IUItILLl1 REPRC$L:NTATIVE OR F'F10r)L)CFR, AND THE CERTIFICATE I10LLIER. ANT:If tho e.artlflt ata huldL�I ib an Al]UITIONAL IN,iG 'I U uln pulicy(les)"lust d,enclltTyed.II`SUBRCIGATIC)N 1$WAIVCD,xulyutl 10 111c 1c11118 UIICI CU14lHIlQl1� Gt Lt1C pGIICy, cahtaln pullclea stay 1„,.I,„:,ll undgrriamdnl.A atutanl@Ill on"Ji5 C01litictitcl tltlGa IILJI cufll'cr riUllta to fit; .� i.Glllllt,ela IltlltlL'1r iL1 IIL(J I;11'ry UCh pIICIPt9U1114111(�) iJAME. Mnr nrct Youll •- -. .._...___-Cal,ly IIIY. -50. f]rJruus _ 4J4 RuuCO IJ4 PHONE . 1NC,No ELII'SOd-7t1O-•JtOO2 ;iuulh llunnlr, MA WW1396-79110 lrvvunN rtlu)AFFORUINucravtHnuu wnitx� -_-_.___ w weE3n;Peerless H)surancl3 18333 INSURER 6:EV:l11ti1011 Im Uranca ('ape. Cocf Insulatl�n {nu "-- _.- - _ t 45a yal illoUtll huiw .NSUhERc:AtlarrtlG Chzu ter Ir1ULrrLl(Icu IlyLlllnits, NIA 0260'1 IWJURrRO: or111110rG0In6Urance?C'onlpan.y 3<I1�'L -----------__—.,..-.._...-_.__-- --- ... IN51.112ER E: - L'UVI:HAt il�;, IN6UNLN r; - C Lhl l F ICAI l NUMBER. RL=VI;ION NCJIVIl1L.R h111 1 �'Hl= NOL ICIE Or IN$, - — t RNNCE LIgI t! nI IAME BEEN ISSl1Ep TO'I hIE INSURED NAMI-D ABOVt_ I-UH I-FIk N)I.ICI'I LIYOti vUi •till.L). NOIWI111,31ANDING ANY hgi�UIRENIENT IERNI OR ( wk!)01,1OF ANY COWTRACTOR OTHER DOCUMENT WI761 FtL-SNLCI" TO tvincrl nus Lr( 1FIGAIL; MAY t3k. IE;SUED OR MAY PERTAIN. THE INSURAN'l, ;u-r01fo6D BY THE POI:ICICS DESCRIBED HEREIN IS SLIDJECl- F0 ALL. 111E TERMS' 1-aGt.USI0N5 ANO CONDITIONS, OF SUCH POLICrES LIMITS si-i- ------- IJWIV p;,;r N,yy�BEEN REDUCED BY PAID CLAIMS. li _. �._._-.- - _ IIN rVPF OF IN IURANCE AQOLSUCiR - --- _ PDLICY EFF Hi,LICY �.� uLN LHAI.LIAHILI7Y — -'-' y ._.Fol-IO,.(.fiViuumfl IMAl10DIYYYYI IMMlOIUYI'YYI ,�—�•,� LIMIT 1: .. CBP826306a AlU112Q12 24FJ 10 2(11'' EACHQCCURHENCE 89 UUU UUU X I.VMNII`NCtAL Gl_NFfIAL LIAML11-Y -- — ---�- _ Rr�kliS1Gl >ZENnu CLAIMSS MADE X OCCUR � n+suua__TI_ 9�1OLI,000 _..-- ,. � ML7Q E)lP inIIY DDU UUIUUDI $;),OOL) .. ._. ...__.-._.-.---------.....-.--___-_.�._--- - PkR&aPIAL li AUV INJUhY. L l 000 Q(0 - .._....._.______.._:.-____._._....--._..,.__-- 1)ENENILNGOi<"dArh 0,000,UUU �,�r1 L A�;C;NkIJAI k[L.IM11'APF'Llratl NCH: •--_-.....___--`..-.........___-- ._ p�;, - .' PRopLlct-S-COMPI01'AGG $llllUtILU11U__.-__-- IPunCY )) AIJTC1mwu1L4LIAUILIrY 12MML3CKVm),, 4JUl/2012 UalU1/I)0j E„'��!;� o1slNCLcuNIiT I UUU UUU illlOWN[.I) Au US tiCYIC-1)ULLU _ - _ BODILV INJURY(P",Aa Z wai) 8 X ru tDAutoU X PROPEfi11`LIANIACIE -... Aurlas - Irurys l'1 X UMURW,LA LIAtl - -- -- - JL XONJ453`i E, 41U'i12U'ly:04:)0112U'1' eAcu of c uriakNnz 11 UOQ QUU L.LAIMS�NIAOk Accrcr..cA11� y� 11UU UUU rL X1r+rlrr+nGrl 'IUU0a —•---- ---__I _._L NulllcltN(;IIhIMf:NgAT WN --- AT AND Ehu4LOYkt1`ri IAUILI ry WCAOU525;IU: 6J3U12U12 U6130I2O 1' AW I FI()I,F21 t: �1 rI ,Cc:u,I Ivd.Y-I N� i G.L.EACH Acclral Nl 1 UUU UUU LIFI u.ER/rol M tt L.C-U4�Of) I AI I N 1 A x; (hlunUulory m NFI ` :-� -•--.-.—_•l_,1._,_l _ _ _ - i lr;�a dum:nliu wxla, - - G.L.L)ISI�ASC I:.A TNIi 1 pYGL: ,QUULI,1ll�! (IL-St'ftlP LION OF UPr•I�A110 S(,claw [.L.Lt15 L=A36-PQLh:1'LIhI1T y'i U(U QQU --�__�_ ._._ N UC)1:Nii'I TUN UI-UPERAI I(,)NS I LOCA I ION S 1 VEHICLES(Atlo h ACLIRO 101,AdJItl.1i 1 it„na,1c 4Chy001tl,Ir'@Pro spR('014 rllghlldG) Workers Comp Infoirnutiorl IIIt=4alv(l Otticera ar Prpprletors C�rtlricate I ILiIdGr is 111GILI(IGd its an aclditiunal insutod UnLlt)I 6unural LillUility wi100 roquired by WrItfGL n ' contract ur agreement, .M , CANCELLATION Cill)O GOO I11"tilJlahQII,IIIC SHOULD ANY 01`THEA60Vr:QE'-$CRI0EDPOLIC)tki ❑E4ANr:rtUa)ulclGRL' n t THE EXPIRATION DATE THEREOF, NOTICE WILL HE C1kLIVkkku IN ACCORDANCE WITH THE POLICY PROVIJIUN3. AUTNURIZFUREPRHBkfJfA'IIVE - ,+ ( 'ifltl -20'IQ ACOITD CURPQRAt'IC)N All 1(91)0 tFJGrW(1. pvIUIUS) I �)f'I flee ACORD nlilna:1nd logo:uu r lUl;lurrld marks of ACORR tfS83d�iUlM83f1�i11 � ,' MkY , The Common wealth of Massachusetts Print Form Department of Industrial Accidents 1 Office of Investigations �- I Congress Street, Suite 100 , l Boston, MA 02114-2017 www.mass.gov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly a Name (Business/Organization/Individual): 4 Address: &M014, City/State/"Zip: I/V1ti IMA'_'_ Phone #: -r2-0�- Are you an employer? Check t e appropriate box: Type of project(required): 1. 1 am a employer with Z0 4. ❑ I am a general corttractor 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 ship and have no employees These sub-contractors have g, ❑ 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 I0.❑ Electrical repairs or additions 3.ElI am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.❑ Roof reps ihrs c(Q ,�insurance required.] t c. 152, §1(4), and we have no 13. Other V"e� fP0 �Z( � employees. [No workers' 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. 'Conn •actors that check this box must attached an additional sheet showing the name of the sub-contractors laid state whether or not those entities have , employees. 1 f 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. 6%va(4InsuranceCompanyName: a `jj�qhL Ouvhv G� Policy #or Self-ins. Lic. #: WGA OD 2Z o . 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 nine 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 tine 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 DLA for insurance coverage verification. I do hereby certify rifler the pains..andrenafties o er'urp that the information provided above is true and correct. Signature: - Date: Phone 4: 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#: ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 0( Map V Parcel Application# Health Division Conservation Division Permit# _ Tax Collector rx t"I Date Issued Treasurer !v, �_ Application Fee 0 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address ' ' d Villages Owner Address Telephone Permit Request Square feet: 1 st floor: fisting proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay n , Project Valuation Construction Type , c- Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 011*11' Two Family ❑ Multi-Family(#units) Age of Existing Structured Historic House: ❑Yes ffNo On Old King's Highway: ❑Yeslo Basement Type: I�Full ❑Crawl ❑Walkout ErOther G1 <, Basement Finished Area(sq.ft.) �� Basement Unfinished Area(sq.ft) 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: 016as 01611 ❑Electric ❑Otherp \ f Central Air: ❑Yes 8'No Fireplaces: Existing New Existing wood/coal stove:A•,YesEl ❑No � t Detached garage:U existing ❑new size Pool:O_ exmhng_Q-K�ize Barn:❑existing O newL size - Attached garage:0-existing ❑new size Shed:0 existing ❑new size Other: Zoning-Board-of Appeals Authorization-❑—Appeal# ' Recorded❑ Commercial ❑Yes EKo If yes, site plan review# Current Use i Proposed Use BUILDER INFORMATION / Name ' 'r wd Tom Telephone Number ! ' Address S P00a ecad License# O Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE pp-p-pp- FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED - MAP/PARCEL NO. ADDRESS VILLAGE r OWNER DATE OF INSPECTION: FOUNDATION Ore- 1 t--0 � FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. �\ l/fG I.+VI/fn•Vrs rrc�a••r• v� iri wrvw.....�....�-.. . \ Department of Industrial Accidents OR Office of Investigations 600 Washington Street Boston, MA 02111 Y v'y /rw .mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plulubers ,,,Applicant Information Please Print Legibly Name (Business/Organization/Individu; Address: ity/State/Zip: } Phone#41 : Are you an employer? Ch&4 the-appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* havehired the sub-contractors listed on the attached sheet $ ❑ Remodeling 2.El am a sale proprietor or partner- . ship and have no employees These sub-contractors have 8: ❑ Demolition working for me in any capacity. workers' comp,insurance. 9. ❑ Building addition, o workers' pomp.insurance 5. ❑ We are a corporation and its � 10.❑ Electrical repairs;og additions required.] officers have exercised their . 3� I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs o� additions myself.(No workers' comp. c. 152,§ (4 1 ,and we have no ) 12.❑ Roof repairs insurance required.] t employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below sbowing 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 their workers'comp.policy infonrnstion. I 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$1,50Q.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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I o here b i n r the airs and penalties of perjury that the information provided above is true and corm Si afore: Date: (01 al 3,0 Phone#: l Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermWLicense Issuing Authority (circle one): 1.Board of Realth 2.Building Department 3.Ctty/—i own"Clerk 4.Electrical inspector 5.Plumbing Inspector. 6. Otther Contact Fersou: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee& 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,parmership,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 lie an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold tbe.issuance or renewal of alicense 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 ofpublic work until acceptable evidence of compliance with the insuramce 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 i s rance 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 contactyou 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 is (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. Anew affidavit must be filled out each year.Wheria.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 ent 406•or 1-S77-NlASSAFE Rev ised 5-2ti-OS Fax#617-727-7749 www,mass.gov/"m'a FTHE la; Town of Barnstable Regulatory Services &'MASS. E$► Thomas F.Geiler,Director 1639. M p 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 Permit no. Date 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: Estimated Cost Address of Work: Owner's Name: Date of Application:, �WP e 21 tZ��n I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied Owner pulling own permit Notice is hereby given that:\ OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Signature Registration No. Date I Owner's Signature Q:wpfiles.forms:homeaffidav Rev: 060606 Town of Barnstable THE l��o Regulatory Services BAStABM Thomas F.Geiler,Director 6 MASS. � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 50$-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB ON: number q stre llage "HOMEOWNER".cI�A lam' ��CC�% .name t\me}p�h e# work phone# CURRENT MAHJNG ADDRESS: � c /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 wotk 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 minimum inspection procedures and requirements and that he/she will comply with said procedures and re en . Si ature 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 o 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 pemut 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 V;�J �- /01 .3 3 A VZw '` The Town of Barnstable �LL; Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis,MA 02601 B-862-4038 8-790.6230 . PLAN REVIEW wner: -D r-t 1 PC-U<. Map/Parcel: � - q _ O . 0 � C-7 7 pjectAddress: i � yS Pat4-b Builder: S V( L' - y he following items were noted on reviewing: �I b 6 f Tlf 6 F G-kt 4 DC N. � � ( D� � �TE1� Po2isdZTo a-K to ITD f S T 7-2C-IA S AZS 7V c a Q G a N N E7eT P 8 S 1-s. `7-a ® r/ tl 7-U &4-S :viewed by: / pp ite: — b f 16' RIGHT OF WAY - 4-B N O cy �� oF�K s RI CA, 2 .� pF LOT 4—A, �Yq y Z� 79310 SF M' Ntb 2 NOTE: STRUCTURES ARE "GRAND FATHERED" WITH RESPECT TO SET BACKS AND LOT DIMENSIONS BUT MAY NOT MEET 'CURRENT REQUIREMENTS. EXACT LOCATION OF DWELLING RELATIVE TO 16' WAY CAN ONLY BE DETERMINED BY AN INSTRUMENT SURVEY. MORTGAGE LOAN ISPTI . ,;,:, ; ML12332 SAGAMORE SURVEY ASSOCIATES SCALE: 1 IN.= 400��T. ,��, P.O. BOX 28 OATS: MAY 22, SAGAMORE BEACH, MA. 02562 � (508) 888 8667 I CERTIFY TO GREENPOINT MORTGAGE - � , THAT THE LOCATION OF THE BUILDING SHOWN HEREON CONFORMS TO THE .ZONING OF THE TOWN OF BARNSTABLE e 4 I CERTIFY THAT LOCUS DOES NOT LIE WITHIN THE FLOOD HAZARD ZONE AS DELINIATED ON MAP 0006C COMMUNITY NO. 250001 PLAN REFERENCE: BARNSTABLE REGISTRY OF DEEDS REGISTRY OWNER: BOOK/-PAGE: PLAN BOOK 5090, PAGE 023 LOT NO.: 4—A PLAN BY: WHITNEY & BASSETT BUYER: DATED: SEPTEMBER, 1949 THIS INSPECTION NOT MADE FROM AN INSTRUMENT SURVEY AND IS NOT TO BE USED FOR FENCES, HEDGES OR TO ESTABLISH LOT LINES. FOR USE OF BANK ONLY.