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TOWN OF BARNSTABLE B'UILD,I-NG:PER'MIT APPLICATION
Neap Parcel -Pool Permit# /v
� 66 A i
Health Division �� Date Issued
Conservation Division �rAA—/ Fee
Tax Collector Application Fee (,/J
Treasurer I LiryiTF®
Planning Dept. }��
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Date Definitive Plan Approved by Planning Board Approved By
Historic-OKH Preservation/Hyannis
Project Street Address r q-
Village TAr4rI.�
Owner s �� t1� 41 A � �A4 Address S � b��no �°Js7-erra e Q�
Telephone ,Fi
Permit Request p C!'a�L 1 9
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Square feet: 1 st floor: xist' g proposed 2nd floor: existing proposed ! To
new Mi
Valuation Zoning District Flood Plain Groaahwater Ovgrlay
Construction Type o
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting d cument&n. a
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Dwelling Type: Single Family �' Two Family ❑ Multi-Family(#units)
Age of Existing Structure VI1a Historic House: Cl Yes ❑No 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 new
Number of Bedrooms: existing_ new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: was ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑flo Fireplaces: Existing � New Existing wood/coal stove: ❑Yes ❑ No
Detached garage:❑existing ❑new size Pool:❑existing Jd new size ft 9 Barn:❑existing ❑new size
Attached garage:N!existing ❑new size Shed:p existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION Q
Name�I�, �� Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
1117
IGNATURE DATE —/f QJ
FOR OFFICIAL USE ONLY
v
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION �1
FIREPLACE
Y
ELECTRICAL: ROUGH 0tr FINAL
CZ
PLUMBING: ROUGH -I FINAL .
GAS: ROUGH FINAL
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FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
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n of Barnstable
-overnight Travel
se Reimbursement
Claim Form
Date
RATE
re to calculate mileage reimbursement rJOrJ
Odometer
Arrived at Departed Arrived #Miles
-- 3 The Commonwealth of Massachusetts
�5 _-
Department of Industrial Accidents
Office of Investigations
600 Washin ton Street, T h g Floor
Boston,Mass. 02111
�S
t Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
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Applicant•->/nyf�ormation. /� ,,� ;, � P,leasePRI.lTtle:�ib.Y y' r
name:
address:
city state: zip• phone# 2� .
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work site location full address):
am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
a-.rtx. m y„, ?✓"�' _a$` �'� .:'`.k yw+ss. rr ,_,,
❑ I am an employer providing workers compensation for my employees working on this job.
company name:
address
city: Dhone#•
insurance co. olic #
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❑x I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices
company name:
address
city: phone#
insurance co. policy#
company name:
address:
city: Dhone#:
insurance co olicy#
AEfach'adtiihonal s ieet if�necessarYeu -�} c ear d. r+ ' E ya fir:,ff£ ha�§-
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
do here b rtify nder t p i and penalties of pei jury that the information provided above is true and correct.
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town official
' city or town: permittlicense# ❑Building Department
❑ ❑Licensing Board check if immediate response is required ❑Selectmen's Office
' ❑Health Department
contact person• phone#• - •
(revised Sept.2003) - ' ❑Other
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual,partnership, association,corporation or other legal entity,or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 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, 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.
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Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that-applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance 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 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.
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City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has.to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the 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 Washington Street,?h Floor
Boston,Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406
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Town of Barnstable
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Regulatory Services
BaxxsraBLE, Thomas F.Geiler,Director
1 a`�� Building Division
TED MP'�
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Fax: 508-790-6230
Office: 508-862-4038
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:T' l,L L_ Estimated Cost
Address of Work:
Owner's Name:
Date of Application, 11 11 S
I hereby certify that:
Registration is not required for the following reason(s):
OWork excluded by law
[]Job Under$1,000
[]Building not owner-occupied
;p Owner pulling own permit
Notice is hereby given that:
PERMIT OR DEALING WITH UNREGISTERED
p�Vr[ERS PULLING THEIR OWN
CONTRACTORS FOR APPLICAB PEROHON IMPROVEMENT TY FUND ERMGL cE.142A.
ACCESS TO THE ARBITRATION
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name Registration No.
0
G^
Date wner's Name
Q:focros:homeaffidav
Town of Barnstable
pFTHE tp�
"o Regulatory Services
• f Thomas F.Geiler,Director
swxxsr�RM •
9�p "9. ��� Building Division
rEn � Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
/ Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
C Please Print
DATE: v
JOB LACATION:.
num er street • age
"HOMEOWNER": �� .I•••(, 0 1 IA I l-I�j��r 6r� �l U�-��O��01�� work hone#
name n home phone# P
CURRENT MAILING ADDRESS: lh i s�6 0 ICI
city' wn to 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 individuaffor hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling, attached or detached structures accessory to such use and/or farm,structures. A
person who constructs more than one home in a two-year period shall not be considered a 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 workperformed 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
remillements.
igna o H meowner
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 ladk 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.
O:forms:homeexempt
Y a r �116 7 1� / , `i / /1 / l\UI �l ;r 1�1/ iY/11 /ll t U`r, Z_ AA
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APPLICANT MARK R & SHEILA A THOMPSON To yy14T- BARNS"TABLE
� �78 3414„ -�
00,
6' c
LOT 40 \� Q
_T #115
DECK
LOT 42
. 00
LOT 43
�50001 0005 C C=__ 08 19 85 'y
FLOOD PANEL —__ ______ FLOOD ZONE. __ DATED 1
I hereby certify that this mortgage inspection plan was prepared fora Plan is For
ARROW MORTGAGE CORP. `Bank Use Only
The location of the building shown does A_QZ__ fall. within a special flood hazard zone. PLAN REF = —35306B SK 3
The location of'the dwelling does ------ conform to the local zoning by—lairs in effect Scale i _3D I f
=
at the time of construction with respect to horizontal dimensional setback requirements -----
or is exempt from violation enforcement action under Mass. General Laws .Ch. 40A -Sec. 7Da te: 09130102
PLEASE NOTE The structures on this inspection were located by tape not instrument and are approximate only An actual survey is necessary
Ufar a precise determination of the building location and encroachments, if.any exist, either way across property lines. This inspection must not
e used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This
>-pection must not be used to locate property lines. Verification of building locations, property line dimensions, fences or lot configuration can'
dy be accomplished by an accurate.instrument survey which may reflect different information Lhan what is shown hereon. This inspection is not
to be used for any purposes
�other than mortgage.. �)onkeTeJSurvey accepts no respoonssibilityy for
damages
7- T11 �resulting from said reliance.
1 T/Y 1 V � V !/ 1T � L�1 Cl��( �LI 1 �/ FAX- 508-4?0-5553
,�O BOY 265, 40 INDUSTRY RD. MARSTONS MILLS MA 02648 PHONE. 508-428-0055 34038 JFBOY 265, 40 INDUSTRY RD. MARSTONS MILLS, MA 02648 PHONE. 508—428-0055 34U38 JF
THE TOWN OF BARNSTABLE
•
33AUST"L
BUILDING INSPECTOR
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APPLICATIONFOR PERMIT TO ..6........................................................................................................................
TYPEOF CONSTRUCTION .... ................................................................................................................................
A...............19.23--
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to.the following information:
Location ......A--7 7................
..................... ............................W,................................................................
ProposedUse ....S. .. ..... ........ .....................................................................
ZoningDistrict ........................................................................Fire District .................................................�.4....................
Name ddress .............
of Owner ............./0"..L.......
Name of Builder ......../I...................... ............ .............. ..Address ...... f.............pr.................;................................I...I........
Nameof Architect ..................................................................Address ............................. ...............................................
Numberof Rooms ........ .........................................................Foundation . ....... ..........................
Exterior 0?1" ..................Roofing ...... . 119zl
Floors .....0 ............................................................Interior .......
-h? ................. ..............................................
o Heating . . .....
............... ................... .. •..............Plumbing ..................................................................................
Fireplace .......^ ......................................... ...........................Approximat,- Cost ...R6?, 'J'4V
.................................................e...........
Difinitive Plan Approved by Planning Board c ------------- 19
Diagram of Lot and Building with Dimensions
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..... rvC. ......................
-
Dacey» W�]]LiamlI" Jr.
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No .�� moe story �
���—.. P arn�hfor ---.--�..��---.
single family
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'/~/— --Terrace /
�oconon — —..—..�. —.-----------.
Hyannis
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Wi]]iazu E. v Jr.
Owner ..................................................................
(
frame )
Type of Construction ..........................................
—~--''-^'''-------------''--~—'—'
Plot ............................ Lot ................................
Permit Granted ......�.������--I�---- ��
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Date of Inspection . .--..--- --l9
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uon, Completed m°� . '
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PERMIT REFUSED
,___,..—_--.-..—..------- lA '
-...—.—.--.._---.....---..—..—.—.--. �
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Approved
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�oFt1KE loyti Town of Barnstable *Permit# G 91QV
O,^ Expires 6 months from is ue date
: BAMS B,Y. : Regulatory Services Fee ¢? 2 ® `�
y MASS. g
G�A 1639.. Thomas F.Geiler,Director
rE01A0�`A Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-403 8 -
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address I l S
j �[[Residential alue-£Work 1,0 o Ot)a
Owner's Name&Address t hJ 1)
L i S ,-ifU - 6 '
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) f 3
4`
Construction Supervisor's License#(if applicable) +
❑Workman's Compensation Insurance JUL 1 ZouZ
Ch one:
I am a sole proprietor
❑ I am the Homeowner ��� F EARNS I AB LE
❑ I have Worker's Compensation Insurance �:-
Insurance Company Name
Workman's Comp.Policy#
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to ter�S'T�t�
ZReof(not stripping. Going over existing layers of roof)de
3 sty IN0Qs-c- �
❑ Replacement Windows. U-Value (maximum.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
L
ature
ms:expmtrg
ed121901