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Home My WebLink About0168 BISHOPS TERRACE ��o � � j S�d�5 ��t'v,s � �. a � ✓ o �� Cape Save Inc. TOW T R-AWNS UB E 7-D Huntington Avenue South Yarmouth, MA Q-664 - ,s ,. Tel: 508-398-0398 Fag: 508-398-0399 DIV1 tj 10/02/14 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 168 Bishop's Terrace,Hyannis has been inspected by a certified Building Performance Institute (BPI)Inspector Ceiling: R-32 cellulose Walls: R-14 densepack cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #cZ r-6 6 q 7,5Q Health Division Date Issued �� l Conservation Division Application Fee ISO Planning Dept. Permit Fee IV Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address /(9 e Village (tot Owner I ✓`f(°S.S Address S44410 Telephone I's j U r Permit Request 14 f't^ S eW u�✓ ��C 4�+ �° ('� C'k `'� �l o C V /la t03( 7V I✓ 4, V Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatior�4 M ^ Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family D,/ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(0,4 CIO r Number of Baths: Full: existing new Half: existing l nRw o Number of Bedrooms: existing _new �y Total Room Count (n including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other mNJ Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes '❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name W. C(��.!!� t-u �' �N t o Telephone Number IS�V 1 ` U V OS j 1b Address ��A to., License #s- rod CA I "1 ( �oZ�� Home Improvement Contractor# ` / 0 Worker's Compensation #1'w 33J _ 96 c ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO YQY�4t0cty17 SIGNATURE DATE / FOR OFFICIAL USE ONLY ' APPLICATION# DATEISSUED ti MAP/PARCEL NO. R y ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE F ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH" FINAL ~ 1 S GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Building Permit Authorization I, Frank Burgess .__, as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to' perform work at my property located at 168 Bishop's Terrace Hyannis, MA'02601 Signed Date �� Pnnt t-orm The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass-gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers please Print Applicant Information ibly Name(Business/Organization/individual): Cape Save,Inc. Address: 7D Huntington Avenue City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-398-0398 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 17 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑ Demolition. ship and have no employees working forme in any capacity. employees and have workers' 9 ❑ Building addition insttrance.A [No workers' comp. insurance comp. 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers comp. right of exemption per MGL 12.❑Roof repairs c. 152, §1(4),and we have no Insulation insurance required.] employees. [No workers' 13.❑✓ 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 andjob site information. Insurance Company Name: Technology Insurance Company T1NC 3353968 Expiration Date: 04/09/2014 Policy#or Self-ins. Lic.#:,? /, Job Site Address: 13Ls k0 rl°�� City/State/Zip: �`�yu�n/J )W 6d 0/ 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 cerdfy under the pains and penalties ofperjury t at the in ormatron provided above is true and correct Si ature: ------ Date --- Phone#: 508-398-0398 Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# F 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#: ® �+ ® C p yy��/ g®� DATE(MNIDOIYYYY) CERWICATE OF LIAB 11 I INSURANCE 4/9/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pol)cy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONIT PRODUCER NAME•CT Colleen Crowley Risk Strategies Company PHO o (781)986-4400 FAQ No:(181)963-4420 15 Pa-ella Park Drive AIL Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Randolph M& 02368 INSURERA:Selective Insurance INSURED wsuRERia.-Safety Insurance Camany 33618 Cape Save, Inc iNsuRERc.Technology Insurance Company 7 D Huntington Ave INSURERD: INSURE-RE South Yarmouth Mfg 02644 INSURERF: COVERAGES CERTIFICATE NUMBER CL134960509 REVISION NUMBER: THIS IS TO CERTIFY THAT THEI POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS. INSR ADOL SL03R POLICYEFF POLICYEXP LIMITS LTR TYPE OF INSURANCE POLICY NUIVISER MMIDD 00 GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocalrrence) $ 100,000 A CLAIMS-MADE 50 OCCUR S199448001 0/16/2012 0/16/2013 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 rPOLICY PRO LOC $ AUTOMOBILE LIABILITY (Ea accident) LIMIT1,000,000 B ANYAUTO BODILY INJURY(Per person) $ ALLOVNNED SCHEDULED 6208200 1/6/2012 1/6/2013 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS ' AUTOS�� PP Taws Y DAMAGE $ X - Underinsuredmotonst81split $ 100,000 A X UMBRELLA uAB X OCCUR 199448001 0/16/2012 0/16/2013 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIIAS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ I $ C WORKERS COMPENSATION fficers Excluded from X O ST.4T(T OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORJ?ARTNER/E>ECUTIVE overage EL.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? Y NIA 353968 /9/2013 /9/2014 (Mandatory In NH) E.L-DISEASE-EA EMPLOYE $ 500,000 ffyos.desaibe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMB $ 500 QOO DESCRIPTION OF OPERATIONS!LOCATIONS,VEHICLES(Attach ACORD 101,Additional Remarks Schedulo,if more spate is required) Issued as evidence of insurance. Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a/ National Grid, Action Inc., Colonial Gas Company and NStar Electric are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light compact PO Box 427/SCH AUTHORREDREPRESENrATIVE 3195 Plain Street Barnstable, Nei 02630 chael Christian/CLC ACORD 25(2010105) a 1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).0l The ACORD name and logo are registered marks of ACORD Massacnuset:s -Deoarrrten;of=uoiic Safetty Board of Suildina Regulations and S andards Construction Supervisor-Specially License: CSSL-102776 WILLIAM J MC C-LUSKEY 37 NAUSET ROAD West Yarmouth NSA 02673 Comirnissioner 06/28/2015 EAN R Office of Consumer Affairs andeusness Regulation 10 Park Plaza - Suite 5170 - Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE- = SOUTH YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. Address 7 Renewal Employment i► Lost Card IS-M-0 5010-04104-G101210 �. J/ce-�a�rv,�aavacrlealtl c��•I�aaJacl:u� _. _..___--.--. _._ _,_ _.... _, _. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �- Office of Consumer Affairs and Business Regulation _—IFF, Registration: . 171380TYPe- g ' Expiration: 3/14/2014 Corporation 10 Park Plaza-Suite 5170 --= Boston,MA 02116 CXI-9 SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH-MA'02664' Undersecretary Not valid wit o signa t s _ Burgess Companyr Burges;� ' %Tide S Sep`tic System Inspector t , 168,BishopsyTe�race li �Y Hyannis;MA 02601 m 781=738-5936 -- rex02l73@gma*ll.com httpJ/www.burgesscompany.biz c ' .Town of Barnstable oF�t+e r Regulatory Services" Thomas P. Ceiler,Director * Building Division * BARNSTABLE, MASS. Tom Perry,.Building Commissioner �'prFo �a 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 50A790-6230 Approved:. Fee: . 5. _ r Permit#: :�01 B 6 e,31 / HOME OCCUPATION REGISTRATION Date: �� 7�/O Name: ��;e' ti��.r e S 5 Phone t#: S-o P Address: /&f 6i Village:_? Name of Business: S _.. -- -- -- -_ --- `hype of Business: _ '!r c fiy rn y� ��,�� M ip/E clt: pe J INTENT: It is the intent of tliis section to allow[lie residents of the 1'own of Barnstable to operate a home occ'upatiou iAritlan single Family dwellings,subject to the-provisions of Section it-1:/1 of tile zoning ordinance, provided that the activity sliall not he discernible front outside the dwelling: tliere sliall be no increase in noise or odor; no Visual alteration to the premises witich would suggest uiything other than<i residential use;no increase in traffic above normal residential volumes; and no it in air or.brnundxvater pollution. After registration with the',fluilding Inspector,a.custornary'honie occupation.sliall be pernutted,as of right sulzject to tire. following conditions: • The activity is carried on by the pernianent resident of a single family resideiitiat dwelling,Unit, loc•atecl witlriir that chvelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the duelling iihich are not customary iu"residential-briiltliugs,and there is no outside evidence of'such use;; • No traffic«rill be generated in excess of normal residential volunies. • The use does not.involve-the production'of offensive noise, vibration,sutoke;(lust or oilier particular m,rtter, odors,"electrical disturbance, heat,glare, humidity or other objectionable eflects. • There is no storage or use of toxic or hazardous Maten:ds,;or flamniable or explosive materials, in excessof . normal household quantities: • Any need for:parking generated by such use shall be met oil the sauce lot c'oritainiug the Ccistomary Honie Occ'upatiou;uul'not.mthin the required frolit yard:: • 'There is no exlerior storage or display of naterials or egiiipnieut.. . • There are no conuiiercialveliicles related to the Customary Horne Occupation,other than one Vari or one pick uI>truck not to exceed one ton capacity,and one trailer not exceed20 feet in lengili_and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation: • No sign sllall_be displayed indicating the Custonriiy Honie Occupation.t — • If the.Custoniary Home OccLipation is listed oi-aolver tised as a business,the street address.shall[rot be t included: - • No pers6n shall be employed in the Customary Home Occupation rclro is not.a perinancnt residentof the dwelling.unit..' I, the undersigned,lhave reread—and agree milt the above restrictions for my�home oc'c'rrpation f am registering. Applicant: Date: YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St; Hyannis. Take the completed form to.the Town Clerk's Office, 1" FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. / / o Fill in please: DATE:_ APPLICANT'S YOUR NAME: j� Y BUSINESS YOUR HOME ADDRESS: 3 TELEPHONE # Home Telephone Number: .7 NAME OF NEW BUSINESS: 6V.1 S_T rS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? c:. YES NO Have you been given approval from the building division? YES NO, ADDRESS OF BUSINESS iG, 11 S. -�— MAP/PARCEL NUMBER 17 S v When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of-the Town o.f '" Barnstable. This form is intended -to assist you in obtaining the information you may,need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of an p rmit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION Authorized Signature** RULES AND REGULATIONS. FAILURE TO COMMENTS:. _ COMPLY MAY RE SLjLT IN FINES 2. BOARD OF HEALTH This individual has oe n informed of tj rmit re ement that pertain to this type of business. Aut orizeffSMnatur&* COMMENTS: 3. CONSUMER AFFAIRS (LIC SING UTHORITY) This individual has b,�et� info d t licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: E 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 'S f Parcel ? `" ` Permit# �� . Health Division - Date Issued a Conservation Division I r f °. Fee ;�O?ld 60 Tax Collector.. Treasurer &4nl Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address , t,19 / ;le® jE.!5: - Village � Owner rJQAAJ k f r r 6.M i2/,U4 8 )jR Address _5,Aw r j Telephone T Permit Request Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 1460 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: 0 Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family J Two Family ❑ Multi-Family(#units) .Age of Existing Structures Historic House: ❑Yes .AdNo On Old King's Highway: ❑Yes ❑No Basement Type: XFull ❑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: Gas ❑Oil ❑ Electric ❑Other " Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size- Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size, Other:• - Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name rtJ Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PE-RMIT NO: DATE ISSUED MAP O.L P N . .•-� {,,VILLAGE ADDRESSa tF OWNER * - • a ; DATE OF INSPECTI0i • r _ ` FOUNDATION FRAME 'INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r. GAS: — ~ROUGH FINAL ` FINAL BUILDING A DATE CLOSED OUT ASSOCIATION PLAN NO. w The Commonwealth of Massachusetts a - Department of Industrial Accidents Office offfiresaffatfoos t 600 Washington Street Boston,Mass 02111 Workers, Compensation ensation Insurance Affidavit name location city hone# ^ I am a ho eowner performini all work myself.g anv capacity I am a sole slur and have no one worku%%/%//////%%/%%'///%/////%%%/%/O///////%//%///////O/%///////////////%'/O�%/%%///%%%//%/%%%/%/%//////%/O%�/G�%%%% I am an employer residing workers compensation for my employees-working.on this job. ::: :;':;;: com anv name: :.:...:.:::::.: .,....::.. ::..::.. .:. ....,.:::::::.:...........:.:.::.:.:...::.:::.::.::::..... a dd c e s :::..::.. .:. ..... .. . qtV• hams#s� ;: ....:.::: :.:. ::.:.::::::::::. ;.. ::::.;::. ............:::::::o;::::.:.::::::: insurance co. .. ;.;.. ..; _.. ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the followingworkers' compensation polices: com anvname: address. :<:?:<:>::»:<:>:::<::::;::»>:>:::< ::::<.»::;,::;:.. ....... ........... .. ................... ........... ........:v:::.::v:::::::v:::::.�::n_::::::.�::.�:::::.�::iii.�:•ii:•i:i}::ii}:::::::•:.�::::::::.•::•?ii4•...:.<•.:v:?�::.:..: ..:v:...................::::.................. .......:•............................................. �j iiii•:ii i•:�:vii:.: h •:Ni:.:�:�:•:;:':� Ci;i : :•:`;:;:`y�:;isj;:;:• i{:v:�:;:;:;'}:ii:is�:��:'r.:�:::j::_::-:'i lone city �d <.r>` ........................................................... :. ...: address: ...::.;; :........... ............. ..:.... : biome# ` ' 3 :'::i:i: iiii ..::•::v:::.�::::•... .. .... .::i�ii:•ii:vii:iiiiii:':i::•:.. ..... .:{4:::i':.::.....::....:v;..:.:....................... .::i?::`:iiii:::i:i::ii.... ::iiii:::is i:••: .:_i;; ..�::....i:..�r:;�:i;i:i:::?:i:;.i..xrix:::;:;iii:ii' i>:iii:i:>ii':>i'.ii}i:i.}::.:�v.y�. .........................::::::::..:...::::::•.....:'::w:.�.:._:i:•i:i:.�:::•.:i'i4i:i{!i4i:i•i:•:�:tC::;,.::::.::::i.. .�:::::::.:: ::•. :::.;•::::.:;:::::::.;':;:;•i:;.:.::.;it i;:;• ..........-x....................:....... �1 ..iY i:ii:.'v.:i iii: .. .... :.w::::..::•::::v C^::•ilia:• i`i'�:i:•Y::i!�i liii:viv?-;}i:i? :::'?i ;<t`T:tii}ii;.h;:<; }:;:;: :}ii; ..:.�:::::.:'�.:�.:.•.:':;h':;^:y'r.}v.;:;::v:..::.y ...�:....:, .......::-.. insurance�co:. ' ' 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 s1,50000 and/or one years'imprisonment as well as civa penalties in the form of a STOP WORK ORDER and a flue of$100.00 a day against me. I understand that a COPY of this statement may be forwarded to the Otflee of Investigations of the DIA for coverage veriflcatlon 1 do her under the pains and penalties of perjury that the information provided above is&w.mid correct Signature Date Print nameO�# Milli oiflcial use only do not write in this area to be completed by city or town otHdal city or town: penmidlicense# ❑Building Department Ucensing Board ❑check if immediate response is required ❑Selectmen's Ofnce ❑Health Department contact person: phone#; — ❑�e'�e (tevued 9/95 PJA) erne The Town of Barnstable ' �0 Department of Health Safety and Environmental Services 1659. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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 /' d�6 Address of Work: , /'s �° Owner's Name: XI (c �6m,= & 4:5 6 5�4 Date of Application: I hereby certify that: Registration is not required for the following.reason(s): Work excluded by law Vob 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 Name Registration No. OR Date Owner's Name q:forms:Affidav Department of Healt a an nvironllnentat bervices Building Division BARNSl�rirr ' 367 Main Street,Hyannis MA 02601- tsesa 059. Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commis_: HOMEOWNER LICENSE EXEMPTION Please Print DATE JOB LOCATION: `/ol number street village "HOMEOWNER": tame home phone# work phone# CURRENT MAILING ADDRESS: city/town state up 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'asstunes 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 p es and requurements. Signature of Homeown r Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to compiv 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 to amend and adopt such a fortn/certification for use in your community. Q:FORMS:EXEMPT\'