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Home My WebLink About0184 BRISTOL AVENUE /�� es✓a� �grE - — � ��-- i' Town of Barnstable *Permit# a61 3 a S39 Expires 6 months from issue date Regulatory Services Fee 3 -- snaivsTwsrs, � ® TA Thomas F.Geiler,Director 01 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 Cj www.town.bamstable.ma.us Office: 508-862-4038 FaxjWV01�230 EXPRESS PERMIT APPLICATION - RESIDENTIAL Q YD? �/ G Not Valid without Red X-Press Imprint 'c Map/parcel Number Property Address / ��/S TTV4/�/ I S IV [Residential '.Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address e I iS 6 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑� I am a sole proprietor am the Homeowner ❑ I.have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) []—Rt woof(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 (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. - *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Cr. ' FILES\FORMS\buil n perms forms\EXPRESS.doc J Revised 060513 27re Corr mottweah*ofMassachrusefts Deparktent of Indm&ial Accr'den& Office ofImvstigaiians 600 Washington Mreet Boston,M,4 02HI wnmt mass.goWdia Workers' Compensation Insurance Affidavit:Biulders/ContractorsMectricianslPlumbers Applicant Information Please Print Legibly Name(i sera ti dnaq:q e g;—;, /e Ike f A A Wit.: f 8f /z 112! — — CitylStatrlZip: /1/ Phone# tyre you an employer?CAeck the appropriate box: Type of project(required): 4. am a contractor an ❑ I_❑ I am a employer with ❑ I tt d I 6_ New construction employees(full andforpart-hme.).* have1 the sub-camtiactois 2.❑ I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling ship and have no employees These sob-contractors have 8. ❑Demolition working for me many capacity employees and have workers' 9. ❑Building addition [No workers' comp.insurance tromp.insurance., regw5. ❑ ate area corporatimand its 10..0 Electrical repairs or additions Ia homeowner doing all wordy office ba-'e exercised their 11_❑Plumbing repairs or additions myself o workers' right of exemption per MGL insurance 13.❑Oth 13 e.152, §1(4),and we have no 12..0 Odleer repairs employees-[No workers' camp-insurance regWred-J *Airy applimnt that checks boa 91 must also U out the section below showing ilea wodeW compensation policy information.. T Sbmeown,ers who submit this affidavit indicating they are doing all wcak and dies hoe o=de contractors mast submit anew affidavit indicating such. TConttactors that cbeck this boat moist attached am additional sheet showing the nmne of the wti-cwa2c tots and state whether ornot those entities have employees. Ifthe sob-cmtmctars bave employees,they most provide thew workers'comp.policy number I am an employer that is provh&g trrorkers'compensation insurance for eny employees. Below is die policy and job sits information. Insurance Company Name: Policy#or Self-ins-Uc.# Expiration Date: Job Site Address: ; CitV Statelzip: Attach a copy of the-workers'compensation policy declaration page(showing the policy number and expiration data). Failure to settee coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.OD andlor one-yeariruluisnnnent,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator. Be advised drat a copy of this statement maybe forwarded to the Office of Imrestigations of the DIA for insurance,coverage verification. I do hereby certify render thepains and penalties ofperjury that the information prosided above is true and correct -Signature: Date: Phone# O,fjkiat use only. Do not write in this area,to be completed by cfiy or town official City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfl'own Clerk 4.Electrical Inspector {.Plumbing.Inspector 6.Other Contact Person: Phone#: - 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the 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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 15.2, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants i Please fill out the workers'compensation affidavit completely,by checking the boxes that aPPI to your situation and ,if necessary,supply sub-contractors)name(s),address(es)and hone numbers along with their certificates of P ( ) g ( ) 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 insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out 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. In addition,an applicant that must submit multiple pemutllicense 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 in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would lice 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 Gommaawealth of Massachusetts Department of Industrial Accidents office of lrnvestigatims 600 Washington Street Boston,MA.02111 Tel.#617-727-4M W 406 or 1-977-IYIASWE Fax#617-727-7749 Revised 4-24-07 w .mass_gov/dia 1 ro,,y Town of Barnstable Regulatory Services i w. Thomas F.Geiler,Director �Eo;9..�►`�� 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 7f�jj//S number street village T"HOMEOWNEW': J — —g- name home phone# work phone# CURRENT MAILING ADDRESS: �l} /�p�aS 4,t_,0_ rY/S , 4z . d� Q/ ci towns 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 buildingpennit (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 proce ures and requirements and that he/she will comply with said procedures and requirements. .fLcLca- Signarl o o eowner 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&ReguIations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot , proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decolll\AppData\Loca]\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 .... .�. � E � . Town of Barnstable j r °* Regulatory Services IIAJWSTAZ[.E Thomas F.Geiler,Director ;p16 �A�`� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit. (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 Q:FORMS:OWNERPEFMISSIONPOOLS 62012 DECREE AND ORDER JN Docket No. . Crl...monwealth of Massachusetts The Trial Court PETITION FOR Probate and Family Court . FORMAL ADJUDICATION11 Estate of: Barnstable Division Louise Schwartz 3195 Main Street First Name Middle Name Last.Name P.O. Box 346 Also Known As: Barnstable, MA 02630 Date of Death: April 26, 2012 (508)375-6600 After a hearing or on the uncontested Petition for Formal Adjudication filed on (� U 0 i ( ate THE COURT FINDS: 1. The Petitioner is an interested person and has filed a complete and verified Petition. 2. The Decedent died on April 25, 2012 ; (clate) ❑ domiciled in the above named County. ® a nonresident of Massachusetts, but leaving an estate in the above named County. 3. Any required notices have been given or waived by all the interested persons. 4. Venue is proper. 5. The Petition was filed within the time period.permitted bylaw. 6. ❑ The Will dated with codicil(s) dated ate ate s referred to as the Will, is valid and unrevoked. There are no known Wills that have not been expressly revoked by a later instrument. The Will is the Decedent's last will and is admitted to formal probate. ❑ There is no valid Will. ❑ The prior informal finding as to testacy is set aside. ❑ The Will dated with codicil(s) dated ate ate s referred to as the Will, has been lost, destroyed or is otherwise unavailable. The above-referenced Petition states j the contents of the Will. The Will as stated in the Petition is valid and is the Decedent's last Will. ❑ The instrument dated with codicil(s) dated is not a valid Will. ae date ® The duly authenticated copy of the foreign Will dated September 23, 1985 ate with codicil(s)dated September 27, 2006 along with the duly authenticated certificate of its legal ate s custodian are true copies and the foreign Will has become operative under the law of Ohio i 7. ❑ Other. _ •. ,! ,'! • A TRUE COPY ATTEST: h c REGISTER ` 1 of 3 MPC 755 (3/19/12) page Docket No. Estate of: Louise Schwartz First Name Middle Name Last ame i 8. The heirs of the decedent are Z as stated in the Petition OR ❑ as follows: Name and Address of Heir Relationship to Decedent David P. Schwartz son 3626 Russell Avenue Cincinnati OH 45208 Joyce Teixeira daughter 184 Bristol Avenue Hyannis MA 02601 9. ❑ Any Will to which the requested appointment relates is or has been previously formally or informally probated. 10. ® The person whose appointment is sought has priority entitling that person for appointment. OR ❑ The Court finds that those persons having priority for appointment are,not qualified to serve or, although given notice of the proceedings, have failed`.to request appointment or nominate another for appointment, and that administration is necessary. The following person(s) is/are qualified to serve. David P Schwartz First Name —Rfl- Last Name First ame --WT— Last Name 3626 Russell Avenue ress Apt; nit, o.etc. (Address) (Apt,Unit, o.a c. Cincinnati OH 45208 (City/Town tate (Zip) ( ity own _ Fate (zip) Primary Phone#: (513) 321-9521 Primary Phone#: THE COURT DECREES AND ORDERS: TESTACY DETERMINATION 1. ® The Will is admitted to probate. ❑ The Decedent died intestate. ATRUE COPY ATTEST: ❑ The instrument is not admitted to probate. 2. The Decedent's heirs are as found above. REGISTER APPOINTMENT OF PERSONAL REPRESENTATIVE 3. The ® aforementioned OR ❑ following person(s) is/are appointed or confirmed as Personal Representative(s) (hereafter"Personal Representative"): David R. Schwartz First Name MA. Last Name MPC 755(3/19/12) page 2 of 3