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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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Date Definitive,Plan Approved by Planning Board
Historic OKH Preservation Hyanni's
re 1C
� --� OwnerMap- -Parcel'
46.
s' ::6 , b —
bV-
Square feet: 1 st floor: existing—proposed 2nd floor: existing
—proposed Total new
Zoning District, Flood Plain Groundwater Overlay
Project Valuation.6 606 Construction Type
Lot Size Grandfathered: LJ Yes' Q No If yes, attach supporting documentation,
7�ne: ���� F8�l�/ | 7\wOFannUv �� K4U�-F�nlik/ �� Un�n Dwelling ^'- ~ ' �- _ ', , `' '_` __-_-__---
Age of Existing Structure Historic House: 0Yes Ll No On Old King'G Highway: LJ Yes 0 NO
Basement Type: LlFUU D Crawl 0WalkOUt J Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number 0fBaths: Full: 8xiGting new Half: existing 8vv___________
Number OfBedrooms: ' existing __new
Total Room Count (not including b81hn\: existing new First Floor Room Count
Heat Type and Fuel: 0G8G 0 (]i| LlB8Ctric LJ[th8r___________
Central Air: Cl Yes LJ No Fireplaces: Existing New ExatingvvOOd/cO8 stove: LJYexs [3 NO
Detached garage: C3 existing U new 8iZ8__PO0|: LJ existing L1 new GiZ8 []8rD: LJ existing [l new GiZ8___
Attached garage: Ll8xiGting LJ new GiZB —Shed: U8xiGtiOg Ll new GiZ8 Other:
Zoning Board of Appeals Authorization U Appeal # Recorded L3
COnnnO8rCia| LlYe8 [JNO \f yes, site plan review#
Current Use Proposed Use
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APPLICANT INFORMATION
-'-----'- '-A0UDLDER-Q&KHOMDIO ---- - --- - - ' - -- ' ----
dN Telephone Number �
Address f36Y SCID UC8n88
Home improvement Contractor#
MA OAS
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
FOR OFFICIAL USE ONLY
f
APPLICATION#
e
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
' FOUNDATION
FRAME 62
{ INSULATION
F
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
t FINAL BUILDING tP� ��� V o / l I —
DATE CLOSED OUT
ASSOCIATION PLAN NO.
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations'
' 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name'(Business/Organization/Individual): C -/
Address:" CAW C► '
l�City/State/Zip: rt°ddr�t //�j� 4.c`�S7� Phone.#: j®�" 7 ` 08O f
Ar'e yyou>an employer? Check the appropriate box:
Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-tirn.e).
* have hired the sub-contractors 6. ❑New construction
2.V 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
workingfor me in an capacity. employees and have workers'
Y P tY• $ 9. ❑Building addition
[No workers'comp.insurance comp.insurance. 10. Electrical re airs or additions
jj required.] , _ 5. ❑ We are a corporation and its ❑ P
am as homeowner.doing-ally work officers have exercised their I I.[:]Plumbing repairs or additions
myself. [No workers'oinp: right of exemption per MGL 12.❑Roof repairs
insurance regtured:]`t"" c. 152, §1(4),and we have no
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.
IContractors 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 and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 tip 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 certi der t e pain a enalties of perjury that the information provided above is true and correct.
Si afore:-*
Date �-
Phone#:
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#:
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 le al entitS,or an 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 152, §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
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 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 odt 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 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 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 of permit to bum 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, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
THE t Town of Barnstable
' . p� ,,�..
P� o Regulatory Services
swxxsrAsiE, Thomas F.Geiler,Director
tFrias .
prFo.196 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: (/`� Q_ 9-6 e
JOB LOCATION: 41 )#Ir � k S f t e s
numlSrr street village
"HOMEOWNER": �I 17 t Q
aim ii t"lp `hhome phone# work phone#
CURRENT MAILING ADDRESS: 1 /-4t 14-c V Lim D� yC CV 9 6
�QG czrt° i? r� DIP, .
/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.
DEFINMON 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"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that.be/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
re ents.
Srgr>Ca re 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
PTI
HOMEOWNER'S EXEMON
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 l D9.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
ct work,that such Homeowner shall a as supervisor."
Many homeowners who use this exemption are unaware that they art 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 awars 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 fore /certification for use in your community.
Q:forms:homtaxem t
P
oTa�ti Town of Barnstable
Regulatory Services
KAsa Thomas F.Geiler,Director
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
0ffice: 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 application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit plea complete the
Homeowners License Exemption Form o e reverse side.
Q:FORMS:O WNERPERM ISSION
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