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0031 BROOKSHIRE ROAD
31 �ta.�dKsrt �R�. �oa� -- - - -- --- --- • • _• rw �• G � �-- - itsk4� 40 -• �rrrl 2 c,�1'fac�.� i • • � �ni� � n � �t� o cv 0 Flit SA71 r -ez) • &Jto o n,- - • .L } �• 4 t, } a t • 11� ± ri { •cam. ,.,,,° .`.....L ia, ix�5 -.f` { 1 t�.r ..ti...„J -1• e: 4��� '� w;?'`;1 �.. -�'.t�i-•• 7RR�---� "l i`_ �`"fi.� __ �r.`.�' S���e ti•��''�.,,,xa.�� �.1I ,� ,� �„,t*`��,f . 4L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma �,J p Parcel Application Health Division Date Issued" Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project-Street-Address Village�/,yJ/1 eOwne' Address -���Yl e Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay a Project Valuatioft Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ 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 (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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name,-- e TlhN umber, � 43 AddreVs�s`/61 fdY ( �Z IJl —License-#,/ 0 3� O HomeF+mprovement Contractor-#__.`6 6 rw Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE= lop _ � FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED MAP_,/PARCEL NO. ADDRESS VILLAGE OWNER 4 DATE OF INSPECTION: J FOUNDATION FRAME INSULATION { t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING_ : ROUGH FINAL E. GAS: ROUGH FINAL } FINAL BUILDING. DATE CLOSED OUT' ASSOCIATION PLAN NO. The Corrrmanicwtdth of UassachuselYs -Department ofhuhnfti l Accidents OTwe o,f Investigations 600 WaYIz zgfom&r'eet Bostan,MA 02111 YVf4 n ttiasmgoWdia Workel<-s' Compensation Insarauc kf'fidavit:Builders/Contractors/FAectricians/Mumbers Ap 'rant Inrmation 1 Ptease Print Legibly Nipfta ( Ofga All A8&e.s&-- K n1 CityIStatzIziD: 3 Phone;g7 7 - Are you an employer?Check the app:ropriaYe box: Type of. o ect r 1_WAS=a employer with �3' 4. ❑ I am a dal contractor and 1 6 ❑New construcbm employees(full andlorpart-time).* havehiredthe sub-contr&ctors listed on She attached sheet. 7. ❑Remodeling I El I am a sole propri�tar or partner- These sub-contractors have drip and have no employees . 8_ ❑Demolition w for me in an capacity. employees and have woricers' orking y 4_ ❑Building addition [No workers. comp:insurrar re comp-insurance.: retlwred_] 5_❑ We are a corporation and its 14-0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers hn'e exercised their 1I_F❑Plumbing repairs or additions myself [No workers'comp_ right of exemption per MGL 12..❑Rnof repanis c.1.52, insurance required.]I §I(4�and we hasm no employees.[No wmte s' 13_.❑Other comp-insurancenquired] *Any anpUcmt that c:herks box K mast also fill out the section below shawkg their workers'compensation policy intfltmadam_ T gameawners who submit this off davit abli at g they an doing all ual and then hoe outside coat mcrars moss subffirt a new affidavit mtriratina such. =Cant maurs that check this boa most attached an additions)sheet showing the name of the sub-==3ctors and state whether or not those emities have emplayees. Ifthe sub<ontmctors bare employees,they must provide their workers'comp.policy numher I am an employer that is prmidikg workers'congmLv atio.n insurance for my em pLoyem Belau is thepaYg and job site information- Insurance rt_ l ,��/� 4�� rfi Insurance Company Name. / ,/ ' U � — Policy g or Self ins_Lies t--� �� r 37U�1 6 l/3 Expiiztion Date: Job Site Address: 31 fJrtSl✓h i R City/Statelzip: Attach a copy of the workers'compensation policy declaration page(shoving the policy number and expiration date). Failure too 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 uzz;msaument,as well as cirri 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 insa ance coverage verffication- I dv hRr eblr caret trrder tka andponatties lrerjury that the inforrrrtttion pratrztiRd ubaue is true and correct Sitmattire: Bate- Phone 9F 64�16 3 1 O, trial use only. IM not write in this urea,to be completed by city or town ofrazaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Budding Deparhueat 3.Cityffowa Clerk 4.Electrical Inspector 5.Plumbing Inspector .6.Other Contact Person. Phone#: 6 Information and Instfuctrons Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an erxployee 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 Iocal 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 ceriiricatc(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 he sure to sign and date the affidavit_ 71ae 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 a out in the event the Office of Investigations has to contact you regarding the applicant_ Please be sure to fill in the permit/licease number which will be used as a reference number. In addition,an applicant that must submit multiple permitJlicense 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 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: ne Gommnnwealth of Massachusetts Depazt mcent of Industrial Accidents Office Of Investigations 600 Washington Street Boston=MA 02111 Ttl.t4 617-727-490O ext 406 or 1-7-I AS E Revised 4-24-07 Fax# 617-727-7749 w .mass_go-v=Idia Aco CERTIFICATE OF LIABILITY, INSURANCE DATE(MMIDD YVVY) o I THIS S 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 policy(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 ; P Y Y 4 certificate holder in"lieu of such endorsement(s). PRODUCER BRYDEN & SULLIVAN OF.DENNIS INC ._ CONTACT - - . PO BOX 1497 ..— -- SOUTH DENNIS, MA 02660 PHONE(A/C_No,EXc) J . . .. E-MAIL ADDRESS:----- "-- INSURERS)AFFORDING COVERAGE - INSURER A LM Insuran—ce L1__.____ INSURED INSURER B SHAYNE DEWITT --- — — — --- -- — -- -- ------ DBA ALL CAPE ENERGY INSURER PO BOX 1492 INSURER o. BREWSTER-MA .02631 INSURERS INSURER F COVERAGES ;,. CERTIFICATE-NUMBER: 17498492 REVISION NUMBER: THIS IS TO CERTIFY THAT-THE 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR I-- ----- :.ADDL SUBR ---------�--- ------ POLICY EFF POLICY EXP —_-- LTR I TYPE OF INSURANCE INSR WVD - POLICY NUMBER MMIDD/YYYY MM/DD/YYYY a LIMITS 4 •' GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED - - _ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR - MED EXP(Any one person) $- --- I—' --- rso — -- h PERSONAL&ADV INJURY $_ GENERAL AGGREGATE $ I`GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ I--- -- LOC PRO- - - -- --------- ----- ---- P $ OLICY AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT - Ea accide�__ $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED +,SCHEDULED AUTOS. _ AUTOS BODILY INJURY(Per accident) $_-_ -_�, --- NON-OWNED PROPERTY DAMAGE HIRED AUTOS I_.. AUTOS _. _(Per accident)_, $ $ UMBRELLA LIAR I OCCUR -.y - EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE I. AGGREGATE $ ( _'--- J----- i --- ---- DFD --;RETENTION$ WORKERS COMPENSATION, WC STATU- 0j,�i- • "` A WC53�1 S-378516-033 / 3/7/2013 9/13/2014 / I TORY LIMITS l__�_tK _ AND EMPLOYERS'LIABILITY YIN - --- ANY PROP RIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $ 5���0� ; OFFICER/MEMBER EXCLUDED? N/A ; (Mandatory In NH) • ,'. E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below i I r' E.I. DISEASE'-POLICY LIMIT 1$- 500000 • I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,.Additional Remarks Schedule,it more space is required) Workers compensation insurance overage applies only to,the workers compensation laws of the state MA. THE WORKERS'COMPENSATION POLICY:DOES NOT PROVIDE COVERAGE FOR SHAYNE DEWITT. CERTIFICATE HOLDER CANCELLATION) 4_ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE, THE, EXPIRATION. DATE THEREOF, NOTICE WILL BE- DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. .AUTHORIZED REPRESENTATIVE Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i7an^as G. 1 ._ cer--L.tca�e'caccels Incne super,:aa.. .L�previ.ously issued cert:.iE:i-cares. Housing . Assistance �► Corporation Cape Cod HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: i PLEASE FILL OUT AND SIGHT THIS. FORM IF YOU ARE / THE APPLICANT HOME OWNER. hereby consent to and agree that .I weatherization work may be done by the Weatherization Program of Housing Assistance. Corporation ( herein after referred as Agency" ) on the property located at: 3{ Q N 1-, Sh:tD 3r� s The weatherization. work done will be based on,programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping .& caulking of windows and.doors, insulation of attics, sidewalls & basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.. in consideration of the weatherization work to be done at my home I agree to the following: I. I give permission to the "Agency " its agents and employees to travel onto or across said property with such equipment and materials as may, be necessary to perform weatherization work on said property. 1 2 . The Housing Assistance Corporation reserves the right to inspect the fuel ,or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is-'completed.. I have read the provisions of this agreement as listed and freely give my.consent. Home Owner: (Signature) ZZL I Date: f i .1 d 4 Agent: (signature) Date: oF�ram, * * R"NSr"LE, ' ,�� Town of Barnstable Alfp Mp'�6 'Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 "�..�~.Property Owner Must Coinplete and Sign This Section If Using A Builder R - 4 a , as Owner of the subject property p rtY r hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: Sh./f e f� (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable Regulatory Services IHE r Richard V.Scali,Director Building Division '* anEuvsrnsr s Tom Perry,Building Commissioner 9� MASS, 200 Main Street, Hyannis,MA 02601 prE° �A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/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 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 he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature 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 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. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Massachusetts -Department of Public Safety - '�`!`. .Board of Building Regulations and Standards Construction Supervisor Specialty. License: CSSL-103842 SHAYNE DEWITT` I 161 Commons Wad ; Brewster MA 02631 A 1� �` Expiration 02/23/2016 Commissioner $ f 4�;ysQ- .: Office.:o onsutner f airs mess egulatiop: r Y HOME'IMPROVEMENT CONTRACTOR �/q 5 Registration 166888 Type. a Expiation �9),2014 rDBA AL PE 9NER( MINr � iO4 . X k;4 SHAYNE DEWITT`` v 9 CHASE LN. / ORLEANS, MA 0265$` 1�£l Undersecretary h l t5 .. 9 Massachusetts -Department of Public Safety 1 b . Board of Building Regulations and Standards • � I Construction Supervisor Specialty License: CSSL 903842 IS SHAYNE DEWITT` 161 Commons Way } I Brewster MA 021r31. I ��•!..� ,ria��' Expiration Commissioner. 02/23/2016 .'. i License or registration va'hd for indrvidiil use only before the expiration date If found return toz Office of°Consumer Affairs and Business Regulation a 10 Park Plaza Suite 517.Os ,, `. Boston;'1kIA 02.116 v` ~'-'Not v lid without signature a * dt a�a'utS3A1 �asfla5Fsrr TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map S2 Parcel Application# 0 66"2 i t�3_ Health Division Conservation Division 7� Permit# Tax Collector Date Issued v-1 Treasurer Application Fee 510 PlanningDept. Permit p Fee � Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 31 RDoks set i2D _ W U3 An a�S Village ���nS ►�6i Owner V = S 2' � - Address 3 '2 'S R e1`. CND ,Sk �tSL 9 nn Telephone 130T- I -R 2,-78 Po box 21 q S Permit Request up J Fri V-S PA+h RM �1`�a�cy; S, Mq Square feet: 1 st floor:existing I ZQ proposed 2nd floor:existing Z 3 3 proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 6')p Construction Type Lot Size C) Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family M"' Two Family ❑ Multi-Family(#units) Age of Existing Structure 57 Historic House: ❑Yes 2flo On Old King's Highway: ❑Yes L9/No Basement Type: &Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) o9 J O Basement Unfinished Area(sq.ft) 3 30 Number of Baths: Full:existing ' new Half:existing new s Number of Bedrooms: existing new Total Room Count(not including baths):existing `7 new First Floor Room Count Heat Type and Fuel: ❑Gas Ybil ❑Electric ❑Other Central Air: ❑Yes YNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes YNo Detached garage:❑existing ❑new size Pool:Coexisting ❑new size 4 ' Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:C(existing ❑new size V 0 4 Other: r -,s Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ ' F Commercial ❑Yes &INo If yes, site plan review# Current Use Proposed Use i // BUILDER INFORMATION — { Name 8A ctC.p � �N �� F`S/ems✓ Sew✓ Telephone Number Address a�� 7 L+ -e— A✓q License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE t FOR OFFICIAL USE ONLY • "PERMIT NO. DATE ISSUED ^"' MAP/PARCEL NO. S ADDRESS VILLAGE, OWNER DATE OF INSPECTION: FOUNDATION +� FRAME D�- ' d 7""d 7 Pk- INSULATION �" C>_7 E FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. J r I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111' wtivw.mass.gov/dia ' Workers"Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Bus' s/Organization/In�7 dual): G K to P 2 ��G�/l �`5" �-✓.S' -"� A-4) City/Sae/Zip:` /� 2 0. Phone.#: Are you an employer?theck the appropriate bog: :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).* • have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the*attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have 8. �]Demolition Dworkin for me in an capacity. employees and have workers' g Y P tY• 9. Building' addition [No workers' comp,insurance comp,insurance.$' 5. F � We are a corporation and its 10.[]-Electrical repairs or additions ,�_ re ui`red.] .- officers have exercised their 11. Plumbing airs or additions ' ' 3� am=a-homeowner doing_all work . g repairs right of exemption per MGL [No yself,_ workers comp, 12.❑Roof repairs c. 152, 14 , and we have no insurance'fe aired tom- § O 13.� Other 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 Horneowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. r 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: lob 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 e. 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 maybe forwarded to the Office of Investigations of the INA for insurance coverage verification I do hereby certify under the ains an 'es of p ry that the information provided above,is true and correct.. :;> �Si ature: - — Phone#: Official use only. Do not write to this area, to,be completed by.city or town off ciaL City or Town: .Permit/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector . 6.Other Contact Person: Phone#: 1 Informationanct 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 producedtacceptable evidence of compliance with the insurance coverage required." Additionally,MGL ehapter..152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the perforance of public- until acceptable evidence Gf�conZpl aaee with the insurance m requirements of this chapter have been presentedto 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-contfactor(s)name(s),address(es)and phone number(s)along with their cerdficate(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 pemut.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are regiured 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 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 maybe 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 fo any business or commercial venture (i.e.a dog license or permit to bum leaves-etc.)said persona 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' o not hesitate to give us a call. The Department's address,telephone-and fax number:. The CommonwWth of Mmsach tts Nparbmemt of WwWal A.eddmts ' Q .ce of Investigat alas 6.00 Washingtofi Street Boston.,.MA 02111 - Td.#6,17-727-000 ext 406 or 1- MAS•SAFE Fax 4 617-727-7749 Revised 11-22-06 WWW.MaSS.gOV'/dia . T3iDle JSZ3p(CGa�IltAef� , Prescriptive Pacicsges for due and Two.Fsxuk Resldcatlsl Ea1lrPln.p'Hested w'itb•1Vall•F Rats 1►fA�Cf141I1hI minimum Glazing Gluing Ceiling Wall Floor B33amrai Slab HeatinglCoofing Arca'C/a) U-vulue= R-vatuel ' R-vsluei R•Yalue° Wau pmimeier EVJFmcat Rmcicncyr Pam, ge - R-values R-Yslue� 5701 to 6500 Heating Degree Dars' 0.40 33 13 19 10 6 NartasI 1; 12% 0.52 30 19 19 10. 6 2+losssal 5 12r. 0.30 31 13 19 10 b 1S�F'IiE T 15, 036 3i 13 25 NIA NIA. �domusl ' 1 j 15°l. 0.46 3S 19 14 10 b Normal 15% 0.4.4 31 I3 2S NIA' NIA U AFUE p� 13% 0.52 30 19 19 10 8 U AFUE ' If°/. 032 34i • 13 ?g. NIA NIA Norval LZ M. 0,42 3: 19 25 NIA NIA Normal 13% 0.42 33. 13 19 16 6 90 AFUE 1"0'/° G30 30 19 19 10 6 97' AFUE 1, ,ADDRESS OF PROPERTY: 2, SQUARE FOOTAGE OF ALL EXTERIOR WALLS: r 3, SQUARE FOOTAGE OF ALL GLAZING: 4, %GLAZING AREA.(#3 DIVIDED BY'42): 5. SELECT PACKAGE(Q AA-see chart above): NOTE.. O MORE INVOLVED METHODS OF DE i'�ERMIN�tG El ER THER GY REQUIREMENTS ARE AVAILABLE. ASK.US FOR THIS RUORMATION. BUILDING INSPECTOR APPROVAL: YES:. NO: q_farms-f3S0303a f - °FTME� Towns of Barnstable yP °� Regulatory Services STAB " � .Thomas F.Geiler,Director 9 lY1AS5. g, 1639. ,` Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 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:_A tL,6 4 4-1 Estimated Cost Address of Work: t IZ (1 D D Owner's Name: 12 l•( �' e. �'l /L Date of Application: q 2 6 o 7 I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 OBuilding not owner-occupied Mwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MROVEMENT WORD 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. O Date Owners Name Q:forms:homeaffidav Town of Barnstable yP�DF'1ME Tp��O� Regulatory Services BA Thomas F.Geiler,Director STABLE, 9 MASS. 039. Building Division rEo � 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: 2 w 4 JOB LOCATION: 12 400 � S 4 r/t. C number street village W"HOMEONER": #1 (:2 //t/ 7 --7 7 3 name home phone# work phone# CURRENT MAILING ADDRESS: �© o d k ;Z 5 city/tov,6 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 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 Leements. Signature of cmeowner 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 . 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. Q:forms:homeexempt 3 �� 04/27/2006 referred to public hearing on 05/11/2006 05/11/2006 referred to a workshop on 05/17/06 TOWN OF BARNSTABLE SIGN PERMIT PARCEL _ID 328057 GEOBASE-_ID. _ 2443-5 ADDRESS 31 BROOKSHIRE ROAD PHONE Hyannis ZIP . - LOT 31 BLOCK LOT SIZE IDBA DEVELOPMENT DISTRICT HY PERMIT 15822 DESCRIPTION SCULPTURE CENTER (20 SQ.FT. ) PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $25.00 BOND $.00 Ox CONSTRUCTION COSTS $.00 �T Qi► i 753 MISC. NOT CODED ELSEWHERE a BARN3PABLE, +' MA$S. OWNER HENNESSEY, JAMES 639. A� I ADDRESS 31 BROOKSHIRE RD ED MIS HYANNIS MA UILDI DIVIS N Y DATE ISSUED 06/12/1996 EXPIRATIOWDATEa a e own ot barns a -ernwt no. Department of Health, Safety and Environmental Services RANNEAMMBuilding Division aatt• �9� 367 Main Shret,Hyannis MA 02601 Application for Sign Permit ' Applicant: Assessor's no._3,,�g - o� Doing iness As: Iz. Tele hone �CQ ' �� 5 Bus .5 13/ Sign Location street/road: Zoning District Old King's Highway District? - yes no c/ Property Owner Name: Telephone Address: 19 J �e L4, Village Sign Contractor ? Name: Telephone I . Address: Village Description Diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new sig to be drawn on the reverse side of this application. Is the sign to be electrified? yes no (Note: if yes,.a wiring permit is required) I hereby certify that I am the owner or that I have the authority of the owner to make application, that the information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinances. G '3 Date i re of Owner/Authorized ent Size (sq. il.) Permit Fee Sign Permit was approved: disapproved: - - �� Date Signature otBuilding Official r Town of Barnstable 'THE Regulatory Services F Tn 4% Thomas F.Geiler,Director Building Division BARNSTABLE, v� MASS' $ Tom Perry,Building Commissioner .s6gp �0 iOrED 39 A 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ax: 08-790-6230 Approved:_ Fee: y x Permit#: HOME OCCUPATION REGISTRATION Date: S—A>e Phone#: c Address: IF/ &elJ k1 XLr kc,�2 Village: ,t/'%yMA-4-' "Name of Business: Ti ,/�-� G! , rA Type of Business: La-* ` - �" Map/Lot: 1 ( -057 rl. INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall.not be.discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. -- • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be- - included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned, ve read and agree with ove restric ' for my home occupation I am registering. Applicant- Date: - -0 Homeoc.doc Rev.5/30/03 TO ALL NEW B SINESS OWNERS DATE:-/.,2 Fill in please: 7 ` YOUR NAME;,! //i APPLICANTS �� � �, �� �� ` BUSINESS ��� ,� '$` YOUR HOME ADDRESS:_ TELEPHONE Tel hone Number Home S"o - NAME OF NEW IN BUSESS �.�}vl�-. t ' �� TYPE OF BUSINESS`S IS THIS A HOME OCCUPA 77 TION? Have;you been g ven approval from e'buildng,dvisi YES NO 1AD00;SS;OF BUSINESS lQ f'1 MAP/PARCEL NUMBER 0 � When starting a new business there are several things you must do in Mer to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below, you may apply for a business certificate at the Town Clerk's Office (Ist floor- Town Hall) or if you get the business certificate first you MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDING COMMISSIONER'S O I E This individual hat' b 41 infor ed n req rements that pertain to this type of business. QAdfK01riVffSignature* COMMENTS: 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: 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 get that through completion of the processes from the various departments involved. *"SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY. d k. c L . v � r � r tea �Y p