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HomeMy WebLinkAbout0186 BUCKWOOD DRIVE � _ - - - - ��� � �. '�f y �� � �� - _ _ �.r¢a��:. / � � s i I E Town of Barnstable *Permit �F TH Tp� Expires 6 months jrom issu ale ' Regulatory Services Fee BARNSTABLE, v MASS. Thomas F. Geiler, Director i639• �� AlED MA't A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY t Not Valid without Red X-Press Imprint Map/parcel Number Property Address 0 6 6'3Jr✓k uuo,3, <:t /7 ylf yes ✓�'1 ` �esidential Value of Work._" Ce)o t 6 Q Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address tom( 1'uwRtfF L410, rc0nFr f 01,02-0 Contractor's Name Telephone Number I tome Improvement Contractor License# (if applicable) Construction Supervisor's License# (if applicable) ❑Workman's Compensation Insurance ®PRESS PERMIT Check one: ❑ Lem a sole proprietor MAR 17 2009 1 am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must,be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [e"'IReplaceme Window / oors/ iders.U-Value i 3L (maximum .44) *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. zz of the Home Improvement Contractors License is required. SIGNATURE: Q.'WIN-I[.ISX.I ORMS\building permit forms\EXPRESS.doc Revised]00608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A1c 4f C"//; �T Address: City/State/Zip: y ,�,�s Phone.#: Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a y emp to er with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-tim.e).* have hired the stab-contractors 2.❑ I am a§ola proprietor or partner-' listed on the attached sheet. 7. QAtemodeling ship and have no employees These sub-contractors have g, '❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers',comp.insurance comp.insurance.# aired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.Mr 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 12.0 Roof repairs insurance required.]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. =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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.M 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 certify uirder the pains and penalties of perjury that the information provided above is true and correct Siggafore: f Date: Phone#: J- Yf3 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 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-contiactor(s)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 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. hi 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 io 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: _ The Commonwealth of Massachusetts"`— Dgpartment of ladustri,al Accidents 4ffee of Investigations, 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia I I r Town of Barnstable Regulatory Services r x.xucr.xr� Thomas F.Geller,Director rdnss Building Division �rED Tom Perry,Building Commissioner _..... .. . ... ..... ,_ ._...200 Main--Street,—Hyannis,MA 026-01 _...... _.._. . .. --- ..... www.town.barnstable-ma.us Office: 509-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': Eck l ����-l/, %^�//3- S,a-ad name home phone# work phone# CURRENT MAILING ADDRESS: cityhAm state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellinzs 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 Tpwn of Barnstable,Building Department minirrmm ' ection procedures and requirements and that he/she will comply with said procedures and require nts. Sigma ' 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 1 D9.1.1 -Licensing of canstruetion 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 arc unaware that they are assuming the respmsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awarcn=often results in serious problems,particularly when the homeowner hires unlicensed personm to this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is uhimatcly responsible. To ensure that the homeowner is fully am=of his/her responsibilities,many communities mquim,as part of the permit application, that the homeowner certify that hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a farm currently used by several towns. You may care t amend and adopt such a fa m/certification.for use in your community. Q:forms:homccxcmpt 4 zTti Town of Barnstable Regulatory Services �xxsrws[.� • y MAB& �, Thomas F.Geiler,Director Ei6 L 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.ba s a e rn t bl .ma.us Office: 508-862-403 8 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 please complete the Homeowners License Exemption Form on the reverse side. Q:F0 RMS:DWNERPERMISSION i ` TOWN OF BARNSTABLEBARNSTUL �7 / MASSACHUSETTS Solid Fuel Stove Permit ��2/9 DATE OF APPLICATION ...........'..`.............................................................. Pam'. ISSUING PERMIT ............................................................ NAME (owner) !: /J?z .11Q/.i��......Y=...... /. gk.V................... NAME (Installer) �<............................................................................................... ....................... h { ADDRESS ..`�.... .........AX&N.OD.............DR. .Ive...... ... ADDRESS (................................................................................................................. STOVE TYPE �............. .C�L� .5................................... CHIMNEY. NEW EXISTING ........ .... �................ Manufacturer .......................... .......................................... CHIMNEY: Masonry ...........��................................................................ Mass. Approval v................... ..L-..... `l Z.............................................. CHIMNEY: Metal ................................................................................................... This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ................................................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. I IssuedB r\ �14.r5..�.�,r-.....................................Title G y: ...........:..:............................... ............. ..... ......�.........��.......�...N��................. Date .........�/...�.Z...�� Permit to install expires 60 days after issue date Stove I�!-w C r;-s o L C i r^6 v L t ........................................................... ............................... .....��...................................................................................... ......... ...: Stove Clearance /2 .��� �` ,•e_�r� LeG ..... ....�.D.L�.... ................................ ................................................................�............./.... ................................................. lr.. Floor 14C_A % s f<i a La �..L l 14 L ).....�........�x.� T. .....�................... ................................C... Smoke Pipe �.J.e. .......... ................................................................................................................................................................................................................................. Smoke Pipe Clearance e... ................. '........L N ........ ! .... �+ - Chimney ............................................./. .``' ....................................................................................................................................................... .................................................... SmokeDetector .......................... ...................................................................................................................................................................................................................I.................. The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ..✓.................................................. has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ..... ................................................... Installer INSTALLATION APPROVED ............./....../.. .,1 ......... By: ... ..... . ........... Title: . ..L ....... dat ttlr��— WHITE: FIRE DEPARTMENT — CANA B ILDIN INSPECTOR — PINK: APPLICANT /A,ssessors Office(1st floor) Map ` / Parcel Permit# 1,2J��� Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) Date Isswd ./ Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Fee W,,5 6 0� Engineering Dept.,(3rd floor House# � BARNSTABLE. MASS. d 19 , i -• CEO IAP'�a TOWN OF'BARNSTABLE Building Permit Application Proj ct tree ddress ((1go(!16Doob hie` 1 Village oitvwl e7 Owner f G H A k D V_ I°�t N E IJ Address - Y "1�(0 EUC K c,0oe © vE Telephone 50Z —71i ;Permit Request r l5 Gi r v(e- b First Floor 1769 square feet t Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection ' Lot Size Grandfathered ? 'Zoning Board of Appeals Authorization Recorded Current Use Proposed Use r Construction Type Commercial Residential Dwelling Type: Single Family ✓ Two Family Multi-Family Age of Existing Structure 30 Basement Type: Finished Historic House Unfinished f Old King's Highway Number of Baths J No.of Bedrooms Total Room Count(not including baths) '7 First Floor Heat Type and Fuel 4A5 (— Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None I/ Sheds Other Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY _ PERMIT NO. - DATE ISSUED MAP/PARCEL NO. - ADDRESS' ' VILLAGE OWNER _ DATE OF INSPECTION: FOUNDATION FRAME I < INSULATION I - FIREPLACE f ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL r - FINAL BUILDING _ t � r 's DATE CLOSED OUT ASSOCIATION PLAN NO. TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION 1g(o r8Cr_k(,000_D DRIVr I7 Venn s. - Number Street address Section of town "HOMEOWNER^ ✓{1G�2CL/ I��n �.�/ 7 7S--aS3S Name Home phone Work phone PRESENT W ILING ADDRESS 19 o ;8UCe&joc, D Dk Vf- :�T•:_ ... QAiliS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupie dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor... DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re side, on which there is, or is intended to be, a one to six 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 Offic.- on a form acceptable to the Building Official, that he/she shall be responsil for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner^ assumes responsibility for compliance with the S� Building Code -aad other applicable codes, by-laws, rules and regulations. The un-dersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirement:; and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE w APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which,.- building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that. if Home Owner engages a person (s) for hire to do such work, that such Home Owr. shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for .licensing Construction' Supervisors, Section 2. 15) . This lack of awaren often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home"Owner- act as supervisor is ultimately responsible. W. To ensure that the Home Owner is fully aware of his/her responsibYhties,. m. communities require, as part of the permit aapppljLca tloii, thaz the Home Owner certify that he/she understands' the responsibilities of a supervisor. On .tl last page of this issue is a form currently used by several towns. You care to amend and adopt such a form/certification for use in your community. f edc,� /,5 pa. me/+ _ /,Ictl Ied ory la/211-71g5- a r /e &11191111ccc. ,OA ( /v4- AC A)c4co b y QceiGAll You- &6L"� V i 1 r Town of Barnstable Building Department Complaint/Inquiry Report Date: q 4 Rec'd by: Assessor's No.: s po Complaint Name: Location Address: (n f e, t1 M/P Originator Natne: Street: 1 J4 W 0,5 Le l e Village: `. 'c' l State: d Zip: O (0 4 Telephonc(�P, �✓ Complaint 1-7—F Description: I W °ice � ©1h `�!" l '(S' U C U 'C' �' r rp t\ C rC'(�� C � 'Sl�i 'rl �O-'�'CQI�e� �► t S'1 j Inquiry Description: For Office Use Only Inspector's Action/Comments Date: Inspector. Follow-up Action Additional Info. Attached Copy Distribution V G7ute-Depan=ent File I i!llory-Inspector „ r_ r'--t—/l7Ar..... r., nIT�P lfanavwrl fi I � a� �+TY �'�'.` 'fix � -�' � +�X.:-�'�>• 8 4�, ^ ` ( Y v I C ra r; ;al , µ i •LP �x lT . ITTM In It 14x36x WHY RENT? OWN A NEW GARAGE FOR UNDER $49O! I�`' �Q Motorcycles,Paintbooths,Docks,Pools, PROTECTION FOR: Cars, Trucks,Boats,RV's, Workshops,Government and industrial Contracts,Sandblasting,Greenhouses,Camp or III Temporary Shelter, Walkways, Hot Tubs,and More! µ-4 HEAVY DUTY,Galvanized Steel Frame. Durable Dupont d4F+ Cover with Zipper Door. Sizes available from 5'to 60' :- Wide, up to 30'High,Any Length. Withstands Rain, High Winds,Sun,Sap&Heavy Snow. Survived Hurricane _ Andrew and Tough Canadian Winters! Assembles and 000 Anchors Easily. No property tax and no permit required. .� _ , Covers last up to 20 Years. SHIPPED TO YOUR DOOR. Iz ; t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 7 Parcel Permit#Ilk Health Division Date Issued Conservation Division Fee S D Tax Collector CC- Treasurer O Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 18(0 SV GK coobb b9 116 Village I-IV AA IS � Owner t j o-hard V. ],�(naerjV Address /g10 l QCff QQ0 D !�U'�)v,_ Telephone (`�0�� '•75' a6-�;� P , Permit Request ,&'e /' ` 1 Tfla y Square feet: 1 st floor: existing S7'�'roposed 2nd floor: existing proposed Total hew Valuation 9-CO De //00 Zoning District Flood Plain Groundwater Overlay Construction Type C edd r 5h;- r le- Lot Size 10,3Q0 s1, Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Ur, Two Family ❑ Multi-Family(#units) Age of Existing Structure 35- i4+4 S Historic House: ❑Yes moo- On Old King's Highway: ❑Yes ff<o Basement Type: alfull ❑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 900^S new First Floor Room Count Heat Type and Fuel: 'lo as ❑Oil ❑ Electric ❑Other Central Air: ❑Yes Url o Fireplaces: Existing New Existing wood/coal stove: H(es ❑ 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 fr mr Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE V DATE ( c c 00o A FOR OFFICIAL USE ONLY w PERMIT NO. DATE ISSUED . MAP/PARCEL NO. ADDRESS, ��� � ` VILLAGE' OWNER > DATE OF INSPECTION FOUNDATION _ FRAME i INSULATION k FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 1 _ ti The Commonwealth of Massachusetts Department of Ind Accidents { _ OffICC OIIDY6'Sl%9811OQS 'd ` . ' 600 Washington Street Boston,Mass: 02111 Workers' Com ensation Insurance ATIdavit location' c *� hone# 6 O city mf all work myse"- I am a homeowner P orming in ❑ I am a sole proprietor and have no one ' i moo,%V.3300"////�/////1?/%/%// worlang an this job.: //// easatitan far my :.}:.:;.>:';.>}:.;::.::::?.::}'.}::.:::;:.:'..; workers �mP „,�,y:::}::}::.}.:::.: rma :.. rxww �,... ... I am an employer.�..::•:: ....: r...........::.....:::•::::..:::::.::•:.:::::...::.::.y:::::::::.�::.......:.:.�::::.:::.:......:.:.:.:.....::.:.:.:.:,..:..:.....:::.:;;.>:. }...... w..w.:. 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'::. i','s'wif v7i'%,4""/'I/si4,r ,I,J i / ! 56.66xnd� insurance co »;:: ;;.<;;:<:,.::::.... to s1s or of p�mltles of a Ema sup that s Failure to secros:coverage as required mtder Seetim 2U of MGL 152 eaa lead to the is the[tnm o[a STOP WORK���and a fiaa of 5100.00 a day against ma I understand one years'imptisomamt as weII as civil penalties ndpom of e w DIA for coverage vedflcation. copy of this statement may be forwarded to the OIDCa o[Inv than the information provided above is true mud corrcd I do hereby certify ep�*and enaida.ofPe� _ Data Signature Plume# D -7 75���j S Print name • or town ofSciai ofn ial use only do not write in this aria to be Completed by city Department permsillucense 11 [Budd qm Board city or town: ❑Lelen Selectmen's Oce ❑Sdectm , use required �g�th Department response checkif immediate Po - QOther Phone f!; contact person: i._vued 9/95 P1A) Information and Instructions on 25 requites all employers to provide workers' compensation for their 152 section Massachusetts General Laws chapter is defined as every person in the service of another under any contract employees. As quoted from the"law",an employee• of hire, express or implied, oral or written. corporation or other legal entity, or any two or more of is defined as an individual,partnership association, rP An employer including the legal represematim of a deceased employer, or the receiver or the foregoing engaged in a joint enterprise, loving employees. However the owner of a trustee of an individual,partnership,association or other legal entity, emp or the occupant of the dwelling house of dwelling house having not more than three aparmzeats who resides therein, �P grounds or another who employs persons to do maintenance construction or repair work on such dwelling house or on the building appurtenant thereto shall not because of such=*Joymad be deemed to be an employer. state or local licensing agency shall withhold the issuance or renewal MGL chapter 152 section 25 also states that every in the commonwealth for any applicant who has of a license or permit to operate a business or to construct buildings coverage required. Additionally,neither the not produced acceptable evidence of compliance with the msuran public work until shall eai,er into�,co�ract for the performance of p commonwealth nor any of its political subdivisions have ontra been presented to the cs^ acceptable evidence of compliance with the misuraz� authority. % 111210199092 Applicants Ple^_e fill in the workers' compensation along� y by checking the box that applies to your situation and nva�bers alamg with a certificate of insurance as all affidavits maybe suapiving company names,address and phone tS�confirmation of insurance age. Also be-sure to sign and ,zed to the Department of Indust _ location for the permit or license is sao be reed to the city-or app date the affidavit. The affidavit should _ Accide�. Should Y�have any questions regarding the`law"or if you oe�.ng requested, not the DCPt[W at the number listed below. to obtain a wort=' ce®pensa�P° 9�P the Department • i i/i are. - - //�i I,. RS 2 /� City or Towns . The Department has Provided a space at the bottom of the please be sure that the affidavit u�P�_� ��' �to y�regarding the applies• Please affidavit for you to fill out in the event the Office of nunnber. The affidavits may be rctathed i^ be sure to fill in the peanit/Iicense=Mber which wdlbe use ference d as a re the Department by mail or FAX unless other mrrangemmts have been made• ons would IOce to thank you in advance for youcoop�on and should you have any questions. The Office of Investigations nl,ea se do not hesitate to give us a call. ro j%01M The Depar ment's address,telephone and fax member: The Commonwealth Of Massachusetts Department of Industrial Accidents Otttse of Imtestlgatlons • 600 Washington street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 °F1HE r, The Town of Barnstable • BAMSfABM 9�A M6 S. �m�' Regulatory Services rEc►9. A Thomas F. Geiler, Director Building Division Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 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,onebut.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. 6l Type of Work: %G� // c5 � � Estimated Cos QQ�— )'l jog, —Address of Work: I g Ce f3 UeKtog L� LXiV,o;;—' 4 ya., ^S AA 0.1G,d 1 Owner's Name: Date of Application:—0'rJ ,apt a000 I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑B ing not owner-occupied LeOwner 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 -= A-CCESS 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. © T c aQdO OR V, Date Owner's Name q:forms:Affidav The Town of Barnstable °�mtO`'ti Department of Health Safety and Environmental Services Building Division snxxsrnsLe. 367 Main Street,Hyannis MA 02601 t►rASS. 9 i639. Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION Please Print DATE: Swj� QO 0 d JOB LOCATION: I 0 to &CKW 066 Dg/ V'E number street village "HOMEOWNER": eICA61tq V, �Pn�I�V �5t��� 77S-a535 (78�) 904P r19�D name h6me p—hone# work phone# CURRENT MAILING ADDRESS: I suCK 1000 D D R y �tf���li� ft`jA, 6a 0 ci /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,provide d 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"as 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. V. 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 to amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMPTN SHED REGISTRATION location of shed(address) ICchom( - o ffeaileH11 property owner's name size of shed I,Z�— � v �X-,-A 5� / signature dat Old King's Highway Historic District Commission jurisdiction? THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN shed LOT 11 o X � ti O O q4 I 1,20 00 , LOT 13 - RES. ZONE.- 'RC—I" This MORTGAGE INSPECTION Plan is For FLOOD ZONE- "C" Bank Use Only TOWN: �AVSTBLY _ _ REGISTRY OWNER: RICFIARD V KENNEDY DEED REF: CT.F_9d_351_ — _BUYER: REFINANCE _ _ _ _ _ DATE: 293 _ _ PLAN REF: 35404A=2 _ _SCALE:1"= _20_= FT. I HEREBY CERTIFY TO BA-YEA MQRTGA-GE AcQB'___ ----THAT THE BUILDING a��P y YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS a PAUL �� SHOWN AND THAT ITS POSITION DOES --__ CONFORM A. CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE MERITHEW N No. 32093 e 143 ROUTE 149 TOWN OF BARNSTABLE_____________AND THAT �G, o 9 �� �� MARSTONS MILLS, MA. 02648 IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD H ZARD �;�,,�fC'STE4 TEL: 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED_�19�B5 _ 003 C munit —Panel 250001 0005 C _ ___ THIS PLAN NOT MADE FROM AN INSTRUMENT 10571 DPG PAUL A.WERI EW P SURVEY NOT TO BE USED FOR FENCES ETC. L_