HomeMy WebLinkAbout0095 CARLOTTA AVENUE ll'�5 �.92L 0 �A /-711
Townof Barnsta1bl�.,.r."'-"";gr•^r�,� a _.: -... . , ..; '.'! �'"a�, e .�j.�� .�..z-::tea-f ,,.'°� �:4*-v+:, �.�•a�..,� u �n
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r@O&tTI1�s:.CardlS.tt-That�t.:Is:Ytstble. rwlcn tbd.StreeL��LK vd�P.lans_Must be.,Retaln d on.•Job,.and this.Cafd.11llust be.Ke r ;sT.. .� � _. �" '..' F't'." tp m3>�.. ' ..�' ' .a.�" :"� „3,.?: , `" �^ #,v. y4-w.,„,�` x,.,, ��� .� ;-,`«y+!,�ww .',� ra,{ess�a.� ➢ ��. �' ;�?:rx
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, , � ::_ 'W.._ s_@gar. . ti at _of_l�Jc..0 .a.. ..s.Re. ut.,ed•�such B�nldtr� •shall:�Not•beOc�u �ed:.until�-a,Fm�1>ans ection.has;been.ma e.. ,.,. .. _ �.���#� �' ...
Permit,No - B7 2-1180 Applicant Name RONDINELLI BRUNO&VITTORIA
Approvals
Date Issued.- 07/24/20i7 Current Use Structures
Permit Type. `Building'-Addition/Alteration-Residential Expiration Date t 01/24/2018 Foundation,
Location: 95 CARLOTTA AVENUE,HYANNIS. Map/Lot: 248-231 Zoning District: RB Sheathing:
- -- - « .. ,
Owner on Record: RONDINELLI BRUNO&VITTORIA �
or Contract Name: Framing: 1
Address: 231 SUNNYSIDE ROAD r `m ContractorLLicense 2
: � ..,. .
NORWOOD, MA 02062 I ; Est Project Cost.- $1,000.00 Chimney:
Description: Box in BulkHead Permit Fee: $85.00
Insulation:
Project Review Req: Box in BulkHead
Fee Paidc` $85.00
Date. 7/24/2017 Final:
Plumbing/Gas
' -4
Rough Plumbing:
l` Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within siz months after issuance.
'All work authorized by this permit shall conform to the approved application and,the approved construction documents#or which this permit has been granted. Rough Gas:'
Allconstruction;
a c. �; .r
and Chan es of use of an building and structures shell be in compliance -
g y g with the local zoning by laws and codes.
�,. �. - � �, _ _ �Final Gas:
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
f
work until the completion of the same.
-` "--- - Electrical
The Certificate of Occupancy will not be issued until all.applicable si natu'res by t and Fire;Offiaaln sare provided on thais`Permit.'
Service: .
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing Rough:
2.Sheathing Inspection - -�- �r .,� : «, :- •, "'
3.All Fireplaces must be inspected at the throat level before firest flue lining.is installed Final'
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation -
7.Final Inspection before.Occupancy Low Voltage Final:
Where applicable,_separate permits are.required for Electrical,Plumbing,and Mechanical Installations. Health ..
Work shalE not;proceed until the Inspector has approved the various stages of construction.,. -
Fi_nal -
Perso co.,tracti . rthunre Istered:contractOrs:do.noth ve.zi ssto the uaran fired asset::ferth in IVIGL:c:142A
g g g ( )
;....-
_. , .:-• - _ ..
Fire;Department.`
} Building plans'are to be avai.lable on site -
Final.
RECIPIENT-
All Permit-�Cards are the property of the APPLICANT;;ISSUED
k� _.__
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
A. Map Parcel Application #_W_��
Health Division rk Date Issued
Conservation Division Application Fee
Planning Dept. °Permit Fee
Date Definitive Plan Approved by Planning Board
h�
Historic - OKH _Preservation/Hyannis �t
-Project Street Address,/ 5 _Ag L P rixi
!Village �LNIV% g
GOwner �-`' &ND I NF_ C G/Address �.�i� 1.1� 7�z/� �f4)
Telephone
Per tim Request /I J/t t1111 ( D ND 1 N!-L L/
12 d)e I<L/ x4
l
Square feet: 1 st floor: existing proposed 2nd floor: existing' proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation / • 0 00. 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: M/Gas ❑Oil LY's/Electric ❑ Other
Central Air: M Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 9'No
Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑existing ❑ new size_
Attached garage: existing ❑new size _Shed: ❑ existing ❑ new size _ Other:
I
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 C 0 D/ = C I Telephone Number 21?5"
-Address., " I5 License #
Home Improvement Contractor#
Email Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE- A4_v9 1 �,� � —DATE .77 // II?
FOR OFFICIAL USE ONLY
APPLICATION #
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
r GAS: ROUGH FINAL
FINAL BUILDING
E
r DATE CLOSED OUT
r
I
ASSOCIATION PLAN NO.
T�i�Co�rnarr�ea�t�,�Fsrfc�rusetfs - - - .
D�pa rknent gfrurlrrstrialAcciaferrts ,
Office ofLnveigafions
600 Washington Street `
Boston BastonAM 02111
' tvFvxun�as�grrnla�ia
a-rbers' CcimpensafimnInmr2nceAfEdzv t B�mlder-lCuntrachwslE ecEdcians/Phmihers
AmUcard Infam &n Please Fi int
is Phanc-, / - . S— d7
Are you an employer?Cheekthe appropriate ban ' T of o'ect r
L❑ I am a 1 with. 4. ❑I am a general contractor and I l e ] ( e4ica
employees(fisll andfor pat-time,)'
art-time * lime]siredffte suit-corm 6. ❑New oans5 tiaa�
2 lam a sole prupFietaff or partner- Tisted aathe.attached sheet. I- ❑Re odaImp,
Them sub-contractors ha e
s11pp and have ao employees $_,❑I7emalilzoa
-worldn,cr, Exim is any capacity employees andhate wodrs' 9. ❑Building addition
tV UL 0M& camp.finumace comp-im3rarI 1 .
r am 5- ❑ re:We a a em �:r�1 pordicaand its 10 Elel- repairs.or aaidifions
J4I ama homeovmer doing aft work officers have e=cised fheir I❑Plumbingrepairs or additions
myself No wo=ksrs' _ zigh of exemption per MGI. 1
innum eereqed]i c-152, §I(4k andwehaveno 13-El other pairs
employees. No wo&e&. 1 -�Other
comp_inm rranm required-j
"Any a Kcznt&acched3vaxIFltm�aLsasnauE��sechnahe3�tws�asiagaieirwodcc�'comp�atinupar�egi�nrmssiaa ;
73amenvrassvrhusubmitdaisAda«indZtrliugtLvyax�dai¢ga1Fwa�saddiffihaEautriderr�,rare,.zamctmbm3ta3emaMdx&iadirvA, sach-
ICaatixeto6lhxt checY�s box mast attached ffi sddiS�al sit shncrirg theme of the snb-ca�cto-a smd s��,rhether ornatf6nse emitieshac�
employees.Ifthesuh-caatrat�sbace emgIof�s,they�stpmtide Y�.eir zsnrke�,'comp.palm aumbcr_ -
I atrt art erlep�r flea!;is prauidin�warkcrs'eaatpertsrdrtfire ir�stirar�e,jvr m}*empla}�ees ,Satoav is TJre pafiey rr�d job aura
informatmn.
Insurance Company Name:
Po$cy 4L or pelf-ins Zio_ E�cpi uDate:
Job%te Address: City/Statet a:
A torch 2 copy of the warkere compensationpolicy declaration page(showing the poficy,number and expir-ation date).
Failnre to secure coverage as required under Section 25A of MGL c�1572 can lead to the imposition of criminal pena2lies of a
fine up to$!,SOD OU and'ar one-year imprisonment;as well as civil peuahies im the form of a STOP WORK ORDER and a fine
of up to$250-00 a dap against the violator. Be adtised that a copy of this statement.shay be fDrwarded to the office of
Investigations of the DIA far insurance coverage:v-edfication.
Ida her-eby cat*b,ands`tha pains and iahres a.fFet xcx�'t7�af f7Eg uc;€orrizattmrgrm rLtfd a�a�na i�bars Id carrect .
phone ik
t Dkhd use wr£y. Do not nuke in this arva,to be cmn-F&sd by cifp arteiin ajokiet
City or Town: PermifIcense#
Issuing Aatwr€ty(drde one):
L Board of ffealffi 2.Buildmg Department I fftyfTowa Clerk 4.Electrical Imspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
formation an' d InstructiOULS
h&,sS7�- Gebaal Laws ffiapter 152 regmes all MaPIop='Eo Prude work'=13P for their employees.
Pmsaa]tto this stag,an ea TIDY,=is defn,ed as¢:evMypeasdnin.Ih0 service of der uader a y bract ofhfi ,
empress or implirA oral or Via."
- assoGrafron,corporAion or ofher Iegal entity,or�Y o or more
Azz�rrpioyer is d�f5ned as as m�idual,P�ei�,
of the foregoing aged is a Joint ease,and inchidmg$ie legalese�afrves of a deceased employes,or the
r=erM
or tzastee of an fiLffVidMLl,P iP,association or other Iegal entity,employing emPlnyees- Mwever fha
owner of a dw Ong house havnog not more tlan fi=apartments and who resides therein,or the Occupant of the-
dwelLmg housa of another who employs pesons tD do maintenance,rnnstac(i on or repair work on such dwelling house
or on.thD grounds or bu11dmg appurten t e rto shall not bmanse of suede employmrot be deemed t o be an employer."
MGL chapter 152,§25C(6)also staffs ¢every sib or local Hcemdmg agency shaR wif hold•fie issuance ar
renewal of a ficeuse or permit in operate a business or to contract buildin.Lm is the c oramonwealt h for any
applicant wb o has not prodnced accepta-ble evidence of compU nm Wi&the ft=ranca r-ovemge regnkrd-
Adcfidonally,MCH- 52,§ _ o political subdivisions shall
iu£I 25 states fiIerthertlie nor any fits
cuter into any conjract feu the prance ofpublic work affable evidence of comPliancewifh the insurance.
rec,==erdsoffinisrjaptrahavebeenp=e:nfe:dtDthemnfractmg.anfloi
A-pplfcaats
Please fiIl out the worlo'as'compensation affidavit compIctr4y,by cherlffig the boxes that aPPIY to your situation and,if
neces5', PPh'sub-cor()nams address(es)andphone nnmber(s)alongwILtheircertifcSte`(s)of
s), s withno employees other than the
�¢m1ce. Lmmifr-dUabMty� �Pes(LLQ orLmait, &IiabtiityP )
members or parbacm-,are not rt quimd to cmy workers'coupeusafian insurance. If an LLC or LLP does have
=pIoyeers,apolicyisr - BeadyisedlhattlhafxdayitmaybesnbmifSi--dinthrDepa-fineatof Tndvsttial
Accidents for confirmation of msmance coverage Also ba sure to sign and date ire of davit The affidavit should
forthepermitibi sted no t Elie De
beT-�traned to tho city or town flat the application partment of
n T A cm e,t� dYOU hm My qn's;ons regardmg the hrw or ifyou are reed in obtain a wor3rs'
compensation policL please call the Deparimezt at tbe:number listed be.IDw- Self-insi companies should eater their
s elf-insurance Iicrmse number on the appropriate lime.
City or Town OfficiaTs
r
Please be sure that the affidavit is complete andpriated IegibIy. The Department has provided a space at the bottom
aaiinnchas to conactyou regardmgthe applicant
of ih e affidavit for you to fill out in.the event the Office of Investi�
Ple urease be s to f ll is the pennWlicense nznnber which will be used as a reference number addition, apph�t
that must submit muliple pe•®WHcen se applications in any given year.need only submit one affidavit md=ting=cut
p olicy i fomation.Cif necessa ry)and under`Tob Sit=.t4-ddrese the applicant should write-all locations n (may or
town)-A copy of the-affidavitthat has begin officially stamped or madce=dbythe city or town maybe provided to fhe
applicant as proofthat a valid affidavit is on file for fatre permits or licenses Anew affidavitmust be f (-&out each
year.There a home owner or citizen is obfaiamg a license or pmmlt not related to any bn mess or=M=al 76ut'n-0
Cio-a dog license or permit to bum leaves etc.)said person is NOT rcqaired to complete this affidavit
The Office of Inv dg inn S would like to thank you.m advance for your cooperafion and should you have any gn ztions'
please do nothcsrftate to give us a cal
The Deparbnm's address,telephone and fax member_
T f�aMMM ttiE of Massachuseft, '
.' _ �c�fialAccldent� •
fora of D, gatio=
• �4�a�m�an S
1 ,MA RI11
Tel.#617L- -4 uxt 4-06 car 1-�8-77 MA SSAFE
Fax#617 727 7749
Revisexi¢24-D7 - wW - -gpv
Town of Barnstable
Regulatory Services
�'THE t° � ; Richard V.Scali,Director
Building Division
a.�xer.xrL4 : Paul Roma,Building Commissioner
nsass.
200 Main Street, Hyannis,MA 02601
'°moo www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
JOB-LOCATION: 1 Y CA d L D 2nd _041z. W� "q/y N
number street village
"HOMEOWNER":4Azzz& 901Vz)1&,61_ L i
name home phone# work phone#
CURRENT MAILING ADDRESS: `2 3 [/ YC',I'VN l/,cl
MJ4
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 strictures. 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.
ignature of Homeowner .,r
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
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:\WPFILES\FORMS\building permit formAENPRESS.doc
06/20/16
Town of Barnstable
Regulatory Services
szirt
Richard V.Scab,Director. "
��� Building Division.
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.mans
Office: 509-862-403 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 tbis building permit application for.
(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 "
QXORM&OWNEUERMSSIONPOOLS
Shea, Sally
From: Rosemarie Spada <rosemarie.spada@yahoo.com>
Sent: Friday,July 21,2017 8:42 PM
To: - Shea, Sally
Subject: Bruno Rondinellir 5 Car_lotta Ay
Attachments: IMG_0370.JPG; IMG_0371.JPG; IMG_0372.JPG; IMG_0373.JPG; IMG_0374.JPG; IMG_
0375.JPG
Attached please find the pictures of Bruno's enclosure for his.bulkhead. If you have any ,
further questions or.needs please let us know.
Rosemarie Spada
781-856-5072
rosemarie.spada(a-)-yahoo.com
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Citizen Web Request Page 1 of 3
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Logged Ian
lin Citizen Request Management Monday, Octob
TOWN\wadlinge Request �Y�
Route to Users Search Requests Create Requests
Request Information -
Request ID: 21371 Created: 10/15/2007 3:19:07 PM
Status: Assigned To Staff Assigned To: O'Connell, Timothy
Health Office
Anonymous: No Request Category: Chapter 170 : HousingOvercrowding - Night Only edit
Estimated 10/17/2007. Change Estimated S October 2007 Nov
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
30 1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 1 25126 27
28 29 30 31 1 2 3
4 5 6 7 8 9 10
Created By: Wadlington; Ellen Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor Tom McKean Request
DETAILS: 200 MAIN STREET LOCATION: -95=CARED fA AVENUE
(HYANNIS) Hyannis7Ma02601
Hyannis Ma 02601
Request Parcel Number
Too many`vehicles and too many Map: 248_3 Block: ?31 j Lot: 000
people. Vehicles parked on lawn.
Large dump truck parked on laws. Parcel_Lookup,
Appaently there are several homes on
this street with similar issues. Tom .
Geiler asked that this be put on the
http://issgl/intemalWRS/WRequest.aspx?ID=21371 10/15/2007
Citizen Web Request Page 2 of 3
next night or weekend inspections
and send him a report.
Email:
Edit Re uestor Information
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Request Work History: Internal Note History:
System entry on 10/15/2007 3:19:07 PM:
Assigned to O'Connell,Timothy
System entry on 10/15/2007 3:20:05 PM:
Related Request 21372
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* Response time: Measured from the creation date to your first actions on the request.
* Do not include nights, weekends, and holidays in response time for most departments.
r Save changes Check to notify town employee below
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c, Save changes and notify F-, to review this request.
citizen* Health Office ;'
G Close request and notify citizen* IAgostinelli, Joan
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http://issql/intemalWRS/WRequest.aspx?ID=21371 10/15/2007
TOWN OF BARNSTABLE BUILDING PERMIT.APPLICATION
P
ap Parcel ,` Application #
Health Division Date Issued I
.:. P —
Conservation Division =, Application Fee
Planning Dept. Permit Fee
t
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Sttregt ddress
Village VA C,Vd�\ (-1\c, -
ci
wner� C� r Address
Telephone \ , �� 1j G��w \
Permit Request �Jl (Y1k ,1+ - rV132r�f�7yy� ri ��c YYI�-�
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S uare feet: ��t floor: existin ro e n oor:.existi ro os Total new
Zoning District !! Flood Plain - Groundwater Overlay
Project Valuation- �-��� 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 s
Total Room Count (not including baths): existing new First Floox.Room Co► t p
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal s ave: UYes ❑ No
Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: 0 ❑gev size_
t rn
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) _ _ _
j
e�J >-� \ G , . mot' pTele hone Numberess C C�.��Dc�_ L � License #
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
t�
SIGNATURE IX/1, Ch x 62M DATE
F
: FOR OFFICIAL USE ONLY
E .APPLICATION#
i
t
DATE ISSUED s
MAP/PARCEL NO.;
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
.. FOUNDATION,
FRAME
INSULATION;-
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
y
GAS:- ROUGH FINAL
:FINAL BUILDING - =tf 7L-�
x ,DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111 i
www-mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A Plicant Information Please Print Legibly
1
1 sine (Business/Organizafion/lndividm�; C
Address: C cf1 .
City/State/Zip: Phone ------------
#: -
�`Ai a you an employer? Check the appropriate box:
4 I am a Type of project(required):
1.❑ I am a employer with ❑ general contactor and I
employees(full and/or part-time),* have hired the sub-contractors 6. ❑ ew construction
2.❑ 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
working for me.in any capacity, employees and have workers'
[No workers'comp. i suMnce comp.incr�nce.t 9. ❑Building addition
��quued] 5. [] We are a corporation and its 10.[]Electrical repairs or additions
3� �I am a homeowner doing all work officers have exercised their 11.[]Phmmbing repass or additions
/ myself [No workers' camp. right of exemption per MGL
✓ msurance required.]t c. 152, §1(4), and we have no 12.❑Roof repairs
employees. [No workers' 13.0 Other
comp.Mara,ce required]
*Any applicant that checks box#1 must also fill out the section below showing then-workers compensation policy
' p cy information.
Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
xContiactors that check this box must at'ached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sob-contractors have employees,the must provide their workers'camp.policy number.
I am an employer that is providing workers compensation insurance for my employees Below is the.pofcy and job site
information.
Insinance 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 up to$1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the informadon provided above is true and correct'
S OJi�/`r �
t rJSsaing
,=uluseonly, Do not.write in this area,to he completedby city or town offzciaL
or Town: Permif/License#
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#: .
�1HE Town of Barnstable - e
Regulatory Services
* snxxsrns , « Thomas F.Geiler,Director
Miss
fD 35;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
! I Please Print
DATE: 1, ��� I V
J( B LOCATION:
number r street `'� village
.HOMEOWNER"- *kC\,' }l /�l S(�
name me phone# work phone#
CURRENT MAILING ADDRESS 6 0 d,1
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
mquirem ts.
+Signature o Homeowner
i (l
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 pnlicensed 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
�IKETown of Barnstable
Regulatory Services
lanes. $ Thomas F.Geller,Director
s639. 1�
c Nun'' Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Eax: 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 before fence is installed and pools are not to be
utilized until all final inspections are performed and accepted.
Signature of Owner �a
� Signature of Applicant
Print Name Print Name
Date
Q:FORM&OWNERPERMISSIONPOOLS
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