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Home My WebLink About0043 CHASE STREET �{3 �� ' - - --� - - - t e Town of Barnstable *P pp THE eZ�C f C)q S P� p Lrpires 6 month ftom issu ate Regulatory Services Fee + IARNSMBLE, 9� MASS. g Thomas F. Geiler,.Director iDlFn MP't° Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barns table.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address &? C h o>c- -5' [�Kesidential Value of Work c��'6 f0 Minimum fee of S35.00 for work under S6000.00 Owner's Name & Address ��►^y 6r' cf,AJ�. f d�':`/7c lzie c1l �-Jfay �y (� Contractor's Name /V 16 r^T �Ci�St_ Telephone Number sc2,r Home Improvement Contractor License#(if applicable) e 11 Construction.Supervisor's License#'(if applicable) c3�a A r:-F) ;r,;; ❑Workman's Compensation Insurance '_ 1, OF , t S i_AEG' t- Check one: ❑ 1 am a sole proprietor ❑ I am the Homeowner P-Thave Worker's Compensation Insurance y . Insurance Company Name ;. .= Workman's Comp. Po icy#A[A_.�C1 �� •, �t,/,r7 G!" Copy of Insurance Compliance�ate'must accompany each permit. Permit Request(check box) [O'Ke-roof(stripping old shingles) All construction debris will be taken to.R,4 !!i c-15 ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i,e.Historic,Conservation,etc. * *Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Hifine Improvement Contractors License & Construction Supervisors License is required. SIGNATURE: Q:I WPFILESTORMSIbuilding permit formAEXPRESS.doc Revised 0704Vd— The Commonwealth of Massachusetts Department of Industrial Accidents f AAL- Office of Investigations i x7.,t. i 600 Washington Street ` j Boston, MA 02111 r www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` Please Print Legibly Name (Business/Organization/Individual): r4`hc r-T a 4 e__ 13 c,l r l ql rr— )Address: 2-S PA jT h!t lI r9QCJ City/State/Zip: Phone #:-3 0,'— 3 `^ 23 Are you an employer?Check the appropriate box: 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 S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4), and we have no 12.❑ Roof repairs insurance required.] t 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. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site + information. Insurance Company Name: �l Policy#or Self-ins. Lic.#: fv . `7C?®� ? @ pC Expiration Date: Job Site Address: iy? Ch M—l' e, HY V411 a S 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 information provided above is true and correct Signature• G��Er/ Date: JF . ^ Phone#: Official use only. Do not write in this area;to he 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 S. 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 I52, §25C(6),also states that"every state or,local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or.to construct buildings in the'commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(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 isTequired. 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.4The 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 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,.MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia THE Town of Barnstable ` Regulatory Services v MB& $ Thomas F. Geiler,Director 16yqL- Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-962-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 6-P r Y Pe 0 S'-e- , as Owner of the subject.property hereby authorize `b ��7' (��p s�, to act on my behalf, in all matters relative.to work authorized by this building permit application for. 3 ChAec- (Address of Job) Signature f Owner Date Print Name If Property Owner is applying for permit please complete. the Homeowners License Exemption Form on the reverse side. �oft�ray Town of Barnstable Regulatory Services Thomas F. Geiler, Director hsAs.4 • Y.6.19. },�� Building Division rEFD Tom Perry,Building Commissioner 200 Mairi.Street,-Hyannis,MA02601 www.town.barnstable.ma.us Offi ce: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print 1 f DATE: JOB LOCATION: number street village 'HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: eityhown 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 tbat,the owner acts as supervisor. DEFINITION OF BOMEOWNER',� Persons)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 constrgcts more than one home in a two-year period shall not be considered a bomeowner. 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) R 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,0$rcial 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 scction.(Scction 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner cngagcs a persons)for bire to do such work that sub h Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc assuning the responsibilities of a supervisor(see Appendix Q, Rules&Regiilations for Licexising Construction Supervisors,Section 2.15) This lack ofawaraness bftcn 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. Tbc homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully awarz of his/her responnbilitics,many communities require,as part of the permit application, that the homeowner certify that helshe 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 forrr✓certifiration for use in your community, IVlassachusitts .Dep utment of Pulilic Safctl p ► irr Board of Building Regulations and St►i►dart)s Vomv�nanure¢/ Construction Supervisor LicenseO,ffceAof>Consumer•Affa►rs.r&�]B' iness.=Regptati, s License: CS 36407- HOME IMPROVEMENT CONTRACTOR _ Restricted to: 00 a Registration �1.01471 Type =z. ;.E�epirat►on 6/26/2012 IndividuaF .: ACBERT C PEASE i }}- ACBERT C.PEASE X 95 EAST HILL RD �� < •` -� � WELLFLEET, MA 0266T _ r Albert Pease 95.East Hill Rd Wellfleet, MA 02667 " Undersecr`etary f aExip ation:,5/13/2012 Commissioner Tr#: 24082 r z a bLicense or,regtstraiton valid for v�dul use onl efore the ex piration date.\If found return to Office of Consumer:Affairs 10 and Business Regulation Park Plaza Suite 5170` Boston,MA 02116 ' Not valid without signature •l ' NOTICE NOTICE TO To. EMPLOYEES ; EMPLOYEES The Commonwealth ' of Massachuset& .I.M.M.DIEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As_required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will-give you notice that I(we) have provided for,payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7008071012010 05/16/2010 - 05/16/9011 POLICY NUMBER EFFECTIVE DATES PO Box 1945 Kerry Insurance Agency Inc N. Eastham, MA 02651 _ (508)255-8000 NAME OF INSURANCE AGENT ADDRESS PHONE Albert C Pease dba Albert C Pease III Builder 95 East Hill Road Wellfleet, MA 02667 EMPLOYER ' ADDRESS 04/23/201 G EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. -_:;A copy of the First Report of Injury must be given to the,injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and.reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER /��sessor's Office(1st floor) Map Lot / `cr' ��'-- Permit# Date ue�d 6- 95 Board of Health(3rd floor)(8:30-9:30/1:00- 2:00) Kngineering Dept. (3rd floor) House#1 � ' BAR Definitive Plan Approvedby`Planning Board 19 6 eo ASBM TOWN OF BARNSTABLE c�xra�>�rffi ' Building Permit Application OONI;�,'R Maio Project Street Address Village 7- Owner � Address Telephone Permit Request j tXe Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None 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 ��G BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY T PERMIT NO. DATE ISSUED June 5. 1995 ! ` kr , MAP%,PARCEL NO. 308. 188 s ADDRESS. 43 Chase Street VILLAGE Hyannis- MA 026()1 OWNER Albert Pease DATE OF INSPECTION: FOUNDATION ' FRAME INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING:. ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING + DATE CLOSED OUTown ASSOCI'ATION PLAN NO. rC