HomeMy WebLinkAbout0067 CHASE STREET r
i
LOT 27
c.B
FND.
100' co
97
�
\ DECK
SHED
o
-===-HSE—_-� 21+
1 - ---#67
o LOT 26 � W -_ - - POSSIBL
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LOT 28 1 ___-___- -o TAKINGS
- 30.2' i
'S T,
NOTE. DARTY0 UT14
THIS AREA REFERRED
TO IN DEED BOOK
13371552
NOTE.- PRE-EXISTING NONCONFORMING.
RES. ZONE.• "RB" This MORTGAGE INSPECTION Plan is For FLOOD ZONE "C"
Bank Use Only
TOWN: _HYA. IS _ _ _ _ _ _ - REGISTRY OWNER: STEPHEN D_WALKER_ _ _ _ _ _ _ _
DEED REF: -9,2L2/65 - - - - _ -BUYER: ALEX &
DATE: 91-14Z98_ _ _ _ _ _ — _ PLAN REF: 12f57 _ _ _ _ _ _ -SCALE:1"= 20 FT.
I HEREBY CERTIFY TO CAPE COD FIVE CENTS SAVINGS o` YANKEE SURVEY
_BANK_ _____________________THAT THE BUILDING ���
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND .AS a��� PAUL CONSULTANTS
SHOWN AND THAT ITS POSITION DOES ____ CONFORM 9 A. 40B (SUITE 1)
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE � MEA{T'riEVY N INDUSTRY ROAD
TOWN OF ---BARNSTABLE --------AND THAT No. 32028
IT DOES— NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD '" Q �0 MARSTONS MILLS, MA. 02648
AREA AS SHOWN ON THE H.U.D. MAP DATED_ 292 ���iryEC�T�R yJZ TEL: 428-0055
Com unit —P nel 250001 0006 D �gio FAX: 420-5553
��((. __ ____ THIS PLAN NOT MADE FROM AN INSTRUMENT 24938 DAF
PAUL A. ER-ITHE , PLS SURVEY, NOT TO BE USED FOR FENCES, ETC.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application #
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee /'7 � �
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address tD 7
Village_ (4 YAA AV S
Owner Wgis-ry 4TkA/5LL Address C07 C 9/4s25 S-r.
Telephone 5 o " 31o'"? 3(O
Permit Request 1 t'C WEN J4 1—W ����0 Vd07`i 6.0
Square feet: 1 st floor: existingm—proposed 2nd floor: existing'No--proposecf—Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation a Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family �C Two Family ❑ Multi-Family (# units)
Age of Existing Structure _7704- Historic House: ❑Yes XNo On Old King's Highway: ❑Yes *No
Basement Type: ,W Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sgft) Basement Unfinished Area (sq.ft) �W j r�
Number of Baths: Full: existing / new Z Half: existing new o f
Number of Bedrooms: 3 existing/new
Total Room Count (riot including baths): existing 6 new First Floor Room Count
Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ONo Fireplaces: Existing ' New Existing wood/coal stow& ❑Y_qs ❑ No
71
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: O'existing '0 nevC--) _
,size
Attached 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
Telephone Number
Add! s `J�x 3 / License # 3 115d Y
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
t L V-tLL, ,
SIGNATURE DATE
:9
FOR OFFICIAL USE ONLY
f APPLICATION#
, MAP/PARCEL NO.,,-!
r
ADDRESS VILLAGE
OWNER
t
DATE OF INSPECTION:
FOUNDATION'-"
FRAME ok 3f xt/l i,lout_-t-
INSULATION r S 3 u y -- =✓
FIREPLACE
'o
ELECTRICAL: ROUGH FINAL
I.
PLUMBING: ROUGH FINAL
GAS:;,k-, _ ROUGH:t% -m-,- i FINAL
.FINAL BUILDING-., - - _-
r
t .. DATE CLOSED.OUT ' -
i
'z ASSOCIATION PLAN NO.
3
C l
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legbly
Name (Business/OrgaaimtiondndividnaI):
Address: VOO) 3
City/State/Zip:S/n lv 17 i^•► 26 V y Phone#: 7-7 L' " rj(o3 1 3 &7
Are you an employer?Check the appropriate box:
I.❑ I am a employer with 4. ❑ I an a general contractor and I7E] d
required?: .
loyees(full and/or part-time).* have hired the sub-contractors uction
2. I am a sole proprietor or partner- listed on the attached sheet.ship and have no employees These sub-contractors have
working for me m any capacity, employees and have workers'
[No workers'comp.insurance comp,insuranCe.$ 9. ❑Building addition
required,] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑-I am a homeowner doing all work officers have exercised their Plumbing repairs or additions
myself~ [No workers' camp. right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12.E]Roof repairs
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'Homeowners policy information omeowners who submit this affidavit indicating they arc doing an work and then hire outside contractors must submit anew affidavit indicating such.
#Contractor,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 co policy mrmber.
mP•P Y
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
informotfon.
Insurance Company Name:
Policy#or Sclf-ins.Lic.A 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of,
Investigations of the DIA for insurance coverage verification.
Ida hereby certify under the pains and p es of perjury that th. formation provided above is true and correct
Signature: Date: 2 Z O / z
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/I,icense#
issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other
Contact Person:
Phone#:
C .a: ..,
�� � �l a►rs"&B siness egu a on..
Office o onsumer, CTOR - J
YEMENT.CONTRA Type: License or registration valid for mdividul.use only.
HOME.IMPRO before the expiration date. If found return for
Registration ;15055Y
4/�11,2012 DBA Office of Con'sumerAffairs and Business Regulation
Expiration
=a 10.Park Plaza-Suite 5170
Boston,MA 02116
LLIAMS COVr5R. w
J
I� JEFF WILLIAMS jg RW
it 10:WEEKPpNp DR` gam.
MA 02�44 r Undersecretary �1
I FORESTDALE, L
l ` No val' rtb ut signature
— - pe ,trntnt of P€lblic S.tfct�.,
- nl�a achu�ett�.- �'
,� ReYulat
ions and Stundar ds
Board=of.Building. ervisor License.
Construction SuP
License: CS ;1035
Restricted to: 00 .
JEF,FREY. WILLIAMS
10 WEEKS POA 02644 .
F6RESTDALE,
Expiration. 1211412013
5 T r# 103504
('ummissioner. i
+
�FIHE T Town of Barnstable
ti
Regulatory'Services
9snxx S. E$ Thomas F.Geiler,Director
Eo;A:�A Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
wwwAown.b arnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize S to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
S 4 atu.re er a e
Print Namd
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
•Q:FORMS:OWNERPERMISSION
I`
oFt r Town of Barnstable
Regulatory Services
sasxsrABM Thomas F.Geiler,Director
bass.
9�A i639. A Building Division
TFD MA'I
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:
JOB LOCATION:
number street village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state iip 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
appEcable 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 constructign 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:fonns:homeexempt
Engmeering-Dept=(3rd-floor) Map 0 Parcel . `�� . Permit# 3' 3
House# w Gem ei Date Issued
Board of Health(3rd floor)(8:15 -9:30/,1:00-*N) w ° Fee '��;,
` , CYO OX b
Conservation Office (4th floor)(8:30-9:30/1:00-2:00) - L. Q
Planning Dept. (1st floor/School Admin.Bldg.) oftNE L
. .
Definitive Plan A e b Planning Board 19 APPLICA A'SEWER
P Y g ,,,�^T i T::L
e►RN ' ' d PRIOR TO
ENGTOWN OF,BARNSTABLE coNs
A '
Building Permit Application •,
Project Street Address Glace -
Village
Owner Fs " / / Address ,,g S 2
Telephone 1 — d2 D, - 1:5 15 4/1S—
.,Permit Request ee `> f�X / •.
First FloorcJ bd square feet Second Floor 200 square feet
Construction Type CA.,OOL
Estimated Project Cost $
Zoning District Flood Plain N O Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes No On Old King's Highway ❑Yes XNo
Basement Type: XFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing _ New Half: Existing _ New
No.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 p No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name C(1'a 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 D �IS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
<�3A
SIGNATURE "I/,(, c DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
.w�. FOR OFFICIAL USE ONLY _
PERMIT NO.
BATE ISSUED. +
MAP/PARCEL NO. M _
ADDRESS VILLAGE
OWNER
DATE OFANSPECTION:
FOUNDATION,- '
FRAME
INSULATION Y
FIREPLACE ;
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL t
GAS: 'rY ROUGH. FINAL'
FINAL BUILDING '
DATE CLOSED OUTe-
ASSOCIATION PLAN NO: '
E,
43 a A,h
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03-05-1999 10:40RVI FROM LOVELETTE INS AGCY TO 7b05140 P.01
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®!740"W5150�
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i� ® ��t'' x dry .w... aL� K•,.i..$�d..,s• xi:'��� IS CERTIFICATEIS ISSUED AS A MATfTER'OF INFORMATION
LY AND CONFERS NO RIGHTS UPON THE:CERTIFICATE
Mal E. LoreletDs l4ris ASCy OLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
the Main Street ALTER E COVERAGEA ORD NELO
P.O. Bo: tVr COMPANIES AFFORDING COVERAGE
West ve mouth IAA 02M COMPANY
A Eastern Casualty his Ca
NAM COMPANY
David Oadman B Maryland /nsirrence Cotepan
Custom Builders COMPANY
St Pond Street C
Vest berms Ma 02670
COMPANY
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 AM,PECT TO WHICH THIS
CERTIFl,ATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 11iE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS.
_E { NS AID CONDITI UMITS S,ICWN MAY MAY-PEEN U, PAI NIA
POLICY 69%CTIVE POLICY ExPIRATION LTAAITB
TYPE OF INViRANOE POLICY NUMBER DATE tMM/DD M GATE (MMIDDIYY)
B 8ENERAL UAEaM SCP328BZ798 03/17/99 03/17/00 GENERAL AGGREGATE $ 600 Q00
Y COMMERCIAL GT3GFAAI LIABILITY PFtODUCT3-COMP/OP AGO $ 600 000
CLAM MADE ®OCCUR PERSONAL&AOv INJURY $ 300 000
FT
OWNvrS&CON'>RACTM MOT FA OCCURRENCE f $ 300 000
FIRE DAMAGE( one be) i
MEO ExP(Any one OtIMAI 10,00
AUTOMOBILE UASLIT Y COMBINED SINGLE LIMIT 3
ANY AUTO
fl0DILY K)URY
ALL OWNED AUTOS (Per par.on) b
SCHEDULED AUTOS
NIRED AUTOS SODILY MA/RY $
(Pm acomentl
NON-OWNED AUTOS
I-R-
F+ROPOM DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA aCGIDENT $
ANY AUTO OT1lFA TMAM
•.;�
EACH ACCIDENT $
AGGREGAM S
EACH 00CV9RENCB S
EXCESS LIABILITY
nGCiREpAT6 3
UMSREUA FOFW
S
Orr"THAN UMBRELLA FOW
WORKM COMPENSAT04 AND
84PLCIYEW 0481IIY uC55G-44-36 03/20/98 03/20/99 EL EACH ACCIDENT $ 100,000
A THE PROPR>ETOW Wa EL DISE -POLICY UNIT $ 500,000
PAATNERSOTCUTIVE FL DISEASE-EA O PLOYEE S 10D,000
OFFICERS AR[s EXCL
OTHER
DESCRIPTION o> oPERATICNsrI�otATd�Ctw.rTes
Carpentry
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SHOULD ANY OF TlE ABOVE pEIiGRBED PO(JCtEs BE CANC91fD B15oRE THE .
EX01RATION DAZE THEAE0p,THE `I'3.+U' INGa COMPANY WILL ENDEAVOR TO MAIL
Town of Bamsteble
South sweet to DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, '
BUT FA1LU SU gHALL IMPOSE NQ OBLIGATION OR UABL17Y
NyanM: MA 02@01 D UPON ANY,ITS A.09M OR REPRESENTATIVES,
AUTHOR AEPR
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TOTAL P.01
epartmen
Office ofinyestig"feffs
600 Washington Street
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name. A�
location (n <� l/A S
CitV S vhone# l —
❑ I am a fiomcowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
Mll
wo
❑ I am an employer providing workers' compensation for my employees working on this job.
com anv name:
address:
city:
insurance co. VolicV#
I am a sole proprietor, general contracto or homeowner ircle one)and have hired the contractom listed below who
r.
have
the following workers' compensation polices:
Prow, ° oO
address
citr: 11-�.Ir-A-)
msurnnce cow
/////%//////
cam anv name:
address:
hone#:
city
insurance co. olicv
Failure to secure coverage as required under Section 25A of INiGL 152 can lead to the imposition of criminal penalties of a One up to 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of 5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature
��c 4 Gf Date 3�g A5 _
�-�~-�'.'�
Print name r 1V '`J Phone# l
Ccontactpeenon:
ard
o:wntieis area to be completed by city or town official
permit/license# I3IdCIBC3Brelensin Departmentding �
g
❑Selectmen's Office
reuired ❑Health Department
phone#; 7_0
O
(revaea 9/95 P1A)
a'
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under anv contra
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
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 c
I- appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h.
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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 yoi
are required to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of th
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. The affidavits may be returned fo
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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 Investlgatlons
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
tM!
The. Town of Barnstable
sum 1e$ Department of Health Safety and Environmental Services
96 Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 309-790.6227 Building Cammissio::
Fax: 509-790-MO
For office use only
Permit no.
Date AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c t4ZA 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 o
r 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: '
� \ ,$ L K Est.Cost
2 54
Address of Work:
Owner's Name n r�
Date of Permit Application:
I hereby certify that:
Registration is not required for the following renson(s):
Work excluded by law
Job under S1.000-
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING wrm UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
MSIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Contractor Name Registration No.
Date
OR
2/!5�/5 9
Owners Name
Date i
o Department of Health Safety and Environmental Services
Building Division
&42NS'"MF. ` 367 Main Street,Hyannis MA 02601
tw►ss.
039. �0$'
ED MA'I�
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
7
JOB LOCATION: l)A S-t— S number l street village
"HOMEOWNER": l J �'�� I—� �G YA A j 23D�_—
name home phone# work phone#
CURRENT MAILING ADDRESS: iJ V—C)
ty/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 suprvisor.
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 to amend and adopt such a form/certification for use in your community.
Q:FORMSIXETIFT
J
!Engineering Dept. (3rd floor) Map G Parcel �(J� Permit# /S�
House# Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee
Conservation Office.(4th floor)(8:30-9:30/1:00-2:00)
Planning Dept. (1st floor/School Admin. Bldg.) THE/q•_
Definitiv an Ap ed by Planning Board 19
• BARNSTABLE. .
' MASS P
TOWN OF BARNSTABLE
Building Pe 't Application
Project Street-Address 7
Village
Owner Address 67
Telephone 77 / - 5-3
o
Permit Request
First Floor square feet Second Floor square feet
Construction Type Estimated Project Cost $ 32-0d
Zoning,District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Q Two Family ❑ Multi-Family(#units)
Age of Existing Structure L �V Y4p 5 Historic House ❑Yes On Old King's Highway ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Others.A
Basement Finished Area(sq.ft.) 7 6 Basement Unfinished Area(sq.ft)
(N Number of Baths: Full: Existing 1. G� �( d/� Half: Existing New
1 No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
�� C Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes CrNo If yes, site plan review# -
Current Use-- rl r- `P Proposed Use
I-r-7 Builder Information
Name /Gf!/'t /
�►-� � Gt Telephone Number 77-
S y
Address /3`a �p/�l � - License# 0S(
M.9 Home Improvement Contractor# /2 3 0(a 7
Worker's Compensation# A&4,9/
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
51 e-1
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWI REASON(S)
FOR OFFICIAL USE ONLY
. t
z ,
t
PERMIT NO.
DATE ISSUED t '
MAP/PARCEL NO. t
ADDRESS VILLAGE I
OWNER k ,
DATE OF INSPECTION: `
FOUNDATION
, r
FRAME
INSULATION ,
FIREPLACE t
ELECTRICAL: ROUGH FINAL
B
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDINGhi�
DATE CLOSED OUT
ASSOCIATION PLAN NO. '}
- - ..wa..d:�m•`GSwa�..ir.bitsa�ar k... .s.`.a::�TJu-s.;.':i:.__. ,.. <s5...tit.�:a :'_.. _._ _.. .... .+a,_'+.:� v :...r=�' .4:..._....�. __ ... _ . . . ..*,-..._._._.. ...,_. »...
HOME IMPROVEMENT CONTRACTORS REGISTRATION
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston , Massachusetts 02108
HOME IMPROVEMENT CONTRACTOR
Registration 123067 Expiration 12/02/98
Type — INDIVIDUAL 07.� ��1�
HOME IMPROVEMENT CONTRACTOR
Registration 123067
THOMAS SCOTT EDL.DRIDGE Type - INDIVIDUAL
THOMAS S . ELDRIDGE Expiration 12/02/98
138 SPRING ST
HYANNIS MA 02601 THOMAS SCOTT EDLDRIDGE
THOMAS S. ELDRIDGE
�W8 SPRING ST
ADMINISTRATOR HYANNIS MA 02601
The Collllllllll secultll of.1 tassacbusetty
l�rl •• ..ii.i.�-:-.•��t Department
I D[f71Ir1111L11t Of I/IllllSlr7Ql.-�CC1l1LIlIS
O�ceDI/nyestlgat/ons
\.�_' :3•,`� 600 !f'asltiilrtun Street
� .�.;
Boston.Alas. 02111
�• workers' Compensation Insurance Affidavit
�iltPiicint informatirin'• _ Plcnse PR1NT'lebt_ijjv
inc ?ion
hem• 77 / -S'3�
l�amhomeowner performing all work myself
am a sole proprietor and have no one working in any capacity
[� 1 am an eniplover providing workers' compensation for my empiovees working on this job.
enntn•ttty n• rne*
;td d refs• -
cin•• nhnnc it•
incur-ince cn nolicv 0
M I am a sole proprietor. general contractor. or homeow�ner�(clrcle one) and have hired the contractors listed below who h.-
the following workers' compensation polices:
comnnnv n•ttnc• - -
addresc-
cin•• .hone+�•
insim-incc rn
coat an• name:
atiti rc�c�
tin.- nhnnc It:
..iic�•t!
incur•tnce co
Attach additional sheet if neeMa_ry -::•.:. * --�
Faiiurc In secure coverace as required under sectton.SA of;11GL 152 can toad to the imposition of criminal penalties of a line up to S1SOU.UU andiu
one v cars' imprisonment:ts weil:is civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that
cope of this statement may be forwarded to the OMcc of Investigations of the DIA for coverage verification.
1 r10 hercht•ccrr'. tit: er rite pains and penalties of perjuty that rite information provided above is tra and c rrect.
Signature Date 5 / !/
Print name 601-1
A- Phone;
w -
' olTiciai use only do not write in taus area to be completed by city or town official
city or tmvn• permitilicense d r guildinc Department
' ❑Licensing hoard
0 check- if imtneJiatc response is required ❑
Sciectmen s Office ►
�- 011calth Department
contact Person:
phone 0: r�Utltcr
T )ns -
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
cmployecs. ,,Ns quoted from the "la►►`. an emtplitree is defined as every person in the service of another under any
contract of rice. express or implied. oral or written.
An entp1grer is defined as an individual, partnership, association. corporation or other legal entity. or:ally two or morc
the foreaoin__ cnuagcd in a Joint enterprise, and including the le al representatives of a deceased employer. or the
receiver or tntstee of an individual , partnership. association or other legal entity, employing employees. Ho►►•ever tite
owner of a dwelling house haying not more than three apartments and who resides therein. or the occupant of the
d►►•cllinm_ house of another who employs persons to do maintenance , construction or repair wort: on such dwelling_ hour
or oil the urcunds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chanter 152 section 25 also states that eycr• state or local licensing agency sltall withhold the issuance or
--ette►►•al of a license or permit to operate a business or to construct buildings in the commomwealth for an-
applicant who has not produced acceptable evidence of compliance with the insurance coverabe required.
-%dditionali neither the commonwealth nor any of its political subdivisions shall enter into any contract for tite
,crformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ita
.een presented to the contracting authority.
Thlicants
!ease fiil in the workers' compensation affidavit completely, by checkin`the box that applies to your situation grid
ipplyin�_ company names. address and phone numbers as all affidavits may be submitted to the Department of
idustrial Accidents for• confirmation of insurance coyera`e. Also be sure to sign and date the affidavit. The
'tida►•it should be returned to the city or town that the application for the permit or license is being requested.
it the Department of Industrial Accidents. Should you have any questions regarding the "law- or if you are required
obtain a workers' compensation policy. please call the Department at the number listed below.
ire• or Towns
=ase be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
affidavit for you to J-111 out in the event the Office of Investigations has to contact you regarding the applicant. Pleas
sure to fill in the permit/iicense number which will be used as a reference number. The affidavits may be returned to
: Department by mail or FAX unless other arrangements have been made.
:e Office of Investi=ations would like to thank you in advance for you cooperation and should you have any questions.
°ase do not hesitate to _give us a ca11. .
e Department's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents r r
Office of Investigations
600 «'ashinbton Street
Boston,Ma 02111
fax #: (617) 727-7749
phone (617) 7274900 ext. 406, 409 or 375
The Town of Barnstable
9 $ Department of Health Safety and Environmental Services
�°r�,,�, t► Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissi(
For office use only
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 withother requirements.
Type of Work: L—SL2-61 I'/ Est.Cost 3 2-0 U
Address of Work: � - �4, 5, >Y,
Owner's Name
Date of Permit Application: 12
i hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner 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
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.
OR
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All dimensions -size designations This is an original design dnd must Designed: 1/23/2012 ,�
given.are subject to verification on not be released or copied unless P_r_i_nti d_: 1/_24/_2012
job site and adjustment to fit job applicable fee has been paid or jab
conditions. order placed.
Atwell bath with shower2 All Drawing #>`: 1
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