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HomeMy WebLinkAbout0085 CHASE STREET,, i . VieTown of BarnstableBuilding Post-This Gard So"That,itis Uis�bleFrom tMe Str,,eet;'A,pproued-PlansMust be,.Retamed on�Job;and,this°Card Must,be•Kept� , ��;, •A�7`.T'[`ABLE. • irc" Fin 6 PostedUntiFinal Inspection Has Been Madera Where,a Certificate of Occu, ant ;is Re cared,such'Bu�ldm shall;Not be Qccu iedu,ntila Ftrnal.Ins eetionhas,been,made „, Permit Permit No. B-19-204 Applicant Name: Lloyd R Smith Vivint Solar Developer LLC Approvals Date Issued: 01/31/2019 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 07/31/2019 Foundation: Location: 85 CHASE STREET, HYANNIS Map/Lot: 307 135 Zoning District: RB Sheathing: Owner on Record: BEAUCHAMP,GRAZIANE Contractor Name BRIEN LANGILL Framing: 1 - U;% ^^ Address: 72 BLACKBERRY LANE Contractor License' %CS=106675 2 HYANNIS, MA 02601 � � Est Pro�e.ct Cost: $24,420.00 Chimney: Description: Installtion of roof mounted photovoltaic solar system�ll 1KW 37 PermlfiFee: $ 174.54 Insulation: Panels Fee Pa►dc; $ 174.54 Project Review Req: - t Final: Date 1/31/2019 a _. Plumbing/Gas / mbing/G as Rough Plumbing: "% This permit shall be deemed abandoned and invalid unless the work authonz'edby this permit is comme ced witfim s z months after issuan �C�a Final Plumbing: All work authorized by this permit shall conform to the approved applicatiorr"and tfie;approved construction documents for which,this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street oKroad and shall be maintained open for public insp ection for the entire duration of the work until the completion of the same. Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures by'the Building and',Fire Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work � 1.Foundation or Footing Service: 2.Sheathing Inspection ' Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is�mstalled ? g 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Final: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Per ns co ratting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Sc Building plans are to be available on site Fire Department TZI All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: r� CA E COD INSULATION �Cl S1pYATIS LA SS SEAMM 4U111AS1 INSUTAt ON SPRAYFOAMICUsPNDKV 11lINOS DEC 23 2015 1-800-696-6611 TOWN OF BARNSIABLE, Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village �Ao d S'T Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) (X-) (X) Slopes ( ) ( ) ( ) ( ) ( ) Floors Walls ( ) (X) ( 13 ) X) ( ) t r o� (VO r ll Fe )Co r,,,,e,a/ l IL y Sincerely rry ssrationpInc. sident Ins TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -096)Map "a Parcel S"N D' .BAR STABLE ApplicatioC420/6 Health Division Date Issued 1 2-' _/ Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Plan nirig�.'Board Historic - OKH _ Preservation / Hyannis O Project Street ddress Village 115 Owner t uwkv-A�2 , Address Telephone 6 Oh - 17S ' 72-3 e Permit Request A IVr �'Z ''o (� j G A-ce Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District , L 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 16rmL Telephone Number c_ Address 7/A yd t) License # Home ImprovementI �� T6 Contractor# Email Worker's Compensation # NCOOW1441 ALL CONSTRUCTION DEBRIS RESULTING F OM THIS PROJECT WI L BE TAKEN TO SIGNATURE DATE h�7 :Y�d 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 GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. a Massachusetts Department of Public Safety Boa rd'of Building Regulations and Standards License: CS-100988 l Construction Supervisor, HENRY E CASSIDY,\ ' 8 SHED ROW WEST YARMOUTH MA 27NWE 3 ; 1/�/�►^^� �/`-- Expiration: Commissioner 11/11/2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Co�tia'otor Registration .Re gistration: 153567 + Type; Private Corporation all Expiration; 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO, YARMOUTH, MA 02664 _ Update Address and return card, Mark reason for change. $CA 1 a; 2oM•05iit [] Address Renewal Employment s Lost Carcl V/6e cpa4�i��zaJUUealC�o�C/��wJJCGO�ctJel — Office of Consumer Affnlrs& Business Reguln4lon License or registration valld for:1ndlvidul use only OME IMPROVEI ENT CONTRACTOR before the expiration date, If found return to; egistratlom -A53567 Type; Office of Consumer Affairs and Buslness Regulation j xplratlon;; 121:15/ZQ:16 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSUL4?I'6N,iNC �' HENRY CASSIDY 18 REARDON CIRCLE",, �Q SO,YARMOUTH. MA 02664 Undersecretnr Y T ut sign e , The Commonwealth`of Massachusetts Department of Industrial Accidents j Office of Investigations 600 Washington Street Boston, ALL 02111 www,mass,gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers A pplicant Information �n Please Print Legibly Name (Business/Organizatiordindividual); f"1 A]1 , 1 / Address: —9 City/State/Zip; ': �i�� M t N� Phone #: Are you an employer? Check th appropriate box; Type of project (required), 1. ,l am a employer with _�"� 4. ❑ I am a general contractor and 1 6, [],,New construction employees(full and/or part-time)," have hired the sub-contractors r; 2.❑ l am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling shipand have no employees These sub-contractors have Demo [No workers' comp. insurance comp, working for me in any capacity, employees and have workers' 8, - insurance,$ 9. ❑ BuildingAddition required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3,❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ 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 H I must also fill out the section below showing their workers' compensation policy information, .r 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 attaq..hed an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, If the subcontractors have employees,they must provide their workers'comp. policy number. 1 am an employer that Is providing,workers' compensation Insurance for my employees, Below Is the policy and job site ,>nformatlon, - Insurance Company Name; t'`i (..iA w` Qi' � '� � � �-- - � r,, Policy # or Self-ins, Lic. 9: t ^C,el0 �1 0 � Expiration Date: �/ Job Site Address; (- 1'"�'✓e ✓�� City/State/Zip; YkH Attach a copy of the workers' con6pensation policy declaration page (showing the policy nu b r 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,�00.00 and/or one-year iimnprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250,00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of - Investi ations of the DIA for insurart. coverage verification, I do hereby certify d the pat an penalties of perjury that the informatlon provided bove Is true and correct, Signature: G Date; 1 V7� Phone#: Official use only, Do not write In this area, to be completed by city or town official, City or Town: Permit/License# Issuing Authority (circle one); 1, Board of Health 2, Building Department 3, City/Town Clerk 4, Electrical Inspector 5, Plumbing Inspector 6. Other (nntnot Parcnn, u. CAPECOO-27 BDELAWRENCE Acoizo' CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDO/YYYY) 6/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT, AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed; If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME; Rogers&Gray Insurance Agency,Inc. PHONE alc No:(877)816.2156 434 Rte 134 E-MAIL South Dennis,MA 02660 ADDRESS: INSURER($)AFFORDING COVERAGE NAIC 0 IN86RER A:Peerless Insurance Company•see LIBERTY MUTUAL INSURED INSURER B;ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc. INSURER C 18 Reardon Circle INSURER D; South Yarmouth,MA 02664 INSURERE: INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTR TYPE OF INSURANCE POLICY NUMBER - MMIDDY� MMI-DD�YY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR CBP8263063 0410112015 0410112016 DAMAGE TO RENTED— PREMISES Ea occurrence $ 100,000 } ME EXP(Any one person) $ 5,000 PERSONAL 9 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES P,ER: GENERAL AGGREGATE $ 2,000,000 X POLICY 0 PE� LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY o i COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NVTOS ED Peace en DAMAGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Ya B ANY PROPRIETORIPARTNERIEXECUTIVE NIA WCE00431901 06/30/2015 06130/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE,,$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (CORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation Includes Officers or Proprietors, Additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Cod Insulation,Inc ACCORDANCE WITH THE POLICY PROVISIONS, 18 Reardon Circle South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD f Town-of Barnstable ®., Regulatof°y Services A& ' Richard V.ScA Director Building Division Tom Perry,BuMug Comtaissioner 200 Main Street,Hywmis UA 02601 www.towc.barnstabiema.as Office: 508-862-4038 F= -508-7904230 Property Owner Must Co plete:andSign This-Sec_tioti If Usine ABuilder I, .P 9 V+ ? i�• G tJ.W, , S� ,.as Ownerof the;subjec#property A) 'to act hereby authorize G� Vl s l/�cn 1`►y on my be half ; iu ali Matters-relative to work authorized by this building permit application for. (Address-of jo§),. Pool.fenc es*arid.alarrns are the iesponsiba—Y..of the,appEcant. Pools are.n6rto be'.filled ar-;utAized-before feree is:2n uhd,and o-fii .inspections are performed and accepted Signature-of Owner. Signature-of.Appkant P a u j>jZ ►= 7 w e4 f4>5 Print.Name Print Name DateFRECED VE NOV 6 20;15,' IDI QTORMS OWIM1PERM1SStONPOOLS -- - --. . ---A } TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION rJ 1f 7 Map Parcel I�J Application #c&l(d Health Division Date Issued Conservation Division �l Application Fee Planning Dept. J Permit Fee Date Definitive Plan Approved by Planning Board r V Historic - OKH _ Preservation/ Hyannis Project Street Address C-A Village Owner'PP 9-vD1 QP30 Address C- 1 Telephone 6C�S `'1 �5 �l Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 4 5010-00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach'oupportingadocuntation. Dwelling Type: Single Family El Two Family ❑ Multi-Family (# units) "a Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's�HighwarLJY s ❑ No 00 Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other . Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name A\rM R l.J, Telephone Number �Aess 7 License # +4-L, Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO GNATURE 0 � � DAT" ^ 1,6 -.11 0) 1 .i 'I FOR OFFICIAL USE ONLY i V ¢ APPLICATION# DATE ISSUED ' f' 'j MAP/PARCEL NO. _ i ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION .r FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING Ob I h DATE CLOSED OUT ASSOCIATION PLAN NO.SOC t The Commonwealth of Massachusetts W Department of Industrial Accideiz�Office of Investigations 600 Washington Street Boston,AfA 02ZII www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibi (Addrtss:_E>:'-5 ame (Business Organizabon/Individual):_Pn y �p W. f�W A RP S ' i /State/Zi t3' P: QZ.:VZ)I 'Phone 6®e `T`1�5 —j Z3<:�) 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition ` working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑ Building addition equired] officers have exercised their 10•❑ Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12,❑ oof repairs insurance required] t. employees.[No workers' comp. insurance required.] 13. Other�� ,C,q� Q�y *Arty applicant that checks box#I must also fill out the station below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they art doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy information. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site informaxion. Insurance 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 hereby ce fy under the pains and enalties of perjury that the information provided above is true and correct V S t ature: cdQO Phone #: �� IF— Issuingfficial use only. Do not write in this area;to be completed by city or town official ity or Town: Permit/License# Authority(circle one): LOther Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector son: Phone#: l 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 bean employer." -- MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C( )states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their 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 ti self-insurance license number on the appropriate line. City or Town Officials Please be sure that-the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town 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 (Le. 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"eommonvaealth of Massachusetts _ Department of Industrial Accidents G.Mce of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax# 617-727-774� vww.massgov/dia 9 Town of Barnstabfe ' P Regulatory Services _ = a,utxs-rtsc.E, Thomas F. Geiler,Director BuiIding Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.t6wn.barnstablr—ma.us Office: 508-962-4039 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: C-H115 r rY y)�+�Af Z number street village ':HOMEOWNER":D'q'Pi pw41 f PS Ir©e4—7716��7A130 name home phone# work phone# CURRENT MAILING ADDRESS: � city/town ' state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hits who does not possess a Iicense,provided that the owner acts aS SllperYiSpr: DEFMT7rON 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 BuiIding Official on a form acceptable to the Building Official, that he/she shall lie responsible for all such work performed under the building permit (Section 109.1.1)' The undersigned"homeowner"assumes responsibility for compliance with the State BuiIding Code and other applicable codes,bylaws,rules and regulations_' The undersigned"homeowner'certifies that he/she understaods the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with-said procedures and raqIlLrtments. Signature of Homeown r Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger will be required to comply with the State BuiIding Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION + The Code states that "Any hbrneowner performing work for which it building permit is required shall be exempt from the provisions of this section(Secdon )09.1.1-Licensing-of construction Supervisors);provided that if the homeowner engages a persou(s)for hire to do such work that such Homeowner shall act as supervisor." Many homeowners who use this exemption-am unaware that they am assuming the responsibilities ors supervisor(sec Appcodix Q,. Rules&Regulations for Licensing Construction Supervisors,Section 2.)5) This lack of awareness often results in scrious_problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannof proceed against the unlicensed persoo as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultirnately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeownrr ocrtify that he/she understands the rcsponsibilitirA 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 forrrJcertification for use in your community. Q:forms:homccxcrnpt l7F TiiE Tp� P� 'Y t tag unSrt arr Town of Barnstable Regulatory Services Thomas F. Geifer,Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arns to ble.m a.us 4 Office: 508-962-403 8 Fax: 508-790-6230. Property owner must Complete and Sign This Section If Using A Builder I , as Owner.of the subject property hereby authorize to act on my behalf, in all matters relative to work authorize this building petnvt application for. (Address of Job) Signature of Owner Date Print Name If Property Owner is applyingfor permit,please complete the Homeowners License Exemption Form on the reverse side. C.k Uscrsldcco l l i k1A ppDatz U-oc&AMi cr oso frl Wi ndowslTc• mpo lntcrrrct Filrsl rz'Y Content 0udoo Revised 0721 10 k1DDYE7A�.Z1EXpRZS5.doc Town of Barnstable Geographic Information System August 16,2011 308182 308183 307127 #]2 #67 3#4 2 307140 #16 #20 O 00 307137 a #; 307128 #5 '. �+ l 97 lot 30#7 �s 307,129 30713 `� � #15 307.139 307270 # #21 �y 307134 �. 307133 #95 = ', 307132 m , #co z v g4 307131002 � "! J� � 307130 #66 Np� 307148 18 Feet t #37 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:307 Parcel:135� boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel w+ 1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:EDWARDS,DAVID R 8 DIANE Total Assessed Value:$340900 are only graphic representations of Assessors tax parcels. They are not true property Co-Owner: Acreage:0.21 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:85 CHASE STREET such as building locations. Buffer �•`'/,i' �a f ' Edwards 85 Chase Street Hyannis, Ma. 02601 Footing§: 8"x 4' concrete Upper deck: 2"x 8" PT for framing construction Ledger- 2"x 8" PT anchored to house evrery 16" using 1/2" lags anchored to 4"x 4" posts using post caps - Simpson ABU442 (or equivolent) anchored to footings using post bases --Simpson ABA442 (or equivolent) Upper ramp: 2'x 8" PT forframing construction attached using joist hangers - Simpson LUS (or equivolent) Lower deck: 2"x 8" PT for framing construction Ledger- 2"x 8" PT anchored to house every 16" using 1/2" lags anchored to footings using post bases -Simpson ABA442 (or equivolent) Lower ramp: 4"x 6" ground contact lumber Railings: Railing hieght @ 36" Spindles approx. 31/2" apart 1"x 2" bumper/stopper installed 1/2" above decking on inside of all railings i I I q,p'+ I � f f I f i I 3'V± + l � I __ P i I I F'x►s-T-I N S 4Z` WALK WAy I = E P.r 5C P,L-E 1 2 of 5 i P.. f l_ 'ym • - •, r 1. CH v i ( � i t j e 1 k-» i I � � Y q e f >3 ' 307- f # 85 k >- I�YPsr�1N�5 is i� off '�ol35 oFY t Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee C 20A BAMSTABLE. v� Mass Thomas F. Geiler, Director ��� prFD"'��a Building Division Tom Perry, CBO, Building Commissioner 260 Main Street, Hyannis, MA 02601 www.town.barnstable.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 , /V 1` d -46 Residential Value of Work C-- c-� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address , '+tr .9 s--,. {/a �aj� f f f ,iil i'/a�//!� �� Telephone Num Contractor's Name ber s Cs%6-.2->0—';z 2j d Home Improvement Contractor License#(if applicable) le3e �� Construction Supervisor's License#(if applicable) b ❑Workman's Compensation Insurance -PRESS PERMIT Check o am a sole proprietor iuN ��❑ ❑ I 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) 6�C i_/_5 P4s FX CI- �47 - ❑ Re-side ��,Z. ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: roperty O r must sign Property Owner Letter of Permission. Home I ro �enontra ttors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFILESTORMS\Express\E RESSPERMIT.DOC Revise060409 The Commonwealth of Massachusetts Department of Industrial Accidents 92 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 Legibly Name(Business/Organization/individual): o k2 , � ArA���,,_5 /✓ Address:.,fi9 C."yc 4:;c-p dVAZ © fo 3 o Phone.#: v"5���` 7' 4 ICs City/State/Zip: �13��mfj4 � � ��� ' 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 employees(full and/or part-time).* have hired the stab-contractors 6. ❑New construction 2.kg'ram 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' 9. ❑Building addition [No workers'comp. insurance comp. insurance.$ corporation and its 10.❑Electrical repairs or additions required.] ❑5. We are a � 3.❑ 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.❑Roo pairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. h Other m__�_C. comp.insurance required.] *My 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. xContmactors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 cer ' nder the ns nd enalties of perjury that the information provided above is true and correct k Si ature: �` Date: 0. _ Phone#: / Official use only. Do not write in this area,tb 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 tiustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town),".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to brim 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 11-22-06 w�r�r mass gov/dia IHKE Town of Barnstable Regulatory-Services BAxxsresM 9 KAM $, Thomas F.Geiler,Director 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 Property Owner Must Complete and Sign This Section If Using A Builder T,.P;q. 6 2 W pq AP S , as Owner of the subject property hereby authorize V I C,,-L—o yQ W 1/ iy i K, q1 N r tJ to act on my behalf, in all matters relative to work authorized by this building permit application for: o� (v .(Address of Job) Signature of Owne Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable Regulatory Services • Thomas F. Geiler,Director 16.1 �. Building Division PIED Tom Perry,Building Commissioner 200 Mairi:Street,—Hyannis;MA vt".town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number strcct 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 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 structur6s. 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 parson(s)for hire to do such work,that such Homeowner shall ad 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 Licmuing 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 caret amend and adopt such a fomr/certification.for use in your community. Q:forrns:homccxcmpt I Board of Building Regulations i ns and Standards � HOME IMPROVEMENT CONTRACTOR Registrat a 100,053 EFcptr � 6618/2010 Tr# 267944 Type Individual f VICTOR J.WIINIKAIN Victor Wiinikainen f 58 CAPE COD g BARNSTABLE, Administrator . � ✓� Z/JO hi�J2697u�t� O��llQ4lL�C6P�.6� e F, Board of Building Regulations and Stagdar`ds i # °:, Construction SupervisorLicense r ,Lic nse CS'998 • `' ,;' Expiration 9/29%2009 Tr#.23k8 tl,, x l f Restnk coon 00, D, k-J VIC J WII TOR NIKAINENI i PO BOX 69 ~ sVi r � W BARNSTABLE;MA 02668 Con missione� �'. 4 f��M Kf ICj (7 0 (1 k� ypFTNE�oyti Town of Barnstable *Permit# �P Expires 6 monthrfrom issue dale y - � 0d Regulatory Services Fee 9 MAN'1659.. Thomas F.Geiler,Director A'ED MAC Building Division .� Tom Perry, Building Commissioner DEC 200 Main Street, Hyannis,MA 02601 1-o�1V® 1002 11� Office: 508-862-4038 1Zg,��JVSTA' L Fax: 508-790-6230 8 � EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number 07 Property Address 05 Residential Value of Work 1/800 Owner's Name&Address �' �'/i�}n/a= �G✓��L Contractor's Name ®t,i t/M- IaC� 1 Telephone Number--eA29- 7-)S q Ci Home Improvement Contractor License#(if applicable) Construction Supervisor''s License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ la=the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 6%) 33S U) PO 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 roofl ❑ Re-side ❑ Replacement Windows. U-Value (maxi_mum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc, Q:Forms:expmtrg Revised121901 rf T 1 f 9/t e ` Board of Building Regula ions and Standards One Ashburtoni'Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 128957 Type: Individual " !ration: 06/14/2003 Oliver Kelly, �� Oliver Kelly 6431U1gin-St. Unit 8 Yarmouth, MIA 02673 Update Address and return card.Mark reason for change - Engineering Dept. (3rd floor) Map ,-, Parcel �.�� lam'Permit# 4,G House# ­_94 � c � Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30)�'NA 1� ./d 'P wee V Tconservation Office(4th floor)(8:30-9:30/1:00-2:00) 3 / 2. Planning Dept. (1st floor/School Admin. Bldg.) THE Definitive Plan Approved by Planning Board 19 BARN3TABLE. 44 l JA MS& a� TOWN OF BARNSTABLE Amiiac�eN Pa WT�xASEWER 1901f THE Building Permit Application �NDtYIsIOW FXft TO t Street AddressS AS r /�►=� Village (•f m a tJi s M 4. 09- 6 0 1 Owner J�q v lj> 4 3>�%J E 15>w g-9-3>5 Address C�105,1` Si 4444te PO I s 04. 09 601 Telephon(--;'00?7`t S• 7),3 D Permit Request 4 First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ U U Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family 0//' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes 2No On Old King's Highway ❑Yes 0"No Basement Type: a/Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 3 O x 3 Number of Baths: Full: Existing_� New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing q New First Floor Room Count Heat Type and Fuel: &Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes F to Fireplaces: Existing _ New — Existing wood/coal stove ❑Yes U No - n r � Garage: ❑Detached(size) o� © -4 o2 D 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 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 owt ` �c��J eX/� • DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) ; • 1 FOR OFFICIAL USE ONLY ?' PERMIT NO. DATE ISSUED r MAP/PARCEL NO. ' ADDRESS VILLAGE .':' OWNER " DATE OF INSPECTION: - - FOUNDATION FRAME INSULATION - FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH ='f 0' 8 FINAL FINAL BUILDING 0 DATE CLOSED OUT , ASSOCIATION PLAN NO. � pl FRENCH _ - --t D R 5 M tD o� '0 Z Q F^ yn I A" � i 1 +r, ti TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION ---------- ------------- Please print. r/Pl DATE /JOB. LOCATION �' cW75 .5:-,-RjFc 7- wiS :.. Number Street address Section of town HOMEOWNER" Name Home phone Work phone PRESENT MAILING ADDRESS Fi 5 C-H$4 55 i jq, ►a 131 s' Q4 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 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: Persons) 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 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 Officia on a form acceptable to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes .responsibility for compliance with the Sta Building Code and other applicable codes, by-laws, 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 rocedures and requirements. HOMEOWNER'S SIGNATURE ✓ �� . � �c 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. 1 HOME OWNER'S EXEMPTION ; The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix 0, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awarenes 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 " caner-' actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man communities require, as part of the permit application, that the Home Owner 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. L THE 11►._ The Town of Barnstable • eAxxsrnsi.E, - 9� MAS& 10� Department of Health Safety and Environmental Services 1 9. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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 with other requirements. Type of Work: Ad f d,,a Est Cost Address of Work• Owner's Name Date of Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. 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 C', 7 ��0 ijef7p14A315 C.-Pw>9RD- Date Owner's Name Thc• Conrnronit'ealth of:1fassachusetts ;,.i ` _l Deparnizent of IndustrialAccidents 4Office of/nvesU921IMS _1! =y :, 600 11'ashin ton Street "�^4,►:�.,-' Boston. A1u�s. (12111 Workers' Compensation Insurance Affidavit L1l�plic•tnt information•• Please PRINT lebjl,��,__ , name• J®HN r>.340, �Incat' n• p4L/ifMws 09L601 hn •0 775 -7a23d. I am a homeowner performing all work myself. 1 am a sole proprietor and have no one workinu in any capacity �-w,. _ntw'•_.,_�rO....w.........._+w.w... •. TP�w•- .•rw.,�..T)w:aw�.,w�._ �!_.y...w.—_�..�..._w-...._w ..• .. , .. .7Mvl+ _s'wvf�T^w.�lrr./9F!•'•�.,X •w.w�wT+•w.�• w.•a�. "Tam an emplover providing workers' compensation for my employees working on this job. commiri n• fine• acid ress• city: ohnne#- in-;urance co nolicv# I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comn•trn• n•tne- address: city• phone#: insurincc ro nolicv# _ ' ._ ...rf.::•!.... yw^.--......�.. �.�Y•-.::... ��._- - ter'^-c�:.�"�•�iT"l�ww..si♦ ^.Tr'�::'...�c.•f -v .`i-'-i--� conirin n• nntne: address: rity- phone#- insurnnee co nolic� # Attach additional sheet if neccisaryry i.._'.....r'-^"-+.--J%"'.r..^• �+`... 2�'-•r••%,••.''.=``":��''�^:'":'"''.•�•ti"Y"."n�3•^•�i`•�-r�_", M.,.�.�'�• . .._.:lw .•.•_- ..�w�Yr,��l�.r�.J�r`Z�•Me��.-.-"-..: -__�,t-.....,� .Oy.�r.....�.WyY_�.�..._t..i'.1Yi'iJ:��i!•.Y4it i�rRL Failure to secure coverage:ts required under Scction 25A of A1GL 152 can lead to the imposition of criminal penalties of a line up to SI.500.00 andior one y cars' imprisonment as well as civil pcnaitics in the form of a STOP N1.ORK ORDER and a fine of S100.00 a day against me. 1 understand that a COP)'of this statement ma% be forwarded to file Office of Investigations of the DIA for coverage verification. 1 do herebt•cirri ruder the pains and penalties of perjure•that the information provided above is true and c rrect. .✓ "�3 �c�s-.�•-y e� Date - 3- I a'cf°mil SI_nalllrl Print name Phone# "official use only do not write in this area to be completed by city or town oMcial r� A7. �� r• city or town: permidlicense# r'1Building Department E [3Liccnsing Board E 0 check if iminediate response is required C3Selcctmcn's mice f EJticalth Department contact person: P hone#: MOIhcr information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their employees. As quoted 1rorn the "law". an emploi,ee is defined as every person in the service of another under anv contract of hire, express or implied. oral or written. An eynphorer is defined as an individual. partnership, association, corporation or other legal entity. or anv two or more . the forcgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the rcceiver 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 dw c11ino boost of another who employs persons to do maintenance , construction or repair work on such dwellin�� lions or oil tite grounds or building 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- 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. 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 ha 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 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 tite 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. Citv or Towns Please be sure that tite 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 Investiaations has to contact you regarding the applicant. Pleas be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to 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. r•-au....+ ....- ..:..... ..�.....o....r....:-��. n...-z�r....�_.�.�r.•nrw-++^w—s....�.w�rr�. 77 '�`•.�o.ns!"+r'. "-. The Department's address. telephone and fax number: The Commonwealth Of Massachusetts r Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 I�