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HomeMy WebLinkAbout0139 COMPASS CIRCLE / , of d it L __ _ �_ _ t Ali r i i i f i i �� r .�� i B9 � �r F JEFFERY JOHNSON - ATTORNEY AT LAW TwELYE CENTER PLACE t 1550 RouTE 28 (508)790-5776 CENTERVILLE,MA 02632 FAx(508)-775-6029 r i---'.�1 �1� �f o ���Y,; ��' �� � U � ������ ��e � � �� . ''�� d ,. i � �� � - ' Y i G� -all Town of Barnstable Building F .� v ter.; `.:� ¢� Bnxx§[wrsse Post This Card{So That�t�s-U�s�ble From the Street Approyed:Plans Must be Retamedon Joband this Card Must be Kept °x v 6 Posted Until final Inspection Has;Been Made ' s z x • eaa Where a Certificate;of Occupancy�s Regairedu,suchBuildrng shall Notbe Oecup�ed�until a Fia�l Inspection has been made er �� k,-.....,._..,....,,,.,....<...�..,�. ,b.,t,�w.,. Permit No. B-18-476 Applicant.Name: DEL CARMEN,CARLOS R Approvals Date Issued: 04/02/2018 Current Use:- Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 10/02/2018 Foundation: Residential Map/Lot 310-418 Zoning District; RB Sheathing: Location: 139 COMPASS CIRCLE, HYANNIS Contractor Name' Framing: 1 Owner on Record: DEL CARMEN,CARLOS R Contractor License' 2 h Address`. 139 COMPASS CIRCLE Est Project Cost: $400.00 Chimney: HYANNIS, MA 02601 Permit Fee: $85.00 Description: walk in closet, building a wall in the middle of a roorimAo make the Fee Paid 8 $85.00 Insulation: walk-in closet i. Dat 4/2 2/ 018 Final: e Project Review Req: kk v . sv r Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work auth. iz.d by this permit is commenced within siz months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl atom and'the approved construction documents for which this permit has been granted. g All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: ir.r x a 4 This permit shall be displayed in a location clearly visible from access street o'r road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ' r Electrical The Certificate of Occupancy will not be issued until all applicable signatures byFtheBuildmg and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or footing ' s - �, -'" Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Pettons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT i-Pr►s��L S�/� . .. � 4 � O Application Number.... ........... s .... .....N........ , sABNS�S[ati �+ * .......Other ee......... Permit Fee:......... ............. }�� ......z Ln M�A, 0 O TotalFee Paid...................................... ............ui... .. z F BARNSTABLE Approval .. on. M TOWN O Permit val by.... v .....� ` BUILDING PERMITPa1......... �. ....." �.............. .0................. APPLICATION Section I — Owner's Information and Project Location Project Address 4 Village Owners Name Owners Legal Address C State zip ity I, Owners Cell# E-mail Sectio n 2—Use of Structure ' E Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling E Section 3--Type of Permit F ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ® Sprinkler System ❑ Addition ❑ Retaining wall ❑_ Solar Renovation ❑ Pool ❑ Insulation Other—Specify AAA Section 4 Work Description Tact imdated-2/9/2019 Application Number.................................................... Section 5—Detail Cost ofof Pro osed Constractio._ p � � �� Square Footage of Project r Age of Structure Dig Safe Number #Of Bedrooms Existing Total# Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage -❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑i Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site i Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No j Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ 1 Section S—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No T....a..�.i..a�.i.111MP%f%10 60 ( ol ;. 2m 5q ----------------- .y C o2AoI Z:1 00 r�, r � rn The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston,MA 02111 www.mass.gov/dta Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ` Address:--�-3 5 City/State/Zip: l Phone#: / ^ 2 2 Are you an employer?Heck the appropriate bog: Type of project(required): l.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑Now 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 g, ❑Demolition workingfor me in an capacity. employees and have workers' Y aP tY• - 9. ❑Building addition [No workers'comp.insurance comp.u1samce.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.�TI 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.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 isproviding 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 certcfy�under the pains andpenalties ofpedury that the information provided ove is true and correct. Signature - ---� - Date:' (Phone# t Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to casy 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 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 hike 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 Aeddents Office of Investigations 6M Washimgtan Street Bostan,MA 02111 Tel,#617-7274900 ext 406 or 1-877-MASSAFF, - Fax#617-727-7749 Revised 4-24-07 - www-m=,gov/dia - Application Number........................................... Section 9—.Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# 1 understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section.10 Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC... Signature Date Section l'=Home Owners License Exemption Home Owners Name:- - - Telephone Number Ce11 orVWork Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation by 780 CMR and the Town of Barnstable. SSignature '� -- "` D�aNj ate-- APPLICANT SIGNATURE Signature 4 A - Date 2 Print NameLoMed phone Number "� 2 .1 E-mail per to: ` Section 12 —Department Sign-Offs . Health Department El Zoning Board(if required) El Historic District ❑ Site Plan Review(if required) ❑ 'Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's Authorization I, as Owner of the-subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name a, i Last undated:2/9/2018 �Gos�� � Oy�� � a�� I 4 1 � ` I O1/12/208 Friday 139 Compass Circle—went with Jim (Health). Found former basement apt dismantled. Tenant landlord dispute. James asked me to go with him. Number of bedrooms exceeds septic. When we got there found-2 bedrooms on 1 sc floor, remnants of a 2 bedroom apartment in lower level. Kitchen gutted, debris on floor, full sized fridge had only beer in it. % `openings in the 2 bedrooms. The findings were: A stray piece of furniture, 2 mattresses in bedrooms, broken glass and debris in kitchen area. Owner unwilling to remove shower. A bedroom on the 2"d floor was being converted into a walk-in closet and was framed dividing the space in half. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 46 Map v Parcel 1 Application # Health Division : : Date Issued l3—� fie Conservation Division Application Fee _Planning Dept. Permit Fee _ Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 6P14 ~ Village Owner Address Telephone ' <;Permit Request 0- tb�. AA A A 0 AA Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 7 Project Valuatio#4 VOConstruction Type a a C, _13 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting d©cumehtation. Dwelling Type: Single Family ❑f Two Family ❑ Multi-Family (# units) ? ' Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's lighway:4 Yes`20 No C1� 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 —(B ILDER OR HOMEOWNER) Name , ` - -- - \�1J ( _ - n// 2-- Telepf�one Number /�Y 2 1 �Address� License# 4 AAA I d) O 2.6 0 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE / DATE "�9. ,Parcel Detail Page 1 of 4 �y e i y BitIN TAx{E.ir.. i`ed�q 161 19�,/;, .,, ✓ �C },4(�4 G py Zi .� Y •1�.--/^:V V,L+V J YI�./'L/4'V [.�4� Logged In As: Parcel Detail Friday,January 12 2018 Parcel Lookup Parcel Info N� Parcel ID 1 10-418 I Developer Lot ;LOT 32A Location 139 COMPASS CIRCLE Pri Frontage 116_;..,.n.._' l Sec Road BEARSE'S WAY sec Frontage 10 � Village Hyannis Fire District HYANNIS Town sewer exists at this address Road Index`0340 Asbuilt Septic Scan: " } 310418_1 Interactive Map - �1 310418-2 Owner Info Owner DELMCARMEN,CARLOS owner. streets z139 COMPASS CIRCLE I streetz city iHYANNIS I state MA zip,02601 country Land Info . _.. ....... .. ........................ ................ ........ . ......... .._.._._.... .........._ ......... Acres 3 use rSingle Fam MDL-01 Zoning r Nghbd 0104 Topography_Level Road 1,Paved g;,:..,mwwwma:x�:.u...awmxwzxear ................_ .. utilitles i blic Water,Gas Septic) Location • Construction Info Building 1 of 1 e�is 1998 ....,,,r •,I stRrucc Gable/Hip w u Vinyl Siding Living co er.A�sph/F GIs/Cmp T Type ;None Style Cape Cod wa l Drywall Rooms 3 Bedrooms— Model Resldential I"t Bats�1 Full-0 Half ooms Floor R .F.;.r.., ..,...r Heat Total Grade Average ._ Type rHot Air Rooms,5 Rooms Stories 1%1/2 Stories "eat Gas Found- Fuel ConC. ^� e Fuel�� abon Gross Area �2344 • Permit History Issue Date . Purpose Permit# Amount Insp Date Comments Weatherization, air 11/2/2017 Insulation 17-3646 $3,400 sealing,weather stripping and blown cellulose 5/13/2014 Restore to SF 201402690 $1,000 SF REMOV KIT IN BMT http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25936 1/12/2018 Parcel Detail Page 2 of 4 6/30/2015 12:00:00 AM 2/27/2014 Solar PV System 201401076 $11,000 7/31/2014 18 SOLAR PV PANELS 12:00:00 AM ON ROOF 4.5KW 11/19/1997 Dwelling 27222 $65,600 7/1/1999 12:00:00 AM • Visit Histo.rY..... _ _ _..�� ___._� _. .-_...._.w--_- Date Who Purpose 4/2/2015 12:00:00 AM Robin Benjamin In Office Review 2/3/2015 12:00:00 AM Teresa Wright In Office Review 8/5/2014 12:00:00 AM Mike White Bldg Permit Completed 1/22/2014 12:00:00 AM Jeff Rudziak In Office Review 5/12/2003 12:00:00 AM Paul Talbot Meas/Est 7/1/1999 12:00:00 AM Andrew Machado Meas/Listed-Interior Access 3/24/1998 12:00:00 AM Lloyd Kurtz Sales..History ... . _._.._... _ ....... ............................. Line Sale Date Owner Book/Page Sale Price 1 6/29/2012 DEL CARMEN, CARLOS R 26463/301 $147,000 2 4/4/2012 FEDERAL NATIONAL MORTGAGE 26219/154 $140,665 ASSOCIATION 3 10/31/1997 EGAN, KERRI A 11037/105 $107,400 4 10/31/1997 REED, CHARLES A 11037/103 $27,500 5 5/15/1987 HOULE, ANNA L& PAULA S TRS 6724/110 $1 6 5/15/1987 HOULE, ANNA M 5723/69 $1 7 1/15/1979. HOULE, HENRY &ANNA M 2926/234 $0 • Assessment History Save Building Total Parcel # Year Value XF Value OB Value Land Value Value 1 2018 $119,900 $30,000 $1,700 $91,100 $242,700 2 2017 $112,100 $31,000 $1,700 $69,700 $214,500 3 2016 $112,100 $31,000 $1,700 $70,200 $215,000 4 2015 $106,700 $18,200 : $2,000 $67,900 $194,800 5 2014 $86,100 $18,200 $1,800 $67,900 $174,000 6 2013 $86,100 $18,200 $1,800 $67,900 $174,000 7 2012 $88,000 $18,200 $1,400 $67,900 $175,500 8 2011 $112,100 $0 $0 $67,900 $180,000 9 2010 $111,800 $0 $0 $104,400 $216,200 10 2009 $124,500 $0. $0 $141,100 $265,600 11 2008 $129,400 $0 $0 $147,000 $276,400 13 2007 $128,800 $0 $0 $147,000 $275,800 14 2006 $124,800 $0 $0 $147,700 $272,500 15 2005 $120,500 $0 $0 $133,800 $254,300 16 2004 $107,300 $0 $0 $100,400 $207,700 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25936 1/12/2018 Parcel Detail Page 3 of 4 17 2003 $87,400 $0 $0 $37,300 $124,700 18 2002 $87,400 $0 $0 $37,300 $124,700 19 2001 $87,400 $0 $0 $37,300 $124,700 20 2000 $71,300 $0 $0 $23,100 $94,400 21 1999 $0 $0 $0 $23,100 $23,100 22 1998 $0 $0 $0 $23,100 $23,100 23 1997 $0 $0 $0 $19,800 $19,800 24 1996 $0 $0 $0 $19,800 $19,800 25 1995 $0 $0 $0 $19,800 $19,800 26 1994 $0 $0 $0 $23,700 $23,700 27 1993 $0 $0 $0 $23,700 $23,700 28 1992 $0 $0 $0 $26,400 $26,400 29 1991 $0 $0 $0 $42,800 $42,800 30 1990 $0 $0 $0 $42,800 $42,800 31 1989 $0 $0 $0 $42,800 $42,800 32 1988 $0 $0 $0 $16,900 $16,900 33 1987 $0 $0 $0 $16,900 $16,900 34 1986 1 $0 $0 $0 $16,900 $16,900 11 Photos http://issgl2/intranet/propdata/PareelDetail.aspx?ID=25936 1/12/2018 Parcel Detail Page 4 of 4 :r � J is! a _ RAMsz4 : x x http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25936 1/12/2018 �i- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map v Parcel 1 Application # Health Division : . Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address C,illage O�_ hAh Address Telep� / - 2 7 ` -- �9 r_Per-mit Requ-est _!_1 9QJ" �Ih 4 10AA AT FLO AA I A A II Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Y Flood Plain Groundwater Overlay (Projec`t Valuaatio Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach s'upuporting d©'cume jtation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) ia: *) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Hi ighway: 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 (B ILDER OR HOMEOWNER) Name. Telephon____ e Numbed Address �1 License # ' Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ' SIGNATURES CDATE' "�1 FOR OFFICIAL USE ONLY ti 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 DA"ESCLOSED OUT AS-S,,Q a4TION PLAN NO. t The Commonwealth of Massachusetts f,. ' • Depmbment of IndunWdAccide7ar Office of Investigations 600 Mashington Street ` Boston;MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Binders/Contractors/Electricians/PlrLmbers Applicant Information Please Print Le b f N� sloTmization/tndividual): Address: City/State/Z-Ip 2 hone#: Are you an employer?Check the approp to box: Type of project ro'J re 4. I am a general contractor and I P (required). 1.❑ I am a employer with ❑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. 7. ❑Remodeling shipand have no employees These sub-contractors have 8. .[]Demolition working for me in any capacity. employees and have workers' con in umce.t 9. ❑Building addition [No workers'comp.;n�r„•an� P• . required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3,. I am a homeowner do' all work officers have exercised their 1 1. Plumb'mS ❑ mg repairs or additions myself [No workers'comp. right of exemption per MGL 12❑goof repairs insurance required.]t C. 152, §1(4),and we have no employees,[No workers' 13.❑Other comp.msmance required.] *Any applicant that checks box#I 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 hue outside contractors must submit a new affidavit indicating such. tContraclnrs that cbeck this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. If the sub-contractors have employees,they mast provide their workers'comp.policy number. I inn 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.Lic.#: Expiration Date: Job Site Address: City/StateJZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required render 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 p and p of perjury that the information provided ove is true and correct. S' aturea' -- Date Official use only. Do not write in this area,to be completed by city or town official City or.Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town'Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General.Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, .express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to.be an employer." MGL chapter 152, §25C(6)also states that"every state or 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 ms+ rznce 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),addresses)and phone number(s)along with their certificates)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 regard ag 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 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 Investigatians 600 Washington Street Boston,MA G2111 14#617-727-4400 ext 406 or 1-877-MASSAFE Fax#1~617-727-7749 Revised 42407 wwwmm.gov/dia Town of Barnstable - -n i1 Regulatory Services - t Thomas F.Gerler,Director .�� Building Division " Tom Perry,Building Conraiissioner 200 Man Stint; Hya=,MA 02601 w".town.barnstable.ma.us Office: 508-862-4038 Fay.509-790-6230 - $olv�owx>R Lrca�rsa;;> 1zox Please Print AAAAA ber strut/ '�iOMFAwi1ER": d)2 �.s'""� name home phone# phone# C_UURRENT MAIL NG-ADDRESS: L 3 `�j) ))Lj JOG. imp a�y state (v/ rip coVd 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 S[IDeIYI50Z. DEFE-MOx OF HOMLOwxER 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 structnms accessory to such use and/or farm strnr tures. 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 yerformed under the burldirigyemok (Section 109.1.1) The und.ersigaed"homeowner"asses responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. Thi undersigned"homeowner:'certifies that he/she un_�tanffi the Town ofBamstable Building Department minim=inspection and requirements and that he/she will comply with said procc&ns and aunt ofHomcowrier ,' � �•". °�'-� Approval of Building Official Not: Three-fa=- r dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMMOV49 RIS F-XEa� IYOx . The Code stairs that luny homeowner pe fo<mingymic for which a buildng penait is required shall be exempt 5vm the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner cogeges a persor(s)for hire to do such work,that such Homeowner shall act as supervisor. Many homeowners who use this exemption an unaware that they are assuming the Tesponsrbrlifies of a supervisor(see Appendix Q, Rules&Regulations far Licensing Construction Supervisors,Section 2.15) This lack of awareness ar=results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cauirot proceed against the unlicensed persau as'it would with a B=nsed Supervisor. The homoowoer acting as Supervisor is ultimately responsible. To ensure that the bmreownar is My zwm-e of hiAermspaasrbilitics,many communities require,as part of the pert application, i that the homeowner=tify that hdslm umderstuirds the trsponsihrlrtim of a Supervisor. On the iastpagc of this issue is a foam currently used by. several towns. You may ear tsmend and adopt such a kno/certi5cation for use in your coon mssty. Q�rn nrshomeaceurpt - - ' r G _ of Town of Barnstable Regulatory SerPiees gThomas F.Geder,Director `,� Building Division Tom Perry,Budding Co ner 200 Main street,$yaffiis,MA 02601 www town.barnsta6Ie.maus Office:: 50M62-4038 Fay 508-790-6230 Property Owner Must Complete and Sign This Section �If Using'A Builder as Owner of the subject property' hereby authortze to act on my behalf; 1n 2E matters relative to work authorized by this budding penult (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. 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