HomeMy WebLinkAbout0123 CONNEMARA CIRCLE -"�s �-�,-�-
__._
. � oFTW r
a , Town of Barnstable *Perm,t#
Expires 6 mnatlrs from issue date
Regulatory. Services
nUss
EARNSUBU. ; Fee— S
,r i639 ►��� Thomas F.r Geiler,Director
05
Building Division
Tom Perry, CBO, Building Com ner missio ' ip
200 Main Street,Hyannis,MA 02601 0
www.town.barnstable.ma us � f ,
2011 „=
Office: 508-862-4038 - -
EXPRESS PERAUT APPLICATION Fax` �l9Q 210`
"SIDENTIAL ONLY t
q /) !` Not Valid without Red X-Press tmprinf
C / 3
Map/parcel Number v /. .,
Property Address Z 3
h�zM irc4eOXa M
�p
esidential Value of Work
Minimum fee of.S35 00 for:work under$.6000.00'
Owner's.Name&Address . a ri n t
z Ct11Ghz ..
J
Contractor's Name Al
° Telephone Number _ r! 7
Home Improvement Contractor License* applicable)
Construction Supervisor's License#(if applicable) g r
[Ellworkman's Compensation Insurance
Check one;
❑ I am a sole proprietor
❑ I the Homeowner
I have Worker's Compensation Insurance
insurance Company Name_ . r�
7Vorkman's Comp. # L t z �y3 7
Policy ✓. S3
-opy of Insurance Compliance Certificate must accoinpany'each permitd.
ermit Request(check box)
❑ Re-roof(stripping old shingles) Al] construction debris will be taken to n
❑Re-roof(not stripping. ;Going over existin la ers of roof)
�e-side g Y
❑'_ Replacement Windows/doors/sliders. U-Value' " ` #of doors
(maximum .44)
#of windows.
*Where required; Issuance of this permit does not'exempt compliance with other town department regulations,i.c.Historic Conservation etc.
***Note; Property,-Owner must signPro e
P rty Owner Letter of Permission.
A copy Of, Home Improvement Contractors License& Construction.Supervisors require ors Lic
ense ce use'_ i .
s
NATURE:
PFILESIFORMSIbuiidin g permit formslEXPRE3$.doc
ised 070110 a',
�-
NOTICE NOTICE
TO TO `-
r
EMPLOYEES EMPLOYEES
The Conunonwe alth
'Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100,' Boston, MA 02114.2017
617-7274900 h/www.mass.Soy/di a
As required by Massachusetts General Law, Chapter 15Z Sections 21;22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees.under the above-mentioned chapter by
insuring with:
LIBERTY DdLTTTJAL FIRE INSURANCE CO
NAME OF INSURANCE COMPANY
PO Box 9102 Weston, MA 02493-9102 1-800-762-5026
ADDRESS OF INS URANCE MPANY
WC2-31S-317211-031 10-03-2011 10-03-2012
POLICY NUMBER EFFECTIVE DATES
BRYDEN a SULLIVAN INg (508) 775-6060
9ATM, OF INSURANCE AGENT PHONE #
88 FALX0= 'RD _ HYA_NNI S KA
ADDRESS OF INSURANCE AGENT o.
CAROLYN BOBOLA & STEVE BOBOLA 24 ST FRALrTCIS CIR �?
EMPT,OYER ADDRESS -r
EMPLOYER'S WORKERS'COMPENSATION OFFICER (IF ANY) — CJ DATE
c?
MEDICAL TREATMENT
The above named insurer is required in cases of, personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with
the provisions of the Workers'Compensation Act. A copy of the First Report of Injury must be.given
to the injured employee.The employee may selecrt his or her own physician.The reasonable cost of
the services provided by the treating physician will be paid by the insurer, if the treatment is
necessary and reasonably connected to -the work related injury.In cases requiring hospital attention,
employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Insured Dopy
License or registration valid for individul use only
Office of Emu,mer Affairs:&Business Regulatiou ,
HOME IMPROVEMENT CONTRACTOR. before the expiration date. If found return to:
Re �stration Office of.Consumer Affairs and Business Regulation
9 158588 „ 10 Park Plaza-Suite 5170
Ezpiratton 2t112012 Tr `291 .50 Boston,MA 02116
Type a Pm eTsgjp
MASS BUILDING YSTEMS
STEPHEN B0BQLA
24 ST.FARNCIS CIROLE
HYANNIS,MA 02601 Undersehretary Not valid without signature
cctQnse�eS �8987 �
STEpHN E�BOBOLA
x1 24 S FRANCiS CtRk3
HYANNtS M;4 0260
- n
v
a .. _ V
The Commonwealth of Massachusetts
DT 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 LeLyibiv
Name (Business/Organization/Individual): .74 74
Address:
City/State/Zip: e,„ h__1 : Phone #: -Y o l$ -771, 8' 9 71
A;K.Iam
an employer? Check the appropriate box:
1. a employer with 1, 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g Demolition
working for me in any capacity, employees and have workers'
[No workers' comp,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 11.[]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §1(4), and we have no . 12.❑Roof repairs
employees. [No workers' 13.[] Other
comp.insurance required.]
Any applicant that checks box#] 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.
$Contractors 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,Lic.#: t✓G z---3 t 3 97 Z t _ -3 o Expiration Date: /u A
Job Site Address: l L 3 .4 ZE-e eq-f-e a e r City/State/Zip
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u r the pains and penalties of perjury that the information provided above is true and correct ,
Signature: -
Date: !� /
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Towne 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#:
r
�1HE Town of Barnstable
Regulatory Services UAZNSrU
g ry es
MASs Thomas F. Geiler,Director
i639. �
Building Division
Tom Periy;Building Commissioner
200 Main Street;Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8
Fax: 508-790-623 0
f .
Property Owner Must
Complete and Sign This Section
If Using A Builder `
as Owner of the subject property
hereby authorize 1 4/C
� ,., to act on tiy behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
Pool fences and alarms are the responsibili of the
ty applicant. Pools
are not to be filled before fence is installed and pools are not to be
utilized until all final inspections are performed and accepted:
e of Owner Signature of Applicant
Print Name. Print Name
Date
Q:FORMS:O WNERPERMISSIONPOOLS
oFTHE r, Town of Barnstable
Regulatory Services
BARNSTABLE, II Thomas F.Geiler,Director
y aras9.
1639. ��� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-852-4038 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 zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides.or intends to reside, on which there is, or is intended to
be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
. person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building Permit (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
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 t amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt
'gi iineerin Dept. 3rd floor) Map
., Parcel Permit# �2,y��.�
House# !-- Date Issued F 5
Board of Health(3rd floor)-(8:15 -9030/1:00-4:30) Fee PF
Conservation Office(4th-floor)(8:30-9:30/1:00-2:00)
Planning Dept.(1st floor/School Admin. Bldg.) THE
Definitive Pl pro ed by Planning Board 19
• BARNSTABLE.
eft
TOWN OF BARNSTABLE
Building Permit Application
Project Street Address ca
Village �h
Owner Address
Telephone
Permit Request ,
L/
First Floor uare feet Second Floor square feet
Construction Type
Estimated Project Cost $
Zoning,District Flood Plain 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 ❑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
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 ❑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 z2cyl/ � Telephone Number
Address 7/ 7aAc,gym., cr/ License#
CU,,,_0 fid Pf , Home Improvement Contractor# j/a 5-3 G
Worker's Compensation# � 4-W���3 GYM,
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE -7
BUILDING PERMIAA I WON(S)
o >
a X . �c
FOR OFFICIAL USE ONLY —
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE "
OWNER
t n�
DATE'OF INSPECTION:
FOUNDATION
FRAME
INSULATION —
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL '
FINAL BUILDING �
DATE CLOSED OUT
ASSOCIATION PLAN NO.
. . : The Town of Barnstable
• e�sr�sr.E. •
' �e� Department of Health Safety and Environmental Services
1659.
659 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: Est.Cost �a�®
Address of Work:
Owner's Name L- n
Date of Permit Application: 7 . _
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
Date Owner's Name
The Commonwealth of.1fassachusctty
Dcparrnrcnt ojladttsrrial.4ccidents
` 1 0l1icE�//m�estlgallans
6110 If'trs dir�;tua Strut
•� -
` Bastoir.Alas 02111
Workers' Compensati0n Insurance Affidavit _
�I�Piic�intinftirntatitin• — Please PRINT Te-61v
a
name*
Inc•ttion• 7/
cit"• �, r� nhnnc 0
1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
-F. rtr•- A'.lNsu�-f'AIRT��)71�+'��..i�T.• r.r. ��w-...w..-�.www+.��..���.....
M I am an emplover providing workers* compensation for my employees working on this job.
crrowanc name*
addrecr
sin nhnnc#t
incurnore cn. / /ey
I am a sole proprietor. general contractor, or homeowner(circle arc) and have hired the contractors listed below who have
the Following workers compensation polices:
cmmnnnr nnrnc•
ntitlrrcc�
sin nhnnc it•
in-mrnnrc ro. d
cmmrinnv nnnnc-
ntldrecc-
tin nhnnc i!•
insurnnce co nolicv d
Attach additional sheet if necessary _ .�rrrtrtr�.-y .J�:�l�• .. �..r.'� �_.�' �.'.:'�':-.�y�f•....�::,.1wL wars.
Failure to secure covernec as required under Section:SA of AIGL 152 can lead to the imposition of Cnmtn21 Penalties ot•a tine up to S1.500.00 andiur
uric ears' imprisonment as Well:rs ciVil penalties in the form 0172 STOP WORK ORDER and a fitte of S100.00 a day against me. 1 understand that a
cope of this statement mar be forwarded to the office of investigations of the DIA for coverage verification.
1 do bercht cerri rr cr t r pair and petraities ojpeijun•that the information provided above is true and correct.
Sinnature Date ; r 7
Print name Phone r
Niacin! "c unit do not write in this arcs to be completed by city or town ofliciai w`'
city or tn►s•n• permitilicense# t-111uiiding Dcplrtmcnt
C3ucensing Board L
a check if immediate respunse is required 0sclectmen's Office ►
t C311caith Department
phone#* Miller s.
contact persnn: i
Information and Instructions
� • lion for th
Massachusetts General Laws chapter 152 section '_5 requires all employers to provide workers' ct�mpcn.s a
employees. As quoted from the •'la++•'•. an entplt tvee is defined as even?person to the service of another under an+
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 inc
and tncludinc the le•• 1 re rescntativcs of a deceased employer. or the
�+ ens �• t t a 'oint ente rise. P
the forc.�om� _a�t.d t ,1 �
• lovees. Howevcr t?
+ • individual , artnershtip. association or other legal entity, employtn�, emp
receiver or tnistce of an n P
owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
d++cllin•_ boost of another who employs persons to do maintenance , construction or repair work on such dwelling he
or on the __rounds or building appurtenant thereto shall not because of such employment be deemed to be an empioy,
MGL chapter 15? section ''S also states that e�•en- 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
R required.
with the m surancc coy era c
:t � iic:tttt ++•lio has not produced acceptable evidence of compliance „
1 P tl�e
• , contract for
Addiuonail+•. neither the commonwealth nor any of its political subdivisions shall enter into any cot C
perforniance of public work until acceptable evidence of compliance with the insurance requirements of this chap:er
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 sibn and date tlle affidavit. T'lie
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 require
to obtain a workers* compensation policy. please call the Department at the number listed below.
City or 'I"owns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. PI:
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returnee
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 an,% questic
please do not hesitate to _:ive 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
fax #: (617) 727-7749
Phone #: (61 7) 7_;-4900 ext. 406, 409 or.:)
Alna.::��titi:�..o.'+>i:rS w:.t ..'�a�'.'�.+�-+� .��wti.*ia�:raw'e�'`! u+�M `ti- �...� �.���--'.L'Y � - - 'Sa1""�i''.�wf►ty:^w.•.
HOME IMPROVEMENT CONTRACTORS �RE:GISTRATION
Board of Building Regulations and''Standards ; p r
.One Ashburton - Place Room ' 1301 sR
" Boston., Massachusetts:,02108 i� t �k
E
{ HOME • IMPROVEMENT CONTRACTOR
Registration' 112536 Expiration s04/06/99 '`# " � � •' falac � �
1 Type DBA a s,
r �tp DOME IMPROVEMENT CONTRACTOR
1 k E "Registration 112536
ERASER CONSTRUCTION ' � = x �� � ` T e DBA
YP
DEAN C . ERASER F ;; �� .4 Ezpiratioa 04/06/99
71 TARRAGON CIR
COTUIT MA 02635 4 ERASER CONSTRUCTION
C. FRASER
ADMINISTRATOR 1 TARRAGON CIR
COTUIT MA 02635
Assessor's map and lot number .... .1. .............. ........ ���— O/� �-( 7.s
SEPTIC SYSTEM MUST BE
.-IA LE IN COo�?C�LI,4iVCE
9 � _ .
Sewage Permit number
t I [A.,.Tl �l_E 11 STATE
IA?Y CODE AND TOWN
TOWN OF BARN"YrANBLE
fob
BABBSTABLE.
o aya,•� :.t BUILDING INSPECTOR
Z.
APPLICATIONFOR PERMIT TO .......... .......................................................................................................
TYPE OF CONSTRUCTION ..............: . ................................................................... ..............
.............. ....... ..................19...
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
p Z
...... C� � N ...C.. 2C
Location .....(U I..............6 ................ . . ... ............. � Q\...:..........................................Proposed Use .:....�.(,--Q 1 ( i�l � I M�L'� � ��V�'
................................................................................. ....................................................... ......................
Zoning District ........!l?. ........................................................Fire District ..........44� ��?���� $
�... .
.� 1
Nameof Owner �:.� / ......................Address ............. . ............. `• ...` ...........:.................
I� ai
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ....:.. ..................................................Foundation ...................................................,....C- .......
�� ✓.. � h r Nl�.-� ................Roofing V7� aJ�. 9 SS ► t�I G—�-.. S`
Exterior ........... .......................................................... �..............................................
1- - . . -`- .. ......................................Interior .............�l.cR. .. :
Floors x Ak...............................................
Heating Q(�..............Plumbing (.
Fireplace ................ ................................................................Approximate Cost ...........�./. .... .................... ...........
Definitive Plan.Approved by Planning Board -------------------_-----------19________. Area
Diagram of Lot and Building with Dimensions Fee �. •�.�
.................... .........................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
L�
IL
cl� Z
2
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..... .. ..................\.^.... .........
�
'
SKM» jo
�
No:�0-5 Permit for
|
^~~== C /
Locodon ������, ..
-----..C�������,8�u�m°--'..---. ......
Owner —.A�...L...Sndloh------------ � \
' ' ^
Type of Construction
— `--------- �
--------'-----------'------''
Plot ---------' Lot ....012....................... '
� .
'
�
Permit Granted �� 1' lg�m
.~=�»��=' ' ----� «� |
Date of Inspection ....................................lA '
unro Completed -� } `
) ^�
' f
PERMIT REFUSED
`
-----_--------------.. lA , |
|
_____.. . |
--------------------.. .
. �
�
.............................................................. /
^^'---'^-----^-----^—~^—^—'---''
..~------------.....---.-----.
Approved ................................................. lA �
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