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HomeMy WebLinkAbout0153 CONNEMARA CIRCLE e,In ea&4v TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Cz Conservation Division Application Fee Planning Dept. Permit Fee ll/ Date Definitive Plan Approved by Planning Board 1 Historic - OKH _ Preservation / Hyannis Project Street Address O N ti M A 1^ A � � ►'-e_ Village Owner 10 )n Address Telephone �J ? g - 3l7 s/z)-3 Permit Request � ) �4 J L! ��/� ,L ti L Square feet: 1 st floor: existing/�0 proposed 2nd floor: existing proposed 01 Tot ew Zoning District J� S Flood Plain Groundwater Overlay ; Project Valuation © 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting docimentation. 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: *ull ❑ 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: `3 existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: PrGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes '1Z 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 `1� Y-S Proposed Use S APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name(�rz, M u_-� Telephone Number •S - 7� / �� Address �� ��N License # L o 5 C,v�s �-tip-�S /-Y\ AI Home Improvement Contractor# Worker's Compensation # 6 9 a 9 7o r_�o?-a ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S s J 3(G O SIGNAT � �"�- DATE A I )/ I ` FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED " MAP/PARCEL NO. ADDRESS VILLAGE OWNER �t ` r DATE OF INSPECTION: FOUNDATION FRAME r INSULATION r' FIREPLACE ELECTRICAL: ROUGH FINAL c PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Town of Batnstable Regalatory Seryices Thornas F. Geiler, D rector �r e6 Building Division Thomas Terry, CBO, BuiIdiag Commissioner 200 Main Strcet,` Hyannis,MA 02601' www..Eown.b arnsta b l e,ma.us 'Offices 508-862-4038 Fzz 508-790-623C PUI RF Y.M Owner U G— Map/Farcel; J project Address�'�� C o tr60-YAA 4 Builder. •�,. ( { C1 / The folzowitzg HLe=Were noted on reviewing: i L C-/ S7 - Date '- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations. - 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Orgmizationadividual): : v �t v Address: / o.✓ t City/State/Zip: -,-s t Phone A: ,24 a L16 Are you an employer?Check the appropriate box: -Type of project re aired 4. I am a ene p J ( q )�. 1FI am a employer with 3 ❑ . g ral 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.- 7. ❑Remodeling s and have no employees These sub-contractors have mP8. ❑Demolition working for me in any capacity. employees and have workers' co insurance.$' 9. ❑Building addition [No workers'comp.insurance comp. �. required.] 5. ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall-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. $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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: -C Policy#or Self-ins.Lic.#:_ 3 O O P D '7.0 Expiration Date: Job Site Address: 1 S�3 CO.J lV Yh e41^ A I- City/State/Zip: I� N JJ`. S r n 6, 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 statemei t.may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do e y ce under th ns�ar enalties of perjury that the information provided above ` true and correct Si afore. Date: .� ) Phone#: �� F only. Do not write in this area,to be completed by city or town ofikiaLn• Permit/License# thority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector son: Phone#: . i 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( ).states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work-anti!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 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: Tb:e.Cammionwealtlt ofMassach=us Departmant of Industrial Accideints Qfface of Invesdpdons 600 Washings Strew Boston, MA 02111 Tel.#f 17R727-4900 ext 406 or 1-$7 MASSAFE Revised 11-22-06 Fax##617-727-7749 w.mas5.g0.v/dia ry en ana Nwilvan Kas own o arns a e OP ID: KS coRO' CERTIFICATE OF LIABILITY INSURANCE DATE(101/1'YYJE 06/01/12 THIS CERTIFIE;ATL IS 1.55UEU AS A MATTER OF INFOKMATION ONLY AN THE CERTIF1 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIC BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORI REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subjecthe terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to certificate holder in lieu of such endorsements. Bryden&Sullivan Ins Agency' PHONe of Dennis Inc. 508-394-226 ac No Ext: (ArC,No): 485 Route 134,PO Box 1497 E-MAIL So.Dennis,MA02660 PRODUCER Dennis Office INSURER(S)AFFORDING COVERAGE NAIC# ' INSURED David Dadmun INSURERA:Associated Employers Insurance 51 Pond Street Unit 7 INSURERB: West Dennis,MA 02670 INSURERC: INSURER D . INSURER E: - INSURER F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 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. INSR TYPE OF INSURANCE --POLICY EFF POLICY EXP " .. POLICY NUMBER LIMITS GENERAL LIABILITY. EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE FJ OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY. COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person)` $ ALL OWNED AUTOS BODILY.INJURY(Per accident) $ " SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE. AGGREGATE $ DEDUCTIBLE $ RETENTION . . $ WO KERS COMPENSATION - WC STATU OTH- EMPLOYERS'LIABILITY TORY.LIMITS ER. A PROPRIETORmARTNERIEXECUTIVE Y/N WCC5009227012012 'w` 05117/12 0S/17/13 E.L.EACH ACC IDEiJr $ 100,00 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) E.L.DISEASE EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below - - E.L.:DISEASE-POLICY LIMIT $ - 50O 00 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) " David Dadmun, owner, has elected to Exclude himself forworkers compensation benefits. TOWN-18 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE _ TOWN OF BARNSTABLE ACCORDANCE WITH THE POLICY PROVISIONS. BLD.INSPECTOR 200 Main Street AUTHORIZED REPRESENTATIVE HYANNIS,MA02601 r 1988-2009 ACORD CORPORATION: All rights reserved. ACORD 25(2009109) The ACORD name and logo a registered marks of ACORD Massachusetts- Department of Public S' Board of 8uiltlinus Re,, Construction Su .,,ulations and Standards One-a sups License and Two_Family Dwellings License: CS 742% DAVID L DADMUN 51 POND STREET WEST DENNIS $` MA 02670 („nrmi.��inner Expiration: 12/31/2012 Tr#; 9743 ,�.� ✓fze U�arvnoowr� a�✓�aa�aelu�aeta _ -. Office of Consumer Affairs&Business Regulation —(B HOME IMPROVEMENT CONTRACTOR _ _= Registration: 128718 Type j \' f.1 Expiration: 5/9/2013 DBA /.•/ D.L.-DADMUN CUSTOM BUILDERS; DAVID DADMUN;..: 51 POND ST W.DENNIS,MA 02670: Undersecretary , ' J J i i i i ANY �r i Z )e lU 17ti C y� i i I j t o �T WO .7r- 13�� r� �:�r���✓ r i Regulatory Services 71mas F,Geiler,Director Building Division Tom Perry,BmId ng Commissioner 200 Main Street,HYannis,MA 02601 ww Aawn.bamdable.m.us Office. 508-962-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A.Builder as Owner of the ettP subject oro 1 _ . Y hereby authoxize A v to act on my behalf, n aII mattets relative to work autha6zed by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized urxtil an fin-al inspections are performed and accepted. Signature of Owner Signature of Applicant ?runt Name Print Name - � ac) Date Q:F0RMS_0WNERPM2 MSJ01V00IS E s �0_�.., ;. o 1 Ior�>r propzr� SdE� �r N �- Ul m Aj O L,AOETA�I .b V. if 34311 G-i` )PRl(w) CIASED ON Llfv£-'y U>°J14�, ON GAMILY. A MORE,'1G,"Qi AD.h(X,;A 10i,: WILL REQUIRE.AN,IW)1'�flltdE h11 o � SURVEY, Scale: . : 3 HN R. I .AU13 .. 6i`^!. A PROFESSIONAL LAND SURVEYOR, AMERICAN SURVEYING COMPANY DO HEREBY CERTIFY THAT THE ABOVE MORTGAGE INSPECTION 1264 Main Street, Waltham, MA 02451 (781) 893-6477 PLAN WAS PREPARED FOR PWC_. rA7-G, C.o IN CONNECTION WITH A NEW MORTGAGE AND IS NOT.INTENDED OR REPRE- Mortgage Inspection PIa� SENTIED TO BE A LAND OR PROPERTY " LINE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT r�T COUNTY REGISTRY OF DEEDS SET. IT CANNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER. BOOK PAGE L.C.Cert.# TABLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: U-' G_ Pl_A BUILDING LINES,THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSOR'S. HEREON.IS BASED ON CLIENT FUR- FECT WHEN CONSTRUCTED WITH RE- MAP# PARCEL# DATED NISHED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: 5 3 CC)k)" C-m • 'I-A G t'124 SUBJECT.TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT __ GGVZIL =� TAKINGS,EASEMENTS AND RIGHTS OF FROM VIOLATION ENFORCEMENT AC- BORROWER:.1:5 U. � I' WAY. RQ RESPONSIBILITY IS EX- TION UNDER MASS.G.L•TITLE VII,CHAP, TENDED.HEREINTO THE LAND OWNER 40A, SEC. 7, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE OR OCCUPANT, IT IS NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSURANCE PROGRAM FLOOD TO BE RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED �_)V�`� -� }���� IS ADVISED WHEN STRUCTURES ARE COMMUNITY_PANEL# 7, DATE 11 ) g 9 SHOWN TO BE V OR LESS FROM CLIENT.-d PROPERTY OR REQUIRED ZONING By Tw FIELDED DRAFTED CHECKED CLIENT REF# �'-'Q�� SETBACK LINES. DATE (1-17-9 II-f 8-gq /� F.B. PGE. J.O.# QO �3S TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION L Map Parcel 3 Permit# �j Health Didisioni OK Y� ® Date Issued Conservation Division E3 114[ca D4k— Fee Tax Collector '� a) Treasurer ' rh 7 AS E Planning Dept. ►MITE®T® Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street Address 1,53 iy Village Address er`� � Ow ner S h S Telephone 60 g" —7 9 0 9 7 1' Permit Request /z Square feet: 1st floor: existing lo9y proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Y Lot Size q Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Fami�y Two Family ElMulti-Family(#units) Age of Existing Structure #-c? Historic House: ❑Yes 511"No On Old King's Highway: ❑Yes ❑ No Basement-Type`�;'�Full RO Crawl ❑Walkout ❑Other - ,tea 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: bGas ❑Oil . ❑ Electric ❑Other Central Air: ❑Yes OY'No Fireplaces: Existing �_ New Existing oo" oal 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 O Yes -1-0 No 1f yes, site plan review - Current Use Proposed Use BUILDER INFORMATION.— N kl� Telephone Number Address License# O Home Improvement Contractor# /a:a43.- Worker's Compensation# �—)U7(-09o39(02s ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN 4 SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE i OWNER DATE OF INSPECTION: i FOUNDATION r 1� FRAME }:? INSULATION - FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL . .+o FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Q _ �pEIME r, Town of Barnstable .Regulatory Services " snxns'rA.MAW. Thomas F.Geiler,Director 9 g' �AIE039. 14`� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,.MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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: �(/L/ Estimated Cost '" �0 Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law FlJob Under$1,000. []Building not owner-occupied weer 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. /6 2-005 of Date tOwner's Name Q:fomis:homeafEdav Town of Barnstable �OFtME Ap�O Regulatory Services ' Thomas F.Geller,Director SAMSTA1314 ' M&63AC Building Division pr fot p Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us nce: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number ,) Q street village ��xoMEowNE1z': s�`C UGC bog- 7 ' o % 7& 3 name t home phone# work phone# CURRENT MAUJNG ADDRESS: C��19- CC ra K 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 suvervisor. 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 m;r,;rrn�m ' ection procedures and requirements and that he/she will comply with said procedures and requi,re Si re 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 �•' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): S * de, Address: /� ��l�I � Q �� rtr�116' City/State/Zip: Yq 9/2 Phone#: Are you an employer? Check the-'appropriate bog:. Type of project(required): 1.❑ !am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet-* 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10,❑ Electrical repairs or.additions rIanni uired.] . . 3. 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.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other camp.insurance 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 hire outside contractors must submit a new affidavit indicating such tContractws that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infoririation. 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u r the p 'ns and pen It' s of perjury that the information provided above is true and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town of City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined a$:&.San indivi4al,.:pa�eq�p,:association, porporation'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 ' trustee of an individual,partnership, association or other legal entity,employing employees. Howev.,er.the receiver a owner a dwelling house having not more than three apartments and who resides therein,or.the occupant of the dwelling house dwelling another who employs persons to do maintenance,construction or repair woilron 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-contractor(s)name(s), address(es) 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 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 provideda space at the botm Of the affidavit for you to fill out in the event the Office of Investigations has to contact ou regarding the applicant Please be sure to fill in the permMicense 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"'tlie 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.orlicenses..Anew 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 bum 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 3. 600 Washington Street, . Boston,MA 02.111: Tel. #617-727-4900 ext 406 or 1877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia PINE HARBOR WOOD PRODUCTS , ,4014, 359 Queen Anne Rd. HAFNWM.MA 02e45CM) pac.FAX(500)430.1115 E-Mail.hmmdm* vhwtpercom AL u py*solo — y xy W Pis wbJirlit 5ei a��.Aw P!►jam �u ,�® -tc � : 201 ly_ ICI a o �- o CC) P M A RA�� a LAIURETAN1 ft 4311 i;4,,l,lRE(S. 0ASED Off 0\ ,qOF y v M0F9 AG 1Hr"rF,, 1.01:;';) WN.L�;Ec]UIRF'At?�If'J��1'kil.1f+�EN1 .. . SURLY, it 1 } Scale: l p �} A PROFESSIONAL LAND SURVEYOR, A DO HEREBY CERTIFY THAT THE MERICAN SURVEYING COMPANY ABOVE MORTGAGE INSPECTION 1264 Main Street, Waltham, MA 02451 (781) 893-6477 PLAN WAS PREPARED FOR P)�C. PATIZ", C.oap. IN CONNECTION WITH ANEW MORTGAGE Mortgage „�+ /+}■ „ D AND IS NOT INTENDED OR REPRE- Mo `gage Inspection Plan SENTED TO BE A LAND OR PROPERTY LINE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED ATE' - COUNTY REGISTRY OF DEEDS SET. IT CaNNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK PAGE L.C. Cert.# TABLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: ", G- PLAk) 'Z-7 o9 BUILDING LINES,THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSOR'S HEREON,IS BASED ON CLIENT FUR- FECT WHEN CONSTRUCTED WITH RE- MAP# PARCEL# DATED NISHED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: S 3 SUBJECT TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT BG le `> I MA TAKINGS,EASEMENTS AND RIGHTS OF FROM VIOLATION ENFORCEMENT AC- BORROWER: STt=tJ t:° 1-- F' WAY. KQ RESPONSIBILITY IS EX- TION UNDER MASS.G.L,TITLE VII,CHAP, TENDED.HEREIN TO THE LAND OWNER 40A, SEC. 7, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE OR OCCUPANT, IT IS NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSURANCE PROGRAM FLOOD TO BE RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED J V L- K -7-4 19 O { R� 9 IS ADVISED WHEN STRUCTURES ARE COMMUNITY_PANEL# -`.3'C)" 0 I 0-�' ^ DATE . SHOWN TO BE V OR LESS FROM CLIENT QO.W _ PROPERTY OR REQUIRED ZONING FIELDED DRAFTED F&RECKED CLIENT REF.# �3` �' SETBACK LINES. BY ►ul E \/fG J.O.# 1 t t�O, = ET DATE F.B. PGE. Town of Barnstaible Approved �� Regulatory Services � Fee o�'J`� Thomas F.Geiler,Director D Building Division Peter F.DiMatteo,Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Home Occupation Registration Date: j�bo/01 Name: Ax'e_Vy, IM/ e6, Phone#: 50?l V-6?7J Address: �S C'.D(ni/LG LL.G�rG �'�L�� Village: r , Name of Business: Type of Business: I'l+lC ,pc%A Utn Map/Lot: ��C%�3 3 INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor; no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration, smoke, dust or other particular matter,odors, electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. •. Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard., There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street.address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent . resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: Date: Homeoc.doc TO ALL NEW BUSINESS OWNERS lt.. 91 Fill in please: �`,� :' � � � r�� , YOUR NAME: _���,�'; APPLICANTS a ti BUSINESS } YO n HOME ADDRESS: lS3 C G E= ,L{ 56�3t� ��` � ---- Te1e �one Number Home TELEPHONE TYPE OF NAME OF NEW BUST :SS 1MU� BUSINESS` GME O CUPAT N? �3 IS THIS A H MAPIPARCEL NUMBER ADDRESS OF BUSINESS C `� — When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below, you may appl �ess certificate at the Town Clerk's Office (Ist floor- Town Hall). " 1. GO TO WILDING INSPECT 'S OFFIC (4TH FLOOR This individual has b in informed o any p requi TOWN HALL)rements that pertain to this type of business. orized Signature COMMENTS: 2. GO TO BOARD OF HEALTH (3RD FLOOR TOWN HALL) This individual has be nformed oft erm', re uirem nts at pertain to this type of business. Aut orized Signature COMMENTS: 3. GO TO CONSUMER AFFAIRS (LICENSING AUTHORITY) - (3RD FLOOR SCHOOL ADMINISTRATION BUILDING) This individual has been ' formed�ftt licerrs r �uirem�entsthat pertain to this type of business. Ab# orized Signature COMMENTS: After obtaining the required signatures you must return to the Town Clerk's Office to obtain your business certificate (cost$20.00: for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. - it does not give you permission to operate -you must get that through completion of the processes from the various departments involved. ' t Town of Barnstable Approved - Regulatory Services Fee Thomas F.Geiler,Director Building Division Peter F.DiMatteo,Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Date: ; b 0 © Horne Occupation Registration l p� Name: UVI�e e (l�l�ee, Phone#: 50? V' J Address: J5 0,D k0:VsQCG r 1'rC—Jf Village: Name of Business: I-kA Type of Business: I r1 L"C l!'C/-t k-0,JEn Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the'dwelling: there shall be no increase in noise or odor; no visual alteration to the premises which would suggest anything other than a residential use; no increase in traffic above normal residential volumes; and no increase in air or, groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration, smoke,dust or other particular matter, odors, electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials, or flammable or explosive materials,in excess of normal household quantities. Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation, and not within the required front yard. There is no exterior storage or display of materials or equipment. There is no commercial vehicles related to the Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. r Applicant: Date: /ko (/ Homeoc.doc 77 Assessor's map and lot numberTHE r Sewage Permit n mber ...... � .. �� ..........-� j ,� WWA �®D • LE, • House number .... ..v.3...................................................... � ,,,b. � 94p Mb q MAL.COD .t TOWN OF BARNSTA9 "uLAT'O14s BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..... ........A...... � .c......................................................... TYPE OF CONSTRUCTION t............................................................................................ j ...� .......19, 7. TO THE INSPECTOR OF BUILDINGS: _. The undersigned hereby applies for a permit according to the foll owing fiinformation: Location ....... ....I�+. .#�f. ? 1..�......................... ................................... ProposedUse ... Ra'�,........ / /`Clw: .. .. ............................................................................................................... Zoning District ..... .......................................................Fire District Naus............................................... Name of Owner ,................Address 5 ....?. ................ Name of Builder .lr1d ....r..l..TZ..-.��Address ����-r. � [ ..... /t�� ......./A....... .Name of Architect .................................................................Address .................................................................................... Number of Rooms ® � c" .........../.....................................................Foundation ...`....................��. .. ....... ..:....:......................... Exterior .......................................Roofing ..... 97X4,1- ..... ....A-M,41—A ............-jT - ...................... Floors .......................................................Interior ..... - . ................................................. Heating .................................................................................Plumbing .................................................................................. Fireplace ....... ...................................................Approximate Cost .. ...... . ........................... Definitive Plan Approved by Planning Board ________________________________19________. Area ... ... . Diagram of Lot and Building with Dimensions Fee // c- SUBJECT TO APPROVAL OF BOARD OF HEALTH \ r L� z � � 50 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam® ..�. , .............. Ricker, Samuel No ....21880.. Permit�i~or ..-Radd breezeway..A ........................... garage o dwellin t �5. ..................... ........................................ Location ........Connemara Circle r. ........................................................ ................ Hyannis...................................... Owner .............Samu.e..l......R..i..c.......ker...... ........ .................... Type of Construction ............... KA1.49................ ................................................................................ - ----- Plot ....................... Lot ................................ Permit. Granted .....December 11 ........19 79 ........................... Date of Inspection ....................................19 9 Date Completed ...... wq PERMIT REFUSED ... ..... .................:.................... 19 LI .... ...... .................. ................... .. .... co . . . ................................................ cc, IM ; ............................................... ev.;?............................................... 0 M Appr .......4-M.................................. 19 M . . ............................................................................... ............................................................................... 77 Assessor's map and lot number ,..9�1.....�..3.3 L �tIHETO Sewage Permit number .......• ?�... �� Z JB BB3TABLE, i House number �j MABa 01 a` TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ?.l.L u t,-: 4 fryer TYPE OF CONSTRUCTION .............................................:............................................ .......... ..... ;.�. ....... , TO THE INSPECTOR OF BUILDINGS: The undersigned hereby/applies for a permit �according to the following information: Location „(.., 4nJstlE ,rvJlfz? .......<......:i.t'.c: ............ ,1 Kmzt✓t. &:!......................... ............................. ..... ProposedUse ...(--.12, A ....... !.&zz............................................................................................................................ Zoning District .......................................................Fire District ....... .ytt4iYUA` ............................................... Name of Owner 7L�M...1/.t—x:..... 1�/ i< ..................Address .:� 'f.......fis........ .......................................... Name of Builder �.f....l.t+,.�..�� . !`.!.. .::. .F �/iJJAddress .... ���� -�1.-' .... ....... #....... Name of Architect ................. Address .......... Number of Rooms ................ Foundation ......���..................>.. ,(Jec:.. Exterior /.'�`..... .............................Roofing .� t(_alf''/fff��!'T ............. Floors .. a11..:........:.............................................................Interior .......... ................................................. Heating ..................................................................................Plumbing .................................................................................. Fireplace .....................r.................................6........................Approximate Cost G....... - .. .......................... Definitive Plan Approved by Planning Board ---------------_---------------19_______. Area ................ . Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH \ F 5 � 0 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ............. Ricker, Samuel -P=290-133 No ......21880 Permit fo-r' add breez4q.. ............ r� ........... . ........... ara e to dwelli ..... ...... .............. Location .......-9-2-.Q.9.meniara... ............. ........................ ........................................ Owner ...............Samuel...RiCk.0...................... Type of Construction ..../................................ . ............frame..... ......................................... Plot .................. Lot ................................ Permit Grant d .......December 11.........19 79 .....I.................. Date of Ins ection ....................................19 Date Comp ted---"k.................................19 PERMIT REFUSED ...... ...... . . ... . ............... ....... ...... ..... . ..... . .. .... ....... ............ ........ ........................... ........................................... ... ... .. .. .. . .................................... Approved ................................................ 19 ............................................................................... ............................................................................... SEPTIC SYSTEM MIDST BE Assessor's map and lot number ...L,.................................. INSTALLED IN COMPLIANCE &1/C . 73 WITH ARTICLE III STATE ..... .... SANITARY CODE AND TOWN Sewage Permit number ��...,.......................... REGULATIONS. yofTxEro�� TOWN OF BAR.NSTABLE i • i i BAHBSTABLL ' "6 BUILDING INSPECTOR APPLICATION FOR PERMIT. TO ................ ....................................................................................................... TYPE OF CONSTRUCTION ......................... -,Pi C v - ....................19y/`. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according do the following information: Location ......... '. ................I..�.................�..�..�..........�....................'..4..:/..........................Y............ 1. .............. ProposedUse .........:. ................... ............I......`........... ................................................................................................. Zoning District A`s Fire District I- ~J.l. ..!: .?. .(.. ........................... Name of Owner .....1.).... ......, ................Address .....................140" f°1 /ti. o S S Nameof Builder ...........................................`........................Address .................................................................................... Nameof Architect ..................................................................Address ....................................................................................1 C 03 Gt�✓'� .d Number of Rooms ................. ...........................................Foundation ......... C- ..................... ` ............................ ............:.. �J .t. a�: i� 1 Roofin �" 7 ✓� S"�� Exterior ................................... !.4 ' S g *1 111k Floors . 4!1 �� r``''c' ..............Interior .............. (� uC ............................... .....�........................................ Heating �!-� `� ( .i........�'`�. ....................Plumbing .................4 !q. ..........� ��......................... ............. .. ............... . Fireplace ....................t.............................................................Approximate Cost ........�..` �....................... /Ogg S . Definitive Plan Approved by Planning Board -------------------_-----------19_______. (p� Area .......................................... Diagram of Lot and Building with Dimensions �( a� Fee ............................................. � W SUBJECT TO APPROVAL OF BOARD OF HEALTH `V �,1 1 /Joy - o _ 3�0,a I hereby agree to conform to all the Rules and Regulations of the-Town oj—Barnstable regarding the above construction. Name .. ..................................................... Smith, J. K. mtw——mtx17 r�/cr'.No ' � — — ---.���. .— ann � or� single family dwelling — � � ��,�� '.� ~ � Location -- ---------- v . ' Hyannis .---~--------.-------------. . . . ' J. K. i5oith � Owner --_-------------'----- ' frame | Typo of Construction -------------- . ^ . ^ -----^--------'------------' / #92 � plot --------'^ Lot ........................... /� | / Permit Granted -- �14--'—..lg 73 � < � � Date of Inspection ------------lV � Dote Completed � ` - PERMIT REFUSED � ................................_---------.. lA '--------'~-----'—'---------- x � | ' n ^—_----...------..—~.------.—.. | ' � - '—^--^--'~'---^~-------------' - � " —.--------.-----..—..---.—...--. ` Approved ................................................ lQ Y ^ � " ^ --------------------------. ` ------------------------.—.. / } / , � �