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HomeMy WebLinkAbout0034 DOLPHIN LANE J� � \ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION C/ p Parcel ;.. Appl+ Macat+ori4c2z �3 Health Division 'Date Issued Conservation Division � `.:zA I cation Fee pp Planning Dept. :Permit Fee Date Definitive Plan Approved by Planning Board Historic -'OKH. Preservation / Hyannis Project Street Address J? `f �a °��� LreL= Village TIN 4 ; F Owner Q 0; 17Lu S C V I U-1 Address '6 - :15rZt4m 0 LC— 00,0 L,JT - Telephone 7K :� f - I o 6 2— Permit Request Ap D i I S` . 17 L4 L - i Square feet: 1 st floor: existing H2 o proposed _ 2nd floor: existing proposed Total new Zoning District Flood Plain GroundwaterOverlay Project Valuation 3 000 Construction Type Lot Size '�O-b Grandfathered: 0 Yes ❑ No hKing's documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# n Age of Existing Structure Historic House: ❑Yes ❑ No y: ❑Yes ❑ No Basement Type: d ull ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.), Basemen nfinis Area(sq. 11_-o Number of Baths: Full: existing new ting new Number of Bedrooms: _3 existing _ne Total Room Count (not including baths): existing ne First Floor m Count Heat Type and Fuel: ❑ Gas :®Oil ❑ Electric ❑ er Central Air: ❑Yes �No ' Fireplaces: Existing Ne Er\yo) woo' o oal stove: ❑Yes No Detached garage: ►4 existing 0 new size_Pool: existing ❑ w sizeexistin ❑ new sizegAttached garage: ❑existing ❑ new size _Shed: ❑ existing ew size Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ , Commercial ❑Yes No if yes, site plan review# -� , + Current Use 2 Q A/L-K9 Proposed Use clu APPLICANT INFORMATION._..-_ (BUILDER OR HOMEOWNER) Name C(� Telephone Number s 6f7sAZX9z1qE�:�3 Address 'IS1 License # CIS a(mb-7 r M� � �� Home Improvement Contractor# 10�1 R<a4 Worker's Compensation # W C\����^3ox►1 1-C���j ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r[l, y ;3) - 9 r r FOR OFFICIAL USE ONLY .. a., APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE �`OWNER DATE OF INSPECTION: I� FOUND �©.N FR = S11. INSULAT2% t FIR�;R, CE .�' ELECTRI 'L!: RH FINAL PLUMBING: ROUGH FINAL t - GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ti , - - �� t PERMIT PAYMENT RECEIPT .'TOWN OF BARNSTABLE 'BUILDING DEPARTMENT *200 MAIN-STREET HYANNIS, MA f 02601 . DATE: !-07/2V09 - TIME:pr_14::20 ----- -`-���,,-----TOTALS. ----------------- PERMIT $ PAID 50.00 AMT TENDERED: 50.00 AMT APPLIED: 50.00 CHANGE:.!�.,' ti � .00 APPLICATION NUMBER:"200002381 PAYMENT-,METH: , CHECK PAYME:NT�REF: 3545 The Commonwealth of Massachusetts Department of lit dustrialAccidents . Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A_PpUcant Information Please Print LeEiblY Name(Business/Organization/Individual): l)N1. GQ�,P�C,, Jc co Address• City/State/ZiPJN3 a ,l Oaf �_ Phone.#: SOY ,4�99 Ara yy .0 an employer? Check the appropriate box: Type of project(required): 1.L`� I am a employer with 4• ❑ I am a general contractor and I employees (full and/or part_time). * have hired the sub-contractors 6. El New 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' 9 ❑Building addition [No workers'.comp.-insurance oomp• insurance.$ required,] S. 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 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 ell work and then hire outside contractors must submit a new affidavit indicating such. tConlractors 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. Lfthe sub-contmctors have employees,they must providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the polity and job site information. Insurance Company Name: Lk Policy#or Self-ins. Lic.M WCJ,'—�� m �_� tom` ' 1 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 E=tip 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 statEmerit maybe forwarded to the Office of Investigations of the bIA for insurance coverage verification. I do hereby erttfy under 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 Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2._Building Department 3. City/Toysm Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: information and Instr rtI0nS , Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.tmployees: ed as"...eve erson in the service of another under any contract of hiro, t [o ee is defin "...every p . Pursuant to this statute, an en p y . 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 forcgoing.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." AdditionaIly,MGL ohapter 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, i. nocessary, supply sub-contractors)name(s), address(cs) 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,phase call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the a ro note line. City or Towji Officials Please be sure that the affidavit is'complete and printed legibly. The D epartmcnt 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 permitllicensr 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 onp affidavit indicating current policy information(if prcessary) and under"Job Silt Address" rho applicant should write"all locations in (city or town)."A cbpy 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 Ucd out each year.Whcro a home owner or citizen is obtaining a liccns c 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 lice 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,tclephone•and fax number: Tht:Cbiamonwu, lth of Massaclluse:M Dcpaz 1nmt of In.d-uz C 1 A,ccidczts QfACQ of luvestigati.ons 600 Washmatm Streat Boston, MA 02111 TO. # 617-727-4900 ext 4.0,6 w 1-M-MASSAFE Fax# 617-727-7749 Bruised 11-22-06 www.mass.gov/dia �o-VEroy,2 'Town of Barnstable Regulatory Services "�swaMAsa '� Thomas F. Geller, Director �p t639. t� rFOMn�a Building Division Tom Perry, Building Commissioner 200 Main Street, 14yannis,.MA 02601 www.town.ba rnsta ble.m i.us Office: 508-862-4038 Fax: S08-790-6230 Property Owner Must Complete and. Sign. This Section Zf Usi�ig A Builder as Owner of the subject property hereby authorize Q0 IN ill Covt.Si12y Cw r to act on my behalf, in all matters relative to work authorized by this building permit application for: t- (Address of Job) Signature of Owner t Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable �OFIHE r, Regulatory Services • Thomas F. Geiler, Director BARNSTABLE, MASS $ Building Division PrE° �A Tom Perry,Building Commissioner 200 Main Street, Hyannis., MA 02601 A wjv.town.b2rnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Plense?rint DATE: JOB LOCATION: number street village "HOMEOWNER': work hone# name home phone N p 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. DEITNITION OR H0114EOWNER •. 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 lo9.1,1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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 fDr use in your community. a '�� : s „fy � w -m .. » . .. �.I'� �...�`,.�,, f #a .� .:' - - I •`A - P,f G �t�i.T. 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Board of BuildmgRegi lations and'Standards Const66ction'Supervisor License �f ' d License: ,CS 22827 ' tid ,, �B�rthdaie�/111954 v } —ot ao /,1/2009 Tr# 29,58 } JOSEPH L 46 ROBBINSST AVON,MAM-322 Commissioner K License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02108 Not valid withou nature 07/01/2009 09:06 17812282306 7404 SHAWS BRAINTREE PAGE 02/02 AC _ Liberty ISSUING OFF'ICI, 1.81. � Mutual, Workers Compensation* and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCT NO77 . Liberty Mutual:Insurance Group/Boston 1-329121 0000 LTRERTY XLTMAL INSURANCR CO 1, POLICY NO, T /CD SALES OM-TCE CODE SAT.ES CODE N/R 1ST WC1.-31S-329121.-038 XX X W.L'STON 102 REPRESENTATIVE 3000 2 YEAR ASSIGNED1991 Item I.Name of.10SEPH QUINN DBA.QUINN CONST.RUCTi3ON Insured FEIN 03.4402402 Address 46 RORMNS ST .RISK I,D 0001.34167 A V ON,MA 02322 Status 01 - INDIVIDUAL Other workplaces not shown above: SFE ITEM 4 Mo-.DayYear Mo.Day Yenr item 2. Policy Period: From 07-23-2008 to 07.23-2009 12fl AM standard time at the address of the insured as stated.herein. Item 3, Coverage A. Workers Compensation fnsura.nce: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employer-, Liability Insurance: Part Two of the policy applies to work in each state listed iur ftem 3.A.hie lim_ s of our liability under Part'l\vo are: Bodily injury by Accident 1,000,000 each accident Bodily Injury by Disease 110001000 policy limit r Bodily injury by Disease 11000,000 each employee Ln C. Other States Insurance: Part.Thrce of the pol.i.cy applies to the states.if any,listed here: 110 . SEE END WC 20 03 06A 1co ' D, This policy i.neludes these endorsements and schedules: SEE .EXTE,NSiO.N OF iNFORMA.TION PAGE Ttem 4, Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Ratcs and Rating Plans. All information required below is subject to verification and charr a by audit: Premtum.Buis antes L.INE110 Per�100 IEl.imntcd Code r_,Omaed olRE- Annunl C.hA�i�ICl1.[tttntti No. ToW Annunl Premiums muner3don Premiums SEE I-ATENSION OF TNFORMATTON PAGYI? Minimum Premium $ 500 ( MA ) Total Estima.tcd Annual Premium $ 575 Interim adjustment of premium shall be made: ANNUAL This policy,including all endorsements issued thcrcwit:h,is hereby countersigned by Antlmtlacd Rr-_r-.ccgtntivr. t)aM 08-11-08 Loc.Code Tenn, Oper, Audit.Busts PeriodicPnymcnt. RntingBasis !?ol.lL.Ci. H„om.c�tncc nividegd RENEWAL OF: 08.11w08 NR MA wC241 S-208161417 Gpo 4030 R1 Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A Insured copy ASSESSORS REF.: o e 'Map 268, Parcel 059 OVERLAY DISTRICT: GP — Groundwater Protection District WP — Well Head Protection District �9� Lot 29 9`P �� ,•'V of 16,784±SF Q Quo v y Existing 70.0' Septic System �Le�� 12.2' (by Inspection) m !, 4� 1sty w/f tK Garage (b• 34 0.o (- aA, 1 Sty w/f �`Qo '\ h Dwelling o = 30.4' 11.3' ti do o FLOOD ZONE: ,. Zone C / OOOO O Q° Community Panel No. #250001 0008 D s July 2, 1992 oy ZONE: ' ce/DH RB (RPOD) nd y Area (min.) 87,120 SF.. Frontage (min) 20' Width (min) 100' Setbacks: �LQy Front ' J Side 10' Rear 10' OFAlq_�:�y I certify that the structures ` Uy shown hereon conform to PLOT PLAN 0343,12 the setback requirements of At,34 Dolphin Lane �ess\o the Zoning Bylaws of the B ����TA��� town of Barnstable. A i'/�ii 29/TvN O� (West Hyannisport) NOTES: MASS, DATE:291JUN109 SCALE: 1'=--M- 1.) The structures shown were located on the ground 0 15 30 45 60 FEET by conventional survey methods on June 25, 2009. PREPARED FOR: 2.) The property line information shown hereon was Edward Tausevich compiled from available record information. 67Bramblewood Drive Braintree MA 02184 3.) This plan is not for recording and is not to be CapeSurv used for construction layout or deed description PREPARED BY: purposes. 7 Porker Road Osterville MA 02655 DWG #. C631_2g1 FIELD BY. RRL/MLL (508) 420-3994 / 420-3995fox _,r,, - � ,X Town of Barnstable Permit#OONON V q p R _ U t1�� Expires 6 nths from issue date Regulatory Services Fee • aMaxsresr.E.MASS * .. 9 1639. $ Richard V.Scali,Interim Director `�',,ri�►,�r INfV OF BARN,113,TABL5 , uilding Division . Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,'MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 6, Property Address1 Residential Value of Work Minimum fee of$35.00 for work under$6000.00 5 Owner's Name&Address Contractor's Naml�� �� `�(, >-j C Telephone Number Home Improvement Contractor License#(if applicable) ����t)�T Email: ����_��� Construction Supervisor's License#(if applicable)Z!� y ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor- y ❑ I -the Homeowner T have Worker's Compensation Insurance Insurance Company Name �esc CTA j Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) LjT Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4'floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Not : Property Owner must sign Property Owner Letter.of Permission. A copy of t4AZaTe Improvement Contractors License&Construction Supervisors License is required. SIGNATURE Q:\WPFILESTORM�Iding permit formsUTRESS.doc s Revised 061313 f Boston, Massachusetts921 16 ':4 Home Improvement Contractor Registration Registration: 104884 Type: DBA . r ' I Expiration: 7/15/2014 Tr# 226574 r QUINN CONSTRUCTION COMPANY .Joseph Quinn � ; 46 Robbins Street 3 Avon, MA 02322t Update Address and return card.Mark reason for change. y_sca I 2onn-os�n Address Renewal Employment Lost Card re '� , Massachusetts -Department of Public Safety License or registration valid for individul use only Board.of Building Re .ulations and Standar ds before the expiration date. If found return to. -Construction Supervisor Office of Consumer Affairs and Business Regulation License:'.C3A22827 10 Park Plaza-Suite 5170 ` ' 1 s Boston,MA 02116 JOSEPH L QUINl - 46 ROBBINS ST "ON MA 02321 o Expiration otvali without aturet:� Y Commissioner 08/01/2015 } r INSURANCE Dover NH 03821-9090 Telephone: (800)653-7893 Fax: (603)334-8162 Email:IMS@LibertyMutual.com Quote Number: 630661-01_Q . Insured: JOSEPH QUINN DBA QUINN CONSTRUCTION Quote Period: 07/23/2013-07/23/2014 _ 46 ROBBINS ST Issue Pate: 05/09/2013 - AVON MA 02322 Legal Status:INDIVIDUAL FEIN:034402402 Principal Title JOSEPH QUINN SOLE P Workers compensation insurance offered by this quote applies to the following states: MA Employer's Liability ` Limits of Coverage: Bodily Injury by Accident: 1,000,000 Each Accident Bodily Injury by Disease: 1,000,000 Policy BodilyInjury by Disease: 1,000,000 . Each Employee Location Number and Address (Notify us promptly of any location changes to avoid issues regarding coverage) —— —001 - 1 . Loc. Class Estimated Ratel S # Code Description Exposure $100 Premium MAs 001 5403 CARPENTRY NOC, 0.. 9.61 0 ' 5545 ROOFING NOC&YARD EMPLOYEES,DRIVERS 0 30.99 0� -. 5645 CARPENTRY-DETACHED ONE OR TWO FAMILY 0 8.68 0 DWELLINGS 5651 CARPENTRY-DWELLINGS THREESTORIES OR 0 8.68 0 LESS Location Total p PREMIUM SUMMARY Charge Description Factor Status Premier MA TOTAL CLASS PREMIUM 0 POLICY MINIMUM DIFFERENCE 291 a INCREASE LAHTS 1.020 0 EMPL M[IVIMUM DIFFERENCE 75 LOSS CONSTANT 50 MA STANDARD TOTAL 75 EXPENSE CONSTANT 159 IM 0090 0311 Account Number. 1329121-0000 Page 3 of 4 TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts. DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston,MA 02114-2017 617-727-4900 hqp://www.mass.gov/dia 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 MUTUAL FIRS INSURANCE COMPANY NAME OF INSURANCE COMPANY PO Box 9102 Weston,, MA 02493-9102 1-800-762-5026 ADDRESS OF INSURANCE COMPANY WC2-31S-329121-033 07-23-2013 _07=23-20141 POLICY NUMBER EFFECTIVE DATES AMARAL & GALLAGHER (781) 341-5116 NAME OF INSUR_AN_CE AGENT PHONE # 1193 WASHINGTON STREET., STOUGHTON MA , ADDRESS OF INSURANCE AGENT - JOSEPH QUINN DBA QUINN 46 ROBBINS ST. EMPLOYER ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE 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 select 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 rTO-BE POSTED BY EMPLOYER Insured Copy The.Commonwealth of Massachusetis Department of IndustrialAccidents Offcce 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/Orgaaization/Individual): G �1 Address: City/State/Zip: N Phone#: � Are you an employer?Check the appropriate box: Type of project(required): 1.[I�'I am a employer with_� 4. I am a general contractor and 1, 6..❑New construction employees(full and/or part time).* have hired the sub-contractors 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 workin i capacity. employees and have workers' g for me n� � �• in�rnance.$ 9. ❑Building addition [No workers conp•comp.insurance required.] 5. We are a corporation and its 10F1 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 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 hue 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 numbea. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L J Policy#or Self-ins.Lic.#: 1C c� _`7u��' �(� °�33 Expiration Date: hn I Job Site Address:w �' (��i� . `� 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 Investi ons of the DIA for insurance coverage verification I do hereb certify under the p�' Cdpenalties of perjury that the information provided above is true and correct Si afore: Date: Phone#: • Official use only. Do not write in this area,to be completed by city or town off ciaC City or Town: Permit/License# Issuing Authority(circle one): ' 1.Board of Health 2.Building Department 3.City/Town CIerk 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(17 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 perfonmance of public work until acceptable evidence of compliance with the insm-an ce requirements of this chapter have been presented to the contracting authority." Applicants PIease 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),addresses)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 connrmation 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 (Le.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 than 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 Commonw' ealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washingtou Street. Boston,MA 02111 TQ-1#617-727-4900 axt 406 or 1- TMASSAFB Revised 4-24-07 Fax#617-727-7749. ww\V.mass.govfdia � E rti Town of Barnstable } Regulatory Services MaxsranNAM $ Richard V.Scali,Interim Director '���,,p�► Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ,. Fax: 508-790-6230 Property Owner Must Complete.and Sign This Section If Using A Builder 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 (A ess 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. Signature of Owner Signature of Applicant Print Name Print Name Date t Town of Barnstable Regulatory Services - oFZxe Teti Richard V.Scali,Interim Director °-� Building Division l WtNSrAsM Tom Perry,Building Commissioner 9� 1 ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6250 HOMEOWNER LICENSE EXEMPTION ; Please Print DATE: JOB.LOCATIQIzIi 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 Persons)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 E7MMPTION 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. ....� -. ;:.-.-. .._..�...._.,..�..__ :., V'�t ..y,�� r. ,.r� . .,� 2r.,.. i„„it tf i°$iv...r�•�^,:+":,r;-..,c�rv�+�w--- t'-�.. � QUINN CONSTRUCTION CO. AVON, MASS. '' �..•---� (508)584-5195 11 / j Name of Purchaser " Phone#7 ' / p 11-3 )fie(, 15 Address ' J Address of Installation Description of Work to,be Performed '"� • Ck `" '��r�•> an �"`a ;"''«-�,rt' 1. �«.��*k� _��';�..�� 't' 1�'�1 ��^��'r ta_l�aC`�,\\``�i, C�:��. �. ,CC't_�""���'1{,�( ��tl:� - cam— Z .c r c:C� Cam\\ = ;1t`a !` l�yc�_ \t'=}vi C \. �'� C..'1�L,tY� t.V1P'1, \(C. c\ -,Qt ; k--( z� 0.k c - (S C-L' \ You may cancel this agreement if it has been consummated by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof,by a written notice directed to the seller at his main or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. $ Deposits Contract Price$ $ r to be paid when material is delivered to job $ 71" to be paid at one half completion $' 60 r to be paid when job is completed Dated at.' I f ;), l�t�,this day of {�(� � 20. r , Signature ACCEPTED Signature Assessor's map and lot number 1'4 3:..�?.... I.""""""' . SEPTIC SYSTEM MUST BE OW" �4rM " "" "" INSTALLED IN COMPLIANCE f� WITH ARTICLE II STATE O Sewage Permit number Q PANITARY CODE AN9 N IREGULATION%. - yof7NETo�♦ TOWN OF BAR.NSTABLE ii c i BAEBSTAMLL i "6 9 BUILDING INSPECTOR o �e APPLICATION FOR PERMIT TO ....... .......... .... ............. ....................................................................... TYPE OF CONSTRUCTION ...............t, ` C ............................................................. ............. ;i....... ..... ...1923 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby a plies for a permit according to the followin information: .W L PHI Location ......... .. .....90........... ........................ .................................................. ..f.............. .....1. ...... ProposedUse .................. 7 '......................................................................................................................... Zoning District ..............�1�.:.. ...... ...... .... ire District .../, `!..'....................... �j Name of Owner .. .....0...... ...... .......... ............Address .... .. ... .....:....... ...................... _ / Q J� ......................... Name of Builder .... �....�`� .. .. (.........Address .��... 7-...r'r3..r...... ...................... ..Q Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation ................................. ............................................ Exterior ............. ....L.`.1...........................................Roofing ........... ..................................... Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost ..........�/2............................................ Definitive Plan Approved by Planning Board -----------_------_-----------19--------. Area ... 4g.....J..... Diagram of Lot and Building with Dimensions Fee .....T e e,' SUBJECT TO APPROVAL OF BOARD OF HEALTH r 67 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ........... .... ...................... r Powell, Mrs. Leo ' No --..:-- Permit for ...... ............................ ................................ .......................................... � . � 34.. . ' Location --.�� �������!'���"�ne-------.. West --------.---.----...---------. 1 ' Mrs. Leo Powell Owner ---___________________ J frame Type of Construction -------------- --------------------------. r� Plot . --------_� Lot __________.. �� Permit Granted �ooaa � lg �q J - � ' 1�^� ------'~-----.. .~ ^ ." � Date of Inspection g / . ' Date Completed .. �� . � Y . ' PERMIT REFUSED ' '----''_----.--.-------. lA ' � '----------'---------------'' ^___—.—� .......... ,,,---- . � � .—.,------------.----..------.. ~ � . ---------~.----....—.--..----- , . [ ' - App,ovoJ .................................................. lA ` ' ---------------^—^---^-----' ' -----------------------.—.— . 4 �