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0142 FIFTH AVENUE (HYANNIS)
/� � � �C�� �: . N 40, 0 WtOE_pUBUC LU5D5VENUEHYANNIS'P_ORT;MA of----------- 3 A55E550IR5 MAP 245 PARCEL 1 13 EDGE__- fENGE G p REFERENCE DEED5: 31549-25G n PLAN REFERENCE:34-23,95-G3 b 109-59 F2 FEMA ZONE:X' f FIRM MAP:25001 C05G4J 18 MAP DATE:JULY I G, 2014, PORGN 2• ItI EXISTING LUNG t !{� cq�+i R5 m GONGRE� - 1 REBY BURIED GAS SERVICE = I ® fOUN0At10 KNOWLEDGE KNOWLEDGE. ON AN IN5TRUMENT SURVEY, -�GFY THAT.TO THE BE5T Of MY StpSE —Wi BURIED WATER SERVICE 1 Fp'so 28 THE STRUCTURES SHON(T},tlqP�EON ARE AS 1 2' THEY 005T ON TH B. lD ��P�GISiEgFogy- A $ 1 'x 0. �s� STEPHEN G� UTILITY POLE i ., W_ c�i DOYLE - ® HVAC UNIT i5 II NO.37559 1 - n, ♦ ! Ss� P �Tf WATER SHUTOFF C O\ ♦a'`� U lE� . . LOT5 3G I -3G5 1 1,949± S.F. o I Ca q IIt - GARAGE FOUNDATION CERTIFICATION PLAN Prepared For 142 FIFTH AVENUE,WEST HYANNI5 PORT MA i Stephen Doyle b Associates C1 g9 96 P.O.Box G2 I {� East Falmouth,Massachusetts 0253G it N790 OG,p4°E Telephone:508 540-2534 s,IdsurveyQa aol.com 1 DATE:NOVEMBER 21,2019 5CALE:I'-20' � FENGC i I 1 0 20 40 1 Feet Building Town of Barnstable r� Il » a PostTh�s Cafd SoThatit is Visible;Frorrt�e Street Approved`Plans Must be Re tamed on!ob and is Card.Must be Kept BARN3'[XB z r 639, Posted UntilFinal Inspection Has<Been Made , r TWhere a Certificate of Occupancy is Required,such Building shall Not:be Occupied until a Final Inspection has been made Permit Permit No. B-19-2973 Applicant Name: Christopher McGrath Approvals Date Issued: 09/24/2019 Current Use: Structure Permit Type: Building-Demolition-Accessory Expiration Date: 03/24/2020 Foundation: Location: 142 FIFTH AVENUE(HYANNIS), HYANNIS Map/Lot: 245-113 Zoning District: RB Sheathing: Owner on Record: KINLIN, ROBERT B JR Contractor Name:'.' Framing: 1 Address: 18 BOGLE STREET Contractor License: 2 WESTON, MA 02493 Est Project Cost: $5,000.00 Chimney: Description: Demolition of existing garage Permit Fee: $50.00 Fee Paid:" S 50.00 Insulation: Project Review Req: Rebuild Permit#B-19-2974 - �° q Date 9/24/2019 Final: Plumbing/Gas 7 Rough Plumbing: '., Building Official , Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzed�by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or.road and shall be maintained open for public inspection for the entire duration of the Final Gas: r � work until the completion of the same. Electrical The Certificate of occupancy will not be issued until all applicable signatures by the Buildmg'and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:, Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining"is installed ' 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons ing with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department —� �'c All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: e-k 321t4 Ps 19 30431 i 0 6--28-2019 a 1 1 - 03a BARSTABLE TOWN CLERK Town of Barnstable Zoning Board of Appeals 19 IN _5 P) Decision and Notice Special Permit No. 2019-027—Kinlin Section 240-91(H)(3)— Nonconforming Lots-Developed Lot Protection j To allow the demolition of an existing nonconforming garage and construction of a new nonconforming garage Summary: Granted with Conditions Applicant: Robert B. and Kate E. Kinlin Property Address: 142 Fifth Avenue, Hyannisport (Hyannis) Assessor's Map/Parcel: 245/113 Zoning: Residence B Hearing Date: May 22, 2019 Recording Information: Deed Book:31849 Page:256 Background Robert B. and Kate Elizabeth Kinlin, Jr., applied for a Special Permit in accordance with Section 240-91.H(3) - Nonconforming Lot, The Applicants propose to demolish an existing accessory structure (garage) and construct a new, 18'X30' garage in approximately the same location. The subject property is located at 142 Fifth Avenue, Hyannis, MA as shown on Assessor's Map 245 as parcel 113. It is located in the Residence B (RB)Zoning District. The subject property is located on the corner of Forest Street and Fifth Avenue and contains .27 acres. The existing garage is located between 1.6 feet and 2.0 feet from the easterly lot line where current side yard setback requirement is 10 feet. The owners seek to demolish the garage and construct a new garage with a side yard setback of 2 feet rather than 1.6 feet. According to the Assessor's records, the existing dwelling was constructed in 1895 and has 4 bedrooms with a septic system and is served by public water. Undersized lots appear typical in this area. Procedural & Hearing Summary Special Permit Application No. 2019-027 for the demolition and construction of a nonconforming structure (garage) was filed at the Town Clerk's office and office of the Zoning Board of Appeals on April 19, 2019. A public hearing before the Zoning Board of Appeals was duly advertised and notice sent to all abutters and interested parties in accordance with MGL Chapter 40A. The hearing was opened on May 23, 2019 at which time the Board found to grant the special permit subject to conditions. Board Members deciding this appeal.were: Alex Rodolakis, David Hirsch, Herbert Bodensiek, Paul Pinard, and Bob Twiss. Arlene Wilson represented the Applicants before the Board. Also present was the Applicant, Robert Kinlin. Ms. Wilson reviewed the existing property and _proposed project and stated the lot and dwelling are legal preexisting nonconforming. She stated that Barnstable Historic Commission (BHC) has reviewed the project and found the garage is not listed as a historic structure. Ms. Wilson acknowledged the submission from Mr. Horn that was received today. Mr. Horn's letter included concerns over trash, location of the trash barrels, and questioned the validity of the stamped engineered survey that was completed. Ms. Wilson stated the proposed garage is located slightly more conforming as to setbacks than the existing garage and will be an asset to the area. i The Board discussed existing and proposed size of the accessory structure (garage) and the location of the trash barrels. Also discussed was the wall located on Mr. Horn's property along the property line and whether it blocks the view of the barrels. i I Town of Barnstable Zoning Board of Appeals-Decision and Notice I Special Permit No. 2019-027-Kinlin The Board Chair asked for public comment and John Horn, the abutter who submitted comments, spoke about his concerns. The Applicant assured the Board that they did not want unsightly trash in the yard as much as the neighbor. Mr. Kinlin explained the existing garage is not tight to the weather so the trash barrels are not stored in the structure currently.. Findings of Fact At the hearing on May 22, 2019, the Board made the following findings of fact in Special Permit Application No. 20198-027, a request to demolish and construct a nonconforming garage: 1. The application falls within a category specifically excepted in the ordinance for a grant of a special permit. Section 240-91(H)(3) allows for the complete demolition and rebuilding of a nonconforming structure by Special Permit. 2. Site Plan Review is not required for single-family residential dwellings. 3. After an evaluation of all the evidence presented, the proposal fulfills the spirit and intent of the Zoning Ordinance and would not represent a substantial detriment to the public good or the neighborhood affected. 4. The proposed yard setbacks must be equal to or greater than the yard setbacks of the existing building. The proposed side yard setback will be slightly more conforming than the existing setback. 5. The proposed lot coverage shall not exceed 20% or the existing lot coverage, whichever is greater. The proposed lot coverage is 18.1%. s. The floor area ratio shall.not exceed 0.30 or the existing floor area ratio of the structure being demolished, whichever is greater. The proposed FAR is 29.6%. 7. The building height, in feet, shall not exceed 30 feet to the highest plate and shall contain no more than 2 '/2 stories. The proposed height is 23.71 feet to top of plate (30 feet maximum) and the proposed structure is 1 '/z stories. a. The proposed new structure would not be substantially more detrimental to the neighborhood than the existing structure. The vote to accept the findings was: AYE: Alex Rodolakis, David Hirsch, Herbert Bodensiek, Paul Pinard, and Bob Twiss NAY: None Decision Based on the findings of fact, a motion was duly made and seconded to grant Special Permit No. 2019-027 subject to the following conditions: 1. Special Permit No. 2019-027 is granted to Robert B. and Kate E. Kinlin, Jr for the demolition of an existing garage and construction of a 540 square foot garage at 142 Fifth Avenue, Hyannisport (Hyannis). 2. The site development shall be constructed in substantial conformance with the plan entitled "Permit Plan" prepared for #142 Fifth Avenue, West Hyannis Port, Massachusetts by Stephen Doyle and Associates dated February 26, 2019 and design plans by emeritus. 3. The total lot coverage of all structures on the lot shall not exceed 18.1% and the floor-area ratio shall not exceed 29.6%. 4. The location of the proposed structure shall be no closer to the side yard setback than the existing structure. i 2 Town of Barnstable Zoning Board of Appeals-Decision and Notice Special Permit No. 2019-027-Kinlin 5. The proposed redevelopment shall represent full build-out of the lot. Further expansion of the dwelling or construction of additional accessory structures is prohibited without prior approval from the Board. 6. All mechanical equipment associated with the dwelling (air conditioners, electric generators, i etc.) shall be screened from neighboring homes and the public right-of-way. 7. The decision shall be recorded at the Barnstable County Registry of Deeds and copies of the recorded decision shall be submitted to the Zoning Board of Appeals Office and the Building Division prior to issuance building permit. The rights authorized by this special permit must be exercised within two years, unless extended. The vote was: AYE: Alex Rodolakis, David Hirsch, Herbert Bodensiek, Paul Pinard, and Bob Twiss NAY: None Ordered Special Permit No, 2019-027 to demolish an existing accessory structure (garage) and construct a new, 18'X30' garage in approximately the same location at 142 Fifth Avenue, Hyannis, MA has been granted with conditions. This decision must be recorded at the Barnstable Registry of Deeds for it to be in effect and notice of that recording submitted to the Zoning Board of Appeals Office. The relief authorized by this decision must be exercised within two years unless extended. Appeals of this decision, if any, shall be made pursuant to MGL Chapter 40A, Section 17, within twenty (20) days after the date of the filing of this decision, a copy of which must be filed in the office of the Barnsta e T n Clerk. Alex do kis, Chair Date Sighed I, Ann Quirk, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty(20) days have elapsed since the Zoning Board of Appeals filed this decision and that no appeal of the decision has been filed in the office of the Town Clerk. Signed and sealed this C�L�ay of\ &f)6 0 Lq under the pains and penalties of perjury. Ann Quirk, Town Clerk IOWN Op V, 3. .� .� Town of Barnstable Building PostThis CardrSo That it�s Visible From<tFie Street Approved Plans stbeRetained on lob andthis CardMust?be Kept , a Posted Until Final Inspection HasBeen IVlades ,- , m +� Where a Certificate of Occupancyns Required,such Budding sh61 qM t be Occupied unti a Final Inspection has been made Peri��it Permit No. B-19-2974 Applicant Name: Christopher McGrath Approvals Datelssued: 09/24/2019 Current Use: Structure Permit Type: Building-New Construction-Rebuild After Expiration Date: 03/24/2020 Foundation: Teardown Map/Lot: 245-113 Zoning District: RB Sheathing: Location: 142 FIFTH AVENUE(HYANNIS), HYANNIS Contractor'Name: Framing: 1 . Owner on Record: KINLIN,ROBERT B JR Contractor fLicense. 2 Address: 18 BOGLE STREET - - Est Project Cost: $ 100,000.00 Chimney: WESTON, MA 02493 i PermitFee: $610.00 Description: Rebuild detached garage after teardown ' ;Fee Paid R, $610.00 Insulation: Project Review Req: As Built Required a Date r, 9/24/2019 Final Plumbing/Gas Rough Plumbing: Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents.for which this permit has been granted. y. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. $ Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Buiiding andFire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:; Service: 1.Foundation or Footing = - 2.Sheathing Inspection , Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: C� a Town of Barnstable RAMYrARM : Planning & Development Department 039. Barnstable Historical Commission www.town.barnstable.ma.us/historicalcommission „r COMMISSION MEMBERS: , Nancy Clark,Chair �� Nancy Shoemaker,Vice Chair -•` _ Marilyn Fifield,Clerk 00 ;-- George Jessop,AIA Elizabeth Mumford Cheryl Powell w Frances Parks April 16, 2019 Re: Notice of Intent to Demolish Structure&Relocate 142 Fifth Avenue, West Hyannis Port, Map 245, Parcel 113 A.M. Wilson Associates, Inc. �. 20 Rascally Rabbit Road, Unit#3 } Marstons Mills, MA 02648 Ann Quick, Town Clerk . { 367 Main Street, Hyannis, MA 02601 Cn Brian Florence, Building Commissioner 200 Main Street, Hyannis, MA 02601 d Pursuant to the attached determination,after review and consideration of your application for Notice of Intent to Demolish a Significant Building, dated March 12, 2019, for the property located at 142 Fifth Avenue, West Hyannis Port, Map 245, Parcel 113, the applicant may proceed with demolition as a public hearing is not required. Please contact Erin Logan at 508.862.4787 or erin.logangtown.barnstable.ma.us with any questions. Sincerely, Nancy Clark, Chair Planning&Development Department,Elizabeth Jenkins-Director 200&300 Main Street,Hyannis,MA 02601 Town of Barnstable . Planning &Development Department aAMEY 39. Barnstable Historical Commission wwx.town.barnstable.ma.us/h istoricalcommission COMMISSION MEMBERS: , �a Nancy Clark,Chair Nancy Shoemaker,Vice Chair ..+ Marilyn Fifield,Clerk t ' George Jessop,AIA Elizabeth Mumford Cheryl Powell Frances Parks . Chapter 112 Historic Properties, Section 112-3 D. DETERMINATION of SIGNIFICANT BUILDING 142 Fifth Avenue, West Hyannis Port, Map 245, Parcel 113 Pursuant to Intent to Demolish Structure (s) The property located at, 142 Fifth Avenue, West Hyannis Port, Map 245, Parcel 113, is not associated with the broad architectural and cultural history of this area. In accordance with Chapters 112-2 and' 112-3 (D), Barnstable Historical Commission Chair has determined that the structure identified as a detached garage is not a significant building. Planning&Development Department,Elizabeth Jenkins,Director Erin K.Logan,Administrative Assistant 200 Main Street,Hyannis,MA 02601 t Town of Barnstable *Permit o0(q q vl Ezpires� xt/u miss ate ulatory Services Fee 4 �srnst.e. � klic4lhXff. DEC 0�? Scali,Interim Director s 014 Building Division DVS j4 Perry,CBO,Building Commissioner Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address Residential Value of Work$1 O,\�T 7..1U.CD Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address -. `L Contractor's Name �V6-C. e ,(1Mgl( C-Ay.9 Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) - k Q)ah 0 ❑Workman''s Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Rgguest(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to -7C�\��. ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ 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. ***Note: Property Owner must sign Property Owner Letter of Permission. A opy f the Home Improvement Contractors License&Construction Supervisors License is ui SIGNATURE: TAKEVIIV_D\Bui i Changes\EXPRESS PERMITNEXPRESS.doc Revised 0613 3 le . _ wn of'Barnstable BAR.> To Regulatory Services Richard V.Scali,Interim Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, HYannis,MA 02601 www.town.barnstable.ma.us Fax. 508-790-6230 office: 508-862-4038 property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize \ 1 to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of ob) Si atur of Owner D to Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN_D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 ........�........�...............-........-........-..v. u..v.unr...v..v...-. �u.v vv.�.crta.w nrv....�vrv�• ��rc�.cn��rwr��------ I n. CvERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil PHONE Exc,508 775-1620 FAX Insurance Agency E-MAIL A/C,No): 5087781218 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# -INSUREWA c National Grange Mutual--Insuranc INSURED Meagher Construction Inc. INSURER a:Associated Employers Insurance Timothy Meagher INSURER C: 772 Main Street INSURER D Osterville,MA 02655 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVO POLICY NUMBER MM/DD MM/D LIMITS A GENERAL LIABILITY MPT1250G 0/16/2014 10/16/201 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGEPREMI TO RENTED nee $500 000 CLAIMS-MADE 51 OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JECT LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS. AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION WCC50050054422014A 6/23/2014 06/23/201 X WC IMIj OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIEfOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT g100 OOO OFFICERIMEMBER EXCLUDED? a NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE .POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE d9 - y�J ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S140580/M140561 CBD f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street umbers IF Boston,MA 02111 www,mass.gov/dia Affidavit: Builders/Contractors/Electricians/P Le bl Workers' Compensation insuranceplease Print A licant Information -------------------- Name(Business/Organization/Individual): Address: l��tir Phone#: - - City/State/Zip: Type of project(required): A e you an employer?Chec ,the appropriate box: eneral contractor and I 4. I am a g 6. []New construction 1.5Cam a employer with have hired the sub-contractors El? Remodeling employees(full and/or part-time).* listed on the attached sheet. 2.❑ I am a sole proprietor or partner- These subcontractors have 8. 1[]Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. comp.insurance.:p 10.C1 Electrical repairs or additions [No workers' comp.insurance 5 We are a corporation and its required.] officers have exercised their 11.❑Plumbing repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 1�,0 Roof repairs myself.[No workers' comp. c. 152,§1(4),and we have no 13 ❑Other insurance required.]t employees. [No workers' comp.insurance required.] '�►Y applicant that Cheeks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit� hed an additional dilat�g they am doing showing the all work andname of the sub-contren hire Outside acctors and stato whotheracto's must submit a eor not thosehose entities have $Contractors that check this box P policy employees. If the sub-contractors have employees,they must provide their workers'comnumber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - y Policy#or Self-ins.Lic.#: V Up 1t b�5"1 A��O` APxplratlon Date: , Job Site Address: ` W 4 t 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 t e DIA for insuranee coverage verification. I do hereby e u er t e pains and penalties of perjury that the information provided a ove ' true and correct Si ature. Date: ' Phone Ot-1.5 s 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): L Board of Health 2.Building Department 3.City/Town Clerk_ 4.Electrical Inspector- 5.Plumbing Inspector 6.Other Contact Person: Phone#• . 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License: CS-102260 .\. MICHAEL S MEAtE[gR;JR 97 EMERALD LANE 0 ' Marston Milts MR OZ �- Expiration Commissioner 11/05/2016 �i �e tpoa�r"zarauseallli a�C�vcaa�ccc�tccdeCl ` UW- Office of Consumer Affairs&Business Regulation rME IMPROVEMENT CONTRACTOR egistration 162938 - Type: Expiration: 4/2712015> DBA MEAGHER BROTHERS CONSTRUCTION MICHAEL MEAGHER:JR 97 EMERALD LN MARSTONSMILL,MA 02648 Undersecretary r Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed splace- j f the Failure to Building code istcause orrent rt evion oocation of this license. State I g For DPS - sing information visit: vvww.Mass.Gov/DPS License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suit 170 Boston,MA 0211 No alid hout signature ��#_ 67-,F /0:1� r Town < # Lf b �v own of B � 8 OF Expires 6 months rom issue d e Regulatory Services Fee * BARNSrABLE. 16 s. Richard V.Scali,Director Argo�,t s Building Division @�e n�E2�� PE NOT Tom Perry,CBO,Building Commissioner , Ir OT 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us SEP 0 8 2014 Office: 508-862-4038 TOWNPF d�0-6 30 EXPRESS PERMIT APPLICATION - RESIDENTIA D of Valid without Red X-Press Imprint Map/parcel Number Property Address �� � � /!�/✓ir ��'L - Residential Value of Work$ �' � �. Minimum fee of$35.00 for work-under$6000.00 Owner's Name&Address 10 Contractor's Nam �"7�11/r/e'/ - � N Telephone Number Home Improvement Contractor License#(if applicable) I s*3- Email: Construction Supervisor's License#(if applicable) 6 q' ❑Worlonan's Compensation Insurance C h e c one. D!� I 4m a sale proprietor ❑1I.- a...the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance'Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to IT/�Wa ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is SIGNATURE: Q MPFILESTORMS\building permit forms\EXPRESS.doc Revised 061313 �F 1 , Hie Consma-trypeakh of Massachuse fs -epurhsrera of bulmsaid Accidents of 1mwstigattorrs 600 Wass-hington.meet Basions HA 02111 ivnw mass.gri/diet ' arke.us' Compensatiaxifxs=—nce- cdavit:$uilderslContr-a:ct-ors/FIectriciauMumbers t pplica t Xnfarnsatinn Please PrDat Lepiblv Hama(RusinesslOrganizafionllndividna : `✓1/P�, ( iarS. h/ Addrtss- C?Cy,/stateMp- Phone _ A an employer:`Checktheappropri ate bo>c: T nf: o ezt r 4_ ❑ I aux a:g�erQi canfractor and I_ I z:-ri a employer with 6- ❑New mnsauctioa e-=—Ioyees(full andlorgafttime).* hatvehir�tbe sub-cauh�ofois. 2_01 a_n a sole proprietor or partner- listed on the attached shrnet 7- ❑Remodeling sl�n aisd have no employees Tlr�se:suh coatractorg Rave g_ Demolitioa aoraa�� me many Capacity_ emplo Yetis and Lave workers, yt 4_ ❑Building addition co f"n�i�sanre. comp-iPSi1ia72 l. _ c sical repairs Gr additionsS..[� ih e a e a corporation and its j-❑ _ am a horneo-,-mzr-doing ail work. o+-fi' �have exercised their I I El Plug repairs or additions right of e��ption per MGL my if [t10 l or-el comp- l�.L]Rnof repair :��aneorequu�d_1% c_ iS2_§1(4�andwo�.--irenG employees.Fu wixkers' eo-p-in5uran-ce required-j zp r-^st f;i chad`s box r1)mnst Elsa M1 oil''he srz¢on Jow do wing ffid woakers'c0nm eUmKdo;i P-iir-g n�nrm�_ t ors s:ram sabmurt tnis zffl ;t inairyti—trey E-a:amt:U Took End the m b_*re oatn&e coahatmrs psi sjnmat a a,--W 'F2..r"s,n,n:,r9 M mcTi =G�a�cars psi c�Jc this Lax musrt�nc�rT air so�iiionsJ saw sne-K°ice t�u�ag c�sdr-a�raon_3 znd s`�=fz:che�•et acliat use�mbes�-?� 11r _ T Yh"=sa--cou+t mcturs emgIoyeps,tb psi p •tee = wor3—s'comp.poLcg ma umber I Lr'I are enTYZL�V--r that is prat idirzg worke-rs'carrpe:n w- sr n iz s'rtraaca for my.e-nT Lgye&-. HeLg s is thepoLicy and job site Z,a�r�ce GGrnpau-y Name: _ --- Pol;.:.s 1 cz Self iaR IirA-L: F_xpiratioaDate: Job Si--Address: Cityv`StfeTtp: Attacli a•copy of the workers'compensation policy decEtrstioa page"(showing-the policy number and expiration date). Failure to secure cave7age as reti red under Sectioa 2S A of MGL c- 152 can Lead to the scnpasition of cri Teal penalties of a fine up to$1,5 0O.00r aadlor one-year impriso� as well as citric penalties in the forr of a STOP WORK ORDER and a fine of up.to S25 U-0 a.day against the violator_ Be a&vL--ed that a copy of this statement maybe forwarded to-the Office of Trrr�sstigatiG�s of�DIf�for i„��c�coverage ve�catian_ .T da kereb4�r_�rfif�re. ss c�'p�r�uiy#ttstSrs irt�orrrtrrirun jtra-rit�d rzbrrx�e is•bztg and corrsct SiEaatur c: Date._ Phone : off ciai rrse an[y. Da trot trite in this area,to ba taautpteted by chtw at town officinL Cite or -own: PermitfLicensc# Fssuing AutharHy(arcle oae): I.Sward of Health .Bu f&ng Deepartme3t _�City-:`fawn Clerk 4_Electrical Inspector S.PlumUag bus actor 6.Gther Coa- t;kct reran: Phone P-: 6 Information and Instructions Massachusetts Creneral Laws chapter 152 requires all employers to provide workers'compensation for their employees, Pursuantto 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.." Au employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged is 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- FAowever 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 appm:tenant`hereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also stz-s tf'i�t"every state or local Licensing agency shall withhold the issuance or renewal of a license or periait to opera-te a business or to construct brileiugs in the commonrrealtl; applicant who has not produced acceptable evidence of cotnplia.I.ce?t�t_h the insurance.cover age requiree." Additionally, MGL chapter 1.52, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract ioz the per orma ace of public work until acceptable e�,idcace of compliance,,,Zuni the iris auce requirements of Ibis chapter have been presented to the contracting asilror -_" Applicants -- Please fill out the workers' co�.n�pensat on a�idavit completely,by checici_!g the boxes that.apply to your situat on and necessary,supply sub-contractor-(s)r_amt(s), addresses)and phone numbe,-(s) along with their c;eri:u cat e(_) of i-isurance. Limited Liability C:ornpaa mes C LC)or Limited Liabil Pa. iex h�s�_.LP)y i hno employees other-hau the members or partners,are not regL -�ed to carry workers' compensaton=i ii7ance,_ sf as LLC or LLP does have employees, a policy is regr>ired_ fie advised that this afEdavit may be s.�brrufted to the Depar[mert of iadns-Tial Accidents for conf=arion ofi-s?,ance:Dveragge. AIso be sure to sign an.d date the a;-5dav t '1"hc aZda'r6t sho>>ld be retlrzned tone city or town hat L e application for the permit or license is being zuuested not the Depa *rent of Industrial Accidents_ Should you`zve an, questons regarding the law oz if you are required to obt.=in a arorkers' compensaton policy,please e,11;=ne Depa rent at the number list i beloVr- `gel;insured companreS Sh.ould enter:heir sell insurance license number on.se:anpropr?ate at, City or'T'owa Officials Please be see that the affidavit is✓omplete and printed legibly. The Depayment has provided a span:,at the bottom of the affidavit for you to ill out : the event the Office of Investigations has to contact you re a she appLczn= Please be sure to fill in the permi f c-ease number which will be used as a reference number. in addi 16cn,an.applicant that must submit multiple perm Jiic-, se applications in any given year,need only submit one ar davit indicating c, rent_ policy information (if necessary) a d ruder"Job Site Address"the applicant would w?-A "ail locations in (city or town)."A copy of the affioiavit that has been officially stamped or marked by t'ie city or town may be provided to the applicant as proof that a valid affix ;it is on file for future permits oz 1icea�es_ A new affidavit m,.?-,t be filled out each year_Where a home owner or citizen i s obtaining a license or permit not related to any bus?Tiess or commercial ,enture (i_e.a dog license or permit to burn leaves etc.)said person is NOT ret uired to complete tl .s afdda�,it- i ne Office of Investigations would like to thank you in advance for your ceoperaiion and should you have arty questions, please do not hesitate to give us a call_ The Department's address,telep watt and fax number: Tb-;�,-CommaaWealth of Ma&sadh- Se, DtiLaitmeIlt CTIadu bial ACC_dcEfs Q-fi(�e of hvestipfiun4 G G Wadiagto-n��t �'.-24-07 Faxr 14f 4- 61F-727-< kZevised - r THE Tp� Town of Barnstable Regulatory Services * snxxsTwsi.E, y MAC. g Richard V.Scali,Director �A i6gy. �0 lf1639. 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 MAN C4.�V rcsyy to act on my behalf, in all matters relative to work authorized by this building permit application for: -F'LPI4 AJE , Ct 00-k (Address of Job) ' Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature o er Signature of Applicant lv�lVI Pant Name Print Name Date QTORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services i Toiyy Richard V.Scali,Director ; ° Building Division STD Tom Perry,Building Commissioner MACS 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 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 on.e 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 workoerozmed 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 109.11-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 for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 09/04/2014 15;03 Wayside. Insurance Agency Inc (FAX)5066651523 P,001/001 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDILIWY) �-� 9/4/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CO NT�CT PRODUCER NAME: House Account Wayside Insurance Group, LLC PH No E : (508)877-5010 FAX No:(508)665-1523 60 Nicholas Road AolAIL P.O. BOX 3337 INSURER(S)AFFORDING COVERAGE NAIC Framingham MA 01705-3337 INSURER AAtlantic Casualty Insurance Co INSURED INSURER B:Commerce Group IG001 Hector Sanchez, DBA: Emmanuel Construction INSURER C AIN! Mutual Ins. Co . 286 Strawberry Hill Rd INSURERD: INSURER E: Centerville MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBERAu RNWL, GL,WC 14-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MIDDYY MMID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE a OCCUR 143002040 /2/2014 /2/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $JFCT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - Ea accident 1 000 000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED WQ314 /l/2019 /1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS AUTOSNED - (Per tDAMAGE $ 100,000 Underinsured motorist $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTI ON$ $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? ❑ N I A (MandatoryinNH) ill Follow From CO /5/2014 /5/2015 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Barnstable, MA 02601 AUTHORIZEDREPRESE14TATFVE L Santarpio/VMYLS1 ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025onion.51 nt Tho Ar0RD names nnrt Inno ara ranictarcrt marks of ACf7Rn Massachusetts - Department of Public Safety Uns merA�oozes Bus nessReguf«t/u Board of BuildingRegulations and Standards �\ Office of Consumer Affairs Qu,Business Regulation I 9 _.OME IMPROVEMENT CONTRACTOR ;. Construction Supervisor SpecialtyZ egistration 145356 Type: E I License: CSSL-099382 xpiration 1/12/2015 DBA ���'� I �. ' HECTOR R SANCfiEZ MANUEL CONSTRUCTIdNr :, f n c - ' 286 STRAWBERRY Hi..µ'ROAD r} a CENTERVILLE MA 02632 1ECTOR SANCHEZ 286 STRAWBERRY HILL RDa i CENTERVILLE, MA 02632 " `W g J '� "` Expiration Undersecretary Commissioner 09/14/2015 I • a; License or registration.valid for individul use only~ before the expiration date. If found return to.; Office of Consumer Affairs and Business Regulation '�` 10 Park Plaza-Suite M70 . Boston,MA 02116 • Not valid without signature 1� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# Health Division Date Issued 0 Conservation Division Fee Tax Collector ._.._ A-2 7 j,;v 9 Treasurer , i Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 1`TZjd r 11 P� Village Aany\� cmk Owner - '- a� t_A05 Address Telephone Permit Request �`� V-O'C— fir- Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new .% Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type , Lot Size 1 f-� ,>C 1� Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure ICXD WeAl..K Historic House: ❑Yes XNo On Old King's Highway: ❑Yes XNO Basement Type: ❑Full ❑Crawl ❑Walkout \4 Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count �J Heat Type and Fuel: ❑Gas Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing '�c� New Existing wood/coal stove: ❑Yes ❑No Detached garage;X existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number Address n License# J!. c�2 7 Home Improvement Contractor# ,;Lworker's Compensation# ALL CONSTRUCTION DEBRIS RE LTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �' DATE FOR OFFICIAL USE ONLY PEkMIT NO. ie►- - DATE ISSUED a ` MAP/PARCEL NO. E r ADDRESS .a: VILLAGE OWNER a DATE OF INSPECTION;: FOUNDATION ` FRAME ' t INSULATION �. FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ; I Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Cressen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL e. 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: Z6O Estimated Cost 30a 6� Address of Work: c Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): (:]Work excluded by law ob Under S1,000 9(:]Bilding not owner-occupied eer pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME HVWROVEMENT 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 Owne s Name q:fomu:Affidav The Commonwealth of Massachusetts f:=_ — Department of Industrial Accidents _ aAtli _=��•�: , .�- OlfJce olJm�estfpat�oas 600 Washington Sheet ' Boston,Mass. 02111 workers' Compensation Insurance Affidavit name: �, �s location: citV hone# I am a homeowner performing all work myself. I am a sole proprietor and have no one worlds in any icity � �/%///%///////%////%%///////////%////i ,�///�/��////�//////%//////O%�%''%////,%%�//O%�'�////%%/// I am an em 1 ding workers' compensation for my employees working on this job.::..::::::.:::::::::::::::: :....... :. dre xi "Tian e :: CV# oil insurance co. ❑ I.am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: manv nam care ss..a :::::::•r::;.;;:::::.;.;..;;:.:::.; .::.::::.;.;;:::::::. ....:..................:::::..........:................. .....................::>ti city* :::.. .. 'ii>h . cbmaanv name:"..:,:.: ;• .............. ..... .. ................... address• .... .....:.. ::.. dtv" :.:.....::;.:<.;.;:....... intone# .........:......................... ><; :.;:.:.:<.>:.;;:;:;;.:;�;;:;>:::>:::;::;;<:<;::;:.::::;:::<>::<::<:::<>::>::;<;:�::::<:::«:::>;:.:-:;;.:>:<;<;::;;;:.:>:::::::::::::.�.. lieu ..,.,.:...::,::....,......,:::,:.,.:::.::::::. 0 i Fafiure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I utderatand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is trw and correct Signature in. Date1��/n _ Print name M A P.s a e I rt/ A 2(l ill1.r Phone# `?7 2i j rl q- official use only do not write in this area to be completed by city or town official dty or town: permit/license# [3Bufiding Department QLfcensing Board check if immediate response is required ❑ electmel Office ❑Health Department contact person: phone#; _ ❑Other r ' UevisW 9195 PIA) ,� _.fy �/ . ��� ' �i __ Building Division t3r►ntasrn�.E. 'a�re►ss 367 Main Street,Hyannis MA 02601 - 1e$ Office: 508-862-4038 . Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION Please Print DATErr— JOB LOCATION: t amber street village "HOMEOWNER": n near hom'pfione# work phone ri CURRENT MAILING ADDRESS: �� � v:� y I — cihtown state - up code The current exemption for"homeowners"was extended to include Qwner-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%he shall be resvoncible for all such work Izerformed 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 tm procedures and requiremeLts. LW Oka& n. Signanae o0lomeowner 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 109.1.1-1.1cetuing 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 pan 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 can to amend and adopt such a form/certification for use in your community. Q:FOMIS.EXEMM A ,J P=*G LOT CDVM by vrft1CTuRL'S' co+vaUNG:a G►iRAL.a D69T1►GtLOT'CovM f3Y.4ARD5CAPf-2.f96 15uiTe PATf01 WAL) a+m►wo. � � � tit � MPOSED lbT'CQYM BY5 5 L 18:1% PLAN LEGEND: PRDP'O$CD LPT COVM 6yKWD5CAPC 2.IS Owl DitDftD f CStATC PAT1C t PWAO tti IIS Y ��W-i liMtRD M•�:\TR:9ilMCl' � � .� R. �C+ iIlllt>"011` �� CIS ®. 11YA{EMT � �. .... ,$ aronr�v�rY,uirr IgTR =U5 MAP OX.r.�+ --►21.3 142 Flf'M-AVfJWWt fo q`p r.,ee. � wtsT ff!'AFiNlS HQ1iT,MA A50[33M.Wr 245 FARML 113 1, l.i `.7 FRAN fttFrRfltCL 34.23.9043 a 109.59 F2 �. 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