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HomeMy WebLinkAbout0021 FOURTH AVENUE (HYANNIS) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division Application F I' Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address a'�) Q. � u x► ,\A<4QaDrZd7- Village 1 nr4 1 uV10 Owner (A/��1 i io r� E� ¢ Address /teaA O 1A4q ago L la h Telephone , 5'7-,P -7 q6 *Permit Request Z2 `7\ JL-/ Square feet: 1 st floor: existing proposed 2nd floor: existing (6 proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type lid PCB' Lot Size Grandfathered: es ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ,� Two Family ❑ Multi-Family (# units) o Age of Existing Structure ? Historic House: ❑Yes 4 No On Old King's frl'ghway: YesE o Basement Type: ❑ Full `® Crawl ❑ Walkout ❑ Other "� v Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) z c� Number of Baths: Full: existing new O Half: existing Number of Bedrooms: existing new 10 rn Total Room Count (not including baths): existing CT new First Floor Room Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes X No Fireplaces: Existing New _� Existing wood/coal stove: ❑Yes ffNo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: 9 existing ❑ new size _Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name S Telephone Number Address ,eQ �r�:_ License # Home Improvement Contractor# e Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL.BE TAKEN TO W,�a SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# w DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: -)MFOUNDA-TJON DAFCt;';:.L),Tf- FRAME : INSULATION;' , , Vt,_� —A, _ FIREPLACE ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH FINAL a GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN.NO. �l�tflJf vC i+s`w� t.J.y.L, t s j The Commonwealth ofMassachusetts Deparhnent of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 r www.mass gov/dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): —�&2=�UEZ Address: City/State/Zip: Phone#: 7 7 g Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.KI am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp. insurance comp.insurance. t required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp. . right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Otheremployees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their worker;comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500:00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, der the p and en of perjury that the information provided above is true and correct I Si afore: Date: 2 l J Phone#: 6 — -;1 - 4 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 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." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance: requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain-a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit(license appli-cations in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number:. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TO.#617-727-4904 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.m=.gov/dia � ,.t • III AFYC Guide to Wood Construction in Hidh #171ndArear:RO mph endZoae Massachusetts Checklist for Compliance(7so wiz 53oi•2.i.i)` P1 ch=lk CDMPli 1.1 SCOPE 7/ Wind Speed(3-sec gust)__...._._...._...._.._._.._•-•------.._.._.._.-_._....-._._..... ._..... .............11 D mph WindExposure Category ._-.._.......-.._.--.-._..._____...•------..............._........ ....-----•------.._........._.--•-_..B t� 'Wind Exposure Category................Engineering Required For Entire Project.......................................0 12 APPLICABILITY. / Number of 8> rles (a roof which exceeds 8 in 12 slope shall be considered a story) stories 5 2 stories Roof Pitch (Fig 2) ... ._.r._._........___. 512:12 Mean Roof Height ---..__..___._...___._..:.._....-__..�._-_._(Fi9 2)................................... _ft s'33' Building Width W Fig 3)........-.-- ----.--- ------------_.__:._. ft sac Building Length,L ................_.__..........__...�___......._-Fig 3)--------- ..................._.... __ <8cr Building Aspect Ratio(LIW) ..... (Fig 4)--.__:..___-..___..._.._.... <_3:1 Nominal Height of Tallest Opening �....(Fig 4)-------------_____________________.......... <6'6' 13 FRAMING CONNECTIONS General corn fiance with frarnirig cDinnections_..._.....__. able 2 ...4:�^....7r.� 2.1 FOUNDATION Foundation Walls meeting requirements of.780 CMR 5404.1 q Concreia............................. .. • .._.. ... U'-�:�..�'!: _:........................ ...................... ..._......_. ConcreteMasonry........_._---..._.._.._................................................_•_•__...._.......---_•___............... 22 ANCHORAGE TO FOUNDATION"3 51S*Anchor Bolts=imbedded or 513"Proprietary Mechanical Anchors as an alternative in concrete only ✓' 13olt Spacing-general ..................................._._.(Table 4)......................................_._ in. Bolt Spacing from end(oint of plate...._______................(Fig 5)....__...__............_.......... in._<6'-12'. Bolt Embedment-cona-ete........._..........:...____.-___...(Fig 5).......__.-....-.__.._..._:-----_-----_._._in._>r Bolt Embedment-masonry.-___-,...__...,....._....... (Fig 5)--_.:..._.r................... in.>_15' Plate Washer..:.. ........ Fig 5).__.................................... >3'x 3'x Y7 3.1 FLODR5 Fioor•framing member spans checked -__-----------_---•--.._(per 7BD CMR Chapter 55)-- ��---� Maximum Rwr Opening dimension....._..........................(Fig 6)....._.....:_..._._______.... < ' Full Height Wall Studs at Floor Openings less than 2'from Exterior Wall(Fig 6).......................... ...... Mbxdmrim Floor Joist Setbacks SUPPDrang Loadbearing Walrs or Sheanwall.___________-. i .... ....... ft 5 d Maximum Cantilevered Floor Joists Supporting Loadbearing Walls'or Shearwall...._._._..(Fig B)_........... ................. ft <d f FloorBracing at EndwaiLs_.._...._..............._._.-----.. _...__(Fig 9)...._------. ....................................._....... Floor Sheathing Type ......_ .........................._.__.... (per 780 CMR Chapter 55) Floor Sheathing Thickness ....... ................ ............ (per 780 CMR Chapter 55).. .. in. Floor Sheathing•Fasterirng_.............. 2).._d nails at in edge in field 4A WALLS ' Wall Height Laadbearing walls --- _....(Fig 10 and Table 5) -- ft _1 D_ < ' Nan-L.oadbearing walls.. _._......_. .__._:_.._._.... (Fig 10 and Table 5)........_ ......_.._ ._ft's 20' Wall Stud Spacing ..................... (Fig 10 and Table 5)............. in.:5 24-❑.r. Wan Story Offset ...._.__._._...._......._..___..............(Figs 7 i£ ft s d 42 EXTERIOR i ku_s' Wood Studs / Loadbearing ........................ -_ft_in, Non-Loadbearingwalis._._.-........_...........:................(Table .........................._..2x_-_ft_in. Gable End Waf Bracing Full.He!"EndwallStuds .....(Fig 10)__......_._........ WSP-Attic Floor Length ____'(Fig 11)_.._--__.............__..._-_ ft�:VV3 Gypsum Cer7ng Length(rf WSP not used)._:_..._.........Fig 11)---_--------_---------............. ft?:0.9W - - and 2 x 4 Continuous Lateral Brabe @ 6 ft.o.r-. (Fig 11). .......... .........................: _................ or 1 x 3 culing furring strips @ 16'spacing min.with 2 x 4 blocking @ 4 ft.spacing in end Joist•ar truss bays Double Top PlafE Splice Length .._.__....._:._.........._.....----•-•-----(Fig 13 and Table 6).......................... AFVC Guide to Wood Cotrstrudiorr, in Higtr lznd Xreas: 110 rrzpli KIN Zorce Massachusetts Checki.st for Complianee (7so CN2R53012.l.1)I Loadbeadng Wall Connections Lateral (no.of 16d common nails)... ..........________.(Tables 7). Non-Lxadbearing Wall Connections Lateral(no.of 16d common nails)..... Table B)._-----•---..---_.._..__..__._....__..._._.< Load Bearing Wail openings (record largest opening but check ail openings for cornpfrance to Table 9) :•� ...-_.._.....__...._. file 9)..._._:....._......_._..-...._ft_m. 11' Header Spans ..... _......... _..... _... (Table SIR Plate Spans (fable 9)_..-.------------------------- < ' Full Height Studs (no.ofstuds).........__--_-.•-_..-________[fable 9).......... < ) Nor.-lid Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9 � Header Spans. .............._.........._._._......__..._.........(Table-9).._.. ...._.... _ _in.-1Z' --•- Sill Plate Spans..-.__:..._.__...:.___...._..-.__._...__..-_(Table 9}.___•----------------•_ft—to 12' .Full Height-Studs(no.of studs)....__...__.__.._------(Table 9)-------_---------------------_.---_---------- Exterior Wall Sheathing to Resist Uplift and Shear.Simu[fanbousV Minimum Building Dimension,W . - Nominal Height of Tallest OpeningZ .......................__..................._.............. ._..._._. _ Sheathing Type....._-_------_.__....-..._........_.....(note 4)------------------------------------------- __. _sue Edge Nail Spacing.__.....................-._--_(Table 10 or_note 4 if less)............._ to_.... _.� Feld Nail Spacing.. _. -.(fable 10) Shear Connection(no.of 1 Gd common nails)(Table 10)------____--------------•---•-----._............. --� Percent Full-Height Sheathing......_:-........ .(Table 10)-_---..-_-_-----------------------_ _4� 5%Additional Sheathing for Wail with Opening>&W(Design Concepts)_.-_.__•__._____ _dl Maximum Building Dimension, L , Nominal Height of Tallest DpeningZ...... ...........................................•_. =6 B SheathingType....__._.._------------------.._..___.(note 4)----------------------------------------------- Ed in. Edge Nail --------------_------..__�_._-_(Table i 1 or note 4 if Less}-._....___....__._.. in. Feld Nail Spacing.............-_-_----_-----•---:_ (Table 11).-....--- _,---.._..._ __._.. ...._ Shear Connection(no.of 15d common nalls)(Table 11)........................ Percent Full-Height Sheathing--._.:._............(Table 11).._._.___.._------------------------_�.---_- 5%Additional Sheathing for Wall wilh'Opening> BY(Design Concepts)___--.--_-- •-:•- Wall Cladding RatedfDr Wind Speed?.........................-.__................................._.................---_...............-._...._.... 5.1 RDOFS Roof framing member spans checked?._._....._._._•_..(For Ratters use AWC Span Tool,see BBRS Website) Roof Overhang .......:(Figure 19) ft_<smaller of 2'or L!3 Tnlss or Rafter Connections at Loadbearing Was / Proprietary Connectors P ' • �,/ Uplift_..._..._._.......-___. --------•--(Table 12).................... _ (Table 12)--------------_-------- - p ff Lateral....------•------..__...._.._. • 5hear..__.._..._.._..__........:....__._.._-:(Table 12).---_--_--.--_.. ........... -pif. Ridge Strap Connections, if collar ties not lased per page 2T... (Table 13}_:_....:.:.................._.T= plf Gable Rake Oudooker................:.............___-------(Figure 20)........._._.—ft s smaller of 2'or L12 ' Truss or Ratter Connections at'Non-Laadbearing Wails Proprietary Connectors Uplift................_...... ...(Table 14) - - - Lateral(no.of 160 common nails)_.(Table 14).......................................L lb. Roof Sheathing Type_._..-._---:•-_--..-_._.-•.....--.._--...(per 7BD CUR Chapters 58 and 59)......_....: _..in._:T116'WSP Roof Sheathing Thickness :.--..---...••_..........................— Roof Sheathing Fastenin .._._.(fable 2)....-...........__.,...__.._. Notes: I. • This checklist shall be met in its entirety, excluding the speafrc excep�on noted in 2, to comply with the requirements of 7301 CMR.5301.2.1.1 Item 1. If the checklist is met in its entirety then the following metal straps and hold downs are not required per the WFCM 110 mph Guide: a. Steel Sttaps per Figure 5 b. -20 Gage'Straps per Figure.11 . c- Uprdt Straps per.Figure 14 d_ All Straps per Figure 17 e. Comer Stud Hold Downs per Figure 1Ba and Figure 1Bb Exception:Opening heights of up to B ft_shall be permitted when 5% is added to the percent fulkheight sheathing requu-errients shown in Tables 10 arid 11. - The bottom sill plate in exterior walls shall be a rninimurn 2 in nominal thickness pressure freafed#2-grade. : . Town of Barnstable Regulatory Services � *i639. Thomas F.Gefler,Director � ►qua' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.townbarnstable.ma.ns Office: 508-862-4038 Fax 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize �� ��1 I-C! to act on my behal f in all matters relative to work authorized by this building permit (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 of S' fate of Applicant AM 1& tint Name tint Name Date QFORMS:oWNERPERMIssroNPOOLS 62012 Town of Barnstable Regulatory Services `* ► . ` Thomas F.Geiler,Director «`e� 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEAWNW- 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,pLojided 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 accessory detached structures accesso 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 theState 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. be exempt a which a building permit is required shallp The Code states that,, Any homeowner performing work for whit g p q 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. Oirthe 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. C:\Users\dec UWAppData\Local\MicrosoftlwiudowslTemporaryIntemetFncs\Contmtoudook\QRE6ZUBN\EXPRESS.doc Revised 053012 671 - Office of Consumer Affairs&B siness Regulation 6i-4 HOME IMPROVEMENT CONTRACTOR Registration: . 141991 Type: 'FEE ru—w: yP - Expiration: 3/3/2014 DBA . HARBORSIDE REMODELING ROBERT WALSH. 250 CAPTAIN CROSBY ROAD', CENTERVILLE,MA 02632 Undersecretary License or.registration valid for individul use only a before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid w•i hout signature ' Massachusetts - Department of Public Safety �! Board of Building Regulations and Standards Comtruction Stihcri kor I �'�, ? Famil License: CSFA-057394 ROBERT G WAL$H ` t• 160 HIGHLAND AVE Cotuit MA 026357, - expiration Commissioner 06/02/2015 io TOWN OFITARNSTABL't £O ? Lei 1, DIVIZ 71, 4® t 30 ° \' J R(D o TOXIN.:OF BARNSTABLE 20B OCT`22 PM 1 g0 ,� I DIVI7IO 1 r. i 75 u �o®X61 51� �11 A�set 11' y O� P T- Ta,'Pk a d � . 5 dl, vt p'i flees Y . 6-T\ a )k /0 jp r- �j T, gk,sF a Tine Gr�wd�, u9 -1 X-PRESS PERM'T table *Permit Town of Barns ��. Exp' 6 tnoe -fro issue date * + P - 3 2013 Regulatory Services B —F MABEL Thomas F.Geiler,Director 039. OF BARNSTABLE Building 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 PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address ( g }�A'i� 1n1T9r6bNA���Dea�dmpg . ®Residential Value of Work 000 - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ��- i ►°� 12 Lph ►® �' ���Dd Contractor's Name Telephone Number T j q 7 a.Fg'— to 9$� Home Improvement Contractor License#(if applicable) °�9 Email:. 6,4c 90 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: j [�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 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) 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 required. SIGNATURE: Q:\WP171IM FORMSZuilding permit formsT)TRFSS.doc Revised 060513 Sep 3 2013 1 ; 18PM No 3641 P 1/2 AGVMU CERTIFICATE OF LIABILITY INSURANCE' DATE(MMIDDIYYM 09/03/2013 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). PRODUCER CoN MTACT NA E: Joanne Bretton Southeastern Insurance Agency, Inc.. A"IC°Noe : 508.997.6061 a�No: 508.990.2731 439 State Rd. E-MAIL ADDRESS: P.O. Box 79398 PRODUCER CUSTOMER ID fI: North Dartmouth, MA 02747 INSURER(S)AFFORDING COVERAGE NAIC9 INSURED INSURERA: Peerless Insurance 24198 Fernando Borges and INSURERB: Guard Insurance Group DBA: Fred Borges Electric Inc. INSURERC: 1800 Acushnet Avenue INSURERD: PO BOX 61416 INSURER E: New Bedford, MA 02746 INSURERF:' COVERAGES CERTIFICATE NUMBER: 2013 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDn-" (MMIDDNYM LIMITS GENERAL LIABILITY BKW5342357 01/01/2013 01/01/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS MADE A OCCUR MED EXP(Any one person) $ 5,000 A 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 JPEQ LOC $ AUTOMOBILE LIABILITY BA1025707 12/29/2012 12/29/2013 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR US05342357 01/01/2013 01/01/2014 EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS ANDEMPL YERS'LIA IBLIIT YIN NY FRWC319323 01/01/2013 01l01/2014 TORYLMITS OTH ER B ANY OFFICE R/MEMBPROPRIETOR/PARTNER/EXECUTIVE /PARTN R/E ECUTIVE � NIA E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 Additional Remarks Schedule,if more space is required) Job Location: 21 Sand Point Road, Osterville, MA 02655 CERTIFICATE HOLDER CANCELLATION FAX: 508.790.6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable Attn: Electrical Dept AUTHORIZED REPRESENTATIVE 200 Main Street Hy nnis, MA 02601 Joanne Bretton ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massaehuse#s Depar hmwt of frrdmsbid Accidents -- Office of Investigations 600 Washington Street Boston,M,4 02111 wn tna-,mgov/dia Workers' Campensatian Insurance Affidavit:Bugders/ContractorslEiectricianslPlumbers Applicant Infarmation Please Print Legibly Dame gksines Orgenimtionrtndividna0: /LO�P►s l ^ G`r�itg Address: 166 Citylstat&zip: Phone f: 77 V_ o�JT$—6 9 1.7-7 Are you an employer?Check appropriate box: Type of project(re qnired)= 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New cons ructim employees(full and/or part4ime)* have hired.tbe sub-contractors. 2-% I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling strip and bate no employees These sub-oontractors have g. ❑Demolition w for me in an capacity. employees and have workers' working y apa. ty. 1 9_ ❑Building addition [No workers' comp.insurance comp-msurarxe- requifed.] 5.❑ We are a corporation and its 10..❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11_0 Plumbing repairs or additions mysI f[No workers'gip- right of exemptioa per MGL 12.❑Roof repairs insurance required-]t c.152,§1(4),and we have no employees-[Na workers' 13-❑Other $ r comp.insurance requireti.j... *Any appliczat[tat checks boat#1 mast also fill out the sectica below showing their workers'compensatiou policy iafsttmadC L T Homeowners who submit this affidavit m&cs mg they are dorm;,all Wmk said then hue outside contractors mast submit anew affidavit indicating such- tCuuiiacmrs that check this box must attached am additional sheet showing the nsme of dte sub-catttzacto-rs and state whether ornotthose entities have employees. If the subtoatmctnrs have employees,they must provide their workers'comp.policy number. .Taman employer thatisprmdding worken'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy 9 of Self-ins.Lic.9: 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 Sectibn.25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a fine up to S 1,500,00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER.and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for inn u=,e,coverage v erification- I do hereby certrfy t thepains ai penalties perjury fhatthe irrformatian prat�ided above is bus and correct 5i tore: 4LALJ- Date: Phone#- r 7 t1- a 9 0,fjuzal use only. Do not write in this area,to be completed by city or town o i'ciat City or Town: Permit/License It Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylrown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: i. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three aparlments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the'commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §256(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 •r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required_ Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of kvestigatlans 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-977-MASSAFE Revised 4-24-07 Fax#617-727-7749 - www.mass.gov/dia l E T Town of Barnstable * °t Regulatory Services 9 'SS Thomas F.Geiler,Director i639• �� prE0.39. 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 w i� ' ` 4 ---- ".✓ V Owner of the subj Property I, 7('�► � ,a Own lect P P riY hereby behalf,authorize D l-P9` �. 1 to act on my in all matters relative to work authorized by this building permit d - (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. Le-� Signa, e of Bwnet sAnatUre of Applicant L r-1 If<'e�� &�"g �- " I g-�' \ f04, Print Name Print Name Date / Q:FORM&OWNERPERMISSIONPOOLS 62012 • BIKE� Town of Barnstable Regulatory Services s S. Thomas F.Geiler,Director �Ep;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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,riles and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . , HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRFSS.doc Revised 053012 �•— _ .. a ;�,_� ✓fze -�omvm"auueca/.lf �✓f/laeaac�auoeT s -\ Office of Consumer Affairs&9siness Regulation ro HOME IMPROVEMENT CONTRACTOR Registration: ... .141991 Type: } Expiration: '3%3/2014 DBA H ORSIDE REMODELING:,,. ROBERT WALSH` 250 CAPTAIN CROSBY ROAD . CENTERVILLE,MA 02632 Undersecretary . F r, k 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 5170 Boston,MA 02116 Not valid wi hout signature Massachusetts -De t partment of Public Safety Board of Building Regulations and Standards Gonstruction Supervisor 1 & 2 Famill -License:CSFA-057394 + ROBERT G Wq � C 0 MGHLANDA VE<• - �/.�,.�JJ�,yI�,~,Commissioner Expiration'.06/02/2015 ♦ t BELOW FOR OFFICE USE ONLY , 4 FINAL INSPECTION SKETCHES PROGRESS INSPECTION 1- - 9 FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING -► NAME i TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED - DATE 19 } GAS INSPECTOR t' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINO (Print or Type) s 3' �5 �4 TOWN OF. BARNSTABLE Date/p( - (/ D 19 IC Hyannis, Massachusetts Permit i_ Building J� Ave- Owner' AT: Location-IL '! Y Name S , _ Type of Occupancy: New ❑ Renovation ❑ Replacement[] Plans Submitted Yes [] NO [] ` w � K w w tYi s � d w K w W O K w ►- pc J w K O v r H _ Z w i s IW- K o o O _ ►W- W ` K W Lb 0 W d X Z H w O n<i W Z Y t W ►- ►- s d H Z J p 1� W r O O '! W M• U J F W Z W Y A K i O Z O w i s i O 0 Z a o I< O O J O a > o a t- O sus-BSMY. BASEMENT 1ST FLOOR 2ND FLOOR 3ROFLOOR ITN FLOOR STN FLOOR STN FLOOR 7TNFLOOR STN FLOOR (Print or Type) Installing Company Name V Check one- Certificate pL(.C.( �� carp. Address '77 ❑Partnership ❑Firm/Company Business Telephone4/aL&3&C Name of Licensed Plumber or Gasfitter 1 hereby certify that ell of the details and Information 1 have submitted(or entered)In above sppHeation ms true and savrate to the►eat of my kno"Iedge and that all plumbing work and Installations petfonned under Permit Issued for this application will be M smpWns with V pertiamt provialons of Ue Mess.chuata Stale Gas Ooda and Chapter 143 of the Gomel L&WL I have Informed the owner or his agent that I .do not have liability Insurance Including completed operations coverage. Signature of Owner/Agent I have a current Ii ility Insurance policy to Include completed operations coverage. By TYPE LICENSE• *j�, Plumber Title Gasfitter Signatyre of Licensed City/Town: .aster Plumber or Gasfitterourneyman APPROVED (OFFICE usE ONLY) J Q„� T wn w *Permit# ' �_o?®�.__ 7 Expires 6 months from issue cdaie Regula ServIces Fee . -PPERMIT . . � , ._� - MAY 2A 2007Tom Petry,CPO, a1uUding Connie, .loner TOWN OF BARNSTABLE 200 Main Street',Hya mis,I�Lk 02601 www.tov u_'..:;rnstable.ma.us "lice: 508-862-4038 508-790 6230 --•����// Not Valid rvitlsoui Rad i Press Imprint 6 f-� )perty Address �_. _ l l4 , j Re:si.dentiai Value of Work_c� Minimum fee of$25.0O for work under S.6000.00 . vner's Name&Address_. o9(P ��C ��Y �1'►.�+_ h lv _ r l _ `(6 � . _ _ �1►��►.. ce �y n dgZ.7.-3z�r0_L>✓tl _Tj �re�ractor's NaT Me Improvement CO-ItractOr Z.icei se#, (if applicable) ,y;✓qm� ' ]�agr1:r•_an's Coape�,�ation Lnsuran.ce ch4 one: � FU a sole proprietor I are,.the Homeowner ® 3 have V�ci: :er's Camper cation 7 isurance swFztce Compv iy Name_—_-7�to ���l2 9 .,�kV(S o hTnan's Ca Policy# opy of Insurwoce Compliance Cc. �.:Dcat.e must be on file. - - - - Request(check box) Re-roof(stripping old sJr files) All co::;.struction debris-wrill be taken to_„ 70�lNh/ Zi­4, []Re-roof(not stripping,.Going over existing layers of roof) Re-side Replacement Windows/c?_--)ors/sEders..U-Value (maximum.44) �Svnererequired, Issuance of this pernvt does not exempt compliance with other town deparhnentregUhtions,i.e.Historic Conservation,etc. *Dote: Property Owner must sign'°roperty Owner Fetter cfPermission: A copy of the Home 1-p-ru'vemEnt Contractors License is recpi:r;;L, iGNATURE: rornms:expmtrg ;vseG�13G6 77i/IIZfl47.t(J6�G/� O�%/(.(r� 7.RGQp - ` Board of Buiiding Regulations and Standard�' HOME IMPROVEMENT CONTF gCTOR L1CQnSe or rie istration valid for individul u Registration 14?99i ate.before the expiration d 1f found retu s rn to: only i I Ezpirat�ori Board of Buildin g 3/3/2003 g Regulations and Standards One Ashburton Place Rm 1301 TYes DBAz Boston,Ma.02108 H RBORSIDE REM0DELING E ROBERT WALSHk .y 250 CAPTAIN CROSBY ROAD, CENTERVILLE, MA 02632 - Administrator - Not valid without signature--— The Commonwealth ofMassachusetts Department oflndustrial accidents Office of Investigations a ' • 600 Washington Street Boston,MA 02111' www.mass.gov/dia ' Workers"Compensation Insurance.A-Mdavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(BusinesslOrganization/Individual): Address: 9 -0 L 46,2 C".-IM A City/State/Zip: QZmif►2 a 3Z Phonet ~ Loi� Are you an employer?Check the appropriate bog: . :Type of project(required) 1;❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction . employees(full and/or part-time).* • have hired the sub-contractors 2,[Rfam a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g;.❑Demolition -;Workingfor me in an capacity.' employees and have workers' - Y P tY� $. 9. ❑Building addition [No workers' comp,insurance comp, insurance. 5.❑ We are a corporation audits 10.❑Electricalxepairs or additions required.] officers have exercised their 11. Plumbing repairs or additions ' •3.❑ I am a homeowner doing ill-work . ❑ . g p myself.[No workers'comp. right of exemption per MGL 12,�oof repairs insurance.required.]t c. 152, §1(4),and we have no employees, [No workers' 13.❑ Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating-such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors'snd state whether,ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I qm an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site' information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date �rr"rv� (f City/State/Zip: Job Site Address: a y . - Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as requited 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 ofup to$250.00 a day against the violator: Be advised that a copy of this statement maybe forwarded to the-Office of' Investigations of the DIA for insurance coverage verification I do hereby certify un er the pains•an penalties o•perjury that the information provided above is true and correct Si tore: Date: Phone#: �D 2c - O S� FCon only. Do not wrife in this area, to.be completed by.city or town offzciaL n:' Termit/License# hority(circle one): - Health 2.Building Department,3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: Information an -instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"..,every person in the service of another under any contract of hue, 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 edeceased employer,or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter-152,§25C(7)states`N.either the commonwealth nor any of its political subdivisions shall *enter into any contract for.the performance of public-work until acceptable evidenee•oi'"co4l&�4 withtlie insurance- requirements of this chapter have been presented'to the contracting authority.'• Applicants Please BE out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,it necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LI.P)with no employees other than the members'or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have s 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 stgn 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 ono 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 markdd 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bairn leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please'do not hesitate to give us a call. The Department's address,telephone-and fax number' The Com ouwWAh ofMomehusetts Dtpartment of bdutdal A.eeideuts Qfu"of Invesagaltoas 600 WaWngtofi St et B44on. MA 02111 • . Revised 11-22-06 Fax#617-727- 749 'w.MaM&ENV/ti0 Town of Barnstable. Regulatory Services BaxxsrnT ' * Thomas F,Geiler,Director D;9;� Building D' I. Tom Perry, Building Commissioner 200 Main Street Hyannis,MA 02601 www-town,b arnstable:ma.us pace: 508-962-4038 Fex: 508-790-6 30 Property Owner Must Complete and Sign This Section If Using ABuildtr L L �` ���61 , as Owner of the subject property hereby authorize QCGi tA-)-A(, to act on my behalf, in-l1 matters relative to work authorized bythis wilding permit applLcation for, , (Address of Job) Signature of zte 1��LLI Pin A �1(�� • . . 1 riat Na-rne O rGRN5:0 Yr�?E rF.T✓ 5?GN