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HomeMy WebLinkAbout0245 HINCKLEY ROAD o?A1S ll Application number.....................l... .a.t.-u. Q► ! Fee .................... .....l.va.c�d.......... ............ Building Inspectors Initials...e :....................... VA ... ..................................... a rJ f Date Issued.:. ..l..l..�...�.�.. Map/Parcel........am...... ../..9........................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET �,`\ VILLAGE Owner's Name: Sr, A/1/ C 4 y.S%/�✓ Phe�ne.Number �/ 090, L Email Address: Ca-" C Number Project cost S zy, Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for ` Mt ' 'accor ance with 780 C k1 , /.2 Owner Signature: Dater TYPE OF WORK 'EVSiding EVWindows (no header change)#_L�— 0. Insulation/Weatherization ❑ Doors(no header change)# Commercial Door`s require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to . CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration' if applicable)# � (attach copy) Construction Supervisor's License# , ,; (attach`copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach,floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Ce or c�number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and t o f rns ble. 1 Or/ Signature Date � d- APPLICANT'S SIGNATURE / Signature Date 7 -r.dl��� �1 All per ' applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents a. Office of Investigations 600 Washington Street Boston,MA.02111 www mass.gov/dia' ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: v City/State/Zip: Da 6o Phone#: Are you an employer?C eck the'appropriate box: Type of project(required) 1.❑ I am a employer with 4. :❑ I am a general contractor and I ' employees(full and/or part-time).* have hired the sub-contractors 6. ❑New constriction 2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling ship and have no employees These sub-contractors have g, Demolition workingfor me in an capacity. employees and have workers' Y P tY t 9. ❑Building addition [No workers'comp.insurance comp. insurance. re a .] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.Ellam a homeowner doing all work , officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. - t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ` I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date- Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.-152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year.imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy.,of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certi er a airs an enald of perjury that the information provided above is ue and correct. Si ature: Dater V. Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/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. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(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 cant'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, lease call the Department at the number listed below. Self-insured companies should enter their P P cy P P self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 VAM.mass.gov/dia CERTIFICATE OF INSULATION - Part 1 - General Address of Residence Name and'Address of Contractor: CA ,l CPr(�e CoU� S�,fl` tUVy Date of Installation: - Part 2 - Areas Insulated A WALLS ( Sq. Ft.) CEILINGS ( b� g ry q ) FLOORS ( _Sq. Ft) Type of Insulation: Type of Insulation: Type of Insulation. l�loS� r_4sS Manufacturer: Manufacturer: . . Manufactur R-Value Installed Amount Installed R-Value Installed Amount Installed R-Value Installed Amount Installed (# Bags) .(# Bads) \ #Bags) 4 Part 3 -Certification - certify that the residence identified in.Part I was insulated as specified in Part 2 and the ins aNation was conducted in conformance t applicable Codes, Standards, and Regulations. natw'e This Certificate must be completed and prominently posted adjacent to the electrical panel. 62 fie, 1L4boo 2 '?,oC(O ."� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Parcel Application# aq l Ov' )(,93 Health Division Date Issued l Conservation Division .-Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project Street Address L _ l'- 4 L_- ' 4 - Village A Owner Address - Telephone �Zzy ` c ,. rmit Request � � � L — v IV Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay roject Valuation B­Pn Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. v Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) ` Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size — Barn: ❑1existing q nevi size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other; '= Zoning Board of Appeals Authorization, ❑ Appeal # Recorded ❑ N e Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use ' ' APPLICANT INFORMATION (BUILDER OR HOMEOWNER) �( Ic Telephone Number Name *� p Address _ License # Home Improvement Contractor# G 6 Worker's Compensation # 5'� ALL CONSTRUCTION DEBRIS RESUL-ING Fbl THIS PROJECT WILL BETAKEN TO)4 � SIGNATURE4� DATE I L } FOR OFFICIAL USE ONLY .r r APPLICATION# } t DATE ISSUED i - Iz MAP/PARCEL NO._ r ' ADDRESS. VILLAGE OWNER DATE OF INSPECTION: S • FOUNDATION-,' FRAME INSULATION.,[ FIREPLACE r ELECTRICAL: ROUGH FINAL j PLUMBING: ROUGH FINAL GAS- ROUGH " .5 FINAL ' s . t ' iFI,NAL BUI'LOING •: ` DATE CLOSED OUT - ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations e g www.mass.it�'is 600 Washington Street. - ! Iltls ° Boston, MA 02111 ov/dia r � Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pleas Print Le 'bl • a Name(Business/OrganizationAndividual): i (. AF Address: 7 Z City/State/Zip: . /110 071-1- 0Z Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.KI am a employer with 4. ❑ 1 am a general contractor and I 11 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance` .5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] " 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4), and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' , comp. insurance required.] 13.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors_must submit a new.affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information: 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. #: °— -Exxpiration Date: 31 - Job Site Address: C ty/Sta�Zip: " l Attach a copy of the workers' compensation policy. eclaratio 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 the pains and penalties f perjury that the information provided above is true and correct. Si natty D Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town;. Permit/License# Issuing Authority(circle one): 1. Board.of Health 2. Building Department 3.City/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. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as."an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance wit h.the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of.compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for.the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ' of the affidavit for you to fill out in the event the Office of Investigations has to'contact you regarding the applicant. Please be sure to fill in the permit license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit.that has been officially.stamped or marked by.the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each, year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 611-727-4900 ext 406 or 1-877-MASSAFE Fax # 6-17-727-7749 Revised 5-26*5 www.mass..gov/dia ACORO CERTIFICATE OF LIABILITY INSURANCE . DATE 12/28/2s/2olo 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 CONTACT Timothy Lovelette Marshall K Lovelette Insurance Agency Inc. A/CN No,Ext: (508)775-4559 A/c No: (508)775-4571 396 Main Street ADDRESS:timothy@loveletteins.com P.O. BOX 836 CUSTOMER USTOMER D#P0004233 West Yarmouth MA 02673 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Hartford Ins. Co. 0006 iNSURERB:Safet Insurance Company 0005 Healy Brothers Construction Corp INSURERC:Western World Ins. Co. 72 Old Main Street IN SURER D: INSURER E: ' South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL10122800606 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR D POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ 50,000 C CLAIMS-MADE F—IOCCUR UPP1278166 4/13/2010 4/13/2011 MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 11000,000 % POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ B ALL OWNED AUTOS 6202555 3/3/2010 /3/2011 X SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE I $ RETENTION $ $ A WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY YINI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) 6S60UB4117P96A10 1/15/2010 1/15/2011 E.L.DISEASE-EA EMPLOYE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 I T DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DAMES RODENBUSH ACCORDANCE WITH THE POLICY PROVISIONS. 245 HINCKLEY ROAD HYANNIS, MA 02601 AUTHORIZED REPRESENTATIVE Jr Timothy Lovelette/TIME ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD vcirar unl'nt UI YUI111C 1afC[% �Q pll �i� K It[IQP.�6 t. Otfice�t`co me�irs srness., egn a on o.tiril of BuildinI Rc��ulutions an(1 Stan(lurds Construction Supervisor License I { HGME IMPROVEMENT CONTRACTOR, Registration js160669" Type 1 License: CS 60855 Expiration: 8l14/2012 Privgte Co,rporat r � V BPQTHERStCONSiTRUCTION MICHAEL A HEALY I t g r 72 OLD MAIN'ST , t,_ > r SOYA I' MICHAEL HEALY �;� RMOUTH, MA 02664 z 72 OLD MAIN ST i � SOUTH YARMOUTH MA 02664 �',L_ �• } Unde ec tary Expiration: 11/22/2012 + t ('unnnisiuncr Tr#: 7457 i THE Towns of Barnstable Regulatory Services • arrsreBM v' noes Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner y 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 7j'S1C117C&,-1 as Owner of the subject property hereby authorize = � �� to act on my behalf, in all matters relative to work authorized by this building permit application for. (Ad ss of Job) o co e of Owner Date Z Print Name If PropertyOwner is applying for ermit 1. p pease complete.the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION r � Town of Barnstable �afz o Regulatory Services Thomas R Geiler,Director Muss. 1639. ,�� Building Division PT f0�,t a Tom Perry,Building Commissioner 200 Maiui.Steet,_Hyannis,MA..02601 viww.to wn.b arnstabl e.ma.us Officer 509-862-4038 Fax: 508-790-6230 HOAIEOVNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: �—� /AI CZ!Kl � / /✓�S//J number street village "HOMEOWNER'MKY �GDL117ysX-1- C name home phone# work phone# CURRENT MAILING ADDRESS: C - 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 HOMEON ER 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 constrgcts more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the.Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that-he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will coroply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 3 5,000 cubic feet or larger will be required to comply with the ection 127.0 Construction Control. State Building Code S HOMEOWNER'S EXEMPTION The Code states that "Any homeowner perfomring work for which a building permit is required shall be exempt from the provisions of this section,(Section 109.1.1 -Licensing of canstruction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc 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 scriaus 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 rnponsib)e. To ensure that the homeowner is fully aware of his/her responnbilities,many communities require,as part of the permit application, that the homeowner certify that hdshe 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:fomts:homccxcmpt sessor's�)ffick Qjl Ma'j",",-,3 Permit�Po o r C) Paf6el q 0 e (91.30 9:30 1:00.74 2:06 Daie Issued a -1 J ,�Onservadbn Office N Nor (8:15 9:30 1:00-4 45)) - - Fee" Board of ikaltlf3rd A 1_ F 10VV Engineering Dept.,3"r Ouse 4", 1 121A 0 CONNE O r-ENG R TO ' B 19 CON MAS& t639. TOWN OF BARNSTABLE Building Permit Application i ' f -.1--Project Str ess 1 Village vivi Owner Id P w I.So ­<Jfdress a < Telephone 5bt 79 a . it Permit Request l A!4tV W, 'First Floor square feet Second Floor square feet fstimated Project Cost'$ CO Zoning District 3 Flood Plain Water Protection Lot Size Gran dfathered ? Zoning Board of Appeals Authorization Recorded Current Use j Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Y—i Two Family Multi-Family Age of Existing Structure 50, tAr3 Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel G QS Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other -%S Telephone Numb Builder Information Name Fve IR-t -7 ;7F 5w-7 o/ Ce Address zo C/ r Rae License# at At,% s /tv oZ O Home Improvement Contractor-#�- Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT,WILL BE TAKEN TO SIGNATURE 6Z DATE ��/� y/4J� BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) t i ` T . .. . MikOFFICIAL USE ONLY PERMIT NO. DATE ISSUED - E MAP/PARCEL NO. + Y ADDRESS 1 VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 1 r d -• ' , f , FRAME INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL s PLUMIIING: ROUGH FINAL GAS: w c sR,rOtUGH FINAL .5r +FINAL EIVILDIN,G-11V _`' 7 . Vs op - S•„ F I DATE CLOSED F # # ASSOCIATION I NO. ' r TOWN OF BARNSTABLE BUILDING DEPARTMENT • HOMEOWNER LICENSE EXEMPTION Please p -:: rent. I +'L,XJ04 L) 'Number Sireet address Section of town ® ® Q a yr\� P �/yr�J a�n Jr- 7c�p Fd 76 -'y Name Home phone Work phone P � � � �DDRSs d. Eex Zq34' ::gip•:_ ;_ qli OfLIA rJl� z6d mi, town State Zip cod The Current exemption for "homeowners" was extended to include owner-occup. dwellings of six units or less and to allow such homeowners to engage an t dividual, for hire dho does not possess a license, provided that the owner acts as su ervisor, DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to side, on which there is, or is intended to be, a one to S4,X family dwellih, attached or detached structures accessory to such use andjoi farm structure A pe_,rson who constructs more than one home in a two-year period shall not cotasidered a homeowner. Such "homeowner". shall submit to the Building off:. on a form acgeptablc to the Building official, that he/she shall be resp®ne for all such work performed under the building a i.te (Section 109a1®1) The undersigned !homeowner" assumes responsibility for compliance with the Bu'7•ding. Code - and other applicable codes, by-laws, rules and regulations. Th( undersigned 'homeowner" certifies that he/she understands the Torn of Barnstable Building Department minimum inspection procedures and requires ,ind that he/she will comply ^wi.th said P ocedures and requirements. M.CMgFOWNER°S SIGNATURE A'?PRGVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be require to comply with State Building Code Section 127. 01 Construction Control. ROME OWNER e S EXEMPTION The code state that® "Any Rome Owner performing work for which =a, J%il.dJ permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 ® Licensing of Construction Supervisors) ® provided that Some Owner engages a persons) for hire to do such work, that such Home shall act as supervisor. " Many game Owners who use this exemption are unaware that they are assumi the responsibilities of a supervisor (see Appendix , Q, Rules and Regulati for .licensing Construction. Supervisor=i, Section 2m15) m This lack of awa. often results in serious problems, particularly when the Rome Owner hire unlicensed persons. In this case - our Board cannot proceed against the inlicensed person as it would with l.icen'sed Supervisor® The Home is er:. as supervisor is ultimately responsible. To ensue that the Rome Owner is - fully aware of his/her responsibilities communities require, as part of the permit application, that the Home *Owi certify that: he/she understands the responsibilities of a supervisor. 01 last page of this issue is a form currently used by several towns. You r care to wend and adopt such a form/certification for use in your commun9 a d r Depart»tent of Industrial Accidents - . exce OUR yes V9211ons ' 61111 11 ashington Street Boston,Mays. (12111 �„�• Workers' Compensation Insurance Affidavit Annlica—n nformatio`n Please PR 1VT'l +jjz]� trimI Dav i P' WAR h ITr .� ention. ` O I A w t.V1 ��'`• gHhl Phone# 504�" 790 Fb70 am a homeo mer performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ 1 am an employer providing workers' compensation for my employees working on this job. comnanv nnme! address: city: nhone#• insurance co. policy# L 1 am a sole proprietor,general contractor, r homeowne circle one)and have hired the contractors listed below who have. the following workers' compensation polices: company name! e�P 1.01i1S!hJtBY► address: city phone r, insurnncc co. Ott�SQJ soli •# �J �'� %TC 6 ��..._ :.: _:�•:'- — .snsxr..t...•.aa�es�e�?:+i•:•�r!rte;«�?7":9Ee'�v=•,c, - --- -- - .r +�i�'tit`.•+w; i�-.^�:'9' -+4+is��•• comnan•name: address: yin•• phone#• insurnnce co. noliev# :Attach additional sheet if oee �s7. •w - Wit; -•+.^�w_ �•*:�.. •�� ""•= "'� Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification Id herebt•cent y under the pains and penalties ojperjwn•that the injornwtion provided above is true and c�jrrect. Signature p ''Print name Vt`.�s' t��z �w/ If��v^+`�� =iPhone# 0 a 70 official use only P do noiiynte in.this area to be completed by city or town official city or town: . ., F -'permit/license# - n[tuilding Department OLicensing Board 0 cheek irimmediate response is required OSeleetmen's Office Oliealtb Department ' contact person: phone t!;_ nOther "ce # ��^+C ,jw►�rpv�y�t n I y 9 `. l' t 6 ; • i .i � E3 The Town of Barnstable MAL �eS Department of Health.Safety and Environmental Services t Building Division 367 Main Strut,Hyannis MA 02601 Office: 508-790-6=7 _ Ralph Cross= Fax 508-775 3344 Building Coromissior For office use only Permit no. Date AFFMAVIT HOME DWROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERNM APPLICATION MGL c. 142A requires that the-recousttuetion,alteratioaS,renovation,repair,moderaitdtion,conversion, improvement,.removal, demolition, or construction of an addition to any pre-c dsting owner ooarpred building containing at least one but not more than four dwelling units or to=actz =which air adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other tequirzmeats. Type of Work: ( z2— at Cost -address of Work: �Oaner.Name: NA Date of Permit Application: �� Z fJ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law. Job under SLOW wilding not caner-occupied pOtYner Pulling own permit Notice is hereby gi♦-ar that:. '` y OWNERS PULLING THEIR OWN PERNQT OR DEALING WTIH UNREGIS CONTRACTORS FOR APPLICABLE HOME iwROVEI4wr WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNI)ER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. 10 5 Z 6 Date Contractor name Registration No. OR Owner's game . March 9, 1995 EVELAND CONSTRUCTION 209 Iyanough Road (Rt. 28), Hyannis, MA 02601 1 508-778-5667 -S p o u f WA 800-386-5667 INSTALLED PRICE LIST CLASSIC 6/12 ROOF PITCH 6 x 8 $ 799.00 8 x 8 849.00 8 x 10 999.00 8 x 12 10149.00 10 x 10 1,174.00 10 x 12 11349.00 12 x 12 1,449.00 LOr 12/12 ROOF PITCH 6 x 8 $1,099.00 8 x 8 1,149.00 8 x 10 1,299.00 8 x 12 1,449.00 10 x 10 1,474.00 10 x 12 1,649.00 12 x 12 1,749.00 SALTBOX 8/12 ROOF PITCH 6 X 8 $ 749.00 8 X 8 799.00 8 X 10 999.00 8 X 12 1,149.00 10 X 10 1,174.00 10 X 12 . 1,349.00 12 X 12 1,449.00 EACH SHED INCLUDES: Full-dimensional Lumber; post & beam frame; asphalt shingles; 2x6 joists and rafters; ,6" tee hinges, metal handle, locking hasp on 36" door; 1" pine sides, roof, and floor, non renting window with shutters and flower box; P.T. pile footings; termite shields; louver ; ramp. OVER- OPTIONS EXTRA WINDOW $45.00 DOUBLE DOOR 60.00 DOUBLE DOOR IN LIEU OF SINGLE 35.00 EXTRA SINGLE DOOR 35.00 POURED FOOTINGS $75.00/EACH [8X8/4; 10X 10/6; 12X 12/9] $25 DISCOUNT may be taken if footings are. already in place-- level and square. .,, UNREGISTERED LAND FILE NUMBER. 71043 DEED BOOK: PAGE: ATTORNEY: DAVID DERATANY PLAN BOOK: PAGE: LOT(S): LENDER: PLAN NUMBER: OF OWNER: FEDERAL HOME LOAN MORTGAGE CORPORATION REGISTERED LAND APPLICANT: DAVID P. WILSON, JR. REGISTRATION BOOK: PAGE: DATE: 12/28/93 SCALE: 1 =30 CERTIFICATE OF TITLE: 117279/127568 FLOOD HAZARD INFORMATION. PLAN NUMBER: 11519-B LOT(S): 134—H FLOOD MAP COMMUNITY NO.: 250001 ZONE: C ASSESSORS MAP PANEL: 0005C DATED: 08/19/85 MAP: BLOCK: PARCEL MORTGAGE INSPECTION PLAN IN BARNSTABLE, . MA N/F BRADFORD Z 60.00' LOT 134—H LOT. 134-I LOT 134-G O O u7 � SHED 1 S 0 Y DW L INC N0. 245 so.00 MORTGAGE LENDER H I N C K L E Y ROAD USE ONLY THIS IS THE RESULT OF TAPE MEASUREMENT, NOT THE RESULT OF AN INSTRUMENT SURVEY AND IS CERTIFIED TO THE TITLE INSURANCE COMPANY AND ABOVE LISTED ATTORNEY AND LENDER. DES LAURIERS & ASSOCIATES INC. THERE ARE NO DEEDED EASEMENTS IN THE ABOVE REFERENCED 30' 0 30 60' DEED OR ENCROACHMENTS WITH RESPECT TO BUILDINGS. SITUATED 130 WEST STREET, WALPOLE, MA 02081 ON THIS LOT EXCEPT AS SHOWN. TEL.:(800)287-8800 FAX.:(508)668-4512 THE LOCATION 'OF THE DWELLING SHOWN DOES NOT FALL WITHIN �`AN of 44,p A SPECIAL .FLOOD HAZARD ZONE.' �� f� + STEPHEN s THE LOCATION dF"THE DWELLING, AS SHOWN HEREON EITHER 9 CONVERSE � WAS IN COMPLIANCE WITH THE LOCAL ZONING BY—LAWS IN Lj No.33%5v ti EFFECT WHEN CONSTRUCTED (WITH RESPECT TO STRUCTURAL e A v �EBS`P O SETBACK REQUIREMENTS ONLY), OR IS EXEMPT FROM VIOLATION ti�Su ENFORCEMENT ACTION UNDER MASS. G.L. TITLE VII. CHAPTER 40A, SECTION 7. . GENERAL NOTES: (1) The declarations made above are on the basis of my knowledg , information, and belief as the result of a mortgage inspection tape survey made to the normal standard of care of registered land surveyors practicing in Massachusetts. (2) Declarations ore mode to the above named client only as of this dote. (3) This plan was not mode for recording purposes, for use in preparing deed descriptions or for constructions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may be accomplished only by an accurate instrument survey.