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HomeMy WebLinkAbout0041 LINDA LANE ACTIVE t ''��1 •� /Z i "' ^� V I Wp i i .c. 'er �� �� 9 �_ a� l < 65�71 `� �j Town of Barnstable *Permit# Expires 6 mondes from issue date rT Regulatory Services Fee MASS. Thomas F.Geiler,Director �639 A� M(� R Building.Division <�.-PR PERMur Tom Perry,CBO, Building Commissioner �{ 200 Main Street,Hyannis,MA 02601 Q C T 2 www.town.bamstable.ma,us 2Q 11 Office: 508-862-4038 1 O'Al 7rFaJ , 91O- t30 EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY t�L� �r Not Valid without Red X-Press Imprint Map/parcel Number � 7 d9 l S Property Address T L 14 4 Residential Value of Work r7I Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address dA C J-- &y�(e, Contractor's Name W t['i Telephone Number '7 4r—"l"?;j Home Improvement Contractor License#(if applicable) IS 3 Construction Supervisor's License#(if applicable) s �q orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 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) e-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 #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *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: C:\Users\decollik\AppData\I.ocal\Microsof\ ows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 lV[as!cachnt¢s=�tepartment of Puhlcc Safcit Board of O- Ing Rego lations and Standards Construction,Supprvisor License L`ices�se:, CS 95459 Restrtrtettto00 3 � ., WILLIAM--SAUP DERS 53 LAl)REUHILL ROAD SQUTHBRIDGE tUtA 0-55D y` ' Expiration'. 11512012 C"inu;s84icrne Tr# 12809 x , y . : � �`Office4gf Consumer A airs �fsiness eguiahon # HOME iMPRO�/EMENT CONTRACTOR � #z '; E ReglsaUan z53955 7YPe O' ' SA DERS ANdKARI � : UIIILLIAMSAUN M LAUREL HILLER r 'SOUTHBRIDG���MA Un rseeretary ti - mg .�':fix " 4-44-1 ..'' k��r`c'�"irs a.-wed: '�-- The Cornanionwealth o,f Massachusetts ` . DgWtment of Industrial Accidents ' - - Office of Investigations �. 600 Washington Street Boston,M4 02111 fuwly.niass;gov/dia. Workers' Compensation Insurance Affidavit: Builders/ContractorslElectaletans/Plumbers Applicant hdarmation Please Print LegibT-f Name(B s/Organ n hdmdual)_..,.S4t'�/'W 1A10 -Yy rJ /'yo����✓� Address: 63 krt4,jP't( h't"' f?l"2 City/State/Zip: Phone 47- 2 Are you an employer?Check the appropriate box: Type of project(required): l"k-I am a employer with 4- ❑ I am a general contractor and I employees(full and/ a have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet 7_ ❑Remodeling ship and one no employees These sadb-contractors have S. ❑Demolition workingfor in an capacity. employees and have woidoers' Y � tY- 9_ E]Building addition [No wodloers'comp_insurance comp_insurance.I required] 5_ ❑ We area corporation and its 10-❑Electrical repairs or additions 3-M I.am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 1: Roof insurance d. I c.152,§1(4X and we have no employees-.f[No workers' . Other comp insurance required.] *Any appkaat that checks box#1 nest also fill out the section below showing their workers'compensation policy information- 1 Homeowners who submit this affidavit in&catmg they ate doing all work and then hue aatside contractors rnvst submit a nea,af&darst indicating such. =Contractors that check this boat must attached am additional sheet shovdag the name of the sub-contractors and state whether or not those Mies have employees. If the suh-contractors have Employees,they must provide their workers'camp.policy number- lain an euipinyer that is prmidbig workers'compensation insurance for my erntplgyees. Below is the polite roam job.site in rmaMon. 00 Insurance Company Dame_ Policy it or Self-ins-Lie..#: Expiration Date: Job Site Address: City/State/Zw: 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. � d do hereby cerhf,y under the pains and penaalties of pedupy that the injormadon jprotided n bcnre is true and correct Signature: .49Z Date: D CT Phone#l: �� �7--A,72-- r? q z OB &al aase only. Do not write in this area,Xv be completed by do,or toutut of ciaL City or Town: Permit/Lacense# 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#: PROPOSAL T T SAUNDERS& SONS ROOFING INC. 13$$ PROPOSAL NO. / t Company Owner On Every Job! 7— 1r R 6 SHEET NO. Accepting all Major Credit Cards 1-866-961-ROOF ' Owner:Bill Saunders Licensed& 1-508-765-0100 DATE Cell: 1-774-272-1798 � Free Estimates Insured. PROPOSAL SUBMITTED TO: Saunders& Sons Roofing INC. NANIE 53 Laurel Hill RoadvL Southbridge, MA 01550 ADDRESS i fS PRONE NO. We hereby propose to fumish tfie.alaterials and perform the labor necessary for the completion of f S t.. G T i.nre" a T f ! o v ill' oie o f % i! nog y e-&F i ND em f ✓ v r « ice �`e i0 G� 4— rio ti fJ r 9. C e 410 n- -loft AA OA, 313146 All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work, and completed in a substantial workmanlike manner for the sum of s e yet— 'r-"a it *A"o rf/t 11 a.aa Dollars with payments to be made as follows: $ o u ccM4.� e T i Q A. Respectfully submitted 4�'V 19 E'ZJr Any alteration or deviation from above specifications involving extra costs will be executed only upon written order,and will become an extra charge Per _ WUH/0 ��� ,Y f0/✓r) over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control: Note - This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. -- I Signature, Date �' 4 f� ) [ Signature -.V FROM Mcilrmth I rtaan'msco <FRt)AUQ SO 2011 75:40ZST.16:421No.7V20O224TT P 7 U 6 1(Li"� tc� / ! r t 18 E ICA IS ISSUED A8 A NIA MINFOMMETION ONLY AND ON ERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN E MING INSURER& ORIZED REPRESENTATIVE OR PRODUCER,AND THE CER FICATE HOLDER MPORTANT: If the Cie holftr Is an ADDITIONAL INSURM,the poticlrtIn)must be and. If 8 BROGAMON 8 WAIVED.subject to the Wm and Coro of the policy,cerbdn poWn mir requhr grid endomment. A ebumwd this cedftab does not confer to the cite hoWer In Mu of ouch wAws want PRODUCER N oroth Irewerwe group Inc. 258 Mein SbW PO BOX 1220 Sturbrde,MA law COMPANI0 AFFORDING SCE INSURED COMPANY A GRANITE STATE INSURANCE COMPANY Sounders S Son RonflnS,Inc 53 Laurel HNI Rd Soudbogs,MA 01&04wl TH818 TO COMFY TWIT THE POUCM OF MtJ11 MCE LISTED BELOW MATE BEEIi N91!®TO THE WLIRED NAMED ABOVE FOR THE POLICY PERIOD MCATED.NOT WTTNSTAMNB AW RMUIR>MENT,TERM!OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHgiTHS C 94CATE MAY 8E MUED OR MAY PE tAIN.TFE INEIAVIIVCE AFFOMM THE POLICIE8 DESCRIBED HMM 18 SLOJECT TO ALL THE TEdtK F IONN AM CONDMONB Of SUCH POLIGE59.LIMIBT8 SHOWN MAY MANE BEEN PACED BY PAID CLAIM& so L'M Mea oe FVA.W1pl�M POWWWWWOATA F9AT5WW11=WM oIMPtOWMLrmnrrY L PRlr4t8TWU ARTpnw4p <CYTn AM e+a o®aa a 1261676 6J23I2011 QrMM12 LffaT Lam I CERTMATE HOLDER bANCELLATION 6MOUW AMYOP TMEASOVEDeMMW PM CM M WOi ng OWPATMNM'M7MMW.WMWUNCOMBINACCMANCE WRTHT?IHPOL CYPROVIIIM AUTHDFU®REPIMENTATIVE oFtNE r Town of Barnstable *Permit# Expires 6 months from i ate Regulatory Services Feed * sM WSrnaLe, 1639. ,0� Thomas F.Geiler,Director .DYED MA'I A Building Division. Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town..bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION . - RESIDENTIAL ONLY r r Not Valid without Red X-Press Imprint Map/parcel Number Q `t Property Address [?-}-Residential Value of Work L(d U u;, Minimum fee off$25.00 for work under$6000.00 Owner's Name&AddressLGl//,�/ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) RESS PERMIT ❑Workman's Compensation Insurance 9 Check one: ❑ I am a sole proprietor JAN 2 0 Zolo 0 I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE - Insurance Company Name Workman's Comp:Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Er Re-side #of doors ❑ Replacement Windows/doors/sliders.U=Value (maximum.44)#of windows *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: a < ' ,ZL Q:\WPFILESTORMS\building permit forms\EXPRESS.doc Revised 090809 r The Commonwealth of Allassachusetts Department of Industrial Accidents 11D� Office of Investigations I' 600 Washington Street Boston, MA 02111 Z ' wlvmmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: </Z Z zzz,/w /Xy ZVA a/,- z� City/State/Zip: Phone #: Are you an employer? Check 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 construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These stab-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t �equired.] 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 myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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: ZIA,1,09 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number an 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 under the pains andpenalties ofperjury that the information provided above is trice and correct. Signature: Date: C✓ Phone k 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,constriction 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-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 permitflicerrse 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 406 or 1-877-MASSAFE Fax # 617427-7749 Revised 4-24-07 www.mass.gov/dia of��>•� Town of Barnstable o Regulatory Services T saRNSrAsLE Thomas F. Geiler,Director aMss. 039. ,�� Building Division prED µAt 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 , �7/� r Please Print [DATE: ,/L�/I/ D L�l/d / JOB LOCATION: `74/ G-1��A Z/=7 . number street .ry /village "HOMEOWNER":294 - /lk L , GrZ '�� J,�i� 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,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. Signs re of omeowner 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 fornt/certification for use in your community. Q:\WPFILES\FORM S\homeex emptDOC �.r THE TOE, - - Town of Barnstable ti Regulatory Services BARNSrAB9 MAM Thomas F. Geiler,Director 3,9.� 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 i Property Owner ust Complete and Sign 's Section If UsingA ilder L V- /Z- , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work a orized by this b g permit application for. (Address of Job) Signature o Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERM1SSION fiuj V Ft� Town of Barnstable o r� do Regulatory Services Thomas F.Geiler,Director jam) BARNSTABLE, MASS. �0� Building Division AlED 39. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 f, www.town.barnstable.ma.us Ct"r. Office: 508-862-4038 Fax: 508-790-623( PERMIT# r�OD�o D�'?� FEE: $ SHED REGISTRATION 120 square feet or less 1� 1 a(� H t L ( /\JA,4 LA NC yy Location of shed(address) Village/ /A 13 C/C J,'I� 4 Property owner's name Telephone number a x Z a Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506 te•d �etol aa5©� z G I / I I',4T10 1 ` LOT 6 Z 1 ST'o R.Y G I Dw E I-L-.I 1J G C No 41 U' O! Z313 -f W D t 1}' Ilo.00' L__ \ , F tN O/ JOHN.S. LAUKTANI M 34311 _ 19��1tfS10'E` LOCATION OF BTRuts� BASED ON LINES of TION ` p ONLY, 1�GC tom' A ACCURATE LOCATION WREOUIRE AN INSiRUMENf WY. 13;110r' 04,i rxs I JOHN S LAIJIiETAN! saele: ��' A PROFESSIONAL LAND SURVEYOR, DO HEREBY CERTIFY THAT THE AMERICAN SURVEYING COMPANY ABOVE MORTGAGE INSPECTION 1264 Main Street,Waltham,MA 02451 (781)893-6477 PLA-EtN WAS PREPARED FOH PREPARED FOR INTEGRATED MORTGAGE SERVICES,INC. PLANN, WAS PREP ED F IN CONNECTION WITH ANEW MORTGAGE AND IS NOT INTENDED OR REPRE• MI ge Inspection Plan SENTEDTO BE ALANDOR PROPERTY �r ,1A7'./i�-iiyl 11 LINE SURVEY.NO CORNEAS WERE THE LOCATION OF THE RECORDED AT sl SET.IT CaNC1Qj BE USED FOR ES. DWELLING SHOWN HEREO BOOK. _PAGE Z COUNTY REGISTRY OF DEEDS TABLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH PLAN REFERENCE:-E-�•r� 1`; }pert.N- BUILDINGLINES.THEUWDASSHOWN APPLICABLE ZONING BYLA ORAWN PER TOWN OF HEREON IS BASED ON CLIENT FUR• FECT WHEN CONSTRUCTED MAP M qqqq 44 ASSESSOR'S VISHED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMADDRESS;41 L_II.Jp I�r I *1 DATED SUBJECT TO FURTHER OUT-SALES REOUIREMENTSONLY),OBI - L Al ti"'* ai _ c TAKINGS,EASEMENTSANORIGHTS OI° FROM VIOLATION ENFORCEMENT AC•BORROWER. IJ`•��WAY.NO RESPONSIBILITY IS EX. TION UNDER MASS.G.L.TITLEVII,CHAP. _ TENDED HEREINTOTHE LAND OWNER 40A• SEC. T, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE--X OR OCCUPANT,IT IS NOT INTENDED NOTED OR SHOWN HEREON.A CON-AS SHOWN ON NATIONAL FLOOD INSURANCE PROD FM LOOP TO BE RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED__�) �-Y 2 I�1 FL pare_I 1- Z4- IS ADVISED WHEN STRUCTURES ARE COMMUNITY PANEL F ..-,�---- CLIENT INKY-�+T� T� SHOWN TO BE 1'OR LESS FROM CLIENT REF.1 Soo 911 oC PROPERTY OR REQUIRED ZONING FIELDED Ar FTED CHECKED ,,._ -,c�. SFTRArw­ Av Tom, Town of Barnstable *Permit# 5 Z 6 Expires 6 months from issue date � Fee Regulatory Services ■ARNSfABLE. Rg Y v HAM Thomas F.Geiler,Director rf0 39. Building Division Elbert C Ulshoeffer,Jr. Building Commissioner y P E S S PERMIT .,-. 367 Main Street, Hyannis,MA 02601 w ^ . Office: 508-862-4038 MAY 9 2001 f,�n Fax: 508-790-6230 ��'U� EXPRESS PERMIT APPLICATION TOWN OF BARNSTABLE LL Not Valid without Red X-Press Imprint Map/parcel Number T� Property Address .Residential OR ❑Commercial Value of Work VV Owner's Name&Address S 'l ,�►•� /l 1,1'`1 4g al-4S Contractor ��� Telephone N umbero�/-7 Z 's Name Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑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# Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value 1%' 34 (maximum.44) 19t ;n Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Sig expmtrg n 1 Parcel Permit# Date Issued Fee Ste' ngineering Dept. (3rd floor) House# BARNSTABLE. MASS. - rf0 TOWN OF BARNSTABLE Building Permit Application Proj t Address L- I W Village C e—`vTC 2 vl c—4—e !� Owner Address '4 Z.67 c��v7�.evlL� Telephone Permit Request /2&— l2 G-v © k-e,t / z_ ,6t,, e 2 C b d First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential �- . Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Basement Type: Finished Historic House Unfinished Old King's Highway ,J Number of Baths oZ No.of Bedrooms o Total Room Count(not including baths) First Floor Heat Type and Fuel �2Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached j Barn None Sheds Other Builder Information Name F WK !�}l��S Telephone Number 7 7 S — -7 6/ 3 Address License# Home Improvement Contractor# --46 /O 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 DATE BUILDING PEWIT DENIED FOR THE FOLLOWING REASON(S) / r 1 FOR OFFICIAL USE ONLY D TE SUED G x AP 8 t FkAR EL NO. �I D VILLAGE - OWNS i yTa�c;'' , • i r , • • 1 I DATE.i F INSPECTION: - FOUNDATION r -. FRAME - F INSULATION k FIREPLACE r t ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL _ r GAS: ROUGH FINAL FINAL BUILDING _ { k r DATE CLOSED OUT ' ASSOCIATION PLAN NO. - i The Commonwealth of Afassachusetty '++71 i = Department of Industrial Accidents ; U _ __ office ofla►M99offons _>\ 6111) Washington Street ;X` Boston,Mass. 02111 Workers' Compensation_ Insurance.AMdavit _ .etjnl1 aint nt(WOin`n,- Plf'Ase PRiIVT, j ^� =� w,— name! !- ���✓� ��/�� Inr ion- ;sit)' nhone it —77 7 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. camlianx n•tmc• address: city: nhone#- insurance ce. policy# V. 1 am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: addresse Sit)';— nhone#: �nSurs�ner rn Deht!y# ��. ^sr.: ..,,. �. — �+snitr.-..4:..:.mss••e:rr,�^.,-'. T:�'�t.•''''7iF''�e+9�� 'TJCFS�•'�t%:wr: 7F•7.^�Sr"' ..�1U3?4�'r..�^.-"'�S �mpam•name: address: city nhone#: insurance co nolicy# :Attach additional'shect if necessary, ::,••:.:- •ram ;:_tom "!�:-`:, :" ��" Failure to secure coverage as required under Section 25A of 1%1GL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day apainst me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the D1A for coverage verification. I do herebr certif}•under the pains andZp ,,es ojperjurr that the information provided above is true and correct Signature Print name /�/��s1i'C // �ls Phone Jew otTicial use only do not write in this area to be completed by city or town official city or town: permit/license# rtlluilding Department (3trcensing Board, ` D check if immediate response is required (3Selectmen's Office C311caltb Department " contact person: phone#; nOther f (revised 3;95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an empinpee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. ,* An entplm/er is defined as an individual, partnership, association, corporation or other icgal entity, or any two or more of the fore-, 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 I'S2 section 25 also states that even•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 commun+i•calth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither tite 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. `:•».w77 *,r.!r.!Y'+�.,���I!w• _ :r'�::•e., ,.,il:. C; .-. 1 ....'M,-4.. �. 1...J. Ad ..+�1'�^M-^ Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits 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. ....:.... :. »i•�. - i:'7- 'T: COY. ' .•.. :�r•' �i.. ice .4i7il! �•• 1 •, ..« •`�raMr' Citv or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 fax#: (617) 727-7749 •. phone#: (617) 7274900 ext. 406, 409 or 375 i dr . '. : The Town of Barnstable Department of Health Safety and Environmental Services Building Division �a 367 Main Street,Hyannis MA 02601 Ralph Crosses Offx: 508-790-6227 Building Commis F= 508 775.33" For office use onlY Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PER&IIT APPLICATION MGL c 142A requires that the"reconstruction,alterations;renovation,repair;modemi=don,=nvernon, ccwl ed improvement,.mmcnmL demolition. or construction of an addition to nay pre �e�}� building containing at least one but not more than four dwelling units or to s uuctures to such residence or building be done by registered contractors,with=twin exceptions, along with other mquircmenm Type of Work: I�G� v v Est Cost/.S� — Address of Work: 4ZZL / `/111 Owner.Name: d1/t-le-141T /C,fv7c�{r Date of Permit Application:------" I herein-certify that: Registration is not required for the following rrason(s): Work caduded by law Job under S1,000 Building not owner-occupied Owner pulling own permit Notice is hereby gh=that: COrTiRAC MRS . ` OWNERS pULLIN 'THFiR OWN PROVEMEN'i' OW RKG DO NOWrM T THA ACCESS TO TIC FOR APPLICABLE ARETIRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PER,TURY I hcrcby apply for a permit as the agent of the owner: Registration No. D to Contractor name OR " - r -�► jx P E19Z0 ql� 4anum wa+r -' At =s STABQ I 1df1UTAI0NI - addl ZOStQI` do 4 slE9a ,,. .Jokusmo .1N3N3Aflb�WI 3WON .a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel � Permit# Health Division 3 —&a.3,ark �����o�� Date Issued fi goo Conservation Division W 131 Lm I --� 1 Fee 2S•dc� Tax Collector �/� P G'"( r /p �� ZIJI) tSTEW1 FuriU i• E= Treasurer _ .c t.� G���-�-' 1 1 IINSTALLED IN COMPLIANCZ WITH TITLE 5 Planning Dept. ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address �� 4//iVDI# �� V .Village /yA/. Owner J +�= I f f Address &A0 A L~� r, - Telephone Z ,q— S-9© (/ - on 77/—Dv zS— Permit Request /6 �N /4� ` Obit, �vnGz�G 1�a �1ss,.e A,w c/ WArAd o4�e_ A,=XV �� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Ar � Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family )f Two Family ❑ Multi-Family(#units) Age of Existing Structure �s Historic House: ❑Yes fXNo On Old King's Highway: ❑Yes ON Basement Type: XFull ❑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: �0 Gas ❑Oil ❑ Electric ❑Other Central Air: XYes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes )dNo *;r Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name— u'►,-ram Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE 6 3/� FOR OFFICIAL USE ONLY ,3 t PERMIT NO. ,r DATE ISSUED MAP/.PARCEL NO. ADDRESS ��:� -} ��' VILLAGE OWNER 1 OWNER DATE OF INSPECTION: o. 4 FOUNDATION FRAME f f INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' ~ PLUMBING: ROUGH FINAL ' = GAS: ROUGH FINAL FINAL BUILDING `_ &C92,4 - ° r. i DATE CLOSED OUT ASSOCIATION PLAN NO. '' T0•d -blQi I, L G { 1 L-C)T- 6 3 tat LOT(Z ~• LCI 9 4J I I �T oR.Y CI DWELL-I0(i 01 Na• 41 U I Z31t 'I O 1 1 I I O.Op' a �M of JOHN S. LAURETANI 11134311 \ SSI00 'r0 SUtI`1 LOCATION OF STRUCTUREIS) u p BASED ON LINES Mum ONLY. EQUIREANNJ RUE LOCATION MM SURVEY. '. I JOHN S LAURETANI sale: DO PROFESSIONAL CERT FDY THAT THE AMERICAN SURVEYING COMPANY ABOVE MORTGAGE INSPECTION 1264 Main Street,WaBham,MA 02451 (781)893-6477 PLAN WA9 PREPAR D FqR PREPARED FOR INTEGRATED MORTGAGE SERVICES.INC. Ewr TMre. G�oR tt CONNECTION WITH ANEW MORTGAGE AND IS NOT INTENDED OR REPRE• Mortgage Inspection Plan SENTED TO BEA LAND OR PROPERTY 27 �7 a LINE SURVEY.NO CORNERS WERE THE LOCATION OF THE OR pECORDEO AT SET.IT CAUNUI BE USED FOR es. DWELLING SHOWN HEREON EITHER BOOK_q� ? PAGE STZ Cr CO.16 REGISTRY OF DEEDS TABLISHINO FENCE, HEDGE OH WAS IN COMPLIANCE WITH THELOCAL PLAN REFERENCE: '��• Ic�i�_P,S�•BUILDING LINES.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF-DRAWN PER TOWN OF HEREON IS BASED ON CLIENT FUR. FECT WHEN CONSTRUCTED WITH FIE-MAP• P CEL N ASSESSOR'S VISHED INFORMATION AND MAY EL SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: DATED SUBJECT TO FURTHER OUT-SALES, REOUIREMENTSONLV),OR IS EXEMPT FjAi IJ>*p� I.l,Y BL.I vi TAKINGS,EASEMENTSANDRIGHTSOI' FROM VIOLATION ENFORCEMENT At;.BORROWER 1 ." a« 'N P_i,Kptil g.f AY.NO RESPONSIBILITY IS EX. TION UNDER MASS.G.L.TITLE VII,CHAP. _ FENDED HEREIN TO THE LAND OWNER 40A• SEC. 7, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE OR OCCUPANT,IT IS NOT INTENDED NOTED OR SHOWN HEREON.A CON.AS SHOWN ON NATIONAL FLOOD IN TO BE RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED__,�vR`NCE PROOF FLOOD GATE � Z ' IS AOVISED WHEN STRUCTURES ARE COMMUNITY_.PANEL N la 1C CLIENT Ir.TI`�GR `T->r SHOWN TO BE 1.OR LESS FROM CLl!NTREF.N Soo 911 olq.A PROPERTY OR REQUIpED ZONING FIELDE DRAFTED CHErKFn in, II�r, SFTAArK I IHF4 nV T�!•M�_ •- '-1 F i 1 t 1� w sue- --ke ,41,zA-Q Pis �8 �g ff I 1 I I Fi- . � � �.., I f , ; �1� A' r . � � / �T� � 5� a�� __ _. . _ _.__._. SJ�� , � f I �-, k I �, \\.. 4 �l� rf►. f I . --- i ��__ ��� x�o Zed,&1, � ��� .� 74 /4, s X® ell sit/ csr�fri GuG 170 r A',e- ,ileA.9 Get ee,/mS l� l i . � i ��N _ , 5'� � i s� /, .—� Zx'° - --- � �- � � �---- � i � ,, I • g Regulatory Services ,, i0'�' •' Thomas F. Geiler,Director Building Division Commissioner _ Elbert UIshoeffer, Building . 367 Main Stress.Hyannis MA 02601. Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AHIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ns.re:novadon.repair.modernization.conversion. Mo.c. 142A requires that the_reconstruction. alteratio -occu ed improvement,removal,demolition.or construction of an addition m any pre-existing owcch Pc agent to on building containing at least e but not mme than four dwelling emits or to structures which are adjacent such residence or building be done by registered ,with certain exceptions.along with other requirements. r Cost=®® Type of Work. �� Address of work All Z'aIdo o li. &Y=^ — Owner's Name: �/o�y f � •�— f'�Z[yiyS,�ll Date of Application• 113 0/ I hereby=M)r that Registration is not required for the following reason(s): OWork excluded by law []Job Under$1,000. [--]Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WORK TH R DO NOTE HAVE FOR APPLICABLE HOME ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. e SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Contractor Name Registration No. Dace i OR "131 Owner's Date e q:fomis:Affidav —j - Department of Industrial Accidents • � --- ,N._-�• Olr/COOI/a�'Sl/081/OOS _ 600 Washington St reet l - - Boston,Mass 02111 Workers' CymeniatdionLm�mrance Amfirlidavvit / name: J9 h V j,"t/3��/ location G•iv�A ci t5hone t,I 2 44 I am a damcowner performing all work myself 5�ik, ZS- ❑ I am a sole Proprietor and have no one working in aav ' on thus 'ob I am as 1 providing workers compensation for say employees worlang : em.. .Pr.............. . .........:::::.::::::.::::::::..:.........,.r.,.::.:::::::::::::::.::.:::..........::::;::::::;:;:::::::.::. :.::..:.:..::.......::::::.:::::.:::::::..:.:.::::::::::.:::::.;;;:.::;:.;: ❑....................::::::::::::.::..............:.::::::..::::.:::::.:.........................::.: m sn ;name:.:. x:::;: ::_......... ...............:..:......y. ::::::::::::.::...........................,.:::.:r:::::.::: ............ ............. ........................... ....... . ..... {. .. �.. .::�:}}±}i±:::?isv±:L:v:4ii};}}}±:•::4:?•:?:.::':ii::<)::::iy};i:::,::;::•4::vi:::;::;i{:Zvi::i;•.;is:#;:i;:i;:y;<.!;.`::•:}v{;.:}iY�i?ii::#�:,vv-:?iiri?iii?:fii`:vt'y.: { ❑ I am a sole proprietor,general contracto or homeowner(Rrc on and have hired the contractors listed below whc have :c::u:.:m......a...n..following n..11.a.. omwe r�.n ..::: iiwo.rke.:.r:sthe .. co ...en.s..a.:id ..,...o...n .....oh: ::i.::•'...!:.::.i:.s:.:.#.:i..::.S.:.::.:::.::.• i ` ;..` .........?: {i{ # s:i%. ; ii ?:v:::• ..•:±::?:•:<:::vv;?%,?::>:.i:{:?::.::}.T�i{:;•}:?:{?•?}.x}:{;{:4.:>:i}}}::{:^.:±::,.?::::;:?,i,^�:::i:}:v.::v::i.:.•..v.w....±.:.•:.:..v.:.:.:.:..v.,.:.......,..:....:.. ... ...... .......... .................. ....v....r. .. n....... .rvM r h x:.;•.}j;::xv::x:::::{{L:•}:ti'{r:::::w.y:::w:::•:'vr:ram:•}'•::::::::i�:::::::::: .......... .............. .................... ................... .v.......4..}.... .......... 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' ............ .............. .................. .............................::............................:w:::.v:•••::nv:n w:::nv ivx•±.w.:�:•h::•.v-.xi;.;::±±!Cn.,x?.__�: v iw.,,•nv.:vv:::. n,•,h•y:,y:}±:±:}:::is •v........ ...:•....v......rw.{.vx::.........................:•::...................:•:v•:r t:........}:,: v....,y., r.M1i, - v .... tn............... .......................... .......v.......... ..v.n.t.....h...n.hkrnv.... .....:.v;,Q:#Svh?:.x{•}. 'f tJ.:nv.:•:::;,v:.v::;:......... ......... ::::..;.::.::............::.::w:?±:{v:N.•nv.::.:::::n::w:.v::::x::•......,...............v. .......r........... .. :::{n:?^}}:-±>±ii}:?;•±±±±i:•}iii;+�.��:•::::•::�:::::�:::::�.�:::::�::v:: glare to seems coverage as required under section 25A of MGL 152 cm lad to the of cdmiml pin of a Sae up to s1,.Nmuu and/or one yem,imprisomnent as wen as dvii penalties in the form of a STOP WORK ORDER and a Sae of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Osrce of Iavestigatiom of the DU for coverage vaisatlon. I do hereby certify raider the pains and penalties of pe*q that tier infomta ion p►oWded above is ou,la,,dco ed -�- Date 5rgmild _. � ) Phone# Pont name oi'dcid we only do not write in this area to be completed by city or town omeiai city or town: pemdi/llwme,# • ❑Bnflding DeparmIld Bo ❑ucemmii [3sdeconen's Office (3 checkif lmmedLte response is required QgeaM Department contact person: phone O' — Other Uvvaed 9l9S PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation`for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any cow 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 c the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receive: '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 building appurtenant thereto shall not because of such employment be deemed to be an employer. MG L chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or rene- of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who E not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until of this have been resented to the pant-acting- authority. acceptable evidence of compliance with the insurance requirements chapter P authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and 41. supplying company names,address and phone numbers along with a certificate of mm=ce as all affidavits may be submitted to the Department of Industrial Accidents for confrmatiom 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 re being requested,not the Department of Industrial Accidents. Should You have any questions gardug the"law"or if yc are required to obtain a workers' compensation policy,please call the Department at the number listed below. oll City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of tl affidavit for you to fill art in the event the Office of Iavestigatims has to contact you regarding the applicant. Please be sure to fill in the peimit/licease number which will be used as a reference number. The affidavits may be retained to the Department bymail or FAX unless other arrangements have been made. The Office of Investigations would Me to thank you in advance for you 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 Invesdoadons 600 Washington Street Boston,Ma. Mill fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 " The Town of Barnstable t�srvsrwet.r; Regulatory Services Thomas F. Geller, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-7 90-6_:0 HOMEOWNER LICENSE EXErvIPTION Please Print DATE: JOB LOCATION: number street , villa-e ,.HOMEOWNER": _)/U,c &, eL//s�S,�b 6/� ��y'5106 6 name / home phone#AA5DO ork p hone# CURRENT MAILING ADDRESS: #f.s A41, '%L /jA6wk,.j /N<s 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 buildine,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. •5 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 1 o9.1.1-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 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 care t amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMM