Loading...
HomeMy WebLinkAbout0569 MAIN STREET (HYANNIS) (22) ✓may AWIIJ ST , Sf trr: ?- APPLICANT INFORMATION (BUII DER OWHOMEOWNER) e�706 � 6 N�umb`_e��d 7 71'11�6Na-e Telephone - ms �Addr —� IOX 3 Y� c�LicenseT#—��s- q/G� Sara/ 77`1/ zz ri. Home Improvement Contractor# ` Worker's Compensation # ` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 0 z SlGN-ATl1RE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map j 0 r Parcel, -.Application # m76 Health Division Date Issued Conservation Division Appilibatio'n,Fee 'Planning Dept: Permit Fee' Date Definitive Plan Approved by Planning Board�Xk C Historic ' OKH Preservation Hyannis 'Project Street Address � Village J y6F,0 ,17 .7 /VaAll g�le2!� Owner Ad ess S­Z;�f Telephone d-Dlx - 2 Z Permit Request cV 1&7.1 A-C_ IV C/ 2!�Z Square feet: 1st floor: existing_;Z.-_proposed '2nd floor: existing proposed Total new Zoning District' Flood Plain Groundwater Overlay Project Valuation -)a. go Construction Type Lot Size Grandfathered: LJ Yes U No If yes, attach supporting documentation. Dwelling Type: Single Family LJ Two Family L3 Multi-Family units) Age of Existing Structure Historic House:. LJ Yes Multi-Family On Old King's Highway: LJ Yes 4401*1 Basement Type: Ll Full LJ Crawl L3 Walkout U Other Basement Finished Area(sq.ft.)- ,Vo�c- Basement Unfinished Area(sq.ft) Number of Baths: Full: existing e7l new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing ZO new First Floor Room Count Heat Type and Fuel: O/Gas LJ Oil L) Electric LJ Other %Jn 4.i Central Air: U/Yes LJ No Fireplaces: Existing New Existing wood/Zblal stove-0 Ll Yes W< Detached garage: L]existing L] new size Pool: LJ existing LJ new size Barn: L3 60fisting 9;newosize Attached garage: LJ existing L3 new size —Shed: Ll existing U new size Other: > CO Zoning Board of Appeals Authorization LJ Appeal # Recorded LJ crt Commercial ®"Yes Q No If yes, site plan review# Current Use S_e7,w. e- Proposed Use Qm e- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name IVC/1;7 e� 11l"o4S S-0 C' • e- 46lephone Number -OF- 77 =ZICZ6 ,!Address 5'69 ea4z License# Home Improvement.Contractor# vk J Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO c- SIGNATURE YZI1,,t22 DATE 7r 7- 0 ' FOR OFFICIAL USE ONLY t ."a s 1-3 APPLICATION# `r DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE ,;OWNER DATE OF INSPECTION: FOUNDATION ill FRAME; INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL T FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 7 i r The Commonwealth of Massachusetts Department of Industrial Accidents j 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): �l//7L' Y z vez l,7S-0-1 �aadress' io .�x �y� r—City/State/Zip: g Do7G o/ Phone#: —45,F' 7 7/- 179 Z3 Are you an employer?eheck the appropriate bo Type of project(required): 1.❑ I am a employer with . am a general contractor and I * have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). - 2.❑ 1 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 me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. ' right of exemption per MGL Y �o workers comp. 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then 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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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 he eby certift under the pains angpenaltir of perjury that the information provided above is true and correct Si nature: O - �.. Date: �` 7 � Ph17 one#: �G 7 / Official use only. Do not write in this area, to be completed by city or town official 7 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 r 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-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 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia I - 'ix- achusetts-Department rd Pubfic� :, F Board of Building Re-ulationx and' ards Construction Supervisor License license: CS 9102 Restricted to 00 j " r 5. ly NANCY L . 3FiN3O1!� PO BOX 342 �i HYANNIS, AAi , 1 Expiration_ ammo C'risw.a�rr.' Tr#. 26306 APR, 9. 2009 . 33PN t BCC T !& 6972 P, 2/2 t FRCE OF THE SHERIFF BARNSTABLE COUNTY The Cm=omeakh of Massa6meeas 6000 Sheriff's Place,Bourne,NIA 02353 $09563.4300 1:ax:508,553.4574 8CS0@bsheriff net INTER NROt 5S1®tlNtl des IL amft TUMCam! RK Bwnatable April 9, 2009 County Coacctionad , F4c lit' To Wbom It May Concern: 508.563.4300 Bureau of' I have been asked to provide a letter regarding,workers compensation coverage for 1n1��ns inmates in the custody of the Barnstable County Sheriffs Office for constructing a 509.375.6125 handicap access ramp and other items at.the veterans' center on Street in Hvalanis. Civil Proccss 503.362.9578 These inmates are not paid wages for the services that they perform. They are Communie46ow providing a community service. They are not employees as a matter of 508.375,6111 'Massachusetts law, They are not covered by Workers Compensation insurance nor C:au-ity are they eligible to receive such, Corrections 508375,6230 The Sheriff's Office itself is self insured for its employees,the Community Service 'y Officers, for Workers Compensation purposes. Wherefore,the Sheriff s Office does house 508.375.6230 not maintain a Workers Compensation insurance policy. 508-56 .406 If you have an questions you may contact me. at r50S 563-�4311. sos.563.444a Y �'q' Y Y � P� ea�e Yours truly, --- 508.375.6232 Technical Division 50R.3?5.6iQ$ TAD Ma hew I Murphy 508-563.4349 General Counsel Youth.PAnch Barnstable County Sheriffs Office 308,373,6120 BARNSTABLE-BOURNE-BREWSTER-CHATHAM-DENrNIS-EASTRAM-FALMOUTH-HARWICI I MASI-IPEE-ORLEANS-PROVIINICETOWN-SANDWICH-TRURO-WELLF L,EET-yARMOITTH I , tTti Town of Barnstable Regulatory Services BAR9 'S. Thomas F.Geiler,Director EoygL 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section, If Using A Builder I, -a s,•Ss. 674^r ��. , as Owner of the subject property hereby authorize����� �. Vp�r�Soy to act on my behalf, in all matters relative to work authorized by this building permit application for. ,Lg'4� Oi S� T! G• moo?G u f (Address of J ) ignature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RMS:0wNEUERMISSION Town of Barnstable M'�P�of tNE Tp�y� Regulatory Services uxl�srwsr.E Thomas F.Geiler,Director MASH - �'PrEo; ''•e Building Division Tom Perry,Building Commissioner _..... .____.. ... ._... ._ ._...200 Main-Street,—Hyammis,MA 026-01 _. .._........ _.._. . .. _._.......... wwFv.town.b arnstable-ma.us Office: 50 8-962-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAU-ING ADDRESS: cityhown 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 s6uctures accessory to such use and/or farm structur6s. A person who constructs more than one home in a two-year period shall not be considered a homeowmer. 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,ruffles and regulations. The undersigned.."homeownee'certifies that he/she understands the Tpwn of Barxtstable,Buuilding Beparhnent 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 ID9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such wort,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 pmum In this case,our Board carmot 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 hiArr nesponsnbilities,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 farm currently used by several towns. You may care t amend and adopt such a fomnIcertification for use in your community. Q:fbnT s:homecxempt 1 g000"x i 1 � . D j. ,d y D� OV w aly �I '