HomeMy WebLinkAbout0006 MARYALICE LANEFM
Engineering Dept. (3rd floor) Map Parcel -, d•3 `_ : Permit#
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House# Date Issued
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Board of Health(3rd floor)(8:15'`9:30/1:00-4-M)Gl f ��i �e C�
Conservation Office(4th floor)(8:30-9:30/1:00;,2:00) G��, .
PlanningDept.(1st floor/School Admin. Bldg.) BIKE
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n Approved by Planning Board 19 SEPTIC SYSTEM M
INSTALLED IN COM
T 4 T@�TITLE 5
TOWN OF BARN m p�
ai9`4':1,4� C1,00E AND
Building Permit Application
lV �T � / L—1 G,:!�- L
Village G Owner F Address _ R �✓��I G L� �"� `
Telephone 76 S
-Permit Request ,� =
First Floor square feet Second Floor square feet
Construction Type ��Y(2�,e "
Estimated Project Cost $
Zoning District 1 Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure j Historic House ❑Yes [ 10 On Old King's Highway ❑Yes ❑No
Basement Type: �kull ❑Crawl ❑Walkout ❑Other \
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing YNew J iyl"
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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
it ❑None ❑Shed(size)
a ❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name Telephone Number
Address License#
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 DATE
BUILDING PERMIT NIED FOR THE FOLLOWING REASON(S)
n FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
i t•
OWNER -
h r- - 3 • b y S., i f � Y , . l 1 `+ � 1 ' � R . q F`e`,4
DATE OF.'INSPECTION: 14
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROU_(V r= FINAL
•may +
PLUMBING: RO�[JG"H "y FINAL t ,
GAS: ROUGH r._ FINAL
FINAL BUILDING '
DATE'CLOSED OUT
ASSOCIATION PLAN NO. "
, F "
�' SIDEWALLING
If located in OKH or Hyannis Historic District- Certificate of Appropriateness
required unless same color/same materials specified on application.
Sign-offs fro
Health
Tax Collectors' Office
Treasurer
Owner's name & address
Estimated Cost
Complete dwelling Information for the Assessor's dept.
.orrect square footage OR number of squares of shingles(times 100 sq.ft.)
Applicant's telephone number
;/"Signature
Workman's Comp. form
Home Improvement Contractor Affidavit
Home Improvement Specialist's License OR Homeowner's License Exemption
;-'<ee
q-forms-PERMITS 1
Rev 6/2/98
The Commonwealth of Massachusetts
Department of Industrial Accidents
t Office ofIfl estigatfons
- � 600 Washington Street
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
��nam,
location:
city `—
c:2rT—am a homeowner rforming all work myself.
0 I am a sole pro rietor and have no one workin in any ca acity
%/ %%%//%%//%%//%////%///%%/%//%%//%%/%%%%%%%%/%%%%%////%%%//////%//%%/%%/%%/%/%/%%%/%%%//%%%%%%%%%%%%%%%/%%%%�%%%///�%%%%�%/%/%/%//%/%///,
❑ I am an employer providing workers' compensation for my employees working on this job.
comaanv name
....
address.
city. phone#.
insurance co. VoWV#
❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
Company name'
address. -
city ph one:#.
insurance ca
oLcv#
comaanv name
address.
phone#.
::.: .:.:..
insurance co. olicv# : i 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
one 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. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature t/ Date _
Print name /" L U Phone#
official use only do not write in this area to be completed by city or town official
city or town: permittlicense# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑health Department
contact person: phone#; ❑Other
(revised 9/95 PJA)
r
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 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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance 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`Uw"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City 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 io
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 invesugatlons
600 Washington Street
Boston;Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
ri
The Town of Barnstable
Department of Health Safety and Environmental Services
BuiIding Division
367 Main Street,Hyannis MA 02601
Office: 509-790-6227 Ralph Crossen
Fax: 508-790-6230 BuiIding Commission:
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization.
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: r'. S Est.Cost
Address of Work: (n Koos l eL/ G�- 14
Owner's Name
Date of Permit Application: —2 / ;FV
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
�r pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE H051E IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner-
Date Contractor'Name Registration No.
OR
Date Owners Name
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE /
JOB. LOCATION C
Number Street address Section of town
"HOMEOWNER" -
Name Home phone Work phone - -
PRESENT 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 such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNERS
Person(sy who owns a parcel of land on which he/she resides or intends to re-
side, 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 Officia
on a form acceptable to the Building Official, that he/she shall be resnonsibl
for all such work performed under the building permit. (Section 109.1.1)
The undersigned "homeowner" assumes . responsibility for compliance with the Sta-
Building Code aad other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands ..the To of
�me-�t minirrnrn inspection procedures and requirewnments
Barnstable Building Depart
and that he/she will comp],y with ¢aid procedure-* and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
HOME OWNER'S EXEMPTION ,
The code state that: "Any Home Owner performing work for which a building
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licens
ing of Construction Supervisors) ; provided that if
Home Owner engages a person(s)
P ( ) for hire to do such work, that such Home Owne
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the responsibilities of a P supervisor (see Appendix Or Rules and Regulations
for . licensing Construction Supervisors, Section 2.15) . This lack of awarene,
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home "Owner-' acti:
as supervisor is ultimately responsible.
J
To ensure that the Home Owner is- fully aware of his/Eer responsibilities, ma:
communities require, as part of the permit application, that the Home Owner
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 to amend and adopt such a form/certification for use in your community.
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