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HomeMy WebLinkAbout0140 MITCHELL'S WAY / 6 _ 90 64 L� - 172 3.5 -- - 7 3.3 31.1, ` 21. El i \ ' 1�29. l 3.7 �34.6 1 31.7 ' 30.9' 1 32.1// ,�� } 3.1 X 31.0 ' 3 i 4- 2 !7A-- 1 _ - -- - `>/28.5 1 30 ' 31.2 �, ,tines sh.;Wn on ftfm puin — - , 7 2 Prow_-t� - r 28<5 <:ss°�ss. ., pu��ses only .:. 1 X 29. 154 dcj nct rep ;sent aryual / —./ -- s�ca'objects ) relationships to P Y , 15 3 / = 16.1 28.�\ i<28.0 ��. . Engineering Dept. (3rd floor) Map L9 Parcel Permit# // -- - House# �ld Date Issued ',2/ 9 b "Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Feeoas1 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) zg 5Eppc ,. a ENS TALLE ! � TOWN OF BARNSTABLE )Building Permit Application Pro'ect�- eet Address J r Village /� Owner 1?— Address 11(,O s J ,Telephone a 6 Permit Request /0c.c_ / 'Trl / rc First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ U Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No.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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑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# O 6-0-Q e9/ (I AIT7 /1 c_C cs' 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 CONSTRUCTIO IS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4/1 SIGNATURE DATE _ 9�9 BUILDING PERMIT DENIED FOR THE FOL OWING REASON(S) EVE , . The Town of Barnstable • a�►axsrnst� Department of Health Safety and Environmental Services F0 61 Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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, long with other requirements. Type of Work: '5st.Cost Address of Work: Owner's Name Z2 Date of Permit Application: S I hereby certify that: Registration is not required for the following reason(s): Work 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 WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MTROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby ply f r a permit as the agent of r: �� ,6 Dat Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Atassachusetts Department of Industrial Accidents It l oficeolioyestigations 600 11 ashington Street Boston.Maas 02111 Workers' Compensation Insurance Affidavit �ppicant_formation• �• - Please PRINTIeb�(L name• loc•ttion• city rhone f1 rJ I am a homeowner performing all work myself. a1 am a sole proprietor and have no one working.; in any capacity ra:::�r;^�•..-.—..•-..1.+.,r ,EeT-^•7FaararTr.i.�IF,.'s�.7...�s„m!. ,r•_ - - +..^.�.+:nr•-.,,.�r-•-....c.[,e-�--.�rs.�. I am an employer providing workers' compensation for my employees working on this job. company name- address: city: phnne#• insurance co volicy# 1 am a sole propri r, beneral contractor, homeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: com any name• �- address• ,53 r Ch. phone#• insurance c , lice # O� �- .. .. _- +.rs1,:: •ot_ :'•T'c�', F^.,"RT _"--"''°" . -TJ!;r.c-.w-:o6..sf:_.- --- :...•--?'.•`• ^A;-+^'�•-'r•-•—z- ._....-_...__._ice.. ....�L- ♦Y• -.'�.- - - - - �:.��r•'.�. Lii�..•i compnrn•name: address- phone#- insur•nce co nolicv# :Attach additional sheet if necessa�y,.�:� w�_:'" '. s,�r:.`t,: ;,;,.r`_.:1 ....,:•.�..•..�•.•-°`'.,."`"., — _`•_s': �"•�;y..r::,a: Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andiur one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be fonvarded to the OILce of Investigations of the DIA for coverage verification. 1 do herehr certi. rurder the pains and penalties of perjun•that the information provided above is true rd", ect, Sienature Date zl Print name Phone# ,. a�ofticial use unly do not write in this area to be completed by city or town official city or town: permittlicense# rilluiiding Department ❑Licensing Hoard ❑check if immediate response is required ❑ SClectmen's+Office ❑Ilcalth Department contact person: phone#: nOther Irmsed 3l95 P1A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers* compensation for their employees. As quoted from the "lacy", an enrpl({pee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An einph rer is defined as an individual, partnership, association. corporation or other legal entity, or any two or more : 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 dwclling house of another who employs persons to do maintenance , construction or repair work on such dwelling hous or on the `,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section '-5 also states that even,state or local licensing agency shall withhold the issuance or reneival of a license or permit to operate a business or to construct buiidinbs in the commonwealth for any applicant who leas not produced acceptable evidence of compliance with the insurance coverage required. Additionallv, 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 ha• 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 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. Tile 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. City or•rowns 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. Pleas 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 liesitate to give us a call. Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 NVashington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 • .. _ ., w>.,. _Stu �:,,...., �:. _ T i r - I-A lie • t ` CI 1 • ^- : - ` � r ,,.,3,tq, ` -`��f ��� yam' e.�� ,�,�.. �'1,m�"E!-('•~-_,_ -d �`—f�_` y R e•. f , ..� :: J.JP;: CU 3 ISSUE DATE (MM/DDNY) ..-........ CAT 0V INSU ,ANCE : 10 27 95 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, RYDEN & SULL I VAN INS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 8 FALMOUTH ROAD COMPANIES AFFORDING COVERAGE YANNIS MA 02601 COMPANY A TRAVELERS INSURANCE CO CO LETTER COMPANY B EASTERN CASUALTY INS CO INSURED LETTER ROFESSIONAL BUILDING COMPANY C D REMODELING LETTER OBERT MITCHELL COMPANY D 3 SUNSET LANE LETTER STERVILLE, MA 02655 COMPANY E LETTER IOVERrtGES .: .... 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. CO POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER LIMITS TR DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY 6 8 0 3 6 4 K 6 0 41 TR I 0 5/2 0/9 5 0 5/2 0/9 6 GENERAL AGGREGATE $ 2, 000, 000 COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 2 0 0 O 000 CLAIMS MADE OCCUR. PERSONAL&ADV.INJURY $ 1 000, 000 OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ 1 O 0 O 000 FIRE DAMAGE(Any one fire) $ 50, 000 MED.EXP.(Any one person) $ 5 000 AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS - BODILY INJURY [,NON-OWNED AUTOS (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ ....................................................................................... ........................................................................................ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION WCP 0 0 0 2 511 0 9/21/9 5 0 9/2 1/9 6 STATUTORY LIMITS .. : :a z EACH ACCIDENT' $ 100, 00c AND DISEASE-POLICY LIMIT $ 500, 00 EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE $ 100 0 O OTILPROPERTY 680364K6041TRI 05/20/95 05/20/96 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS ORKERS COMPENSATION POLICY - STATE OF MASSACHUSETTS ONLY CERTIFICATE HQLDER CANI,I ATUN _.. _. _. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO NAM VETS ASSOCIATION M11( DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE ATT: CHARLE S BROWN LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 565 MAIN STREET LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. HYANN I S MA 02601 AUTHOPZED sA1 ATIVEt � INRT 199255(70 ISR t THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA ri h_ fie �arvinaauuea� a��aaaac/uc�et�i DBPARMIT Of PUBLIC SAFETY CORSTRUCTIOR SUPERVISOR LICERSE Ruiber: Eapiresc. Birthdate: _ CS 050051, 03/08/1998 03/08/1946 Restricted To: 00 ROBERT I KITCHELL 452 STRAWBERRY BILL RD CENTERVILLE, MA 02632 :y s Restricted To: Of , :, •+ Of - None 1A - Masonry only iG - 1 & 1 Family Moles Failure to possess a current edition of the Massachusetts State Wilding Code is cause for,revocation, of this license. i�t { y' l $ v f lBuilding Town of Barnstable [I: ELA Post This Card So That itis:Visible From the Street=Approved Plans Must be Retained on Job and this Card Must be Kept - wST �� $`s�� ' Posted.Until Final Inspection Has Been Made. Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Perm.11. Permit No. B-17-3706 Applicant Name: VIE1RA, RENATA Approvals Dat6Issued: 11/06/2017 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 05/06/2018 Foundation: Location: 140 MITCHELL'S WAY, HYANNIS Map/Lot: 290-068 Zoning District: RB . Sheathing: Owner on Record: VIEIRA, RENATA Contractor..Name: Framing: 1 Address: 140 MITCHELL'S'WAY Contractor License: 2 HYANNIS, MA 02601 Est."Project Cost: $ 1,200.00 Chimney: Description: Two windows on second floor Permit Fee: $85.00 Insulation: Fee Paid: $85.00 Project Review Req: BAY WINDOWS Date: 11/6/2017 Final: r y ._..... Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. . Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the.local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough:, 2.Sheathing Inspection 3.All Fireplaces.must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting.with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: . All Permit Cards are the.property of the APPLICANT-ISSUED RECIPIENT . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V Parcel V Application # '��J �DV Health Division Date Issued Conservation Division Application Fee GG{{ h Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/ Hyannis Project Street Address NO M/ k Lu ak Village f?✓l 1 a - /� Owner Address ®1/V : hell 5 W ca�- Telephone 02-3 Y3 Yf0 13 Permit Request iu)d C0 ►1 Cie) Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1' � Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. 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 Su Central Air: ❑Yes ❑ No Fireplaces: Existing New nA. Exis AeXood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existin new ?0�jBarn: ❑ existing ❑ new sizegr Attached garage: ❑ existing ❑ new size Shed: ❑ existing J neW Other: 9 g 9 — 9 l� Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR OR HOMEOWNER) Name VOI� l� rG��� Telephone Number P13 �--2,65 Address ��1� /4 4C 6 6 t(S f tJ C�V License # Home Improvement Contractor# Email 0 ' �� � C©�"'1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE - DATE ® 6 �� z. FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ` ADDRESS VILLAGE �.` OWNER 1� DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Con=07tirm, tit op ussadrusetts Departineut gfrurizuhiatAccidents ` _ 600 Washutgtoti Slireet Boston,CIA 02112 • tVF{�'b:TItaSF_�f3P�[1�ltl . Wm-ke& CamTensafetrn Insn-mce Affidavit$.mlderm/Crmtradurs/E ech icians(Phmibers AppUcant Iuformafikn Please Print �xI Na1ne(IIt��ssf�ig+nn+t,onlFu�v�al� �lb (® �i",�' Z. - e tam n� aY3 AU 63 Are you an employer Checkthe appropriate boo.. ' Type of project(req ed}= L❑ I am a employer 1 wit5. 4_ ❑I am a general coafcactor and I ti New eonsizuction. employees(fall andforpart-time * lmvelured.the sub-coatmcf= 2. I am a sole prupiieta r or gartaer- Tisted"the,attached sheet. L_.El Remodeling slip and have no employees These sub-confractors have g-,0 Demolition working fore in any capacity: employees andhace wogs' INQ� , romp_r�nrmce comp.m¢vx cel �. Building addition. rezluired-] 5. ❑ We area corpormfian and its- IOL❑Eleetrcal repairs or additions officen have exercised -3_�] I am a fiomeavmer doing alb work Ito Plumtriugrepairs or ad�ons• set€ o work.nm tight of exemption per MGL ' F 17 0 Roofrepaim ine c.152'§1(4kandwe have no triamre i2L�II1fSd�[ 13.❑other ' employees_I1•a wormers' coma_inmum-m required) •6nyagpficrsCB�atchedaboafflmwtalsnfalo ttheswfimberawshaveagtfi*wok'uecompensatianpo1iicyiafaems'uaa �ffameoaraerstehu sabmit tins sftida«i�atifip thP_y aiet]aing a1Ewo�auk(bPal�Ie au5idecratmctatsnmst 5ahmit a new sffida�t mdicabno rnrR - fCaatmctocsihst ebee1t3ris box mast sttacb smitimsl sheet showing thenmeof The snb-comt=ctamsn i stafevrhethes or notrlose sAitesbave emplayees.Ifthesubtaatradncshzce empIo theymastpmvide their Wwkess'pomp.party atmbm I artt art etxpr tltrrf;is prmzriiryq tvarlters'cart�rtsrdia�rt ittsrtrartee form}*e�lv}�eer $cToty Ls fJte pnFicy torsi jvla�a in�armrrhbtL . Insurance Company Nam: 'Policy lf'or Self-ins_I_ie--41k HKpinr&nDate- Job Oe Address; cityfStatellrsp: Attach a copy of the workers'compensationpolicy-declaration page(showing the poficy number and,expiration.date). Fa€lnre to secure coverage as require4under Sedian 25A of MGL a 1572 can lead la the imposifioa of criminal penalties of a fine up to$UOa OU andl'or one-yeariimpfisvnmenk as well as civil penalties in the fomr of a STOP WORK ORDERaud a foie of up to MOO a dap against the violator_ Be adcdsed that a copy of this stateammt-xnay be forwarded taa the Office of Ines igations of the DIA for iflsrrrance-coverage veeifica -I4£a Ifereby c P 'is arad�psrlalitizs v. Fee crf fltatf7ts infarx�o#irJrt prm road a6a r i�true artd correct [,Silatafrar •� f Date: A9 t Phone 0&fid use 0711y Do nat write in this area,to be campked 6p cxfy artowl o jrciaL City or Town: PermibUcense#i Issuing A ufh*X4(cnxle one): L Board of Health -Buffi ing Departmeat S.QtylTowa Clerk 4.Electrical hispeetor S.Plumbmg lnVecter fi.Other Contact Person: Phone#: 6 o rma-iaa au' d TastruefiWas l�.s_sa r-I wise# Ge be al Laws ffimptex 152 regmres all croployea to provide worir&compMSHfjon for iLir empIoyees. Pursaar]tto this sty,an EzTLVw is defined as";eQetgPecanih fbe service of anofiaerunder aiy cotract ofBite, express or implied,oral or wrftf3=f assocr�iun,CCM Mahon or otheg legal errLity,or any two or more An =T&yM-is defned as"an mdivulnA partnership, ex eatdivcs of a deceased employer,or hie of the foregoing engagrI m a Joint ,and in hu:rmg tho legal sepres r=eiV d'or trustee Df as lw p ip,assocfi±i=ar oflier Iegal entity,employ'ng employ- However fhe owner of a dw eIlmg house having not more 1hm tb=apartments andwho resides fhesein,or the 0=3pat of the- dw61I�house of anon who employs persons to do mamfmce,co nskuc ti on or repair vac on such dweIlmg house or on Elie grounds or bmIdmg aiPr�ar¢iheretu shaIl notbecause of snrJi employmmtbe deemedin be an employer ' MOL cliapfrr 152,§25C(6)also slimes fib¢every sr n or local rr n a agency sh,-a Withhold•fie ismatnce or renewal of a ficexise or permit to operate a business or to constrict bmldings zi the commonwealth for airy applicantwho has notproduced acceptable evidenm of cdmpfianee with the iasuzan coverage required-"Additiona2y,MOL chapter 152,§25CC7)states¢Ideithcr the co®.anwealfh nor a'ny ofits political subdivisions shall enter into any conirad for the perfman-ce ofpnblio wont nnbl acceptable evidence of ompliance Wn hie msarance•. regim=cufs of ties chapter have been presented to the Oonfrart M)ffaoizty:, Applicants . Please fall oil the fir''compensation affidavit compleirly,by checidng die,boxes fBt apply to your siinaiion and,if nerxssaiY, PIY soj {s)name(s), a&h (es)and Phone nnmber(s)along wifhth=cettda-cate(s)of „crn�nce_ Limited Liabi7ify ComPames(LLC)or LimitedLiabz7ityPa Ine�ips(IU)with no eaapIoyee s other than tiie members or p are not rbgrzffed to cant'workers'campensaiicm insurance• If an I LC or LLP dDes have employees,apo licy is reqused. Be advised faat this affidavit maybe snhmftted to the Department of Indusfrial mpld�fur coAcc m�tion of insnran�e coverage Also Be sure to sign and date the affidavit. 'Ihe affidavit should be•reto m.ed to ,fie city or town ffiA fhe applicafi m for the permit or license is being recjuested,not the D epartmenf of Ansiii al A-cdde�+ts_ 9EMIdyou have any questions regatdmg the law or if you are rein ed in obtain a woI3tr rs comppmsafonpolicy fhe ,PIewacaatbdDepmfinentatnnmberllstr below: SCH-fiLwledc ompanics sh 0uld en tr zthea self-immn=ce Hcease.lrmnbm on the appmp6ato line. City or Town Offs als r Pleasebe sore that the:afsdavitis complete andpritdedlegibly. 'Ihe Departmenthas provided a space atthebottom atic has to con act youregardiag flee applicant of the,affidavit for you to fIl out in the event the Office oflnvest o� on Please be szse in file peamit/Iiccm rnnnber which w�be nsed.as a reference mob=- In.addition,an applicant that must submit multiple pennWlice nse appEt�ions is any given Year,need only submit one affidavit Indira r;,,g t p olicy infom.ation(if ne�y)and under"lob�e MI -ess�the applic should write"all locations n ( `or town)_"A copy of the-affdavitfhathas been officially stamped ormmicedbyt�Le city or townm W beprovided to the applicant as proofthat a valid affidavit is on file for future permits or licenses- A new affidavitmnsst be tilled opt eiach year. Where a hDme owner or eiiizen is obtaining a license or pew not relaied:ta arty b u-�si e--ss or commeMial vim' (ie_a dog license or pcmh to bum Ieaves eto.)said person is NOT xtqahEd to eompleb this affidavit The Of ofrnvestigaJinnswouldlicetothankyouinadvance foryour cooperation and sbouldyouhave anyqueslions, please do nothe�to givens a c M The D eFF rtmmf s address,telephone and fax n=Les: - ��Cl-n �Qf�11 Dcparfm mt of lidmtdd A DUenta Qff�ce a livgafiaa • ���un�an S'tr�t Bostou.,MA 02111 Tf,-L1 GIT- -4 t�xt406 car 14 MA&SAM Fag a7 72'-7M Rmised424-07 WW nasg-ga�r Town f o Barnstable a wilding Department Services �Im Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 iA www.town.barnstable.ma.us 1639. Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print . DATE: 2L� �,//<7�[ JOB LOCATION: A/10 7 C h el/5 unkj II ON4/-S number p , street �- 'village "HOMEOWNER": PQ k IO P r 1-Z_ a3q A13 a 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 reMonsible 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 undersi ed'!homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedtr ents and that he/she will comply with said procedures and requirements. Signaturedf Hom er Approval of Building Official r 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 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. Q:IWPFMESIFORMS%building permit forms\EYPRESS.doc 08/16/17 " 1 Town of Barnstable Building Department Services Brian Florence,CBO �i639. R�� Building Commissioner Ep� 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 1 as Owner of the subject property hereby authorize to act on my beh4 in all matters relative to work authorized by this building permit application for. 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