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HomeMy WebLinkAbout0260 OAKLAND ROAD d66 �a.�2�..� /waste. r . W11-41SNF .D/XoN 19.7vX. Q rA 76 - - Q .'3T.4�LEY F. DO�I/Y� J J 6T. v X 1 _ Q r o ♦ to � A 2 4 _ r y i STA/►/L Z y R. 10007 PGA At OF e-A NO iN IVIIIVNI All /y/y/IS. /`7 i¢SS. Town of Barnstable Buildin 9. •. <P..ost This Card So'that�t�s 1/isible;From_,tke Street-A , roved PlansMust be,Retamed,on Job and;this Card,Must:be;.Ke t � ; •- �ARNSTAitt:�. ' ,�, '� .�„, �3fv?a,'-= ,x �,,,.�� pse,"_ "� ', €z" � ^'�.i. R' � a, ;.. r ,4 � i:``�'�3 p . erase Posted Until=Final Inspection Has Been Made n _ � � �� � � g i634' ,,,,>,:✓ ,%. i, "s., y" n o „a^ ...: r ,r `,.._. / '' ,fix •.,, .% ;• i. '.,x .!, - � x Permit . , �t �� Where as Certificate of Occu an�c ,.�s Rye uired,;such Buildm shall Not;be�Occu red unt�f;a F,,mal Ins'°ect�onhasbee�'n oracle y,:� Permit No. B-18-2016 Applicant Name: Mark Mordini Approvals Date Issued: 07/06/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/06/2019 Foundation: . Location: 260 OAKLAND ROAD, HYANNIS Map/Lot. 271 087 Zoning District: RB Sheathing: Owner on Record: SCHIRCH,TIMOTHY W&EILEEN �.` Contractor Name `R MARK E MORDINI Framing: 1 'a l i Address: 260 OAKLAND ROAD _ � Contractor License;CS 057645 2 HYANNIS, MA 02601 Est Protect Cost: $ 17,060.00 Chimney: Description: strip roof shingles and re-roof per GAF specs(22 square),ice and Permit Fee: $87.01 water shield 6'from fascia and T from rake boards and in-valleys, Insulation: . install soffit and ridge ventilation, install utters and downspoutsFee Paitl: $87.01 g g Date', 7/6/2018 Final: Project Review Req: Plumbing/Gas --�: Rough Plumbing: �VI �.. i��. _.k Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by tli s permit is commenced within six month�s¢afte, suance. Rough Gas: All work authorized by this permit shall conform to the approved applicatio n and the approved construction documents for which t permit has been granted. ` Final Gas: All construction,alterations and changes of use of any building and structures shall be incompliance with the local zomng,�by laws-and codes. 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 andFre Off cialsre p ovided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work �, Rough: 1.Foundation or Footing , L A 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low.Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final '4 ersons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). Fire.Department I Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ' Town of.Barnstable BARNSTKAM 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-18-2016 Date Recieved: 6/23/2018 Job Location: 260 OAKLAND ROAD,HYANNIS Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: MARK E MORDINI State Lic. No: CS-057645 Address: North Attleboro, MA 02760 Applicant Phone: (508) 280-0156 I (Home)Owner's Name: SCHIRCH,TIMOTHY W& EILEEN Phone: (508)280-8953 (Home)Owner's Address: 260 OAKLAND ROAD, HYANNIS,MA 02601 Work Description: strip roof shingles and re-roof per GAF specs(22 square), ice and water shield 6' from fascia and 3' from rake boards and in valleys, install soffit and ridge ventilation, install gutters and downspouts i o CO n Total Value Of Work To Be Performed: $17,060.00 \-' Structure Size: 0.00 0.00 0.00,-P Width Depth Total Arm I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued, it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Mark Mordini 6/23/2018 (508)280-0156 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost': $17,060.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $87.01 6/23/2018 $87.01 xiooc-XXXX-XXXX- Credit card 4147 ... .. . ........ . ... l ...... . ......_ _....... ...._....... ...... ..................................__..__............ Total Permit Fee Paid: $87.01 , , THISFIS NUFTC PERMIT R� �r &ro �,;, S �.,, ..e-tea«. �-s�•�,�,_ <..a.. .FW,__ .. �..� �w�,,_°�� � • t' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION l/ Map Parcel pp A lication# T Health Division Conservation Division Permit# Tax Collector Date Issued l® /l ®lo Treasurer Application F Planning Dept. Permit Fee J l Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 7.6 O D rC Village f T� Owner S CLIicc Address 26 © 04 IC ct.��t Telephone 0 5 O 7 / 7 Z Permit Request CoRokvT De Square feet: 1st floor:existing i 50 proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 00.00 Construction Type WOO A r'Q�nl e_ I�' Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family (d Two Family ❑ Multi-Family(#units) Age of Existing Structure 3 g ) `� Historic House: ❑Yes 2% On Old King's Highway: ❑Yes ❑No Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) "�t.mber of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air: ❑Yes 2(No Fireplaces: Existing -2— New Existing wood/coal stove: ❑Yes L9No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:O/existing ❑new size Shed:L/existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑_, — — - Commercial-- Yes 8No , If yes, site plan review# Current se Proposed Use BulfbFk INFORMATION Name % a✓t C h ,r C L Telephone Number _ y ?(Fe �/7 Address 2_:.c e., 6 A k I re : License# d l`9 4- • -S i-M / ; Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO D SIGNATURE !C-211iyt� v l ATE �'1U(e l ' t _r i ` ' FOR OFFICIAL USE ONLY j y tf PERMIT NO. DATE ISSUED f + MAP/PARCEL NO. ADDRESS ' VILLAGE OWNER S DATE OF INSPECTION: t FOUNDATION �� P ® � FRAME Q/C ) + INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL I _ PLUMBING: ROUGH FINAL g I GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. f The Commonwealth of'Massachusetts . Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,M www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): f% Address: Zy s C—�J K l , 0, J City/State/Zip: . 14 Y ei &I "-,,5 in f , O 2 6 o j Phone#: S 9 — Y 7 Z Are you an employer? Check the-appropriate box: Type of project(required): i.❑ I am a employer with 4. ❑ I am a general contractor and I 5 employees(full and/or part-time).* have hired the sub-contractofs ❑ New construction 2.❑ I am a sole proprietor or partrier- listed on the attached'sheet:'# ❑ Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for me in any capacity. workers' comp. insurance.- , g,,❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or, additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ of repairs _ 'n insurance required.] t employees. [No workers' 13.[� Other 1 t ©°�r camp.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 subcontractors and their workers'comp,policy inforrriation. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER; and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certide=d1tiy of perjury that the information provided above is true and correct Si ature: K Date: Z-c O 6 Phone#: .!�_O c) 1-7 Official use only. Do not write in this area,to be completed by city or town ofcial City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk a.Electrical inspector 5.Plumbing Inspector 6. Other Contact Person: Rhone#: 3 °F'THE 1° Town of Barnstable Regulatory Services BAMSTABM ' Thomas F.Geiler,Director f 'MASS. �pT i059 g .�1" Building Division en►�► Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date a 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: l7 �-�✓ ��C � Estimated Cost F®0d(-)c3 Address of Work: 2 C) ,A K I cs— Owner's Name: Date of Application: I hereby certify that: Registration is not required for the.following reason(s): ❑Work excluded by law ❑Job Under$1,000 �uilding not owner-occupied wner pulling own permit Notice is hereby given th at: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME 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 Signature Registration No. Dat � Owner's Signature Q:wpfiles.forms:homeaffidav Rev: 060606 T0'd _11d101 iJ TU K L-AIN E Q l_oT It C ' &- 12 A 5-r7r pY O 4 I DwEL_UN )<; U � 1 N)D.2_60 l _ 371t �I E5 i w o H- ,, OAK�� D Rr��D JOHN S. LAUREl'ANI �"�_^; LOCATION OF STRUCTURE(Si III JXZ11, i°: ONLY A MORE ACCD ON LINES URATE LOCATION WILL REOUIRE AN!NSTRUMEN? s r Scale: !r= 3,0 1 r _ PROFESSIONAL LAND TIFYSURVEYOR, AMERICAN SURVEYING COMPANY � HEREBY CERTIFY.THAT THE MORTGAGE INSPECTION N FOfl 1264 Main Street,Waltham,MA 02164 (781)B93-6477, W*'`A WAS PREPARED - IosrcN 1+ E,.,MTV, IN D IS TIONNOT INTENDED OR FIE RE Mortgage Inspection Plan .�,:lD IS NOT INTENDED OR REPRE- >iNTED TO BE A LAND OR PROPERTY JE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT COUNTY REGISTRY OF DEEDS T. IT CANNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK 2eR--7 PAGEL.C.Cerr.S ;.jOLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: '•":!tLDING LINES.THELANDASSHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSOR'S PEON IS BASED ON CLIENT FUR. FECT WHEN CONSTRUCTED WITH RE- MAP# PARCEL A DATED ?HED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: QA YZ17 16JECT TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT 1 1` S l5,M KINGS,EASEMENTS AND RIGHTS OF FROM VIOLATION ENFORCEMENT AC- BORROWER:YIYn2 A. I' 5¢al, rYI r Y. LyQ RESPONSIBILITY IS EX- TION UNDER MASS.G.L TITLE VII,CHAP, •f.�» 1 NDED HEREIN TO THE LAND OWNER 40A, SEC. ), UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD TONE — I;OCCUPANT,IT IS NOT INTENDED NOTED OR SHOWN HEREON.A CON-AS SHOWN ON NATIONAL FLOOD INSURANCE PgOGRAM FLOOD -:BE RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED < T T 19 YEW- IS ADVISED WHEN STRUCTURES ARE COMMUNITY_PANEL#1$OGG ICI C.iTE SHOWN TO BE 1' OR LESS FROM ENT KU�INEVIG PROPERTY OR;REOUIRED ZONING FIELDED DRAFTED CHECKED e ._ ;LENT REF.0 SETBACK LINES. BY ✓�L DATE, 22.954 4.A-9 `-mot-9Y FA6 30 arc I Ll r oFtKE r� Town of Barnstable Regulatory Services sAxxsrAste, Thomas F.Geiler,Director y MAss. g qj 039. Building Division ArfO��p 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 VZO/0 Please Print DATE: 6 JOB LOCATION:- G,. � 0 0 A k /Gt, , 11 I f 11 number street v y village �� "HOMEOWNER": to SC(A.i rc� S oO ! U V l /Z 5�'':3 Z96 3 S name home phone# work phone# CURRENT MAILING ADDRESS:— Yet li'm ;_5 4 vL�® 1 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 su ep rvisor. 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. T Signatu 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. P 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 Sunervisor. 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:homeexempt - .y. Dec�, n e w :.4. .: Da VY t� 811 r"'1" f a� P 1w pGCK + a a S i I lz 6-0 Opt to 1.0 ' c �N to B : �p ; Engineerir'g Dept:(3rT d floor) Map Parcel �$� 4"Permit# House# ate Issu d 5 '� t. f Board of Health(3jt�-(8:15 -9:30/'1:00-4:30) /, J011)1 c77-T Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) ' Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SY T IM INSTALLED Definitive a Approved by Planning Board 19IT C. ENWRONM I ND TOWN OF BARNSTABLE TOWN REG IONS -� Building P snit Application Pro t treet dress GOT, /C, Village �-w Owner _'r!^�0 ct,,, Q r t /IC P1 k Address Z 6 o 604 k l�•. � , Telephone o Z Pe 't Request v ��"j C C k p �- 47 6--,c K o ko-,, S e �S �( /S ' First Floor square feet Second Floor square feet Construction Type rrSS u re_ J e (� [.J C +� Estimated Project.Cost $ 90'7/ Zoning:District Flood Plain Water Protection Lot Size 13 x OLOO Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 3o Historic House ❑Yes S�4o On Old King's Highway ❑Yes 3 10 Basement Type: M/ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Z 5_0 Number of Baths: Full: Existing '2. 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 sr61 ❑Electric ❑Other Central Air ❑Yes �/No Fireplaces: Existing 2-- New Existing wood/coal stove ❑Yes (1To - 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/�f 5 c �+ n re t, Telephone Number r*-7? Address o } IC I ,�/ �� • License# f LC.f,•v O L S 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 IIESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 6 B IFk FOLLOWING REASON(S) e 1�� FOR OFFICIAL USE ONLY PERMIT NO. _ DATE ISSUED; MAP/PARCEL NO. t ° _ _ i f `� ( •. _. Yam* ADDRESS VILLAGE ` OWNER DATE OF INSPECTION:. FOUNDATION FRAME ' INSULATION ` FIREPLACE ELECTRICAL: ROUGrp FINAL PLUMBING: 6 UGR FINAL it ` GAS: IIO1 M FINAL FINAL BUILDIN �;i 21 DATE CLOSED O� _ ASSOCIATION P O. 71 The Town ;of Barnstable, • sA,srnaz e. • " 9� '& 10�' Department of Health Safety and Environmental-Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 5081790-6230 Building Commissioner For office use only Permit no. Date p 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. , V Ty a of Work: C o r e&� r �r Est.Cost ®O t Address of Work:- wner's Name S �"` �G L` ate of Permit Application: g! G ! 9 -2 I hereby certify that: i Registration is not required for the following reason(s): Work excluded by law Job under S1,000. 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 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 Owner's Name The Conttnonlrealth of Atassachusctts • ..ice . . • , •Al! . I" . ;_:•�•-: • Department of Iurlustrial.4cciJeftts office allnvest/gat/ans - r r 6110 ti ashitt tutr Strc et 4'�• J Bmvwit.Alas. 02111 Workers' Compensation Insurance Affidavit 1 li • n inf rn ion-• /-C � Z6o 0/1 i- C11,. S 55 D � �o � ho •a �o� 7a�Zf�� I an a homeowner performing all wort: myself. 17 1 am a sole proprietor and have no one working in any capacity [1 1 am an eniplover providing workers' compensation for my employees working on this job. comiumv namr• ;tddre�S• cite- nhnnc i!• in.xurnnce rn nolicv 0 •[] I am a sole proprietor. beneral contractor. or homeowner(circle one) and have hired the contractors listed below who n: the following workers compensation polices: rnmnnnv n• ine• •tdriresc• - �n nhnnc o• in!qurnnrr rn nniicv d _ cmmrinm• nnmt•• addresc• city• nhnnc its insurnnee co nofic�•ae -Attach additio'n21sheetifneees_sa'r Failure to secure c*ovcrace as required under section:SA of f11GL 152 can lead to the imposition of criminal penalties of a line up to S1500.UU andio uric -cars' imprisonment:t. 'ell:is civil penalties in the form of a STOP WORK ORDER and a 111tC of 5100.00 a day against me. I understand that copy of this statement may be fur,varded to the omcc of tavcstirations of the DIA for coverare verification. /do herebr ecru[•fit •r the pains and penattics ofperjury that the information prodded above istrue�and-comct Si_natu Date J /6 Zq -7 Print name Phone# '•oRcial use univ do not write in this area to be completed by city or town official city or tntvn: permittlicense i! r tluilding Depnrtment tC31.1censing Board t check if immediate response is required 05cicetmcn's ofBcc ► �. C311calth Department phone 0: r1t)ther contact person: � 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 empinree is def incd as even, person in the service of another under any contract of Bice. express or implied. oral or written. An rmpinrer is defined as an individual. partnership, association. corporation or other legal entity. or anv two or more tltc forcuoinu enduaged in a•joint enterprise. and including the legal representatives of a deceased etnplover, or the rccciver or trustee of an individual . partnership. association or other legal entity, employing employees. However the owner of a dwellin�_-ho use having not more than three apartments and who resides therein. or the occupant of the dwc1lin�,: house of another who employs persons to do maintenance , construction or repair work on such dwelling_ hour or on the urcunds 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 rencival of a license or permit to operate a business or to construct buildings in the commonycalth for any applicant who lies not produced acceptable evidence of compliance with the insurance coverage required. -%dditionall.,. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the wi-formancc of public work until acceptable evidence of compliance with the insurance requirements of this chapter iia -ieen presented to the contracting authority. klilrlicants 'Ease fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and upplying company names. address and phone numbers as all affidavits may be submitted to the Department of idustrial Accidents for confirmation of insurance covera`e. Also be sure to sign and date tite affidavit. The Ftidavit should be returned to the cite• or town that the application for the permit or license is being requested. .ot the Department of Industrial Accidents. Should you have am, questions regarding the "law" or if you are required o obtain a workers' comperisatior policy. please call the Department at the number listed below. ity or 'towns !ease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of e affidavit for you to Fill out in the event the Office of Investi,,ations has to contact you regarding the applicant. Pleas sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to e Department by mail or FAX unless other arrangements have been made. ie Office of Irtyestications would like to thank you in advance for you cooperation and should you have any questions. ease do not hesitate to Live us a call. . ie 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 #: (6I7) 7274900 ext. 406, 409 or 375 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION P ease print. DATE JOB LOCATION 2 6 O 6 wP-x n, 5 Number Street address Section of town HOMEOWNER" � G L, 8 7`Z 0 2 / S/ Name Home phone Work phone . PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupie, 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 HOMEOWNER: Person(s)' 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 Offic= on a form acceptable to the Building Official, that he/she shall be resnonsik for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the St Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner", certifies that he/she understands the Town of Barnstable Building Depar 'ent minimum inspection procedures and requirements and that he/she will com y with said procedures and requirements. HOMEOWNER'S SIGNATURE CT 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 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person (s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awareneE often results in serious problems, .particularly when the Home Owner hires unlicensed persons. In this caser ou •Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home 'bwner actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/bier responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the la--t page of this issue is a form currently used by several towns. .. You may .are to amend and adopt such a form/certification for use in your community. '� t t�t':.� � q r�•.;� t _ m �1 pG 40 71 yr AAO E pi sy q4.� - @d a 4.8 U94 t3,� 93 3B4C vo k O O re � ,! rE � 1) t 11t o •L9ee96 4�11 x r '`'{° v 4.58 4C N 44 9 92 Ki 30gC_ rY'I, S • -So 94. 434C 6 e k 4 �- e4a, y r . 9 T go, yo AC— &40 h E to � �" �,}, 3F . t _ _ - � —_ . O • O5� � � of � � •3), i Q '3 n ) i 4C c 0 94�7 @ I• C z- S E" — 9 �`� d 0 � 9 3 7 qC � ii f. — qc 6 8 •a J. i. L c 9 *� C - A @6 3 9 e® • 4C. 0' ��,' ,• + I '�' .!} i .20AC, .2agC +r t 9 ,� O d :.wa,r••i j $ 294C p� 710 f , i II 234C a -3)4C Nod f'� - 244C 24 qc , : alp at .244c ©. r t ° I ' O(/NNl PONO Y It 3e� .. �7 `3 { } t Q .244C r ,. � }:' i C.Y.. r "• " : v •��•� n Lli�� i .36AC ry 2�4C S z _ 4, itt V i PREPARED UNDER THE DIRE aCTI s t' i BARNSTABLE BOARD ON OF THE t r j ASSESSORS AVIS AIRMAP INC. MASsaCHUSETTS- ' S r r CONNECTICUT i = +' i ci;;v 1 Oo i V r