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HomeMy WebLinkAbout0021 PAINE AVENUE ill �a�ne qve. -- - - --- r - - - J i r y Town •of Barnstable9 y *,sera © � ` ERMIT TK*zres 6 mo e Rea` ulatojy` Services Fee 94� 0�2 Thomas R.Geller Director :, pia rut n . . Building Division~ rc� TOWN OF BANSA ft' Tom Perry, GBO; Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town barnstable ma.us Office: 508-862-403 8 `. r, ` ' e , Fax: 508-790=62301 EXPRESS PERlYII'T APPLICATION s — RESIDENTIAL ONLY , Not V.Md wrthout Red X-Press L T j t Map/parcel Number P-operty.Addross ye' e-• . /`�dG1iIYlI S t � �;?�/� ' F Residential Value of Work-0�3,.00,0._d 6 Mmimnm fee of$35:00 for work under$6000 00 Owner's Name&Address Je 7 �/ • Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable): FWorkman's Compensation Insurance' Check one: ` El I am a sole proprietor, 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 Re (check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken- []Re-roof(hurricane nailed)(not stripping. Gomg over existing-layers of roof) [] Re-side } #of doors ` ❑ Replacement"Wmdows/doors/slidess.U-Value (maximum.35)#of windows •0 Smoke/Carbon Monoxide detectors 4 floor'Ian marked with red S:and inspections required.''. Separate,Electrieal&Fire Permits required.` - - *Where required: Issuance of this permit does not exempt compliance with other town depazhnentregaMous,i.e.Historic,Conserv-6- ,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&'Construction Supervisors License is j re tired. SIGNATURE: 'Ago The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston,MA 02111 ',K •�•�'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Le ibl jj1 e(Business/Organizarion/Individual): JG® � Address:�y o� Awe (C_%ty/State/Zip:-� A 6d7 ,60 Phone.#: .s®if— 17"7 Are you an employer?Check the appropriate box: Type of project(required):. 4. I am a general contractor and I 1.❑ I am a employer_with � 6. ❑New construction- . employees(full and/or part7.time).*4. have hired the sub-contractors 'listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees 'These sub-contractors have g, ❑Demolition and have workers'a n working for me in any capacity. employees9. ❑Building addition [No workers' comp.insurance comp.insurance.$ 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.]- ` officers have exercised their I L❑Plumbing repairs or additions Ym3' I am�a homeowner doing all work myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t 'c, 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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 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 I do hereby certify under th pains and p allies of perjury that the information provided above is true and correct: -S—i— a�e: Date: ® S 1,2 l S gntur Phone#-- „64t01f,— 6?,� - 77 Official use only: Do not write in this area,to be completed by city or town official City or Town: Permit/License V Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing 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,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 stafes 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-contractors)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 CommQnweaM of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02 111 Tel. ##617-727-4900 ext 406 or 1-977-MASSAFE � Revised 11-22-06 Fax##617-727-7749- www.mass.gov/dia r oFZHEr , Town of Barnstable 0 ` Regulatory Services �. �rrsrnsts. 9 ass Thomas F.Geller,Director s639• 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 a Property Owner ust • L Complete and Sign 's Section •` If UsingA udder t,` I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work auiho ed,by this building permit Address of Job) **Pool fences and arms are the responsibility of the applicant. Pools are not to be filed o utilized before fence is installed and all final inspections are per ormed and accepted. `, ". ,'` •'�- :.} Signature of Owne Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERML4SIONPOOLS 62012 Town of Barnstable , Regulatory Services BARNSrABLK Thomas F.Geiler,Director y MASS. 1639• Building Division . Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstab l e.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print JOB LOCA QN:_ / !Give Ate number /� street - village /�j / «HOMEOWNER":' �^ - -,.__ - �d govPIJC//�// �i 77) -&7 1a2f'fj0 /�7//J name ' home hone# P work phone# CURR T 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 requireme s. m �-S—i� f gnature-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 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, hat 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:homeexempt a0UZC�3�I �Co oFzx> r 'Town of Barnstable ermit Expires 6 months dale X53 .; NM- ' t _ I � Regulatory Services Fee oz 9 MASS. ,$ Thomas F. Geiler,Director - $q� D 39 Z00� N1A F BARNSTABLE Building Division '�'OWN ® Tom Perry, CBO, Building Commissioner 200 Main'Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Q� I Not Valid without Red X-Press Imprint p�`P Ma arcel Number D l 0 , / - � ° ZProp rty Address P Q 9✓!/e. Pave— � G� �li1y . 7 /, (AC0 1 esidential Value of Wort. Odd - Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 's<y/41VN I�t�r l~r?Y�./� f/. � al,111-e, Contractor's Name— JA/296_`=i �(,� �/ Telephone Number qy —(, 21 600 1 Ionic Improvement Contractor License#(if applicable)�/>p l' Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ` ❑ I am a sole proprietor ❑ 1 m the Homeowner have Worker's Compensation Insurance Insurance Company NameG' (�/1� � �✓V �� Workman's Comp. Policy# �} Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles)'All construction debris will be to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-s• e © Replaceme Gindodoors/sliders:U-Value o-3 (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required, SIGNATURE: — _ W\N PI-ll.IS\J:0RMSN[ilding permit forms\EXPRESS.doc Revised 100608 Customer Name: Ycar Built: `, Renewal by Andcrstn of RI&Capc Cod + Address: - 7V R{"Y' Cuaromer ID#: 1137 puk East Drive Sales Agreement Ciry$�� Zip: Da�o1 Order Number: Woonsodcer,R102995 CMPhone-Home � yy licenu If Rl 12259•MA 119535-CI'' n�°mPIDr PhonrWotk: PwL of Due , •,--•f� '! 0562725 Email: Woks ueanrna GRILLES oamdrsler�a S PRICE S F (N G STD ca �7 0 �=F I . L.meuve Miscdl P R C or Ex en tom) suti law ww I; Payment Method pr n to be widrd dr< ..a id rbc• a the $ninin m boEl urdeetn red Rnrro+l ht�n (�C - Svb Tntal pdrxrarW OcKreptjnn a'N«/,/a.�•l. �Q id/ S P,iw S tliedt .+Ijll� Sub total w�a.n rcn sal.aeprtarne:oc ras ptdit Cerd mdmdmd m fimrlrh a a�nao.�r rna din.edpdrcd m«.new•w !Z1Cl� S"�" Mbc,credits a FspensQs apq:ea amount rpm:;.dha agm—and remrdetg m dtc rnmr h—f ---r. flnarldrg nd Conditions of Sale.You.the buyer,tray cancel iartal rior to midnight of the third business day Sher 'lease teemed notice of cancellation for an Saks Tex ri�Q /h 7'oralMlacelLmmwCradiuor£apmsca nddReerl Y ddrrsad.nrn+.d.d (ar'.yavei�rnil re mirc oviirlmpaae mturan ad rlbhJ YorkPermk Corr VIraadrde dlf►nl t d Signsnne SpQi,l Odder Nonr Tool Artwuln of Agretnwrt pwfto— kA.- Nor 0 0 .in6laerga Signrrun Deposit R&Wred Mnnal rrdrr:nulladlrn iVata roe er w rrauuhir a bUm drvrdnp Ralance Due on Completion e' drumdawr �an sry pdwnd.�..pr nerrectl arpmerardr�nda ��.. : cwavrn��v d h dodawa:maq amil.m�...w A.pm rdeyerrnpoiearhry, Priacindwka labor,matcriaLc ieuullarion, tat Me damns uNex sddwkerwbR+�mrid wralm rrvovta •• .,, �, ►e vn red de.Jm r�eerm�.nee.nu r. ren,ova],and diapwiof produces repLaaxf. ���w dnn ra.a nwrlMewt and W1dd;-Reneval by"Mde+scn Yteow lnstnllatwn Pink-MOlnearnei t Castors ' 1 r� r '• � O�J1l/!7 �j���� �Jy L4CRW* Valid r ice of C®nsurner,Affairs.& sines Regulation before the t t�dat =ifrG d m to: ,HOME 0PROVEMENT CONTRA.CTt?R Board al' afo � fm& <; O Asb Plateft t3oI R�pi�t��ti�rl. `�19535 t a; tp�rfi�snx `? 211.. Tr# .285438 pta on Type MOON ASSOC iJ �K!DtJAM QON ut iu 1137 PARK EASi�ib WOONSOCOT, R`f,0 $ .z,� Undersecretary v: }Lr t� Y �ti«.s bss.�xtta vltxtt't c'tti or Public N;it`r1i tt:� l , tilt#i R��9atrl�stit= +artai°t ttDar l tw FWS tcor z -, .eft �.Shy P i� N �Wa way t t1�g COO for �. eftoon of t Itcesm . . . _ rr W. Tea R r The Commonwealth of Massachusetts. Department of Industrial Accidents Office.of Investigations 600 Washington Street w Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatio Individual): AM OV41)• fpc C. Address: T � , City/State/Zip: 1/ JI/. �� Phone#: 40ll Are y an'employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I . 1. I am a employer with��_ ❑employees (full and/or part-time).* have hired the sub-contractors 6. �E]Ne construction 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling; ❑shiThese sub-contractors have e and have no employees . Demolition i employees and have workers . Working forme in any capacity. A - [No workers' comp.insurance comp.insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 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 ❑,Roof repairs insurance required.]t c..152, §1(4);and we have no 12. 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractomand 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: e Wd'Al / 'l tl 11V D Policy#.or Self-ins.Lic.#: � Expiration Date: �n� Job Site Address: Pal N� !-�V e— - City/State/Zip: /v J Attach a.copy.of the workers' compensation policy declaration page(showing the policy num er 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: �i,,.,�� Date: ,r 1 1 _C719 Phone#: 447 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#: pram;ehaumv Rouesm mtaf a .try, ratdo. 'kw,Doom atoda XWE X" ex Insurance, n �� , �� €����`� NOT SEENc�� ylal�O TME"bt UT 02189 MORE ,R8QY M*JMM%P".TOP? 'OMMMOr AW c ls°I cYozonm o -ice`n"gzpz=TOVMCH lm ;�MAY 89 miwom MAYPMAKM a.� test ' «ta t� � 3a . .... f 0000 o, 0 42000000 p3': c . ANY A00 r A &MD T spy"AM 4 Oka OO GARASS MRMMVAAW to - a Fn;, ...... �x a 41000000 / / 0 Amm 2109 fl .. WMMM COMPMAIMM AM M �... . . t CAPO D' p t. of adwAaistxk"t I ,_=j4300-UMI rd 0,Q MMUrl?CAR AW MOW UPON Iv-MMURM ttM s CR po C.,vu Ita Hill . .., x c'�4..r A x 1'Ri. a3X�vT I Assessor's map and lot number ..... ....... 1.j -.A/ Sewage Permit number .......... ................................. h q THE TO-W& OF BARNSTABLE BARISTLIBIL 039 NAM . BUILDING . INSPECTOR APPLICATION FOR PERMIT TO .... ....... . ................................ ................ TYPEOF CONSTRUCTION .......... .......... ...................................................................................................... ........ C, Z2..........1923 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following* information: 44 .Location ...... r.J..: . ...... ....... . .................. ...... ...........................................I..................................... ProposedUse ............�-a ..........................................................................................................I......................... Zoning District ........./7..... ...............................................Fire District ........�fl- ....................................... ....................Name of Owner ...Address ....06./OA-�... ............................ rr Name of Builder ..... C ?—0 C . .... ........Address .............................1'(/.................................................. Name of Architect ...................................................................Address .......*V40-W ... ................ ................................. Number of Rooms ............../ '. . .. .�..x...... . .....................................................Foundation Q� ... . . ...... .......Exterior ........7--,-.�. ......a.1...............................................Roofing ....... ............................................ Floors ........ ......................................................Interior ........... .... ..... ............................................. Heating .......... .....................................................Plumbing ........ ........................................................ Fireplace .......... ...................Approximate Cost .......... 0, 0 0 ...................... Definitive Plan Approved by Planning Board --------I-----------------------19--------- Area ............ .....5d................... Diagram of Lot and Building with Dimensions Fee ............................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH pol- I hereby agree to conform to all the Rules and Regulations of the Town Tf Barnstable regarding the above construction. r Name .................................................... ......... .............. Rocheteau, Ralph No ... Permit for .....add,brae,de.. ...... sam aq..ta.Awf?UU&........................... Locatio�...l Paine..Ave. Hy ........................ ..8 .......................................... Owner ............Ralph ..................... Type of Construction ..............frame ............................ ................................................................................ Plot ............................ Lot ................................ September 17 73 Permit Granted ........................................19 Date of Inspection ....................................19 `'�Date Completed ...................lg PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ............................................ .... 19 ............... .............................................................