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Application number..,P.......
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N 1 12019 Building Inspectors Initials..
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Date Issued... � / ............................ .." Ur uSIADEE MpParcel....a ` lG Z. .......................
.. . ..TOWN OF BARNSTABLE-
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: e1511h ,�� / S
.NUMBER TREET VILLA E
Owner's Name: i7 ,'/,E � eG Phone Number ��
Email Address: Cell Phone Number
F Project cost$ L4 0 0 0 - °`'` Check one Residential L/ Commercial
OWNER'S AUTHORIZATION
r As owner of the above property I hereby authorize
to make application for a building permit in accordance with 780 CMR
Owner Signature: Date:
TYPE OF WORK
Q Siding 0 Windows (no header change)# E-1 Insulation/Weatherization
0 Doors(no header change)# Commercial Doors require an inspector's review
Roof(not applying more than 1 layer of shingles) . T
Construction Debris will be going to �6,v'M12 v1-E We k5- K
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable)# S�g (attach copy)
Construction Supervisor's License# (; L. 6 q I (attach copy)
Email of Contractor ' Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 7S YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION NUMBER...................r.......................................
*For Tents Only*
Date Tent(s) will be erected Removed on number of tents total
Does the tent have sides? Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X, X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No F
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent
Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required.
Natural Gas Yes No ,if yes,a gas permit is required.
If food is being served at.your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number Cell or Work number
I understand my responsibilities under the rules and'regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date
APPLICANT'S SIGNATURE
Signature Date
All permit appl' ations are subject o a building official's approval prior to issuance.
I
QN The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,AVIA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 99 Please Print Legibly
Name(Business/Organization/Individual): rrl 0 (2, �6
Address: L �a� �_�y In P YYc4 L+--
0
City/State/Zip: Wo-.5t 0 r Yvt-v v`ff Phone#: .9-P 8 7 -z 1;-
Are you an employer?Check the anipropriate box: Type of project(required):
1.R I am a employer with 4. ❑ I am a general contractor and I
employees(full and/o art-time .* have hired the sub-contractors
6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P t3'• 9. ❑Building addition
[No workers' comp.insurance comp.insuranCe.:
required.] 5. ❑ We are a corporation and its 10. 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 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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: L►6 e—Aw m u+-v a e-- ►l-,re— j o-5'
da
Policy#or Self-ins.Lic.#: [ [ ucl 6 -3 Expiration Date: to ~ — 2.b 12�-Z
Job Site Address: 3 (+ G�,Q,?�� bin City/State/Zip: �'}
1'
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: !D ' —.4�f
Phone#:
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#:
r.
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 states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 cant'workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington.Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
d
y
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction-Strpetvisor Specialty
CSSL-099166 E itpires:01/24/2020
JOSEPH E KINGI
36 CHECKERBERRY LANE' j
WEST YARNIOUTH MA02673 :
Commissioner
Office of Consumer Affairs&Business Regulation
Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR
before the expiration date. if found return to: TYPE:Individual
Office of Consumer Affairs and Business Regulation Registration Expiration
One Ashburton Place-Suite 1301 150889 05/04/2020
Boston,MA 02108 JOSEPH E.KING
` / JOSEPH E.KING
36 CHECKERBERRY LN:
Al td v13ICI WItItOtJt Ct; WESTYARMOUTH,MA 02673
Undersecretary
I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map ��� Parcel 13 6
INSTALLED IN OO��y L9t��� it# '� ._ ��
WITH TITLE 5 �
Health Division al _ DO �."��, ENVIRONMENTAL CODE k Issu 2-
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TOXIN REGULA �Conservation Division TION,SFee
Tax Collector
Treasurer
Planning Dept. t
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address / . r Z
Village
Owner e Address « J �J'
Telephone 7:7 7
Permit Request /� .�%�
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost bay Zoning District Flood Plain Groundwater Overlay
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 ;)-94 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑No
Basement Type:cAFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) /,6 ice` Basement Unfinished Area(sq.ft) ov�
Number of Baths: Full: existing l new Half:existing new.
Number of Bedrooms: existing new
Total Room Count(not including baths): existing lv new First Floor Room Count
Heat Type and Fuel: OGas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes dNo Fireplaces: Existing New Existing wood/coal stove: Cl Yes ❑No
Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:Cl existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial Cl Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name Telephone Number
Address License#
t.
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR DATE _ � n '
c r
FOR OFFICIAL USE ONLY ^
PEP.,MIT NO. w f
t
DATE ISSUED
MAP/PARCEL NO.
ADDRESS - VILLAGE
OWNER a.
DATE OF INSPECTI04:
FOUNDATION
FRAME t;--
INSULATION: '
FIREPLACE -
1
ELECTRICALo `— ROUGH FINAL
PLUMBING: ' ;ROUGH FINAL �
GAS: ROUGH FINAL, r
FIN+I}AL BUILDING a `
DATE,CLOSBD OUT
ASSOCIATION PLAN NO.
1 4
°F IME
• ~°� The Town of Barnstable
► 1ABNSMBLE, •
9�AMAE& �m� Department of Health Safety and Environmental Services
rEn 39r A Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 50&790-6230 Building Commissioner
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: Estimated Cost
Address of Work: 3� /z �s o� d✓ / ��1�ems.`
Owner's Name: f���
Date of Application:
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 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:
y Date Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affidav
e own ot Barnstal)le
�FIME T
Department of Health Safety and Environmental Services
' Building Division
• BARNSrABM ' 367 Main Street,Hyannis MA 02601
� t Knss.
s639•
•. '°?ED Mph A
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: C2
JOB LOCATION:
number street LL/ village
"HOMEOWNER":9 1 14� 2d Z lz 4A a
d name y home phone# work phone#
CURRENT MAILING ADDRESS: / /GY/t%°t✓ ✓/1 l.�y
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 requirement
Signalure of Homeow Tr
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,that 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 to amend and adopt such a form/certification for use in your community.
p Q:FORMS:EXEMPTN �'
°ComDlaint`Number: 1666 - Taken by FaUILDING SLRVICLS `
-°
Date:} 12/ 7/2000 - �MaM)arcel: - 290/113
Referredgto: BUILDING 7711$4_6J
SUBJECT OF'COMPLAINT¢
Business/Occupant Name: RICHARD LEROUX
Number 331 4Street: PITCHERS-WAY
VillaL,e: HYANNIS
COMPLNT INFORMATION LLB.
AI
Complainant's Naive: CITIZEN
Address:
Telephone Number:
P i p Com lairit Description: --ADDED NEW DORMER
j:
m
{ Actions 1 aken/Results: REF TO TOM PERRY ,S
C 1
4
5_ 1�-3,o 330jG. UX—S -t;
w
`Date'Closed: