HomeMy WebLinkAbout0048 PRAM ROAD ya f'..�.a.,r�� ae,
,f _ —�.
t
f
l
6
11000
{
.;�,:v�+pt+ ���, o &,,g,x Ffit,�-�'} ,�y ..+�:J� �. L'� i j' ,�.�,.a;�c+a �'� r L f - +I��,t-� ,r•'�,�""� C ,+..
r.•
� w±..� fit ��` t di♦,r*Vw, s r, i �� �,�.-`' �. "'f.� 'd 'ffi
�p �� `�.� �hJ'.''t�'�yY,. J «L Jb. f t ��• '-S. N/��X\� t." ,may. , M�7 7
,. '� a « ,r' 'mod 3d �$t �.'.7� l5 �' �?P�'♦Sv � � i ,,�• f v r. ,_ - k
,mot»k ' � X X� 3J�k sir44, t §5-
ft-w 4 r °
■ � a:-��� �1 '�o, :� w�\�5+�`s - }'�%' r'' c1� r "a', d • ' ,{" �.. 3 , � a, , �} s�`t ;;.- •,
VIV
��".Jn id4. 4� ar L �� s"'�r ,f.� .'� �e� .�A�� �1"r��,+�+fJ�'�•r 4 w:"`- _ �
i, »i � rK3 q-s' �i�"�i�\ '� ••y'�4 � oS 7. ` �. SI:K, �y``'c.�� ��?a��,�, �„}` ii'�t^Yf:' '��� �,1. •�'° ''-L;� �i t{ �!
'xc*�> 1 r�'i•-'..�'^7 '�� ,i`>•i J�F�4A+- P� `:3i � � ��. i"s k �w � �- � 7��}i•i.s J s' �I• s." ,.{�.� #"y�•f i
(� a
i°•�+ .' ! ... ♦ s:�� i 1�7: � •1`. P'�p14, A .L•♦^'*�•. 'j. - ,;� a ".,. Rp 6rv.. Y �� � �c' _
ts � Vie* a• ♦,d} lJ j e .�yti s , �:r. nN 4 � _ R�� •.
x '`4 •v � ,..,; ,♦ �' �� S.r'�_ }.• _ �'R 3♦�J°ry- � _.J,.s... �. i ��. y y��`•4. 'L' � � 4�� s'J
� '34.y' 6� �'fi}i+'. :�� ♦ �:.. .r •�1•!'Fo i',r^� s'�"'�"x - � � �S i �'1� "F, 'a'' _ °],+i � �, ,js �".'K
°`� r',:�:': Syr ..a. r',•., � .. � ! „ ,�
♦t
1
1 W
\ � e
,i, � �• .�' /^� '� Y i �^--.mks ..a�e���'� "�'
WWI
t�- ';.4T1 � c..--r•�+t:� �•g"�1 .,vim' '$fit k�- Y �i''.
g 3 Ya \•�-.;;�4, r ,F'\d �� � .,.,., +`" a �tsq t�•""�
ilk
if
+yy� ;�, te♦ 'Jl�,.- .:1!� tS®'�`�,e z�tit YN�,C �� .�P'�^S''��,�t��*_�'`+��� �;F�`4�y�7'
Z "► -�_�c� , "k 1 d ,-dt�',.aiF+l'f1}i !.
OF
ik I I _Zr � �'� �� �.'•�,•, ?♦µ � .�4:jgr�"'y���' y. ee l�I
' v�48eaT(! g
r
fit. - *, ��.✓I �,t e e��.�p.g��:sue''-"
H'
�r ,• �.� �F �„��� sue,,.�
t.
:w
i :" i•� � "^s �+, ..a ._ fir`
10
• � �y�,�'�� -�"�"�+A�• .{ ,.� ..y\_7 .JCr �, t r�
AX
o �y r7�rY` � y�'q ���'r'#wi�� v,y j( -P
< ;' ® �a � )) ��4� �!;�„`'''sMt.� �•, 5���1'* � •(�� r-:r' I•r �i � a�, ..� i•+�.�4� - � a: .�
7 � . a . -R'3' r^�:! � � � ';^ xy'*'}r ��-•..siiilPl� flr�t'>_}�+�ik 4� - ?;<��q,�� �+�� !
t � 1 ,y-.•jr� �4¢�'
° -luJ't GOP
� i .
iVA
V A,&
w
_r f `� qt /-...r��" +—{_ ,� 1 ..r•�"� "!'. '?'�� zJ�'F�..�ta 1
v _�� j k ;,__ � ���:'•-" i.�,,.s�,...�c-'� .�.-�_s--.r"1'*'X:�.G�,��i"� p.. rlb,s�-�'�, ss�i,r'
it ONE
.. max sz,.
WWI
_
+-�z'{�� �ir
LA
• 1
WE
op
AW
Loom
'�F',: i'r� •�, '"'may, � ^1 _._ y 's5"`.�"' �� �_ _
tq �}q�i .. -•c:A.. zrr.=n:." .�-. vK"�}1'°�,'Pr`� �Y Y�J- ..-•....,. '` � ��a �
�.}:. ! f � \ � K ��4 sit-` � �ic-•:� _ -
' �`., t ( py� � �:�!fi1� � f ;'•E•- - -�-X"'" '�Jl �a �^s�p!��i�':4,m'�'r'y �t",�?.' ''.t`�.`�°,
r �. .ram .!/ y �i . Rti��•,, - #�. jai': ,' tZZ�, I
-
s�e
Y
�.
_ � � �•�ap •t" /r L'�.r 1y/� Y' !r' r<l!` •d t!i
I S r ell {:
It
TO Vh
• r`, ,, �4�'�, �'tom �.�i*�':}��
it'F'
Z a"
PIT
f• � I � t � �!'mil�? �!•
lop
�.
� �;r Ttt u„✓
® `1..
v
fir+
y
Qeate Internal Request Page 1 of 2
{
.ggf'�:3y y •bti::./ /�'))s.)�y�+�;�./.,.y) ;//,'jJ}j'
E a[a7P+N K t . k i/ GL/ /f%
Logged In As: {- p� m' Q 9 Thursday, August 12 2010
TOWNlringe Citizen 'Request Management
Route to Users Search Requests Create Reauests
1. Requestor Contact Information: f-i Routine work f`Estimate
r Email requestor with updates on this request. If checked,email required below:
Email (optional if not checked above) ;
r Anonymous-- Personal Info'not required when.checked,skip to step 2.; �_ R
Is contact address a Town of Barnstable address? F,
* Uncheck Town of Barnstable address:
If only name and phone are given and*F check to fill with Unknown,
if contact address is not in the Town of Barnstable, or if,you want to enter manually: `
First Name Last Name _ Requesfor i.00kup
House.# Street Name !RoadSL s[' ( unit, suite, apt;
etc.) ' r F
City State ;Zip Phone(optional) b.. _
_.w ._ w
2. Location of.request in The Town of Barnstable; (enter manually ) `
�- *. .. s
Fill with same address information from above:I 1 f7 r This is not,needed skip to step 3
:Owner.or Business Name atlocation (optional)
House # 48 . (leave blank if is for the whole street) ( unit, suite, apt;.etc. e
Street Name PRAM ROAD
' Roatl List ''
M.
.City Hyannis State Ma ':Zip �.. ._ _
Map: 268 = $lock: 048 ' Lot: 000 f Parcel Lookup '
3. '
The Request Text:
http://issgl/IntemalVVRS/WebRequest.aspx 8/12/2010,, ,
Create Internal Request Page 2 of 2
CALLER STATES THAT HOME OWNER HAS ONE- COMMERCIAL,
TRUCK WHICH HE USES,FOR' TRANSPORTING MULCH AND TREES, +
jPLUS -HE KEEPS TRAILERS AND A DUMP—TYPE TRUCK AND
CHERRY PICKER THERE ALSO. THEY ARE OUT MOST DAYS BUT
BACK IN THE DRIVE/YARD AT NIGHT: OCCASSIONALLY ONE
€EMPLOYEE IS THERE ALSO.
i Spell Check'
Assign Request: A
Department:
Building Dept
Assign to:- Last twenty assigned E
Anderson, Robin•
Category: (use Ctrl for multiple)
•. .i
,�•_ V
Work with
out permit
Zoning- Illegal apts
Zoning Illegal business
d � r
Priori
Medium ; '
Internal Notes: (optional)
` _Spell Check C ate
Ilk
#
http://issql/InternaIWRS/WebRequest.aspx r`' 8/12/201.0'
Town of Barnstable *Permit
�FTNE
Expirewd thsj.A;Affl issue dale
Regulatory Services 1♦e
..- ABLE,
s A
4 Thomas F. Geiler, Director
TFD MA
Building Division
`Sys' 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
Not Valid without Red X-Precs Imprint
Map/parcel Nurnbel;�&—�
Property Address _._�_C> ✓� Cal , �'1T) /yl n O Z6-0 1
G3
IV2esidential Value of Work I-1 0C)o Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address (lC,—1U
Contractor's Name 17S-1 _ __ Telephone Number .3�,�,�f 7/s' f
1
1 Ionic Improvement Contractor License# (if applicable) w _
C=3
Construction Supervisor's License#(ifapplicable) _ o
❑Workman's Compensation Insurance ' n
Check one: U)
❑ I tm a sole proprietor Z Ma. T
I am the Homeowner cr
B-1 have Worker's Compensation Insurance [
w b
Insurance Company Name i
Workman's Comp. Policy#i_
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re roof(stripping old shingles) All construction debris will be taken to� , — ( C,�A L Ic .
❑ Re-roof(not stripping. Going over existing layers of roof)
Rc-side
❑ Replacement Windows/doors/sliders. U-Value (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.
SICNATURE:
Q:` I1FII_F.S`•F0R building permit forms\EXPRE doc
Revised 100608 -"
i
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111'
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LejZibly
Name (Business/Organizatio jd&�ivid7,Z'5�> ra� SQ 1 V1�Tc /1
0
Address: �16VaAl2e�
City/State/Zip: 41rnni Phone.#: "tZ8 -,Ipf)-31ci9
Are"you an employer? Check the appropriate box: Type of project(required):.
1,"❑ I am a-employer 4. [] I am a general contractor and I
with 6. New construction .
employees(hill and/or part-time).* • have hired the sub-contractors
listed on the'attached sheet. 7. ❑Remodeling
2.0 I am a'sole proprietor or partner-
ship and have no employees These sub-contractors have S. []Demolition
e loyes and have workers'
working for me in any capacity. emp 9, []Building addition
[N workers comp.insurance
comp, insurance,$•
5 We are a corporation and its 10.❑Electrical repairs or additions "
quu .ed.] . .
3. I am a homeowner doing all work officers have exercised their lt.[]Plumbing repairs or additions
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 ornot those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I arts an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy 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 maybe forwarded to the Office of"
Investigations of the MA for insurance coverage verification.
I do.hereby certify and r the pains•and penalties of perjury that the information provided above is true and correct.
Si afore: Date:
Phone# l L7pt, 3 —'3
1
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#: "
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 ehapter..152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for•the performance off public work until acceptable evidence of co nplaaEe 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 then
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/li.cense 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;.
�CozxzM(mWWth of MU-Sachusctts j
DQpartin=t of 1nfustr al A,cci&mts
Offlce of favestagat ous
600 Washington Street
Boston,MA 02111
TO--.##f 17-727-400 ext 406 or 1-977-MASSA.FE
Fax#(517-727-7749,
Revised 11-22.06
w .InaSS.gov/dia •
A.
Town of Barnstable
�pf SHE tp�y
Regulatory Services
BARN r"LF. : Thomas F.Geiler,Director
ktess.
q�A 1639. .0� Building Division
JFD �s 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
Please Print -
DATE:
JOB LOCATION: `—L (� rv� - A ` 'f �ftnG1%5
number{ street village
••HOMEOWNER":_:yQ$1'1 U W �(✓1 c 10\ tZg—,S6-6-3 9 c
name �^ home phone# work phone#
CURRENT MAILING ADDRESS: J e_
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 Deparhnent
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
S' tur of Homeowner
S(�T
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 persons)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 t amend and adopt such a form/certification.for use in your community.
Q:forms:homeexempt.
SHerq,� Town of Barnstable
Regulatory Services
BAANSTASr LEg, Thomas F.Geiler,Director
�'iDren a Building Division
Tom Perry,Building Commissioner
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
I, tel as�a UA 41 I�C�U� , as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
g d'X(a-/vim �01
(Address of Job)
c, ztfu
Sig e of Owner Date v
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FO RM S:O WNERP ERM IS S ION
I
Town of Barnstable
"o Regulatory Services
It -
Thomas F. Geiler,Director
wwsreBM
9� MASS.9 � Building Division
�Fo► Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www,town.barnstable.m a.us
Office: 508-862-4038 Fax: 508-790-623(
PERMIT# D 6 �� 7 FEE: $ �ZS^• 66 t
cola
SHED REGISTRATION Q
120 square feet or less
y 8 P(Am
Location of shed(address) Village
'(3 �U�1 ��In ,n SDI—36 D-- 3 /17 �
Property owner's name Telephone number
_l OCR/ 0 e-f A
Size of Shed Map/Parcel# .
706(2
igna a Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature is required)
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMNIISSION FOR DETAILS.
THIS FORM. MUST BE C-e MPANIED BY A
PLOT PLAN \
Q-forms-shedreg
REV:042506 `• f
r 1
Town of Barnstable Geographic Information System October 1,2007
26804-
#31
s 1 268191 4�$
#11
'. 268047
268040 k -�
#41 N
G 268051 $
25 * �
`�
T f „
268048k
#48
8
Td r �' ,,......,A..�,,,..
268039
#51
MR. 5
� lt
0
At
268038
#6141
r
0 18 Feet
DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:268 Parcel:048
boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel
1.=100'may not meet established map accuracy standards. The parcel lines on this map Owner:SISCOE,MELISSA Total Assessed Value:$307400
are only graphic representations of Assessors tax parcels. They are not true property Co-Owner: Acreage:0.25 acres Abutters
boundaries and do not represent accurate relationships to physical features on the map Location:48 PRAM ROAD /
such as building locations. Buffer
I
Town of Barnstable *Permit# fill 76 O
Expires 6 months from issue date
Regulatory Services Fee
Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number y�' (Yg
Property Address B Pz—Al" /2d, /4,oa—y s /444. 0?—66, 1
[Residential Value of Work sue , ` Minimum fee of S25,00 for work.under$6000.00
Owner's Name&Address at—PA-1 12Cf /-7 Arr)i S M& O Zf O l
Contractor's Name C�S 1'� �/� � 1/1. t=) Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance ESS MI
Check one: a R I
❑ I am a sole proprietor
:. I am the Homeowner O C T — 1 2007
❑ I have Worker's Compensation Insurance
TOVVN OF BARNSTA13LE
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
10 Re-roof(stripping old shingles) All construction debris will be taken to l h
❑ Re-roof(not stripping. Going over existing layers of roof)
Re-side
® Replacement Windows/doors/sliders. U-Value�5 ,1 (ivaximum-:44)
''Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e;Historic,Conservation,etc..
***Note: Property Owner must sign Property Owner Letter`of Permission.
A y of the Home Improvement Contractors License is required.
SIGNAT z
Q:Forms:expmtrg
Revise061306
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.m ass.gov/dia
Workers" Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name (Business/Organization/Individual) rt
•Address: �& 0,le9M l2 d /7 ��0
y drr+n� t
City/State/Zip:-«z&C) 1 Phone.#: 53 72 72 i�d
Are you an employer? Check the appropriate bog: -Type of project(required)
1.❑ I am a employer with 4. ❑ I am a general contractor and I
. employees (full and/or part.time).
have hired the su'b-contractors 6. El New construction .
2.❑ I am a•sole proprietor or partner- listed on the'attached sheet. 7, ❑Remodeling
s and have no employees These sub-contractors have
mP8. []Demolition
working for me in any capacity. employees and have workers'
insurance.$' 9 `❑Building addition
[No workers' comp.insurance comp. ,
d.re uire 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.]
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
insurance required.] t c. 152, §1(4),and we have no 12•�Roof repairs
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 iuch.
Contractors that check this box must attached an additionalsheet 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.
ram 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 iip to$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of 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
Ido hereby certff u e thepains-andpenalties ofperjury that the information provided above is true and correc4
Sienature: Date:
Phone#: '"�--_..1 /'</• rr
Official use only. Do not write in this area,'ib be completed by city or town ofcial
in .�
City or Town: Permft/I;i'cense
Issuing Authority(circle one): -d „f,,,,•r..
1.Board of Health 2.Building Department 3.City/Town CIerk"4.•Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
7
a
�pEVE Tp� Town of Barnstable
Regulatory Services
BARNSTABte, Thomas F. Geiler,Director
MAS&
p11639. A.�� Building Division
Ep MA'I
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: 06 1 . I . C) U�
JOB LOCATION: L4 8
number street village
"HOMEOWNER": 0:5�A0 4 509- 350-31s <
name home phone work p one#
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
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
requiremen .
gnatu a of omeowne
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 t amend and adopt such a form/certification for use in your community.
i
THE T TOWN OF B AR.NSTABLE
EAHHSTALLE, i
"6 9 BUILDING INSPECTOR
O HAI p
APPLICATION FOR PERMIT TO .. v. r-' ........ i/x/%... �� �.L�.. . '?..................................
TYPE OF CONSTRUCTION ..... ......................................................................................................
............... �. ..................19'7./.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
l
Location ......... ... o'. ».....�JJP.dt�........... ....✓�fi.a... .:..............
ProposedUse ........,.,v./a�..�,J.l�...... .v J? ?.....................:......................................................................................
ZoningDistrict .........................................................................Fire District ..............................................................................
Name of Owner ..��1/...�i? ... lcr�.�1 ..............Address 1a1:..�i(.y.a�.Jl.l}J.S .u. .............................
Name of Builder . .ti S !..1,...�G(. ./�a.G/...%..�!.r.AddressO�o?,/ .. -e..� ��....1'Y.t../�.P�.�..1....
Nameof Architect ..................................................................Address .........✓...........................................................................
Number of Rooms ........ C:.........::.................................Foundation ....`J 0..4.. .......................:........................
Exterior ..... S.:...........................................Roofing ..."I-,evo.'?. .... .1.hg.1..`5�..5....................
Floors .....cl.)�a2A................................................................Interior ..............................................`./....................................
Heating ....... ?�.`.... /...�.........................................Plumbing ..................................................................................
Fireplace ..................................................................................Approximate Cost ...... ..... .....................................
Difinitive Plan Approved by Planning Board ________________________________19--------. s
Diagram of Lot and Building with Dimensions
/o 10
�S
hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ................. ....:.1/1...���. ...................... t......
Hays, Archibald
DEC 31 1971
No ..13935.... Permit for .........add. ..to. ...single............ .. .... .. . ...... ....
family dwelling
...............................................................................
Location .........:48..P. ..
ram Road....... .... .....................................
West $yannisport
...............................................................................
Owner Archibald Hays
..................................................................
frame
Type of Construction ..........................................
................................................................................
Plot ............................ Lot ................................
+r
i
{
Permit Granted ..... June..7..............:.....19 71
Date of Inspection .......... ......... ...............19
Date Completed ..... ............19
1
i
PERMIT REFUSED V
................................................................ 19 4
I
...............................................................................
............................................................................... ,
f -
Approve .................................................. 19
...............................................................................
...............................................................................