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0062 QUISSET ROAD
CD ad C'� �-`� Sse-{� ��. _-- - - -- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # I r Health Division ��® Date Issued 0 0)(72 �z Conservation Division ®G�� '�� �� Application Feed Planning Dept. �� ;,,Permit Fee Date Definitive Plan Approved by Planning Board ➢ '' Historic - OKH Preservation/Hyannis Project Street Address . �0 2 C a t 5s ek Rd . ! Village Tl14 11r11J Owner G o r ba a e..�I eyn g_ I,c "CIO Address fn 2 (S� Lk i SSe-}- (Zed,C� Telephone -71�Permit Request de, \0 9 . ZsX Ito Beck. C'e,S+r C+ Seo,s0sr �sd-e,� ( moo rhea.}) ®r� pawn-e i2- l Square feet: 1 st floor: existing 9010 proposed �20 2nd floor: existing 71 proposed aPC-Total new i77 3 ZoningDistrict Flood Plain Groundwater Overlay Y Project Valuation 0 00 Construction Type wooed -p-hAl - Lot Size q Grandfathered:, ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2( Two Family ❑ Multi-Family (# units) Age of Existing Structure 33�(f Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: dFull ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 2 new C3 Half: existing 0 new O Number of Bedrooms: existing o new Total Room Count (not including baths): existing 5- new / First Floor Room Count — Heat Type and Fuel: ❑ Gas DJ'Oil ❑ Electric ❑Other Central Air: ❑Yes ,0"No Fireplaces: Existing—t_New ® Existing wood/coal stove: ❑Yes YNo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:%existing ❑ new size _Shed: ❑ existing .❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name G V h+-IbC t �J-o ce. Telephone Number _%4'3 q 17 Address 4& Mow-4, (t 0.A• License# Home Improvement Contractor# Email t C�La i )GO l., COM Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE \`A • FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO.. \ A �G f a p� ZIP TA c e� P\ 9 p S� _0 0 s \ � -.. o T 3 - - 0 Q O{r` �� v 77 3 lip 0RAi . .. �vu ru vA.T i a,r`..► C��TI F IcaT i o�.l s LO -35 a0155 C-T A-0A i } On the basis of my knowledgep information and GaI.JT�tZV ILLrc, l�atziJ5TA0LF'c, MA . belief, I certify town o/ � that as a result of a survey��de on, t e ground avCA iZ, on , .I find that: The s . ructureks) are located on the site as shown. /nC��s-Jpla.�ca K/ !i �hcTocv.� 2mn•�9 , the s WsC &VIVU0 r-/�.MO0TN A . The title lines and lines of ocoupatiori o� site are as ahozm hereon. J" of The site is situated in F1004 1 one Al - r G �E� Mop COmm=ity panel YJo, zSoco 09 Date: ��� WILLIA M. Date: iS : : WARWICK ),aa�. No. 19771O a '9 Fc/STE�� . r I�.111am. I�•• W��w�.ak>,ILLS tip S�R��-�� JHa1Ur��v► 1 Lr -T 6(-,,bCD(�iYec- o c)�- Ric\ , i Town of Barnstable Regulatory Services m�s Richard V.Scafi,Director Building Division Tom Perry,Building Commissioner 200 slam Streets Hyannis,MA 02601 wwwAown.barnstable.xua.us Office: 508-862-4038 Fax: 508-790-62 a0 Property Owner Must Complete and Sign This Section If Using A Builder 1 U G .P h e -,as Owner of the subject property hereby authorizes .I Q. UC-UCe to act on my behalf, in all matters relative to work-authorized by this budding permit application for. QtQt&%d Road,GeRtspAa,MA Q - (Address of Job) �-s **Pool fences and alarms are the responsibility of the applicant.Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Dina ure®� er Pofp �cm ' Marne Print ame d n / Date Tlre.Commo.-riveaith o,f Massachusetts Department a,f rndustrialAccideras `�- - -- Offi--e Of r7i figations , 600 Washurgtorr Street Boston,M4 021II t►mn-V.frassgovIdia Workers' Campensatian Iusurance Affidavit Bt ildei-s/ContractorsJElecfricians/Plumbers Applicant Infarmatian Please Print Lev Na= ens a � �: c� he a Jai. c D �( 0, Address:q�o �- LDN- A ; City/Sfa&Zip---� ,.. . Phone G.. 1. Are you an employer?Cheek the appropriate bad: ' Type of project(required): I.El I am a employer u7tli 4 U'I am a general contractor and I 6. ❑New construction employees(full and(or part-time).* lta�*e hired.tFte sub-contractors �.❑ I am a sale proprietor orpartner- listed on the attached sheet. y- ❑Remodeling These sub-contrac-#ors have ship and have no employees. These ❑Demolition w g far me in any capacity-_ employees and.have workers' or�nb t5` 9. Building addition [NO worke insurance comp,in ance Comp.mn rani # retlrured-] 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.E Plumbingrepaim or additions myself_[No workers'camp- right of exemption per MGL 12.❑Roofrgmirs insurance requiredl i c.152,§1(4h and we have no employees.[No workers', 13.❑'Other camp.insurance required.] *AzLy MUcant dmtche&s box MmruI also filloulthesec&onbeiowshaRing,dierwor&execampensatinnpolicyinfnns cn- #Hameowners who snlmiit ibis.of Am A mdirx g they are damg all wmk sad then hiZe outside contactors amst sabmit a new affidavit indicaliog sncTi fCantzactoasi5st eheckthis bmc mast attached addilianal sheet showing the nameof the sub-cw=xc-tors and state whether arnot those eaeitieshmve employees.If the sub-cont:actashave employees,tbeymnstpmvide their workers'ramp.paUU number. I am an employer that ispr4niftg workers corrrperrsadmi funtraaca for eery encp&yees Eetoty is the pvM7 and fob site fr forrnalforz Insurance Company Nam: Policy if'or Self--ins.Lic.4-: ExpirationDate: Job Site Addn ss: City/Statel2tp: Attach a copy of the xsorkers'compensation policy declaration page(showing the policy number and expiration date). Failure to secs coverage as required undrr Section 25A of MCI,c.152 can lead to the imposition of criminal penalties of a fine up to$1,54D.OQ andror one-ywimprison=ueut,as well as civil penalties in the form of a STOP WORK ORDERand a fine of up to WO-0O a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Irrmstigati,ons of the DIAL.for insurance-coverage"-edfication. Ida hereby cethfy alyder tliepains arrdpsrraWes ofpet�ruty-f iattlre frrformador!prat rled above is bus arrd carrect Sitmaiure: /. Date: tj i Phone 021 al use anly. Do not mite in this 4 ea,to be campteted by city ortoom a iciat City or Tom•n: PercmtUcense# Issuing Authority(tarde one): 1.Board of Health 2.Budding Department 3.Citytro n.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions- M.assarhusetts Geheral Laws chapter 152 regoaes all employers to provide wa3kers'compensation for their employees. p tp this sue,an ej7L7yee iS defined as_"_...every person in the service of another under any contract ofhiM, express or iDplie4t oral or write mf An e ,Try,is dad as"an.individual,partnership,association,corporation or other legal entity,or only two or more inch the le representatives of a deceased employer,or the is a oint ' e,and including gal the fore J �TP�of foregoing engaged receiver or tr-astee of an individual,partnership,association or other Iegal entity,employing employees. However the owner of a dymEing house having not more than.three apartments and?vho resides therein,or the occupant of the - dwelling house of anoher who employs persons to do man trnance,construction or repair work on such dwelling house e an or on the grounds or building appuiEn�t r thereto shallnot because of such employment be deemed to b empto yer.n MGL chapter 152,§25g6)also sues that"every stair or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a bless or to construct buildings in the commonwealth for any applicant who has not produced acceptable evid iII ence of compliance with the suran r ce.coverage equired_" Addi(ionally,M(M chapter 152,§25C(7)states-Neither the commaawe-alth nor nay of its political subdivisions shall enter into any contract for the performance ofpubho work until acceptable evidence of compliance-valh the insurance, rU M-r.TF ents of this chapterhave been presentedtD the contracting aathD sty." Applicants , Please fill oi± the workers' compensation affidavit completely,by cherkiag-die;boxes that apply to your situation and,if necessary,supply soh-contractor(s)name(s), address(es)and phone numbers).along with their certificates)of . insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to catty workers' compensation insurance. If an LLC or LLP does have employees,a policy is regnired. Be advised that this affidayit may be submitted to the Department of Industrial Accidents for confirmation of msur�ince coverage. ATso be sure to sign and date-the affidavit. The affidavit should be retvmed to the city or town that the application for the permit or license is being requested,not the Department of Tnrh,si,-iai A ccidm s. Shouldyou have aay questions regarding the law or ifyou are required to obtain a workers' compensation policy,please caIl thD Department of the number listed below Self-fimumd companies should enter their self-msar +ce license number on the appropriate line. City or Town Officials Please be sore that tha affidavit:is complete and pried legrlrly- 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 till.in the p=7 Wlicense number which v M be used as a reference number. In addition,an applicant that must submit mulliple pennWhcense applications in any given year,need only submit one affidavit iadiratiag cmTeat p olicy infbmiation t`if necessary)and under"Job Site Add[-ess"the applicant should write-"all locations II (crt5'ar town)_"A copy of the-affidavit that has been officially stamped or maiked by the city or town maybe provided to the " applicant as proof that a valid affidavit is on file for fuiare petmi_ts or licenses. A new affidavit must be filled out each year.W: here a home owner citizen is citi rs obtaining a license or permit not related to any business or commercial verdure Cie. a dog license or pennitto bum leaves etc.)said person is NOT reTal-a to complete this affidavit The Office of Investigations would h-ke to thank you in advance for your cooperation and should you have any,questions, please do not hesitate to give us a call. The Departments address,telephone and fax number 'Ihe CammmwwIffi of Rfassachusttts Deparfment cif Induslaal AoCdentz Mace of TItvtstig4aa-Ei (500 Waabhoan M&oI l II Fax#617-727 774 Kevised 424-07 WW vxaa_--_gaVjdi8_ • Depai�ttter�aflaj�4rr-�dvs�f� _ offl,ce af1wu a arcs 600 Warhbvton Street Bas*MA 02717 - . i ww.r'rra�rgm�f�ia - • Worimup Comp emsafionlnsm-anceAfUdzvffi-BtaZdetslConiraefnrs/IIec�icianr/P1IImbers AppIirant Informatibn Please Prins Le� Name(Bnsmcsslo j2o 1, t Ye6L - Address: l2., -m S Z.-6ou 2 N I2 e � rzip: . Phone 9 7�1 75 � s� Are you an employer?Check ihe appropriate bmc 1. Type at`proJ ❑ I� Wi h 4. ❑I am a general caoftwt ff and I ed( ' 2.�Iop��ees(hu and/or pazt Vic).* have hnzd fhe i 6 � i Cw nn a sole proprietor or pmt=- - Iisfzd aoa the at achad sheet 7..❑R=drlmg ship and have no employers Th=sul)- 6 havo S. ❑Dc�oIiticm wo g forma in-my capacity, a gloycrs�dhavework¢s' [ND wOLkeis'comp.incnranrr_ Comp.incmanr_.•$ 9 additicnl rcquin ] 5. ❑ We am a cmparation and ifs 10_11 BIwtricalrepaim or additions 3.❑I am a homeowner doing an work offic=have exercised 1hrir 'IL❑pb=bmgrepaju or addi ims myself [No worm'comp. Ii&of==PfanperMGL ' bsmm=-turd.]t a 1,§I(4),amdwe have no. ME]Roofregaas c,mnp,iommz=regahm&j *Any app1i=mtthat d=c m box#1 aunt also bII m:�j ==:t=brjDw shmft&swG6=&eompmsation PAY ntfi=Ddon_ t gnm=nm=vdw sabmiMis aT3dnv$md'i ft 1hL7' domS 3H wad aad thro b(=Oubddo fs za�t svbmrt ancp�affidavrtmdica ngsnrb_ kCoahacr fiT eh=kthis box=st attaaed ea add nnaI sbmtsbowh6 ib muao aftbe sab-waft=tu==d sib whdficr crnot those c jh=hope aaQloyee�If the sab- mxs hive�lopccr,tbeP mkt Iav�ide thca wo�aa'conxp PAY=.bQ I airs arc earplvyer that is pravidmg orlrers'corr�ensafiait nrsra nre for i np emp1byem Belor it the perry and job site Icu=auce Company Names Policy#or Self-ins.I ic.#:. Firatiom Date: t Job Site Address:: . Atfarh a copy of the workers'compaasafioix policy declaration page(showing the policy number and expir-AAcin date). Faihaz to s==coverage as requiredmnrI Sec.dm25A ofMGL r`152 can Icedtm the imposition ofEM-UP cmminaipiccoalfies of a to$I,SOD.00 and/ ono-year imprisc�er as well as civil penalties in tht R m�of a STOP WORK ORDER and a fine of i3p to$250.00 a day against the violator. Be advised that a copy of fiiis statement map be f mm&d to the Office of` hmmdgaiions of the DIA for ins coverage Vmiacadom. I do hrreby catfy under gmpairrs and pew bfpwjmy Ojai&e hzformatio>t praysded above it t5zce and coirerl S- Dam l J•o ZD f Offidal use only. Dv not write in fhis arrn�to be cnmplded by city or tmm marl City or Town_ Issrrmg Authority(cu de one): Board ofHealfh 2 BmIdmgDepartmint 3:CiipJTown Clerk 4. icallnspmfor S.Phn#iagInspector, 6 Other ConfactFerson; Anne Information and Instrueflons ; AfiRcca ' Laws chapter IU=qm=all employers to provme waimrs'c mpematim for'rhea ermpl0yees. P rsoantto this sty an employee is defied as'.cvcq person in fm service of anal=ceder any canbxact of7 tr; eXprCSS or implied,oral or writtCEL An.anpbj,er is defined as"an irufividnal,pmtacrship,assocation,corportioi or ocher legal cn f,or any two or more of the foregoing engaged is a join mtrprise;and inchrdmgthe legal repr=mfatives of a deceased eurploye[,or me receiver or trustee of an individual,pa taccslrtp,association or offiar Iegal entity,e o loymg employees. However the owner of a dwellinghouse havingnotmote tban$nee apart neat s and who resides ferein,ar the Dccapant oftbe- house of another Soho m3ploys persons to do ma-�anc,ccroshuction or rcpaa work am such dwelling Noose �or aee grounds or building sballnotbecanse ofsuch employrnmtbe deemed to be on employer." MGM chapter 152,§25C(6)also states that"every sfafe or local licensing agency shall wnhoId fhe issuance or reaewaI of a license or permit to operate a business or to construct buildings in the common wealth for any aprplicantwho has not produced acceptable evidence of cdmcpliance with the hm-a ance.coverage required-" Additionally,MQ,chapter 152,§25C()states`Neidhm the comronaweatth nor any ofits political subdivisions shall _ enter into any contract for the performance ofpoblic workunt it acceptable evidence of compligace with the insurance.. requsemevts of this chaptrrhave been presented in flze conhartmg anihoiity." Applicardts I Please fill out the workers'compensation affidavit cotapletely,by d=Jdmg the boxes flik apply to your sitnation and,if necessary,supply sub-contactor(s)name(s),addr ss(es)and phone numbers)along wilt their certificates)of insurance. Lfinitzd Liability Companies(IS.C)or Limited Liability Partnersbips gJ2)withno employees other than the members or partners,are not regahrd to carry workers'compensation insorance. If a a LLC or LLP does have employees,a policy is required. Be advised ihatthis affidayk maybe submitted tD the Department of Industrial Azcideots for conformation ofinsmance coverage. Also be sure to sign and dat-ethe affidavit The affidavit should be retuned to the city or town that the application fur the permit or lirease is being requested,not the Department of Indhistrial Aoddents. Should you.have any questions regarding the law or if you are rcga imd to obtain a workers' compemsationpDlicy;Please can the Department at the number listed below. Self-insured campanics should eater their self-insurance license number on the appropriate line. City or Town Officials Please be sarr.that the affidavit is complete and printed legibly. The Depar lmed¢has provided a space at the bottom of fhe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant: Please be sine to fill in the pe rdt/license mrmber which will be used as a reference rramber. In addition,an applicant Ie ermt/liceose litaiions in car need only submit me affidavit indicating cruet $rat must submit rortitip P �P �9 l�Y - policy f ifu mafion(if necessary)and umier"Job Site Address"the applicant should write"all locations in (city or town)_'A copy of the a.ffidavrt that has been officially stamped or mm3ced'bytha city or town maybe provided to the applicant as proDfthat a valid affidavit is on file for firture permits or lireuses. A new affidavit must be filled Dirt each year.Where a home owner or citizen is obtaining a license or permit not related to any business or cox m e-cial vent= (ie. a dog license or permit to bran leaves etc.)said person is NOT required to completo this affidavit The Office of Investigi ions vudd Irk-to thank you in advance for your cooperation and should you have any goesfiDns, please do not hesitate to give us a call The Dep7 m.enfs address,telephone.and fax nmnber. -�Rke Commonweala of Mssmi - , DEepad meat of 1n Ao ideaft ()M=Of gated - Das�n,MA E1�11� Ta 9 617-7` -4900 cxt 406 or 1477 MA.SSAFF, Fax#617-727 7749 Revised424t)7 WW v mas,, AHa l Office of Consumer Affairs and Business Regulation 10 Park Plaza'- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration '= Registration: 184556 j r Type: Individual Expiration: 2/3/2018 Tr# 286224 CJ'S HOME IMPROVEMENT SERVICES CYNTHIA JOYCE " 46 GREAT MARSH RD; CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 fb 20M-05/11 U/ae ipoairnao�rrcac�c�G���C�/f/�ctJJC�cluoett , Office of Consumer Affairs&Business Regulation- License or registration valid for individul use only f OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistratiow.. ,<184556 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 xpiration 2/3/2018 ; Individual Boston,MA 02116 c �� _ , CJ'S HOME IMPROVEMENT SERVICES. CYNTHIA JOYCE 46 GREAT MARSH CENTERVILLE,MA 02632' ^Undersecretary of valid wit&ut Nenatkre Massachusetts Department of Public Safety � 4 Board of Building Regulations and Standards t License: CSFA-094426 Construction Supervisor 1 & 2 Family ROGER W LOYER 12 MELBOURNE ROAD ;,� HYANNIS MA 02601 Expiration: Commissioner 06/09/2020 i � x Elevation - Side View BUILDING UBPT• JAN 12 2017 TOWN OF BA-,,jt,%STA13LE Ws Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 • . Elevation Front View . deck 6'z j2' IT- Ground Level 12"x 4'concrete pier F; CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 Floor Joist Plan exterior wall of home exterior wall of home DTT DTT 2 x 8#1 PT southern Pine Notes LU28 Joist hangers LPC connect joists to Connector ledger and rim .� LU24Z hangers LPC 12 ' connect sides joists Connector to ledger All connectors to be ZMAX or hot galvanized 16D hot galvanized nails for LU toenail SD#9 x 1.5" screws for all other connections Ledger to house rim connected with ledger locks at ECCLL464 11" intervals Connector LPC 64 See foundation plan Connector ECCLL for post to joist Connector connections 16' CJ's Home Improvement Services- 62 Quisset Rd, Centerville, MA 12/27/2016 1 Foundation Plan LPC Connectors (see floor joist plaqn for locations) carriage bolt Li 0 0 ABU46Z 2" x 8" PT Joists LPC 0 0 00 - 5/8" anchor bolt 4" x 6" ground contact PT Post 12" dia x 4' concrete pier CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 Foundation Plan ECCLL464 Connectors (see floor joist plagn for locations) o ABU46Z 0 0 ° 0 ° o 2" X $" „ 0 anchor bolt 2 x 8' 0 0 4 ECCLL464 O o o ° ABA46RZ CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 End Wall Framing Plan H2 connectors on each rafter 6„ 2'x 3.5 x 10 LVL 2"x 6" HH4 connectors to support each header LSTA15 to tie headers to top plates 8' Simpson H6 connectors at top and bottom of each full lenght stud to connect stud to top plate and stud to floor joist - _� 3/4"sub floor 2 x 8 Joist 1 g' CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 Side Wall 1 Framing Plan 2 x 6 2 x 8 HH4 connectors to support each header LSTA15 to tie, headers to top plate 8' Simpson H6 .connectors at top and bottom of each full lenght stud to connect stud to top plate and stud to floor joist 121 CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 Side Wall 2 Framing Plan 2x6 . 2x6 2x6 HH4 connectors to support each header LSTA15 to tie headers to top plates 8' Simpson H6 connectors at top and bottom of each full lenght stud to connect stud to top plate and stud to floor joist 12' CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 Roof Rafter Plan exterior wall of home exterior wall of home Notes: 2 x 6 3.5" x 10" LVL- H1 connectors to tie each rafter to the LVL beanm & wall top plate 12 ' 3/4" sheathing 13' for roof deck underlayment architectural asphalt shin le —�—' P 9 2 x 4 top plate step flashing at roof to siding • joints 17' CJ's Home Improvement Services 62 Quisset Rd, Centerville, 'MA 12/27/2016 y Deck Plan 2 x 8#1 PT southern Pine Ground contact Notes:. Deck surface will be approximately 12" above ground level with one 36"step It will be set on concrete forms/ set into ground approximately 8" deep. It will not be attached 6' to any part of the permanent structure LU28 joist Hangers 12' CJ's Home Improvement Services 62 Quisset Rd, Centerville, MA 12/27/2016 42 TOWN OF'BARNSTABLE Permit No. ?5' __-----_-------__--_- Building Inspector cash • - --- — - �e�a arrr ` OCCUPANCY PERMIT Bond Issued to S L S Trust Address Lot 35, 62 Quiss�.t Road, Centerville ` Wiring Inspector �- L i �. .�--- , "�'- ,Inspection date Plumbing Inspector V / Inspection date Gas Inspector `,/ _ Inspection date Engineering Department f, Inspection date/ r 1:" r._ 11-•���frr!f /lief �'f -.. �l^ tl Board of Health -�.� ✓ .i_ _ � — > .f Inspection date Z? j THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. __. _..... , '' Building Inspector i a -d NIP 9 �l� o c a� g` 34 It V 0 0 s � LoT3� z7 �< 0 V 40 s a �• t tr S J 0 R A IRN �. t ;cnv�j C7A F. IcA.T i o� information and �-oT �5 ou 55 ET s•Zo�o On the basis of MY knowledge, G�IUT�RV ILL!'c, l'��f��5TA0L!'c, MA . belief, I certify to a on; t e ground AvrA i2, I�W3 that as a result of a survey on —v I find that- 'lhe�cture(s) are located on the site as aws uJM, M,wn 2u.� IG K ' n►.�.�%L' I r�1G, shown. In Cam-* /11 aca WWA �/�7v�v.� Zmn��y L The title lines and lines of .00cupatio o the �K �' I �Jo. �nLlvtovTN , AAA , site are as shown hereon. \iH of The site is situated in Flood Gone Al - � G� ► "'qrf oomm pity Panel N0. Ifa OD Date- � WILLIAM7-1 q`yc M. en WARWICK 'Date:; � No. 19771 Assessor's map and lot number /...............r�.............!/ OFT Er0 Sewage Permit number ..Y ....................,9 t,: . .... -...... House number . ..................lQ.. .:J�........... 9Sd9T M A31L . � s63q. ♦� �DYPrAr TOWN OF BARNSTABLE ._ BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..:..�.:.... / :�/ J ...�. ....................... .......... .......... . TYPE OF CONSTRUCTION .........0 5.- 49..V............ ................................................ ............ ��0..............19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following info ation: Location 5 .......... .... ...... ... .... ... .. ... ...........C��'... Proposed Use ........... ..V."t f T ........PLV.. .........l. .. .. .......... .................................................. Zoning District g ..................�...b........ ......................:.......Fire District ....................... Name of Owner . . .�1....1....f V.. ...... .........Addressl.�-' Name of Builder Qrlr..-:.. !/l..('e:.............. ......Address .................................................................................... Name of Architect/..�/ ../atQ ... .......Address �1............11trov/. Number of Rooms ................^�................................................Foundation ..... . .v. n. p.... �..��� \ C Exterior ...................................................Roofing .. C'. 1........ .....:............ Floors ....P ...>— .,�........................Interior � 1� .................................... Heating le ..................................................Plumbing ..... ....L/`� �.1 Fireplace .....: .� ...............................................................Approximate Cost ......... y�� ...................... ........ Definitive Plan Approved by Planning Board -----------_-------------------19--------. Area ......../../�.I....'f `:::t........ Diagram of Lot and Building with Dimensions Fee 4? '............. .................. SUBJECT TO APPROVAL OF BOARD OF HEALTH . . v lvl OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r arding the above construction. Name . .. .................................... Construction Supervisor's License�, may/.. t L S TRUST 't o 25442:.. Permit for ....................................Story ` ,,_< •/ ,.Single Family Dwelling r ............ .. .. . .. Lot 3 5' �Ra.�... Location ............................... ........................................ ............ , i — •• Owner ..s.. :L...S.....TRUS ................................. , J Type of Construction!Z-KAMQ.............................. Iv ...................................................................... Plot .............................. .........r................. Lot ................................ Permit Granted ,, August. 19.,...........19 83 a Date of Inspection ....:19 Date Completed .. ............1,9 D ' f 1 � . .J 64 ff . Asse' ssor's map and lot number .............................................. ! O%THET�y Sewage Permit number �......,f.... P o Z 33398d9TLB L i House number ..................` t ' rasa �O,s�1639 CEO MOR a' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....!:.................. ........ ....... !............................. w TYPE OF CONSTRUCTION ......... ..: r::.....:....................... ........................................................................ ............ ..............................19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location a �t �C ..... ............. .......�.... '........... .... .. 1 .....! ............. .................................................... ProposedUse .......... �! ..1.f, l,. '....... 1 F.?.?��%;/ `./! ...... ................... .................................................. 7, i Zoning District ..................at` .. ........�..............................Fire District ............................ Name of Owner .� .. ................. �, ....,...... Address f. ., / t �1 ,f ...... �` .;�..�... !�'. !� l ... �/ .Address ! . ... r Nameof Builder ........ :_ ......... ...-....'.......................`.................................................. Name of Architect' "?; /. l a. �....5 !!�.R:�.......Address :�..1. .� ! ... .!. � ! 1 '/. ? �r. Number of Rooms .................................................. �` Foundation ..... ?2 Exterior ! ....:................................................Roofing % !"�.?g..!- '....... ? . !........................ Floors '��'� --} '�� .,t........................Interior �h��. `.. .................................... Heating .. ........................................................Plumbing ... ....... .. :.. . rl t ...................�;. v'r�r ; Fireplace ... ..-............................................................Approximate. Cost ........4 1(-,-9 ................................. Definitive Plan Approved by Planning Board -----------_------_-----------19________. Area .......� e�t?/..S .......... r Diagram of Lot and Building with Dimensions Fee .� ..........�� SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ' Name .... '9` .. .: '.................................... Construction Supervisor's Licensef.::" ''1 �... .. S L S TURST A=250-41 & 40 25442 1-1-2Story No ................. Permit for .................................... Single Family Dwelling ..........................� ........... . Location .Lot 3 5, oad ...'.. ........'............. �iL�14t.�S Owner ......S... . ..... S Trust. ........ ............... Type of Construction ...Frame .......................... Plot ............................ Lot ................................ Permit Granted ..August 19, 19 83 Date of Inspection ....................................19 Date Completed .................:....................19 f OO-1c. a 5v -/3e o , OpTNET Town of Barnstable *Permit f0 Expires 6 months from issue date t `o Regulatory Services Fee BARN''i`ifH' ,.s ' � Thomas F. Geiler,Director MASS. a 9�A �9• Building Division - � �v/I N'6& _ leo a a �U�$ Tom Perry,CBO, Building Commissioner 1 QWN.Q� ��� s� _ 200 Main Street,Hyannis, MA 02601 ABLE www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-79.0-6230. EXPRESS PERMIT APPLICATION - .RESIDENTIAL ONLY Not Valid without Red X-Press Imprint . Map/parcel Number,L—`) ISO �{y / �yr // -- Property Address_. t9.. - SS �4.� U� �ICZ U� / Residential Value of Work j 07R1 Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address C �t Contractor's Name o�t f� /rvu /✓� ' /�f s/C e_ v elephone Number I lame-Improvement Contractor License it(if applicable)_ Construction Supervisor's License tl(if applicable) C S ❑Workman's Compensation Insurance. Check one: ❑ I am a sole proprietor ❑ 1,am the Homeowner Mflhave Worker's Compensation Insurance Insurance Company Name_ U �CQ^� ` . l 0 ' Workman's CO-inp. Policy 7 I Copy o1'Insurance Compliance Certificate must be on tile. Permit Request (check box) n Re-roof(stripping old shingles) All construction debris will be taken to ,✓/ ❑ Re-roof(not stripping. Going over. existing layers of roofl ❑ Re-side yAjl �Zeplacement Wt`ndows/doors sliders. U-Value (maximum .44) *Where required: Issuance of this'perinit 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. (JUS-IGNATIJRE: u.4. Q:`WI'FILI.IS'.I-*ORMSlbuildingpennit forms, S.doc Revised 100608 The Cotnrnonwealth of Massachusetts Department ofIndustrial A ccidents Office of Investigations 600 Washington Street Boston, AAA 02111 www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / n Please Print oLe�ibly Nazxle usiness/Organizatio dividual): �.���� r/��l vn /y 0Yi/f Z r_C1__- `(M " Address: 0c) City/State/Zip: / e-y 14 Phone.#: S7&_ d Are you an employer? Check the appropriate box: 'Type of project(required): 1. I am a employer with_ 4. ❑ I am a general contractor and I employees(full and/or part-tim.e). * 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 h $ 9. ❑ Building addition [No workers' comp.insurance comp. insurance. required] 5. ❑ We are a corporation and its 1 J.O.❑ 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.❑ Roof repairs insurance required:] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Othc R-re 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.- XContractors Heat check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. if the sub-contractors have employes,they must provide their workers'comp.policy number. I am an employer that is providing workers' compensationn insurance for my employees. Below is the policy and job site information. / Insurance Company Name:. r6tM, 1 f :771VS Policy#or Self-ins. Lic. #: ?& Expiration Date: 9 Job Site Address: - -rd 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 tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and.a Pane 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 ofperjury that the infortnation provided above is true and correct. Signature: t Wel`-u Date; �B (11 Phone#: �—� (4 7 ?6 Offrcial.use only. Do not write in this area, to be completed by city or town offcciab 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#: Kassachu:setts Department of Public Safety11w artCt>f Building Regulaatiotis and Standards Ot 6strut four Supervisor License. t,:eccnse CS 81653 w WALTtR,-, AFREN JR 40 AL 1%1 A bk!:.: �'.,.YARM0QT t tIA 02675 t , 14 is�t312Q1 C`eti�S3aSatttte7" 1'a7i 3952 F i oar o ui frig e u at ns and =an �ars�� One Ashburton Place - Room. 1301 Boston. Mass husetts 02108 ' Home lmvro ement o ractor Registratioii ReMstration: 145832 '1"vbe: DBA Expiration: 3/4/2008 TO 127455 NORTH SIDE HOME IMPROVEM �d ' WALTER WARREN JR, 40 ALEXANDER PR. ry YARMOUTHPORT, MA 02675 a Update Address and return card.Mark reason for change. " w. address Renewal i Employment J` host card OPS-CAI 0 WM-0&0&PC84&0 ,,... ._ Board"af'111uifn'gegu ttdoiis/,.a`d txp ands License or registration valid for individui use only HOME IMPROVEMENT CONTRACTOR j before the expiration date. If found return to: ROOtMt(o(!f,,146832 Board of Building Regulations and Standards E on p09 TP#t 127456 i One Ashburton Place Rm 1301 Bbston,Ma,02108 NORTH SIDE HOA4 b4 1 ksCt WALTER WARREIV,�j 40 ALEXANDER OR YARMOUTHPORT MA 02H75 aRt�,��,s�ar,s,. Not valid ovithou ure GRANITE STATE INSURANCE COMPANY 92252-0000 WC :._ 742-76-59 13102 013-66-05o8-oo ATEM 1. NAMED iNSURED: MAILING ADDRESS . . WALTER R WARREN JR. Member Companies of 40 ALEXANDER OR YARMOUTHPORT, MA 02675-0000 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 I.D# .. HUB INTERNATIONAL NEW ENGLAND LLC WORKERS COMPENSATION AND EMPLOYERS 437 STATION AVE LIABILITY POLICY INFORMATION PAGE SOUTH YARMOUTH, MA 02664-0000 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL RENEWAL 00206991 . OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE -Wg80510 I7EI012 POLICY PERIOD 12:01 A.M.standard thne at the Insured's maRing address FROM. 05/19/o8 To 05/19/09 nlEm 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Comp ensation Law of the states fisted here: MA S. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 100,000 each accident Bodily injury by Disease $ S00.000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 trEtp 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re- Premium X Annual 3 Year muneration Annual 3 Year SEE EXTENSION OF ITEM 9. OF THE INFORMATION PAGE - WC7754 Oft-WE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $159 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM Ss 00 If indicated below,interim adjustments of premium shall be made: Saml-Annually Quarterly Monthly DEPOSIT PREMIUM 05/27/08 ASSIGNED RISK 66 issue Date Issuina Office Authorised Represent ive WC 00 00 01 Northside Home Improvement Estimate 40 Alexander Drive Yarmoutport,MA 02675 Date Estimate# 10/7/2008 226 Name/Address Wallin,Eric 62 Quisset Village Centerville Ma_02632 Project Description Qty Cost Total Replace three existing skylights in home,home owner to purchase 5,000.00 5,000.00 skylights separately. Remove existing shingle.roof. Re-nail loose boarding. Install.32 aluminum drip edge. Install Weather Watch or Stormguard ice and water shield on bottom edge,in valleys,around penetrations. Install 15 pound underlayment/felt on entire roof. Install GAF Timberline 30 year brand Architectural shingles. All shingles to be storm nailed(six per shingle). Vent pipes to receive new flashing., Trim boards and gutters to be covered for protection. Cut open and install Cobra ridge vent at peak. All`rooting related rubbish to be removed by Northside Home Improvement. Construction Supervisor License.#91653 Home Improvement Contractor License# 145832 Workers Compensation#WC240-69-41 (copy to be mailed to you. by insurance company) Full Liability Insurance(copy to be mailed to you by insurance company) Payment is 50%upon acceptance,50%upon completion. I accept the proposal as described above and permit Northside Home Improvement to remodel my home at 62 Quisset Village, Cenetervilie Ma.02632 Hom ErikWallin l Builders Signature: Walter R.Warren Jr.DBA Northside Home Improvement Total $5,000.00 Town of Barnstable Regulatory Services ft � tia Thomas F.Geiler,Director £ . ......... . ABLE Building Division ,-� ti IO- i+ y KAM Tom Perry,Building Commissioner .16 9. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us (31`�i5iQ Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: — HOME OCCUPATION REGISTRATION Date:�{�q- ©5f Name: �G Zi l�—5 Phone#: OF 3 _ �) Address:)6 0 j6Vl Village: Name of Business:—� � //1/��6�1 Type of Business:-_I/Z/ - Map/Lot: ��0/3 O Z07- `35- r%r=: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. 0 No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. 1,the undersign r d and agree with the above restrictions for my home occupation I am registering. t� Applicant Date.• ! ` Homeoc.doc Rev.5/30/03 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost $30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1s` FL.,.367 Main Street, Hyannis, MA 02601 (Town Hall) ty� DATE:2Zia 1�v W:: P Fill in lease: APPLICANT'S YOUR NAME: GIG � 5�• BUSINESS YOUR HOME 3 _ TELEPHONE # Home Telephone Number .j NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES N.O. Have you been given appro fro the building division'0 _ ADDRESS OF BUSINESS �' �/If/Y. ' '+ MAP/PARCEL NUMBER S®�3� LIST When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 20Q Main St.—(corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM ONER'S OFFICE This individ al has en infor of any,permit requirements that pertain to this type of business. u horize ignature.. COMMENTS:no � 1On ks 2. BOARD OF HEALTH This individual has b n informe o e=, =ir fin'is that pertain to this type of business. u orized S' atur COMMENTS: 3. CONSUMER AFFAIRS(LICENStNG AUTHORITY)n N0latA10 This individual has �e i orm the icens eq it m t that pertain�to this.type.of business. Authorized Signature** AON 900Z COMMENTS: { TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Permit# T-1 >; Map _ ® Parcel � � � - - Health Division Date Issued Conservation Division Foe %.:!�; 00 Tax Collector/se.Q � Treasurer Planning Dept. Checked in By. Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis i Project Street Address r Village - n r'1 I S Owner /v lL�2 �G�� Address Oail 5Sk% 7. C'Gs�i GA_I/&L� Telephone ,�i de- -y5-- __3','77 Permit Reques 0Ae ,11 �`quare feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new V ' J� a Va uatio r 4 V rW e/l Zoning District Flood Plain Groundwater Overlay Construction Type kyoq Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .N- Two Family ❑ Multi-Family(#units) r- Age of Existing Structure Historic House: ❑Yes IWNo On Old King's Highway: 0 Yes ❑ No Basement Type: ❑ Full ❑Crawl Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new j Total Room Count(not including baths): existing new First Floor Room Count ; Heat Type and Fuel: -9Gas ❑Oil ❑ Electric O Other Central Air: ❑Yes a No Fireplaces: Existing New Existing wood/goal stover,❑Yes No Detached garage:Otexisting ❑new size Pool:0 existing ❑new size Barn:alexisting 0 newt size Attached garage:Cl existing ❑new size Shed:❑existing 0 new size Other: ' Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION /Name /Telephone Number 0�p_ Address rg 0 S56l' License# U/ o Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,,-,-SIGNATURE DATE - �- l 1 r FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS ~ .r ;� VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME 00i 1% - 2 J INSULATION FIREPLACE t ` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING i . DATE CLOSED OUT ',' ASSOCIATION PLAN NO. 0 I ,� r /761Izze tip ;-sd1-0 L Y , 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 Legibly Name (Business/organization/IndividuQ' t%G�• zg&54• ^ Address: (�__ _ : City/State/Zip:f3� lilG� Phone Are you an employer? Check the appropriate box:. Type of project(required_): 1.❑ 1 am a-employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (fu1T and/or part-time).* have hired the sub-contractors listed'on the attached sheet # ?• ❑ Remodeling 2.❑ I am a sole proprietor-or par�aer- • ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9, ❑ Binding addition (No workers' comp.insurance 5. ❑ We are a corporation and its 10.7 Electrical repairs or.additions required] officers have exercised their 3.�I am a homeowner doing all work right of exemption per MGL 1.1.❑ Plumbing repairs or additions myself-[No workers' comp. C. 152,§1(4), and we have nQ � 12.0 Roof repairs insurance required.]t employees. [No workers j 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contmdors and their workers'comp..policy infoaznatioa I am an employer that is providing work 'compensation insurance for my employees.'Below is the policy and job site. information. Insurance Company . e: 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 STOYWORK ORDER and a line of up to$250.00 a day against the violator.,Be advised that a copy of this statement may forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certi _ e pains and penalties of perjury that the information provided above is true and correct. Si atnre: Date: — - �Phone# Official use only. Do not write in this area,to be completed by city.or town officiaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone.#: Inform ation anal Instructions. Massachusetts General Laws chapter 152 tequires all employers to provide workers' compensation for their employees. in the service of another under any contract of hire, pursuant to this statute, an employee is defined as"...every person express or implied,oral or written.";. ' « , association,Mporation or other legal entity,or any two..or more An employer is defined aS=:an iudxvi¢ualpartpersip of the foregoing•engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the association or other legal entity, employing employees. HoweY.er: e receiver or trustee of an individual,partnership, ant of the owner of a dwelling house having not more than three apartm�ts dcdownstruction oesides r repair work on erein,or the s dweIling house use of another who employ$persons to do maintenance, to be an employer." dwelling house the deemed emp y d g because of such loymen • building. urtenanttheretoshallnotbec employment . on the grounds or or • MGL chapter 152, §25 C(6)also states that*every state or local licensing agency shall withhold the issuance or ewal of a license or permit to operate a business or to construct buildings in the commonwealth for any Ten ce of compliance with the insurance coverage required." cce table evidence P of produced acceptable all applicant who has n p ter 152, 25C states"Neither the com�moi<wealth not any of it-political subdivisions shall Additionally,MGL chap § (� 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 f. checldng the boxes that apply to your situation and,i necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certifiocate�s otohf� the insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no emp ,y members or partners; are not req Beadvised thatothis affidavit may be submitted to the Departmentf Industrial employees, ensation insurance. If an UC or LLP does have a policy is required Accidents for confirmation of insurance coverage., Also for sur theor licensee to sign es being requested,�not the Department of should. be returned to the city or town that the applicationf P Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workErs' lease call the Department at the number listed below.. Self-insured companies should enter their compensation policy,p self-insurance license number on the appropriate lime. City or Town Officials . Please be sere 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 tion, an applicant Please be sure to fill in me perrmt/hcense number which will beused ars,need arc subbmmit on affiber. in davit indicating current that must submit multiple permittlicense applications in any giveny ` policy information(if necessary)and under"Job Site Sddress�or�k�a�should write �ley b��d���e or to.Nn)"A copy of the.affidavit that has been officially tamp applicant as proof tha a valid affidavit is-on file for;future permits•or'hcenses..Anew affidavit must be filled out.each year,Where a home owner or citizen is obtaining a license or permit not related any lete�eass�a�mmerdal venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT requiredcomp The Office of Investigations would lice to thank you inadvance 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 Icepartment of Industrial.Accidents Office of Investigations f. 500'Washingfon Street . Boston,MA 02.111.. Tel.#617-727-4900 ext 406 or 1-877-MASSAF'E Fax#617-727-7749 Revised 5-26-05 Rrww.mass.gov/din oF�E Town of Barnstable - Regulatory Services Thomas F.Geiler,Director 'OtEQ ,t► 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 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: 6 Estimated Cost Address of Work: 0_� 5A( �• r C��7' Owner's Name: � �5� Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑lob Under$1,000 OBuilding 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 kDate Owner's NaAge Q:forms:homeaffidav Town of Barnstable FTNE� Regulatory Services Thomas F.Geller,Director + BARNSfA9I8, 6' �.� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us 5ce: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION (� Please Print DATE: JOB LOCATION; �.� �C/I � I NIP nulmberQ street village ^� "HOMEOWNER': name home phone# work phone# CURRENT MAIL NG 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. DEFMTION 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 yermit- (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 require Si6ature of H 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 Supavisors);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 homeovvaer 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:homtw=npt