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Home My WebLink About0030 REDWOOD LANE 3D �e c�c.�oocQ �..�.h e �,. ,` Y i� f ` f�He r ' Printed On:12t2012019 Comp aint�C�a�IlIRe�ort r -BARNgrMLE.�� ., , ' p 30 REDWOOD LANE HYANNIS i6�9• �0ro - , ' ems,�„�,.e' r ,, ' m � x� �". - ;re Case# 19-2�96 Case#: C-19-296 Address: 30 REDWOOD LANE, HYANNIS Date: 4/29/2019 Owner Info: Property Info: HAND, NANCY D MBL: PO BOX 19 288-083 HYANNIS PORT MA 02647 Owner Notified?: Complaint Details: Type of Complaint Classification of Complaint Method of Complaint Fences, High Priority Phone Complaint Summary: Pool fence falling in -unsafe conditions.Worried about children. Action History: Action Taken Date Description Fee Inspector Close Case 12/20/2019 yard not accessible $0.00 bowerse natural barrier in place pool empty Inspector Assigned to Complaint: bowerse Filed by: andersor Comments: Comment Date Commenter Comment 4/29/2019 andersor Assign to Ed as Bob is on vac o a a a Date: 12/20/2019 Town of Barnstabld f Town of Barnstable r' *SHE r Building Department Services „ Brian Florence, CBO v MAE& Building Commissioner Arfin6 3M¢A'S� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 COWLAINVINQUIRY REPORT Date: Rec'd by: Complaint Name: Map/Parcel Location a -/ AIA Address: , ` t 2,6: 174a'-.2nA- / la-. Originator " Name:- Street: Village: Stater Zip: Telephone: Complaint Description: Q OU I.e � Q FOR OFFICE USE ONLP Inspector's Action/Comments Dater Inspector: 10 Additional Info.Attached Q:forms:complaint �7f Revised:08/16/17 4 t ,� -"�� ,Y PA. f 'tk g*i p� �nrtj.•�5 -: ~� Y,y '�. •'�,» ..�Si ». a`:�r 'fit ♦'c.'f Yv��/ � � r• I / H _ t� d�•).� � si'k� ,��a��"��9�s��,A� ��Q� .fs5�,�,a�`�"s�4*�}( #4 'A,' -� � ¢� 't� t♦�@i ? iY if !i)t'� `� 1 �f�.♦ ,�` � -(,y «s. ��} Alm I�,.•� ti,;«'� '�+� « � � ,'�J ',R�'t�''Lsm,•,7 SDI./.�� _ t w, t rf * 41 env � r ;.� �..s.�e.,� 1S�IF�e a � • ��. . 1+« fix• Y e 51. . .sd �` +•"� . r s j [1 rrtp�e { � l y{ $A r b tA'• ip �� "1i t �•9. i� `a �itl, 'C" .'Y r.. s�•. �*� r, :� y �S 1 I a r {pirr ' ;i(` _�; f� +•.,,,,� .�,r .Zip"` �t*„�` 'f�� }` IL. 9,4. � \fir o •``P' �. t �I. ,1xa. s7 if ✓Yt Il. r - t t�f '#. yi a k. ,y_' .1�i� r -Tell Y, , 1 Srw+i'7 AV It lk .I d y K • • �r 1 it's. #� @ �r, a.,aa;, - 1 ,�.-,"3. -.,� �_ "" � "T•t,� )a .J aV'6'•: t 'r*• t +'�`, 1,+ I'�;y" y.., .fi� ��``(1. 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Y�e�9a"•J�q� ��r �"'ei�h,�� ..mac 'A`,� 't.;�� ;., r > a- A'"r. � s"- �,°t' ..J�� ta��q 3,' a � t�h I- � .. �''y ��, .� '"�R',�- )'t ,�"� �•' '}itrf� y� �- a,-`s�,T' �� $� �, �i.. . it �'`�, •. �►` � "{ � 't `�'r �'�;�''' `:'` ',�'i ' ` �r 8 �t w � , _ Wiekt, e, t, )f a �. ,art.�-�.... i -. ,,,. ,�y � �M,� „ dam•` :a` '�.. r /`q vy Ron v S , J F J s rt , M May ,r C� y Ip , +; �; ,� �w Jr,?i�� gyp-�,a ,•, �,; •�� , y s I• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel' Application # Health Division Date Issued Conservation Division Application F I Planning Dept, Permit Fee d' Date Definitive Plan Approved by Planning Board Pi Historic - OKH — Preservation/ Hyannis Project Street Address n y ZAZ Village 1-t1r_57 AzwM&<Ae , Owner , IUCLI ��'�� Address .:ca' Telephone Permit Request i;6 el -C/-4c-7AJ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation lld r Construction Typei Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family` Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes �No On Old King's Highway: ❑Yes ,�l 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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑//Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes t ] No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: C _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 j ON. APPLICANT INFORMATION J (BUILDER OR HOMEOWNER) co FT] Name ZlnKl 1Cld C,&-p A.)C y Telephone Number 4 Address /5�2 � �,� r�/ License# C 5 s/,lO Mo v7W ,4 d '6 73 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO t/,f=t:!!ca VT-0 SIGNATURE � � DATE ZO d FOR OFFICIAL USE ONLY APPLICATION# Y DATE ISSUED• MAP/PARCEL NO. S ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. " TheCoitirnonweaft/z of Massachusetts Department of Industrial Accidenif fn; I Office of Investigations 5 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Ins u rance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information please Print Le ibl Name (BusimsslOrganization!Individual): j /C /.��/� C — ►�� Address: C�z City/State/Zip: A/ y✓� e � 114A Phone #: 50 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• [] r am a general contractor and I 5. �]New construction have hired the sub-contractors. employees (full and/or part-tune).* 7, Remodelin 2. ] I am a sole.proprietor.or partner- listed on the attached sheet. g These sub-contractors have g, Demolition ship and have.no employees insurance. employees and have workers', working for me.in any capacity.. $ 9: ❑ Building addition_ NO workers' comp. insurance ` comp. 10:❑ Electrical repairs or addition required.] S ❑.We are a corporation and its officers have exercised their 11.❑ Plumbing repairs or additioi 3.❑ I am a homeowner doing all work myself. [No workers':comp. ; right of exemption per MGL „12.0 Roof repairs insurance required.]J. 152 §1(4), and we have no employees..[N o workers' 13.❑ Other comp. insurance required.] e do below showing their workers'compensation policy information. + 1 must also fill out the s c n g Any applicant that checks Uox# t: it this affidavit they are doing all work and then hire ou tside contractors must submit a new affidavit indicating such. Homeowners who subm tcontractors that check this box must attached an additional`shect showing the name of thc'sub-contractors and state whether or not thosc.cntitics have. employees. If thasub-contractors have cmployecs,theyiMust provide their workers' comp.policy number. Tam an:employer that-is providing workers' compensation insurance for my.employees° Befow is the policy and job site .information- Insurance Company.Name: f, Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: a r 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; 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 f 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 herebycerii tinder' he and enalties of perjury that the informadomprovided above is true and correct, . ) _ Ie Date: Phone# Official use only.' Do not writekin.tftis area; to be completed by city or.town.officiaf Permit/License#_ City or Town: ., Issuing Authority.(circle one):' i 1. Boar.d-of Health 2. Building Department 3. City/Town Clerk 4 Electrical Inspector'S. Plumbing Inspector i 6. Other Contact Person: Phone#: i Information' ;j. nd Zpstruefi®nS. Massachusetts General L'a4vs 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, ` l express or implied, oral or written." ore An errrplbyer is defined as "an individual,partnership., association, corporation other s of aedeceased e al rbtity, r a yew oo�e of the foregoing engaged in aj.ointenterprise, and including g P nfali receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant the to do maintenance, constniction or repair work on such dwelling house of another who employs persons dwe1lling house or on the grounds or building appurienant thereto shall not because of such employmentbe deemed to be an employer: MGL chapter 152, §25C(6),also states that"every state or local licensing agency shall withhold the issuance or reneW21 6f a license or permit to operate a business or to construct buildings in the commonwea for Any lth applicant who has not produced acceptable evidence o•f compliance with the insurance coverage required." onwealt Additionally, MOL chapter 152, §25C(7) states "Neither the comh nor any of its political subdivisions shall m enter into any contractfor theperformance of'pub)ic work until acceptable evidence ofcorripliance with the insurance regiiirements of this chapter have been presented to the contracting authority." Applicants satiori affidavit completely, by checking the boxes that apply it ertificcate(s) of on and, Please fill out the work"ers',compen if necessary,supply sub-contractors)name(s), add o address(es) and phone number(s) g 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 ofinsiirance 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; Shouldyou have any questions regarding the la elo or 1you Self-insured ompaquirnd to niesshould enter their compensation policy please call the Department at the number listed b W 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 Off Investigations has to contact you regarding the applicant. e number: In addition, an.applicant Please be sure to fill in the penniUlicense.number which will be used as a,referenc that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating(ci Y or policy information(if necessary) and under"lob Site Address the applicant should write"all locations in town),"'A copy of the affidavit that has been officially stamped or rriarked by the city or town may be provided to the that a valid affidavit is on filrh e for future permits or licenses.. A new affidavit must'be filled out elure applicant as proof ess or commercial vro , P b us m P � related to an i year. Where a home owner or citizen is obtaining.a license or.peimit not r'ela y t y T required to Complet e this affidavit. (i,e. a dog license or p ermit to bum leaves etc.) said person is NO q n advance for your cooperation and.should you have any questions, The Office of Investigations would like to thank you i please do not hesitate to give us a call. The Department's address, telepbone and fax number: The Commonwealth of Massachusetts Department of Indutstrial Accidents Office of-Investigations 600.Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-87.7-MASSAFE Fax #..617:-72777749 RP1/1fPA -/.4-0/ occ nnV/rtta �r� ' ENERGY' CONSERVATION APPLICATXON FORM FOR ENERGY'EFFZCICIENCY F.OR .ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name:li ,� Site Address: Of edb � � �C�La'�dJ��✓ print ✓ Town: Applicant,Phone: :5 G-:p- -:3e,e �J Applicant Signature: 1 Date of Application: 6 .14 Oel d NEW CONSTRUCTION: choose ONE:of the fo tiro o tioms 780 CMR TABLE 6107.1 PRESCRIPTIVE"ENVELOPE COMPONENT CRITERIA FOR NEW'ONE- AND.TWO-FAMILY BUILDINGS MA5CIMUM MINIMUM Ceiling or: r Slab Basement perimeter . ❑ Option l: Fenestration • exposed ,! ' ,Wald Floor Wall AFUE HSPF SEER U-factor floors �iR-Value R-Value R-Valve R-Value R-Value and De th National Appliance Energy R-10, Conservation Act(NAECA)of 35 R-38- R-19 R-19 R-10 4 ft : 1987 as amended,minimums or reatcr as a licable Note, This form is not required if you choose either of the two versions of REScheck as listed.below: ❑ Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed (780 CMR 6107.3.2) RES'check-Web wli"ich can be,accessed at http'%/w�uw enerycodes gov/rescheck/ ADDZTIOl�FS ORALTERATZONS;TQ EXISTINGBUILDZNGS:OYER.5 YEARS OLD* *Buildings under 5 years old must use option 91"or 42 in New Construction section above. Complete the following forrnula to,determine,the'% of glazing: (a) .Gross Wall& Ceiling Area equals Formula: (100 x b = a) f SF l _' 100 x % of.glazing . b {b) Glazing area equals SF If glazing.is < 40% use.the chart below, '.M.If'glazing is > 40.% roceed to "SUNROOM" section i - 780 CMR TABLE 6101.3 PRE SCRIPTIVE'ENVELOPE COMPONENT CRITERIA ADll.ITIONS.TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM . MINIMUM r Ceiling and Slab Pel;imete Fenestration .0 all Floor. Basement Wall R-Value Exposed floors .'' R-Value R-value. R-Value , and De th U-factor' R-Value r39 R-37 a.,l R-13 R=19 R-10 . R-10, 4 feet a R130 ceiling insulation mayrbe used in place of R-37•if the insulation achieves the N11 R-value over the entire ceiling area(i.e:not compressed over exterior walls, and iridtidin any access openings). 'to an existing building/dwelling unit where the total SUNROOM=An add"ifion or alteration El glazingarea of said addition exceeds 40% of the combined gross wall and ceiling area of the addition, Note: . Owner fo fill out Consumer Xnforrrcatzon Form.(found`in Appendix 120T) r �0FIKETp To Y,T ry-of.Ba astable Reguldtory:Services nARNv s sLE$ Thomas F:Geiler,Directbr Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis;MA 026.01. yrtyw.Iowa.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner*Must , Complete ,and sign This Section If_Using A BAder as Owner of the subject property hereby authorize /9�/C� �,�lP�/ to, act on my behalf, in all matters.relative`to.work,authoriz-ed by this.building permit application for: I (Address of Job) ,t. ign e:of C;nner Date : rint N e . . w F - i If Prope-M Owner is applying for pennzt please complete the Homeowners. Exemption Form on the :reverse side a Q:FORMs:owNF—uFRmissioN j. Town of Barnstable �QF i KF �. o Regulatolry Services Thomas F. Geiler,Director F IARNSTABr.E, Building ]Division rid Mat Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 y,,Nr.toNvn.barnstable.ma.us .s Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: F JOB LOCATION: number. street village "HOMEOWNER": work hone# name home phone# p CURRENT MAILING ADDRESS: city/town. ' state zip code The current exelnptiomfor"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 Bamstable.Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or.larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that:,"Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.". Many homeowners who use,this exemption are unaware that they are assuming the responsibilities of a,supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems;particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, 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:\WPFILES\FORMS\homeexempt.DOC r..,A!'+ ,. .A�'.An:of . .•�"ryt,�t7.k F4ry,kk`"1.'. . '. .v. .. .,.. " , , 'tt u'� •,, �4a��.. ,,c,.;,We rh,N"E.Kr.� 7..tdt. Yr^r 1k"a.r �^ ,,. ,�,,: i y."� �2'.. :,.. ...;,.: �*4T•'.�-d W..�+�.�. n� ~. ,.7 .�l dr +.rl.:-.•� rt;. ..bHs. yx,.>rm �^- :.,.In.*�:. R d 3n.„a�r �•'�!�.:,t r�f'^&. y'�., .t k.�;,Sz';e _i ,., ,' ,r16+. �. '.!`i�'V-� •� .., '..,.,N •�r .�,a yz c,Yfi ,. ..,y... 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Y A 02116 pfflee of Consumer A T.CONTRD� �r. pV EMEN Boston,M IMpR _ Tr# 2g1626 t{OME � �346a ' ge9lstration' C212012 ror� c{a Exprrat b a1 GLI ` re TYPei X,3160 r ONG. sinatu � 10NSsREMO Tlot vah INFINITE SO `UT. Y� a g FtICHARO GOON �K w. UadersecretaY9 _ .outh, W est Y arm - - _ Massachusetts- Department of Public Safet) Board of Buildinl( Regulations and Standards Construction Supervisor'.License License: CS 81947 Restricted to: 00 , Y.r RICHARD T COONEY f 19 CHERRY LN W YARMOUTH, MA 02673 Expiration: 8/2/2011 ('onunissiuner Tr#: 1961 APR-13-2010 10:47 HOME DEPOT HYANNIS P.009 `" .y 12, 7' 1" 38�„ � 29,„ 3 ,,,, l 0,„ _ • T '} ��,, , ,w,, W2130R W3015 3' 'V3030 U N :h' B33 2FWT*: `,, t •1,. — °� —J l N x B36 ;, w F.P4834W N i s M 321 -�17,„ r +a is CAL AI imensions Fite doclgnat.lons This is an original dosigft and must Designed:4/9/201 gi en are subject to vorifieation onG��' not be releasod or copied unless Printed:4/12/2010 job site and a4lustrnent to fit jobapplicable fee has been paid or job j conditions. ordor placed, i ..,� 3260bbd6.kit _ All Drawing#: APR-13-2010 10:47 HOME DEPOT HYANNIS P.009 I l ! 1481' i 12" 7 .,. 1,. 30' 7 30" 0 , . 0 6.. „ W21'3'0'f2 W3015 • . 3' •W3030 U cv e., :,u�',; `^:'l'ta' 2' '�D"IS' DI'IV � � .;,.:,5;, , ,,r ,� N 0'-G rS;R:fLG: B3.3'2FWT' c� -� x ~ to s = 4C I O O aoo °O Ed C A = a Q �N(j Y � Q w A. � X B36 1 to cri i m, �.. A A4834•W D ` lj b I \ I - j _,,. �81olf 3211, +6 AiII i ..._ ,48•, VVA I . i • i i Al imensions .size docignations This is an original design and must Designed:4/9/2010 Eri en are subject to vordticadon on not be reloswd or Copied unless Printed:4/12/2010 job site and a4iikstment to fit job applicable fee has bcen paid or job j conditiowL ordor placed. 3260bbd6.kit All Drawing#: 1 Town of-Barnstable, *Permit11 # �` 'b Expires 6months o issue Regulatory Services Fee sextvsrABM : Thomas F.Geiler,Director 94, ' A n Building Division ��-- .e�ED MA'I A 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 09 0<�3 3 , Property Address 3o h a w L a ti? ' esidential Value of Work/G1 0c)o Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address AYJ N C' D /4A J D a Contractor's Name ;�J/�ri h (� Telephone Number(50,P) 7Z/'`1 7 7 Home Improvement Contractor License#(if applicable) a' <orkman's Compensation Insurance PERMITPRESS Chef am a sole proprietor w ❑ I am the.Homeowner APR 2 3 2008 ❑ I have Worker's Compensation Insurance Insurance Company Name TOWN OF BARNSTABLE P Y Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side U]'Leplacement Windows/doors/sliders.U-Value ,2 (maximum.35) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. M SIGNATURE QAWPFILES\FORMS\building permit forms\EXPRESS.doC Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): i cAllj iL b Ly 6'ug X2 e:A Address: P,0. [3o x R3 City/State/Zip: NA.)ir Phone.#: (s-oY 3-9T 5315 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.V]?'am a sole proprietor or:partner- listed on the attached sheet. 7...�' remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its' 10.0 Electrical repairs or additions 3.❑ 1 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.❑ 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. 1Contractors 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a:STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statemerit may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalties of perjury that the information provided above is true and correct Signafore: t Date: 4,1 a.- 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#: 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 'lease fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant tiat 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 1-977-MASSAFE Fax# 617-727-7749 Revis,-d 11-22-06 www.mass.gov/dia Town of Barnstable • BARNSTABLF. MAM Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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, ,as Owner of the subject property hereby authorize }�r c N 2.uP y }2 r�. ��,1�. 7;ic�r . to act on my behalf, F in all matters relative to work authorized by this building permit application for. �G ReJC0cdc'+ (Address of Job) l� Si nature Owner Date . 1�1 �x a 0 q a,__J� Print Name QAWHILESTORMS\building permit forms\EXPRESS.doc Revise020108 �t� . Town of Barnstable •. ~o„ Regulatory Services STAB 'Thomas F.Geiler,Director MASS.1639. .�� Building Division ArED NIA't� 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: number street village "HOMEOWNER": name home phone# work phone# 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 requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, 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:\WPFILES\FORMS\homeexempt.DOC � r -Board of Building Regula ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement-Untractor Registration Registration: 134392 Type: Private Corporation Expiration: 11/13/2009 Tr# 260471 RICH GURNEY &ASSOCIATIES;'I:N.C. RICHARD GURNEY P.O. BOX 837 - DENNIS, MA 02638 4'1 t_11` Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CA1 0 SOM•07/07-PC8490 . �'!e 1°o7rumaivaeall/ a�,/�aaaac`ivaella , � � Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:._ 134392 One Ashburton Place Rm 1301 Expirationr�i1/13/2009 Tr# 260471 Boston Ma.02108 Type Private Corporation RICH GURNEY&ASSOGIATIES°•INC. " RICHARD GURNEY 900 RT 134 SUITE S.DENNIS,MA 02660 '�� Administrator of valid without signature Y Town of Barnstable *Permit# fJ2 -7 8 Expires 6 months from issue date Regulatory Services Fee dV Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner PERMIT 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us S E P 9 - 2005 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIALO qF BARNSTIABLE Not Valid without Red X-Press Imprint 4ap/parcel Number 'roperty Address a residential Value of Work��¢ io Minimum fee f$25.00 for work under$6000.00 )wner's Name&Address A � JA0 ;ontractor's Name � jJ��g ,r✓ Telephone Number C%2 i — ;L come Improvement Contractor License#(if applicable) ;onstruction Supervisor's License#(if applicable) �Orkman's Compensation Insurance Check one: 2�_a��s e, roprietor PIP I am the Homeowner I have Worker's Compensation Insurance nsurance Company Name .4. , An Workman's Comp.Policy# 'opy of Insurance Compliance Certificate must be.on file. 'ermit Request(check box) ErRe-roof(stripping old shingles) All construction debris will be taken toym ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. 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: Properly Owner must sign Property Owne etter of Permission. /��/ Home Im rovement Contractors License ' equired. iIGNATU4 : ~ 1Torms:expmtrg :evise071405 . The Commonwealth of Massachusetts Department oflndustrial Accidents A .•j Office of Investigations ' a 600 Washington Street Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)' Address: ��%•. .. City/State/Zip: feg�o, Phone#: ,,r, ►re you an employer? Check the-appropriate box:. Type of project(required): ❑ !am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. .❑ New construction ❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for mein any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required] officers have exercised their 10.❑ Electrical repairs or.additions am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions yself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other ny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: � .omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp•policy information. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'ormation. ;urance Company Name: licy#or Self-ins.Lic. #: - - Expiration Dater Site Address: City/State/Zip: tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Uure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of . restigations of the DIA for insurance coverage verification. o hereby c.erto under t pins d penalties of perjury that the information ormation provided above is true and correct: �ature:. Date o ne#: Off ccial 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 In 6.Other spector 5.Plumbing Inspector Contact Person: Phone#: Town of Barnstable Regulatory Services MUMSTABr.E. ; Thomas F.Geiler,Director � "�: � Building Division ArfO�.la 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: O S JOB LOCATION: O QED t tip number // street village "HOMEOWNER": /WcK /`1./;Q name home phone# work phone# CURRENT MAIL NG ADDRESS: 3 o 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 r uirements and that he/she will comply with said procedures and / requiremeW. sig&tdre of Hom owner 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. Q:forms:homeexempt �w �'., � _ \` J� � �,a:°evil '"•, t i ! 1� Assessor's office (1st floor): THE Assessor's map and lot number toy♦ Board,of Health 1(3rd floor): Sewage Permit number ...... ...... t EAUSTADLE, ........... Engineering Department (3rd floor) '°oe�"639 m0 House number e APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....:�?<!.`11—.. .......... . I.C....... .U�I JIJffN�r„ , ........... TYpE OF CONSTRUCTION ...ram..UIV/: ..................................................................................................... .._.....�.`...�: .................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... 1 ..lwU.0............. r^�......................................................................................................... Proposed Use .....� L l ,,/�,r/h?. .................�. •!'(/1 ,, / �r-.......................................... Zoning District ........� .:... ...:.............................................Fire District ....!'' :S...r ..J......................................... Name of Owner ..! .y...... � I�(/cf� �. l�/Z .......................Address .................. .....,....,..........:.......... ....... .............:. Name of Builder( ......C.0....................Address/?A`.. J /l�l� /y � l ...... ....... Nameof Architect ...............Y..................................................Address .................................................................................... e Numberof Rooms ..................................................................Foundation .............................................................................. Y . Exlerior ..................................................k5...1 `................v..:Roofing JY Floors .. u ?...,...........Interior ............... `...................Plumbin ........... — Heating g Fireplace .........::.:.....................................................................Approximate Cost .:rL/�,/..��f...!.................................... 4 Definitive Plan Approved by Planning Board ________________________________19________ . Area .......................................... Diagram of Lot and Building with Dimensions Fee .....'{.-7 '`' "................................. .V SUBJECT TO APPROVAL OF BOARD OF HEAL H r . -... j n i Ncv- y iM A ° X 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. NameC;c�!T, u-%••••. r6.r... ± .:. �.... Construction Supervisor's License (.20.&.6. .Y.3......... HAND, NANCY A=288-83 No ....2.927..7.. Permit for ...Sw.i=i.ng..P.00l.... Accessory to Dwelling Location ....!Q..Redwood Lane„•......... . ..... •' ..........................Hyann *...................................... Owner Nancy. Hand................................. Type of Construction .......F.XaMe........................ ................................................................................ t Plot ............................ Lot :............................... Permit Granted ...April 30, 19 86 Date of Inspection ....................................19 Date Completed ......................................19