HomeMy WebLinkAbout0077 RIDGEWOOD AVENUE ao�3 a 7 36-3
DIME Town_ of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services Fee :3 5z --'
+ RA MsrABM +
MAC Richard V.Scali,Interim Director
639 A1� ,
MA'I
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 3&_0 91 5'
Property Address -77 j e_GJDO e) Pdv
❑Residential Value of Work$ ; Minimum fee of$35.00 for work under$6000.00
Owner's Name&Addresses r1L L
72 ®off , ���,s
' �.
Contractor's Name J ? m l rDrlh '' Telephone Number, j,! 15
Home Improvement Contractor License#(if applicable)' 1015 / Email:
Construction Supervisor's License#(if applicable m
�V orkman's Compensation Insurance
Check one: O C T 10 2013
❑ I am a sole proprietor
❑ I am the Homeowner
P-I have Worker's Compensation Insurancce TOWN OF BARNS
TABLE
Insurance Company Name �� �t/1 TS S ,
Workman's Comp. Policy# C��h e0_F'6- 5/0
Copy of Insurance Compliance Certificate must accompany each permit.
t
Permit Request(check box)
❑ Re-roof(hurricane nailed)(Qpping o&.-shingles) All construction debris will be taken to ypfk"OtA ✓k�t'�7
❑Re-roof(hurricane�ailed)(not stripping. Going over existing layers of roof)
Re-side i
❑ Replacement Windows/doors/sliders.U.'falue (maximum.35)#of windows "
- #of doors:
❑ Srnoke/Carbon Monoxide detects: plans marked with red S and inspections required.
Separate Electrical&Fire Perm:._.zquired.
*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&Construction Supervisors License is
required.
SIGNATURE:
Q:\WPFILES\FORMS\building pe s\EXPRESB. c
Revised 061313 ' ° � t
the C'omwomveal'th of Massachusetts
Department of li ush al Accidents
. ......: Office o.Invesfigafions
' 600 Wmhington Street
Boston,MA 02.111
wmitmasmgm./dire
Worket-s' Compensation Insurance Affidavit:Blinders/ContractorsMectricians/Plumbers
Applicant Information Please Print . 'b .
Mamie gks w_W0igsnizafion&&vidnag: e dro-77✓1 C_
city/sz�p:
Are you an employer?Gbeck the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I ain a general contractor and 1 6- ❑New aonsfinrctioa
employees(full and/or part-time)* have hind the sub acto s
1 0I am a sole proprietor or partner- listed on the attached sheet ?. ❑Remodeling
slug anal have no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp-h=anml
required-] 5. ❑ We area corporation and its 10..❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officals have exercised their 11.❑Plumbing repairs or additions
rnyf[No workers'comp- right of exemption per MGL 12..
rrs�e required.]T c.152, §1(4-,and we hinm no ❑Roof /
13.KOther
employees-[No workers'
comp.insurance required-]
*A-f appticut that checks box#1 mast also 5Il out the section beIaa slowing their wodcers'compensadion policy informaticm.
Sameowners who submit this of adsvit mdkxftg they are doing all wodk and then hue outside contractors must submit a new affidssit indicating such_
tractors that check this boat mmst attached as additional sheet showing the name of the soli-caaracwrs and staIR whether ornot those ez=ws have
employees. If the sub-contradnrs have employees,they must pmuide their workers'comp.policy number.
I am an employer that is providing xrorkers'companalien insurantce for try employees Bevaw is the poUcy and job site
information
Insurance Company Name:� f� !/e.//e f'S i S'
Policy#or Self-ins.Ile-#: e! G u • d /3 r✓12.1^7 / Expiration Date: /f
Job Site Address: Z'e�(v riE t/e _ City/State/zip:
Attach a-copy of the workers'compensation policy declaration page(showing the policy num ei-and ex ration 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$1,500.0a and/or one-yearitnprtso as well as civil penalties inthe fort of a STOP WORK ORDER and a fine_
of up to$-50-00 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 �
I do hereby cer nriet the insandpenaldi ihatthe infotvnatron provided above is Irus,iitd correct
c r�
Si Dater :
Phone#:
Qokfirl use only. Do not write in fins area,to be completed by city or town of"iciat�
City or Town: PermitUcense#
Issuing Anthority(tdrde one):
1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 9:
6
-
Information...and.Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto 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 thaw 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 of building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any -
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their cent-ficate(s)of
insurance.. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required_ Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not The Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i-e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
d S
The Office of Investigations would like to than_k 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: '` >-
Fhe Commonwealth of Massachusetts
Dega tIidustrial Accidents
o luve'stigations
+� 600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-977 MASWE
Fax#617-727-7749
Revised 4-24-07 w .n=,govldia
oFmE l Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Ar 619. , Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnsta6le.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorizeA
G 4` e'�-14 r �?✓l to act on my behalf,
in all matters relative to work authorized by this building permit.
11�?17 /11'q,A*4'.'azmm Alec
(Addre of Job)
;.,
**Pool fences and alarms are the responsibility of the applicant. Pools
r .
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
; o pp Signature of Owner 'r Signatureli,mrit'. ✓
Print Name Print Name
13
Date ;
Q:FORM&OWNERPERMISSIONPOOLS 62012
Town of Barnstable.
Regulatory Services
'* BAW� ' Thomas F.Geiler,Director
&1 •�� - -
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
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
- CURRENT MAILING ADDRESS:_ 4.
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. f
J
Signature of Homeowner
Approval of Building Official :' .'
" Note: Three-family dwellings con;twin n 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
` ,�O-E(OMEOWNEWS EXEMPTION
The Code states that: "Any homeowner perfocnimg work for which a building permit is required shall be exempt
from the provisions of this seen Sectioit 109.1.1'-,Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire,to do such work,that suoh Homeowner shall act as supervisor."
Many homeowne s who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations.f Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems;:particularl,., en the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with wlicensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible
To ensurCthat theyh)meowner is fully aware of his/her responsibilities,many communities require,as-part of the
permit application,that the Homeowner c rt fy that he/she,understands the resgonlbilities�of a Supervisor. On the last page I
of this issue is a form currently used by several towns. You,may care tan end,annd,adoptEuch a form/certification for use in'
your community. j
C;\Users\decolldc\AppData\Local\Microsoft\Windows\Temporary'Iritteymet Files\ContentOutlook\QRE6ZUBN\EXPRESS:doc
Revised 053012
Office of Consumer Affairs and Buslness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116 `
Home Improvement Contractor Registration
Registration: 173208
Type: Individual
Expiration: 9/17/2014 Tr# 231345
MICHAEL J. ARONNE
MICHAEL ARONNE
14 CYGNET RD
W. YARMOUTH, MA 02673
Update Address and return;card.Meek reason for change.
SCA 1 0 20M-05n1 � Address Renewal ;�`Employment Lost Card
CJ��e�a�rr��to.�zrueall�o�C�//%t!rreerzc•/%rc1c/!ti _ � '
Office of Consumer Affairs&Business Regulation License or registration valid for individul;use only
f — = ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
gistration: 173208 Type: Office of Consumer Affairs And Business Regulation
xpiration 9/17/201.4:.., Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
MICHAEL J.ARONNE!.
MICHAEL.ARONNE
14 CYGNET RD L�W.YARMOUTH,MA 02673 a
Undersecretary Not valid without signature
Massachusetts=Department of Public Safety ..
Board of B'uildin Regulations'9 and Standards
Construction Supemi.cor
License: CS-042027
MICHAEL J ARONE
14 CYGNEJ'ItD
W YARMOUTH MA a _
554— Expiration
Commissioner 08/23/2015
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3.27 G 1-7 Parcel a? #
"et,iaT�
Health Division _ Date 'asued D O
Conservation Division vA D—0
Tax Collector Permi 00
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 7 7 A fds`z �✓�®� �T y �
VillageYg �✓'f
Owner k<fi R AJ 141 �C� r�! Address 7`7
Telephone .Say- 7 7 3C 4 7 3
Permit Request 11e-C7"9-11 2 V-C /,VX
N y'/£ ®X✓ £ lr4o£ G ,�� s%o� ��-�I /d S�-*,-A f
Square feet: 1 st floor: existing 70 0 proposed 2nd floor: existing 7D0 proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatiori'�/�� Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. ,
Dwelling Type: Single Family CeY Two Family ❑ Multi-Family(#units)
Age of Existing Structure _7e )f/Z—f Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: UrFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) moo
Number of Baths: Full: existing > new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing 7 new First Floor Room Count .�
Heat Type and Fuel: ❑Gas &6iI ❑ Electric ❑Other
Central Air: ❑Yes Alo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:8rexisting ❑new size/W>1'--20 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
BUILDER INFORMATION
Name ST� A/ / ��� Telephone NumberD
Address '7 X License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE / - DATE
FOR OFFICIAL USE ONLY
LA
PERMIT NO.
e r
DATE-ISSUED f r r r
v
MAP/PARCEL NO.
ADDRESS VILLAGE`
OWNER t /
DATE OF INSPECTION: :�' ✓ !.l
FOUNDATION 1
FRAME
INSULATION '
FIREPLACE
i r
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL- r
.r
GAS: ROUGH FINAL
FINAL BUILDING
v
DATE CLOSED OUT, -
ASSOCIATION PLAN-NO.
t
M s�
:,RESIDENTIAL BUILDING PERMIT FEES
APPLICATION FEE
f
New Buildings,Additions $50.00
Alterations/Renovations $25.00
Building Permit Amendment $25.00
FEE VALUE WORK,SHEET
NEW LIVING SPACE
square feet x$96/sq.foot= x.0031=
plus from below(if applicable) '7
ALTERATIONSIRENOVATIONS OF EXISTING SPACE
square feet x$64/sq.foot= x.0031=
plus from below(if applicable)
ACCESSORY STRUCTURE>120 sq.f� ,
>120 sf-500 sf $35.00
>500 sf-750 sf 50.00
>750 sf- 1000 sf 75.00
>1000 sf-1500 sf 100.00
>1500 sf-Same as new building permit
square feet x$96/sq.foot= x.0031=
STAND ALONE PERMITS ,
Open Porch x$30.00=
(number)
Deck x$30.00=
(numb )er)er
Fireplace/Chimney x$25.00=
(number)
Inground Swimming Pool $60.00
Above Ground Swimming Pool $25.00
Relocation/Moving $150.00
(plus above if applicable) Permit Fee
projcost
f
790 CMR Apperda J
Table ALlb(continued)
prescriptive Packages for One and Two-Family Residential Buildings Heated with F03ail Fuels
MAXIMUM MINIMUM
Blazing Glazing Ceiling Wall Floor Basement Slab Heating/Cooling
Area'(%) U-value= R-value' R-value' R value' Wall Perimeter Equipment EfEicicnry'
Package R value` R value'
5701 to 6500 Heating Degree Days'
Q 12% 0.40 38 13 19 10 6 Norma!
R 12'/e 0.52 30 19 19 10 6 Normal
S 12% 0.50 38 13 19 10 6 85 AFUE
T 15% 0.36 38 13 25 WA N/A Normal
U 15% 0.46 38 19 19 10 6 Normal
V 15% 0.44 38 13 25 N/A WA 85 AFUE
W 15% 0.52 30 19 19 10 6 85 AFUE
X 18% 032 38 13 25 N/A N/A Normal
Y 19% 10.42 1 38 19 25 N/A N/A Normal
Z 18% 0.42 38 13 19 10 6 90 AFUE
AA 18% 0.50 30 19 1 19 1 10 6 90 AFUE
1. ADDRESS OF PROPERTY:
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS:
3. SQUARE FOOTAGE OF ALL GLAZING:
4. %GLAZING AREA(#3 DIVIDED BY#2):
5. SELECT PACKAGE(Q--AA-see chart above):
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPROVAL:
YES: NO:
q-forms-f980303 a
f
780 CMR Appendix J
j Footnotes to Table J6.2.1b:
' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and
basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall
expressed as a percentage. U to 1%of the total lazing area may be excluded from the U-value requirement.
area, expr p g p g
For example,3 ft of decorative glass may be excluded from a building design with 300 R2 of glazing area.
Z After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with
the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for
whole units:center-of-glass U-values cannot be used.
' The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full
insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38
insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between
the conditioned space and the ventilated portion of the roof.
Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include
exterior siding, structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER
by R-19-cavity insulation._OR.R43_cavity_ insulation plusR-6 insulating sheathing. Wall requirements apply to
wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction.
3 The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements,
or garages).Floors over outside air must meet the ceiling requirements.
The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
dt=ribed in Note b.
'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs.
" If the building utilizes eleetric resistance heating use compliance approach 3,4, or 5. If you plan to install more
than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city or town see Table J5.2.1a
NOTES:
a)Glazing areas and U-values are maximum acceptable,levels. Insulation R-values are minimum acceptable levels.
R-value requirements are for insulation only and do not include structural components.
b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested
and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.
One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35).
c)If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
F_- -___� The Commonwealth of Massachusetts
I. - -- Department of Industrial Accidents
-
600 Washington Street
Boston,Mass. 02111
Workers' Corn ensation Insurance Affidavit
name: �%p A.) /v' r U
location
city A�,I-Al/V i 1 phone#
®Tam a homeowner performing all work myself.
❑ I am a sole r rietor and have no one workitl in an ca achy
❑ I am an employer providing workers compensation for my employees working on this job.
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❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who
have
the following workers' compensation polices:::;, : :::::::.: :::.: :.::::.;-.}:.}:.;:.;:.} ;::<.;.;:X. ;;.;:.;:.;:.;:.;:.;:.;;:.;;;:::;}:.;::};:.::.:;.;:.:>;;;:.:.;;::.;:.:.:;.;::;::i<.:.=s;:°.:.;:.;;;::
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification
-"---.7 do hereby certify under-the pains-andpenalties-ofp/er�jury-that-the informationprovided_above_ts true_and_correct __._.: ----- _—_ - ........_. .
Signature , �� �"�' ^ �' '< Date 2_
G
Print name
oRM
fficial use only do not write in this area to be completed by city or town official
city or town: permit/license# []Building Department
❑Licensing Board
❑check if immediate response is required [-]Selectmen's Office
mftb
_❑Health Department
contact person: phone#; ❑Other
(devised 9/95 P72)
Information and Instructions
ter 152 section 25 requires all ern to Pens compensation for their employers provide workers com
Massachusetts General Laws chap q p y P
employees. As quoted from the"law", 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 section 25 also states that every state or local licensing agency shall withhold the issuance or 1.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,neither the'
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
numbers along with a certificate of insurance as all affidavits may be
address and hone numb Y
supplying' com an names, addr p ng ., _ .._
company ..
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 Xou
are required,to obtain a workers' compensatioa policy,please call'the DepartiYient at the number listed below:.
City or Towns
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 permrtllicense number which will be used as a reference number. The affidavits maq be retuanedto
the Departme b mail or FAX unless other arrangements have been made.
Y.. :._:-. .. . :::.
The Office of Investigations would like to thank you in advance for you 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
De artment o f Industrial Accidents p
Me of Investigatlons
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
II�
�o&VE� , Town of Barnstable
Regulatory Services
* sn MASS.
* Thomas F.Geiler,Director
y nsnss. g
�'AIEOM,ra�O Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
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: JS��`��/� v /�� `vim Estimated Cost ��P
Address of Work: 7 X I
Owner's Name: 5-7-A"? N /-J
Date of Application: 4
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
[]Building not owner-occupied
[Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor.Name Registration No.
Date Owner's Name
Q:forms:homeaffidav
h
w
l
Ne>/"-r
Town of Barnstable
�OF SHE
yP 0 Regulatory Services
snrrxsTnsLe Thomas F.Geiler,Director
v t►rass. �
16;9. Building Division
AlE p �p. Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038. Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: 7 & C_i p0 5 /,Yv 9- l" y� �✓ti i J
number street village C
"HOMEOWNER,,: S7-09 .J /LI aL2'ft 0� 7 7-f- O? .3 rj
name home phone# work phone#
CURRENT MAILING ADDRESS: 7 -7 w 00 e /� v �
of-246 l
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be,a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirement
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 forn-/certification for use in your community.
Q:forms:homeexempt
` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r
Map o� Parcel O 9 Permit# 0
5 .J
Health Division - -; Date Issued J
w
Conservation Division r Fee
Tax Collector i. :'�� - �' • -
Treasurer ;
Planning Dept. F
F
k
Date Definitive Plan Approved by Planning Board
Historic-OKH ' Preservation/Hyannis '- -
Project Street Address 7 �� e-��i £ �'�' 1 U E- 6��./`f.N A."sf
w
Village di i f
�.
Owner STD 14'/'6—.19- Address 77 /2��f oeY�,,••��
Telephone
r
Permit Request 5,7 R' d . 4
Square feet: 1 st floor: existing ry 7 a r/ proposed 2nd floor: existing proposed Total new
y.
Estimated Project Cost Zon ng District' Flood Plain` . Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. r
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) ,
Age of Existing Structure ' 7 Yi2 s Historic House: ❑Yes �Mo On Old King's Highway: ❑Yes ❑ No
Basement Type:' mull .Cl Crawl t ❑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 7 new First Floor Room Count s
Heat Type and Fuel: ❑Gas Ert iI ❑ Electric ❑Other . .'
Central Air: ❑Yes ZWo ,Fireplaces: Existing- New Existing wood/coal stove: ❑Yes &Iqo
Detached garage:9'existing Ci new size/S Xk' Pool:❑existing ❑new .size ✓-Q— Barn:❑existing ❑new size
Attached garage:❑existing -❑new siie A-14- Shed:❑existing ❑new size A14- Other: y 4-
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes t If yes,site plan review#
Current Use Proposed Use I
BUILDER INFORMATION '
R Name ' Telephone Number -
R. Address /�l &V �'�2. License#
Home Improvement Contractor#
` Worker's Compensation#
.ALL L CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT-WILL BETAKEN TO '
SIGNATURE DATE _ 7—3 O
FOR OFFICIAL'USE ONLY
r
PEkMIT NO. a x. f • _ �' ' *. . a . .
. -.... »fix't * `,�"_ > i r, o ,`• i ..} {• - ; .. i•
DATE ISSUED r
DA
MAP/PARCEL NO.
. • • 1. �' , , � ' f + i • - �•-! ♦f -• r t
ADDRESS i'' VILLAGE
OWNERr
DATE OF INSPECTIONx
r FOUNDATION
FRAME ' t - L r e
1: t . - : .l • -... ' -1 t - '"' T . e�. 1 -;_ .t 4 y L`,r a '•� 6- e .j ° Y_ ._' -
INSULATION r, t t - A° y L '� F
ta
, FIREPLACE - 4 `. t c' 1- ;�- ;' _ < � � `J _ — w :� .a `� f'. ` - •
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH- FINAL' j, • -" _ '
Jt GAS: ROUGH FINAL r
FINAL BUILDING
Ar
• i t t i
DATE CLOSED'OUT
ASSOCIATION.'PLAN NO.
(( a own of Barnstable
Department of Health Safety and Environmental Services
Argo�►'�' Building Division
367 Main Street,Hyannis MA 02601
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: a ol"p l Al e n/ le Estimated Cost 6
Address of Work: 7 7 It, �_v 0 0-,!D fez&4j CV 1 J,
Owner's Name: �%rfi /� Q 4
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
C]Work excluded by law
C]Job Under$1,000
Building not owner-occupied
Winer pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME 11"ROVEMENT 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 �
Date Owner's Name
g1orms:Affidav
Ifte Lommonweauix oj .,vassacizuseas
+ -- Department of Industriai Accidents
Alk �� Offrceallnsestigatians
600 Washington Street
Boston,Mass. 02111
Workers' Comyensation Insurance Affid2Vit
XXX IN
name: S/ iJ Al :;z
location: 7 l2 ZS
city x/4�/"///J phone# 7- 72J a 7-7 rj
CEI—I am a homeowner performing all work myself.
❑ I am a sole pronrietor and have no one working in any ca acity
❑ I am an employer providing workers' compensation for my emplovees working on this job.
comnnnv name:
i
address:
city:
phone#•
insurance cn. palicv#
❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who
have
the folloti%ing workers' compensation polices:
comonnv name:
address:
city: phone
insurance ca. ... ....... .
. :...;..:.....:.gin......
com n a nv name: .,. ..:.... :::::...,..:,:•:.,•}:.�: :::.... ..
address
cit-,- phone#� ;
:..
Insurance co. politVi! ::...:.:,:,...' . .........
Failure to secure coverage as required under Section 15A of MGL 152 can lead to the imposition of criminal penalties of a tote up to 51.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tote of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verfIIcation.
1 do hereby certify un the pains and penalties of perjury that the information provided above is tru•and eorreed
SiMature ��' 'l sib' Date
Print name S%l�/v /� /LI �,,� ice/ Phone# S d 7 7 S` o ? 3
Ccheck
W
nly do not write in this area to be completed by city or town official
permit/license q ❑Building Department
❑Licensing Board ..
nptediate mQottse is required ❑Selectmen's OMee
❑Health Department
on: phone#; _ - ❑Other
lm'um vA5 P1A1
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compens=ion fdr
employees. As quoted from the "law", an employee is defined as every person in the service of another under any cam-
of hire, express or implied, oral or written.
An employer is defused as an individual, partnership, association, corporation or other legal entity, or any two or more
the foregoing engaged in a joint enterprise, and including the legal representatives oft.deceased employer, or the recen•e: -
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 c:
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew
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,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 coatrac^r.=
authority.
MEMO,%%.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
,,please do not hesitate to give us a call.
The Department's address,tekephone and fax number. �
The Commonwealth Of Massachusetts
Department of Industrial Accidents
UMca of liwastloadoos
600 Washington Street
Boston'Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
I
Bunaing mvision
m' 367 Main Street,Hyannis MA 02601
ruse.
4
h
Office: 508-862-4038 Ralph Crassen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
4 Please Print
DATE: O — —70
JOB LOCATION: 7 -7 ��/iTC c�i yoo/J Ao -f__
number street village
"HOMEOWNER": �57_,2�/L) /--/e;l__5;7,,�_0 S—v7 77,F D 72 ' .moo 7 77J"-yfyj—
name home phone# work phone#
CURRENT MAILING ADDRESS:_7 7 X!
cityhown state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellineg 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 su eR rvisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requireme .
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,marry communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used
by several towns. You may care to amend and adopt such a form/certification for use in your community.