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Home My WebLink About0108 RUDDER ROAD 08 ,Euaa�r ,ems ACTIVE Efficient Buildings, LLC October 31, 2011 Town of Barnstable Attn: Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 y . re: 108 Rudder Road, Hyannis, MA 02601 Dear Mr. Perry: This affidavit is to certify that all work completed at 108 Rudder Road, Hyannis, MA 02601, has been inspected by a certified Building Performance Institute (BPI) inspector: Work included installation of 9 Fiberglass batting on attic floor(68 sq. ft.), 6" dense pack cellulose (120 sq. ft.) in walls, and 10" cellulose (1068 sq. ft.) in attic. All work performed meets or exceeds Federal and State requirements. Sincerely, Steve C. White Owner/Managing Member Efficient Buildings, LLC = w_s ,.E 8 Jan Sebastian Drive, Unit 10, Sandwich, MA 02563 Tel: 508-888-1110 Fax: 508-888-1109 TOWN OF BARNSTABLE BUILDING PERMIT.APPLICATION Map c Parcel l Z Application # 1 �U� Health Division Date Issued L l' CC) Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board �I — Historic _ OKH Preservation / Hyannis Project Street Address Village vV✓�< S Owner Address Telephone ��' 5-7-', 3 57 Permit Request oo_� a5-Q-- - L add tesrcz� oc1 vAivco__ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project ValuatioT Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑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 Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other ° rE Central Air: ❑ e Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: LI-existing LFnew�size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: =z `c> t� Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ a rya Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - - ` (BUILDER OR HOMEOWNER) Name Telephone Number' Address License # Home Improvement Contractor# 3 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ;�- f a t FOR OFFICIAL USE ONLY 4 . APPLICATION# r DATE ISSUED MAP/PARCEL NO. { ADDRESS VILLAGE OWNER 1 `s DATE OF INSPECTION: FOUNDATION i t-r,:`,; r' FRAME :';INSULATION- =A t FIREPLACE S ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL F,GAS _ "' ROUGH =S.7`'_ _C:7.;'• FINAL t t> FINAL BUILDING ' ITIN - l} L C , :DATE CLOSED,OUT ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 600 Washington Street \ 111 !1 Boston,MA 02111 �`IN www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly { Name (Business/OrganizatiorJIndividual):, cC,�`Q9_cf p p, Address: City/State/Zip: G�-kv:tS Phone a-`6D Are u an employer?Check t e appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or p -time).* have hired the sub-contractors , 2.❑ 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 me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] I officers have exercised their ]0,❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work - right of exemption per,MGL . I LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ R f repairs rr insurance required.] t 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.. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: QG Policy#or Self-ins. Lic. #: ��oZ S7`�J `- Expiration Dater'. 1( Job Site Address: I- �JrQv City/State/Zip: Y 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 M_GL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif «d r the pains and penalties of perjury that the information provided above is true and correct. Si nature: �" Date: C - rc la . ..`. 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 notbecause 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-contractor(s)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 r 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 mustsubmit 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address;telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia ( AiCORD CERTIFICATE OF LIABILITY INSURANCE DATE{MMIDDIYYYY) 09/1S/2010 PRODUCER S08.94S.0393 FAX 508.94S.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpki n Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 697 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 INSURERS AFFORDING COVERAGE NAIC# INSURED Caliber Building and Remodeling LLC - INSURERA: National Grange Mutual. Ins Co 14788 INSURER B: Commerce Group CIG001 147 Ridgewood Ave INsuRFRc: Granite State Ins. Co.-ARWC 131 22 Hyannis, MA 02601 -- Y � INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MMIDD/YYYY DATE MWDDIYYYY LIMITS GENERAL UABIUTY MP027360 i 09/1S/2010 09/15/2011 i EACH OCCURRENCE $ 1,000,000 DAMAGE t_x__ C0M MERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ S00,0O aCLAIMS MADE OCCUR MED EXP(Any one person) $ 10,00( A _ PERSONAL&ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEWL AGGREGATE LIMIT APPLIES PER, PRODUCTS•COMP/OP AGG $ 2,000,OO POLICY JECOT- LOC AUTOMOBILE LIAIMUTY BBNVCS 02/16/2010 02/16/2011 1COMBINED SINGLE LIMIT ANY AUTO j(Ea accident) $ 11000,000 I ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS I(Per person) $ B I HIRED AUTOS j BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ JI AUTO ONLY: AGG $ 1,EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ (—J RETENTION $ g WORKERS COMPENSATION WC74ZS40S 03/02/2010 03 02 2011 AND EMPLOYERS'LUUNLITY Y/N / / TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 500,00 C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ S00,0O Nes,describe under --- ---- ECUIL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER j DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS arpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1-0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Barnstable IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Attention: Building Department REPRESENTATIVES. 200 Main Street AUTHORIZED REPRESENTATIVE Hy nnis, MA 02601 Alan R. Long Presiden 1, ACORD 2512009101) 01988-2009 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD I i I .'�.'ioJ 0ll7il i I I IVliI 'dl(idlY n i i so Massachusetts-Department of Puhlic'Safet'. Board of Building-, Regulations and Standards Construction Supervisor License License: CS 95038 Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE HYANNIS, MA 02601 Expiration: Z28/2012 C„mmi� i,ncr Tr*: 19311 Beard of Rdbft Regalmdo and Surds NOW NPROVEM AT CONTRACTOR :.:154359 E 2618=11 . Tr# 280764 \ tdld IMbility.Corporation CALI!$ER BUtLDi 6*M 6 9 UNCo,LLC. . STEVEN WHITE 147 RIM EWOOD AVE-. �.4.,�Q.�...` IiYANNIS,MA 02601 Administrator use or, :VWLfer indhWal an only bdore ffie spa daft If found return to: 2021M of Bdd 'Aftulaftm and Standards One AsMwrti*,f%ee+Rm 1*1 Boston,Ma.all" . Not' wiitheut si8ndttrr . r as owner(s) of the subject property at: hereby authorize Steve White of Caliber Building And Remodeling, LLC (contractor)to act on my behalf in all matters relative to the building permit application. signature of wner dat signature of owner date �(Y�n Town of Barnstable *Permit CF ZME Tp�� &pires 6 Moon�ths from issue date „�,�� Regulatory Services Fee BARv� HAS& $ Thomas F.Geiler,Director %619. �0 Building Division �A Elbert CUlshoeffer,Jr. Building CommissWRESS PERM'T 367 Main Street, Hyannis,MA 02601 w S E P 2 1 2 0 01 Office: 508-862-4038 Fax: 508-790-6230 N OF BARNSTABLE EXPRESS PERMIT APPLICATI� Not Valid without Red X-Press imprint Map/parcel Number_2a-L� (� �1V . Uf omt�p�j � Property Address Value of Wor kResidential OR ❑Commercial Owner's Name&Address �UG Telephone Number Contractor's Name 16'Home Improvement Contractor License#(if applicable) � �a3 — _ Construction Supervisor's License#(if applicable) . ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name _ Workman's Comp.Policy# Permit Request(check box) Re-roof(stripping old shingles) Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maximum.44) Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic.conse rvation.etc• J . Shmature expmtrg TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map L/ Parcel, Application # Health Division Date Issued te let Conservation'Division Application Fee Planning Dept. Permit Fee �r Date Definitive Plan Approved by Planning Board Historic'- OKH _ Preservation/Hyannis Project Streets Address I GV Pr- �,dI Village iJecte` Owner SS ��^ e Address Telephone Permit Request stir / -n-✓� N �- �21 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District S " Flood Plain Groundwater Overlay Project Valuatio6` Construction Type Lot Size Z Grandfathered: ❑Yes ❑ No If yes,'attach supporting documentation. Dwelling Type: Single Family ;a' Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes 4, W6- On Old King's Highway: ❑Yes ,2 0 Basement Type: 0 Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) _ - i Basement Unfinished Area(sq.ft)_ Number of Baths: Full: existing !_� new----. Ha . mg new Number of Bedrooms: Z existing=-Revd---"' Total Room Count (not including baths): existing 6 new First Floor Room Count Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric kr Other Central Air: ❑Yes gE'No Fireplaces: Existing/New Existing wood/coal stove: ❑Yes i�No Detached garage4M existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existin ❑ new size_ ti Attached garage existing ' ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ tex -- v co Commercial ❑Yes ❑ No If yes, site plan review# -� Current Use Proposed Use C-0 C ca r APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _S. "4LIet-- Tele hone Number Address License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESUL ING FROM //THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER ' I I '# DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH ;FINAL ; i7 PLUMBING: ROUGH FINAL l:Y r GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations " 600 Washineon Street Boston; MA 02111 www.masy.gov/dia Y _ - rsEIectriciansPumbers Workers Compensation �ensation Insur c e Affidavit: Builders/ContractoPlease Print Le bl� A licant normation Naive (Busmess/Orgmaization/Individua): 2G • Address /(J� ��r �� . City/State/Zip: Phone.#: 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 6. ❑New construction employees(full and/or part-time).* have hired the sib-contractors 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 ees and have workers'loy Working for me in any capacity. emp T 9. Building addition . [Na workers' cOnrli,fr,�rrrance comp.inerrraarce. ] 5. ❑ we are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions Myself[No workers' camp. right of exemption per IviGL 12.❑Roof repairs msuran=required.]t c. 152, §1(4),and we havt no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that ehmlm box#1 mart also fill out the section below showing their workcxs'eo ap=sation policy inform atim-L t Hornmwocn who submit this of dm it indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. TCantractors that cbmk this box nnrst attached an additional cheat showing the name of the sub-antraCbM and stale whether or not thosd entities have employees. If the sub-mntraetarr have miployccs,they mustpnmdt their vrorkcn'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and jab site information_ , Insurance,Company Name: Policy#or Self-ins. Lie.#: 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 rri_m_TTal penalties of a fine uip 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 statamerit may be forwarded to the Office of Lavcstiratiaw of the!)IA for insuramc coves c verification. I do hereby certify undeVthhepains.andprnaldes of perjury that the information provided above is true and correct. Si atmre: Q.r/ Date: Z — Phone ZU Official use only. Do not write in this area, tb be completed by city or town officiuL City or Town: Permit/Liceme# Issuing Authority(circle one); 1.Board of Health 2.Building Department 3. City/'Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6..Other Contact Person: Phone,#: • r Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their emmployces:' , 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 Iegal entity, employing employees. however the e three apartments and who resides therein, or the occupant of the owner of a dwelling house having not nor than p dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house ent be deemed to be an employer." c o such employment building appurtenant thereto shall not because f or an the grounds orb dung pp mP Ym 1� MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a Lcens or permit ermit tooperate 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." chapter 152 25 states`Neither the commonwealth nor an of its political subdivisions shall Additionally,MGL ohap , § C(7) Y enter into any contract for the performance of public work until acceptable evidence of complianrc with the in-surancz 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 accessary,supply sub-contractors)name(s),addmss(cs) and phone numbers) along with their certificatc(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the nembers or partners, arc not required to carry workers' compensation insurance. If an LLC or LLP does have :mnployees, a policy is required. Bc advised that this affidavit may be submitted to the Department of Industrial &,ccidcnts for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should )e retumed to the city or town that the application for the permit or license is being requested,not the Department of ndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' :ompensation policy,please call the Department at the number listed below. Self-inured companies should enter their c number on the appropriate line. c1f-inc��ranr,C liccns ;ity or Towp Officials 'lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ,f the affidavit for you to fill out in time event the Office of Investigations has to contact you regarding the applicant ,lease be sure to fill in the pemmiVEcense number which will be used as a reference number. In addition, an applicant hat must submit multiple permit/license applications in any given year,need only submit our,affidavit indicating comment .olicy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or )wn)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the pplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit,must be filled out each ear.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture C. a dog license or permit to brim leaves etc.) said person is NOT required to complete this affidavit he Office of Investigations would blmc to than you in advance for your cooperation and should you have any questions, [ease do not hesitate to give us a call to Department's address, trArphone.and fax number. The Commonwealth of Massarhuse#ts De)artmwit of Industrial Accid=ts Office of bVestigatian:s 6.00 Washington Street Boston, MA 02111 Tel. # 617-727-490.0 ext 4-06 ar 1-877-MASSAFE :d I1-22-O6 Fax# 617-727-7749� www.mass.gov/dia Town of Barnstable map THe rpm Regulatory Services • Thomas F.Geiler,Director =Axrvsmwz. y &LASS Building Division Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 www.town.barnsiabl e.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / Please Print DATE:___ JOB LOCATION: / Zo number street ! r Ilage "HOMEOWNER": ��S t/y�G� �Grri 'Z aJ �71�C 0 ag—ZE 3 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 HOMEO\'VNER 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.L 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 requ'Men to 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 perfomung 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 pmon(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. Town of Barnstable a Regulatory Services ` s.+arrsrAsLe. Thomas F. Geiler,Director T$ MASS. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 _Property, Owner Must Complete and. Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all.matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Da te Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. r , r- - PROJECT +P NAME: I ADDRESS:` C I tUt K= s I PERT iIT# PERMIT DATE: I -. - LARGE PLANS ARE FILED IN: x - BANKERS BOX l FILED ALPHABETICALY�BY STREET IT INFORMATION SHEET FILED IN STREET+FILE x q/wpfiles/forms/archiveBANKERSBOX , P - - r - ,