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HomeMy WebLinkAbout0038 SCHOOL STREET �� ���I S-I-.. _ . - " Town of BarnstableBuilding av��•,.w--y- av�w•�w� ,r.,�..�-m..� ,p�.,:,, y...:: Y. .T��`r,�.-._.-•�•x.w ,,,.��r, r awe .,...6; _r • IPost.This CardgSo?hat it is.Visible'Fromahe Street-Approved Plans_Must be Retained on Job and-this Card Must be'Kept` enxrssreai a II , ,., ,. ' �$ IPosted Until Final Inspection Has BeenVade �'._ ram, • N is ,u „ �� L ti , � � � = W Permit Where a Certificate of Occu a ancy is,Required;such'Building shall Not be Occupied'until a Final Inspection has been,made Permit No. B-16-1666 Applicant Name: HURLEY, PATRICIA A&WILLIAM F TRS Map/Lot: 327-235 Date Issued: 06/14/2016 Current Use: Zoning District: MS Permit Type: Shed-Residential-200 sf and under Expiration Date: 12/14/2016 Contractor Name: Location: 38SCHOOL STREET,HYANNIS ,,,Est. Project Cost: $0.00 Contractor License: ' i.� Owner on Record: HURLEY,PATRICIA A&WILLIAM F TRS Fee . $35.00 Address: 38 SCHOOL STREET �. Fee Paid r�. �$35.00 HYANNIS, MA 02601- Date -,6/14/2016 , t Description: 10x14 shed a . 'x !/ Project Review Req Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. . ., All work authorized by this permit shall conform to the approved application and the approved constructionsdocuments for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be-in compliance with the-local Toning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for:public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or Footing = m 2.Sheathing Inspection s `X 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed n x r 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site ' All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT t , t" Town"o f Barnstable oFT"E Regulatory Services Thomas F Geiler,Director. w 1AMSTAHLE, s ;: MASS. Building Division'`' � 16g9. �� A �� ► Tom Perry,Building Commissioner c 200 Main Street;-Hyannis,MA 02601, www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERNIIT#. .. FEE: $ F SHED REGISTRATION 200 square feet or less CINO Location of shed(address) Villa e S Property owner's name Telephone number Size of Shed Map/Parcel# _ o Signature : Y Date Hyannis Main Street Waterfront,Historic District? Old Kuig's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(Signature,is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE::IF ARE WITHIN THE JURISDICTION OF ANY OFT ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE PLEASE SEE;THE APPROPRIATE COMMFSSION°FOR DETAILS. . THIS eI+OlZM.T WSYBE ACCOMPANIED B.Y.A - PLOT PLAN f x Q-forms-shedreg '..'.`—REV:05201 ' 7V p E.Arkm' . b s CIO Ao `• .Y 1 4- mom. . . d --- ---- - _--= -1 100 LID of Js �. ..T'e r a,:.i S r 11 ®a' 5 C H an 8 Ro�e_n OF ¢.: AO as 1 ncC6 ����'. - 144(; A • - .. i..ff 'h 4 bid' �'} - le CAPECOMIN'o",-AR T ! —INSULATION C - PIRER 6kA5$ SEA.l i SPRAYMAM SV SPENDW \AM OvTIM .INS.4TI Q91UNOS - - 1-800-696-6611 VVICTON Town of Barnstable p �3 Regulatory Services Building Division, 200 Main St Hyannis; MA 0260,1 Dater Dear Building Inspector Please accept this Affidavit:as documentation.that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod .Insulation did this in accordance to the specifications listed on the building permit application.All.work has been inspected by a certified Building Performance Institute (BPL) inspector. All work preformed meets or exceeds Federal &.State Requirements: Proyerty Owner Property Address Village SdLoo[ ''S l Avg r16 Insulation Installed: Fiberglass Cellulose R-Value Restricted. ' Unrestricted Ceilings Slopes Floors Walls O 0 4,W1 P1 Sincerely hCodI Jr� President Coon; Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map'. Parcel Application #4 f Health Division Date Issued I IA61- 1,6 113 Conservation Division Application Fee Planning Dept. Permit Fee 3S Date Definitive,Plan Approved by Planning Board �—�� Historic - OKH Preservation / Hyannis . Project Street Address ..fG 1 f D Village Owner Address .� Telephone cJ_;�8 X0 Permit Request R*,-f" .� �/✓ass / G�//v,/��—� ���.y ,�' �G �/�G� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation oo a Construction Type/L/,fy//�f�®►t✓ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family L Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes X to On Old King's Highway: ❑Yes A!CNo 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 bath,):_existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: existing EP-nev c5s ize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use �= APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ��� ,�,�/�>� /l/c� Telephone Number, _2 15L Address//e License Home Improvement Contractor Worker's Compensation # � �� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE e FOR OFFICIAL USE ONLY r << • APPLICATION# DATE ISSUED MAP/PARCEL NO. • ADDRESS VILLAGE M OWNER r s " A. 1 DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' f r I + FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL . i y FINAL BUILDING - DATE CLOSED OUT d ASSOCIATION PLAN NO. I OWNER AUTHORIZATION-FORM PO4nC1�- S . �L1te, (Owner's.Name) ' owner of the property located at (Property Address) (Property Address) 'herebyauthorize - (Subcontr tor) C an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building r permit.and to perform work on my property_ r Owner's Signature Date D r._ NOV 7 } '4 iUl;ry. Ilassactulsetts - I)c 1 lrtment of Puhlic SACIN i Board I)f Buililirl.", lte).-ul:uiuns xnd."'t:unlartls constwiption Supervisor License" hJcen�:'-CS 100988 � . HENRY CASSIDYA. €hsa ti f Cfl F 8SHED ROW 1r YARMOUTH, MA 02679 WES, o Expiration: 1.1/11/2013 ( nnuii Awl, -- Trrr: 7620 V, Q�h,G�,1,1f1�Cfl-lilt:?� 1 . �I Office of Consumer A>`fairs and Business Regulation 10 Palk Plaza.- Suite 5170 Boston, Massachusetts 02116 Hon-le-Im' pirovement Contractor Registration Registratioli: 153567 Type: Private Corporation Expiration: 12115/Zb14 Trk 233831 . CAf'1= CODJNSULATION,'INC HENRY CASSIDY --- 18 REARDON CIRCLE SO. YARMOUTH MA 02664 Update Address and I'eturu card. 11'lurlr i eason for rliaagc; r �j Address ' I Itencvvsil . I.._l mploymcllr I. I Lost L'III r. lire 61 0FYI.lno,e(M ! - / .. £ • . uriirc of t oosuUler Affairs & liusuless Regulutioll License or registration valid for individuhtise.wily �r hIOML IMPROVEMENT CONTRACTOR before the expiration(late, If foUlld'1'ettll_ll to:. i�F y. egistratian: 1535b7 Type: Office of Consumer Affairs and Business Regulation t ;Expiration; 12/-15/2014 Private Corporation 10 Part:Plaza-Suite 5170 Boston,NIA 02116 -P1 CQI)1N,a )LATIUN,.`INC. •i, �Itl' i aSSil)Y , Iti Rk 1RI)ON CIRCLE , Sig Y ARWUII1. MA 02664 - � — — -� -- Uu(lcrsecrctiu'y Ut tial Wltho t flat re The C'onrnionwealth of Massachusetts I'nnt l orm - Department of Industrial Accidents OffCe of Investlgatlotls 1 Congress Street, Suite 100 Boston, M-4 02114-017 www.nrass.gov/ilia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plurtrlbers Alrltlicant lnl•or-nration Please Print Legjbl Mllllc (It usulcss/UrL,<uuzrrtton/lndivtdual U CIIVSI_[C/'/,Ci:_.... �.`---- V v�tr��- dVC K� Phone #: -C200 77,t; - I Z I - -- --- rc you an employer? Check d e; appropriate box: �rype of project (required): ( y ('� 4. ❑ l am a general contractor and I I :un a ::In Flo c t' with 6. ❑ New construction "rltpfoyccs (I'tl11 anti/; r earl-tune).* have hired the sub-contractors ..� I .uu �[ sale proprieAr or partner- listed on the attached sheet. 7. ❑ Remodeling ;Ilil, ;old have no employees These sub-contractors have S. ❑ Demolition ��orl:lllg lirr qie in any capacity. employees and have workers' r JNo workers' comp: insurance comp. insurance. ❑ Buildinb addition rryllircd.( 5. ❑ We are a corporation turd its l0.❑ Electrical repairs or additions I itin a homeowner doing kill work officers have exercised their 1 LE] Plumbing repairs or additions right of exemption per MGL ui)s:�lt'. lNo workers comp. 6 P P' 12.❑ .RooPre ors ut,urancc rcclttirCd.l f c. 15? 11(4), and we have no jpj � t(,��� J� employees. [No workers' 13.� Outer V�' -K _--- Tl _-.-- —_—_ comp. insurance required.] _ ,u, applicalli that cltcckS box it I must also till out the section below showing their workers'compensation policy information. I I.nuc crs who,ubrnit this aflidav it indicating they ate doing all work tu,d then hire outside contractors must submit.it new al'lidavit indicating such. �t,mmt,lots Iha1 check this box must allached all additional sheet showing the na,ne of the sub-cont-actors wul state whether or not lhosc eutitics have riuplupc a I1 ll,c sub -contraclors have employees,they nutst provide their workers'comp.policy number. I am an emploYer tltut is providing workers'coinpensalion insurance for tay etuployees. Below is the policy and job site u,/urru,uit,rr. rInn!� I,� n . in•,rir,u��� c'uutpuuy Name: ����L �V���� IVI�V�{,(/l G� I'I,lic� rt t,r ticl( ins. L,ic. fl: vl tCA ODD Z12 Expiration Date:" C�---/ -- 1oh tiuc Address:-.—_ -- ___-- City/State/Zip: Attach a colt)' t,f the workers' corrrpensation ,policy declaration page(showing the policy number and expiration date). l M1Ur„ l,,seCurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a i 111c up to$I,500.00 arid/or orrc-year imprisonment, as well as civil penalties in the fibrin of a STOP WORK ORDER and a fine til tw to r'iu.UU a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of' tHVOS I', ons of'the DIA I-or insurance coverage verification. I du hereby certi& 4n7l-'r the tuitrs.lLr�rl penalties oh erjury drat the inforrnatiort provided above is true and correct. - i tiiifuur�_, Date: 7:1 i Official u.ve only. Do not write in lids area, to be completed by city or town official. I t ilk or"town: Permit/License# Issumg Authority (circle onc): L Ltoard of l-lealth 2. Building Departnient 3. City/Town Clerk 4. Electrical Inspector S. Plunibing Inspector h. Other t'ottlacr Person:___ Phone#: �'�►. CAPECOD-27 SPURDY ACORQ' DATE(MM/DD/YYYY) I CERTIFICATE OF LIABILITY INSURANCE ___ _ 412_41201_3 � j THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ! j CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. j IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _ [PRODUCER CONTACT NAME: Cape Cod Commercial _ 1 Rogers&Gray Ins.-Dennis Branch PHONE 508 398-7980 j�"� NoJ (877)816-2156 l j434 Rte 134 IAalc,rro,ExtL� ) C .. E-MAIL ;South Dennis,MA 02660 ADDRESS: - ___INSURERS)AFFORDING COVERAGE NA_IC# INSURER A;PEERLESS INSURANCE COMPANY INSURED INSURER 8:COMMERCE INSURANCE COMPANY I Cape Cod Insulation Inc INSURER C:Evanston Insurance Company i 18 Reardon Circle FINSURER D:Atlantic Charter Insurance Company j South Yarmouth,MA 02664 I INSURER E: I I r- -- --- -- - ---- - -I INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR -- IADDL SUER - - POLICY EFF- POLICV EXP I Y I_LTR I TYPE OF INSURANCE _ INSR WVD- POLICY NUMBER (MM/DD/YYYYJ LMM/DDIYYYY LIMITS !GENERAL LIABILITY EACH OCCURRENCE $ 1,00�000i `DAMAGE TO-RENTED """ ' !A I X I COMMERCIAL GENERAL LIABILITY CBP8263063 4/1/2013 4/1/2014 ' PREMISES Ea occurrence)__ $ 10 _ 0001 — r CLAIMS-MADE X OCCUR I MED EXP(Any one person) $ 5, OOOI PERSONAL&ADV INJURY I$ 1,000,000I s 1 [GENERAL AGGREGATE i$ 2,000 OOOi I GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS COMP/OP AG G $ 2,000,OOOj _ t _.._ - --- I i I I POLICY%I JECT._.�_LOC I I $ ' -- -_ AUTOMOBILE LIABILITY «..I I COMBINED SINGLE LIMIT 1,000 0001 (Ea accident) _ $ -- -' 8 ( ANY AUTO 12MMBCKVMK 4/1/2013 4/1/2014 BODILY INJURY(Per person) $ - - ' ALL OWNED l SCHEDULED — - - IX I BODILY INJURY(Per accident) $ I AUTOS _I AUTOS I NON-OWNED PROPERTY DAMAGE X HIRED A $ UTOS X I AUTOS I I _(PER ACCIDENT) $ X I UMBRELLA LIAB X OCCUR I EACH OCCURRENCE $ 1,000,000I (, 'EXCESS LIABr- XONJ453512 4/1/2013 4/1/2014 . 1,0_00,000Ir A - .MADEi DED _RETENTION$ 10,000 _ -__ ----- -------- I WC STATU OTH $ i 1 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN L X TORY_LIMITS D ANY PROPRIETOR/PARTNER/EXECUTIVE I'-" WCA00525903 6/30/2012 6/30/2013 E.L.EACH ACCIDENT _ $ 1,000 000 I OFFICER/MEMBER EXCLUDED? N I A _ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000 000 I If yes,describe under I DESCRIPTION OF OPERATIONS below_-__ _ _-__ _-__- _ - - E.L.DISEASE-POLICY LIMIT $ 1,000 0001 I • I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) I Certificate Holder is an additional insured under General Liability when required by written Contracts or agreements. • i i i _ f t ..�... ._ ---- ----._.-w..-._..-- ------- -------------.._�..----- --- -'----. -. ... ----------.i CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i EVIDENCE OF INSURANCE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 'IN I ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # S J Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Pr 'ect Street Address Village �wner Ao//� Sri�eY Address S� Sc�om�rj`, ✓�y,�l� Telephone lephone 5—�S's' 7 71' -5-S Permit Request2�q` f�� T � L�—/ , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation loaa 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 I 'i 's Highy: g4Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other o Basement Finished Area(sq.ft.) Basement Unfinished Area' q.ft) Number of Baths: Full: existing new Half: existing _y nev Number of Bedrooms: existing =new .a Total„Room Count (not including baths): existing new First Floor Room Czmnt m Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing' ❑lnew size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Gv y�� Telep hone Number �� 77 F ^5 Address a- SG/z®� S 7` License # y/I/l p Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 1 SIGNATURE r CT / DATE U 4 f P FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. :x `1 ADDRESS VILLAGE t OWNER DATE OF INSPECTION: 4. A,FO_UNDATION ' FRAME t INSULATION FIREPLACE k ELECTRICAL: ROUGH FINAL r c PLUMBING: ROUGH FINAL i` GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. _ The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A"phc�ant Information Please Print Legibly NZer BBusiness/Oro Ti tion/Individual): > //��l /�- /�G!/ k4 Address: ' 4d® l S� /City/State/Zip:.. a%�Phone##: S'D S- Are you an employer?Check the appropriate box: Type of project(required): 1.El 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 sub-contractors 2 ElI stir a sole proprietor or partner- listed on the attached sheet. 7. [ modeling . ship and have no employees These sub-contractors have g. Demolition. working for me in any capacity. employees and have workers' 9 Building addition [N6 workers'comp.insurance comp.insu ance.$ d.] 5. We are a corporation and its Zre'quue10.❑Electrical repairs or additions /3.N!I am a homeowner doing all work officers have exercised their I l.❑Plumbing repairs or additions right of exemption per MGL Q / my'se1£ [No workers comp. 12.7 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 oat the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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 sub-contractors 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$1,50.0.00 and/or one-year imprisonment,as weIl as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day-against the violatot. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby..certify under the and n es of perjury that the information provided above is true and correct, �Si afore• �/ )ate: 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 Deparhnent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: w. Phone#: 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 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 Iicense 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( )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 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 enterthei.r 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 per=it/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 currant. policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city.or ' towel)."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 Zevised 4-24-07 Fax 4 617-727-7749 www.mass.gov/dia s T Town of Barnstable Regulatory Serviees Thomas F.Geiler,Director Mass. 9�b 1639. ,m� Building Division QED Mp'1 a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 wwv4.town.b arnstable.ma.us Office: 508-862-4038 Fax:.508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: r 0 /3 JOB LOCATION: 3�� -52GAo® / number street village ,O //i, ( � 'le✓"HOMEOWNER": L 77 53"ya 73 -3 3 S '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 OR 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 be/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,rates 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 re .ements!t ignature o omeowner 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 fuI3y aware of his/her responsibilities,many communities require,as part of the permit application, i that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. i Q:forms:homeexempt j i OFSME rqy, Town of Barnstable 0 Regulatory Services F Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-403 8 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 (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOLS 62012 y i y . o r`� � LL �. - " TOE N' Or SA R STA 2013 APR 1,6 Avir,9: 41 o x D JVJv-T,ofj . n rb S CAoo y &JA)l5 _ 14 -rot [mot P /fR•ti b,h s 171, ' 20 3 � r6r3 3' ��to�J Z—� -