HomeMy WebLinkAbout0021 SILVER LANE f ---
a s;� ��,� <q�
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�TMME t Town of Barnstable *Permit
�p�' Expires 6 mon rs rom issue date
N ^ Regulatory Services Fee
+ sexxsrnsr.E, + _
9� "039. Richard V.Scali,Interim Director
♦0
AlFD MA't A
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 50&790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Number L*� Not Valid without Red X-Press Imprint
Map/parcel jP
Property Address Z/ S 1 L V&tz LtJ 14 VA 1,/i✓I S
Residential Value of Work$ 2 9-0o, ck-.-p Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address CLA)rZ.0-- ►3ECT ,✓i
Z� S)LuFtL LnJ
Contractor's Name plA .. 1`A k T Telephone Number s D 2� 0 96 3
Home Improvement Contractor License#(if applicable) O z- Email: ' 1 ■
Construction Supervisor's License#(if applicable) �S ^ ! O "3C
z[ Workman's Compensation Insurance N
Check one:
❑ I am a sole proprietor '6AI1'S
®�
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name A r i-x MV t upt L I^)S U ILA nJ CC
Workman's Comp.Policy# 60 16 D 8 50 O� Z
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to )14 fL&OU f, 1/Cpsq(,
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission. s
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNAT..
QAWPFILESTORMSUilding permit fomvs\EXPRE .doc
Revised 061313
e CammornttewM oof'Vassachuseits
Deparftnent af1Yddks Accidents
- Office ofinvatigrcdans
600 Washington&reel
Wmv 7nu,-mgas rlux
Workers' CompensatiunbsnrancAffidavit:$.uildersfC-antractorsfl':iectriciansfMambers
Apt k--ant Information Please Print Legibly
Name(Bus news orpui-zxfim ndbridnap:��,n�;o �. �1/�R�A -jEJ Z
Address:
awstate/Z p_AY A n/Nr A o t�A Phone 2-1- 4 3
Are you an employer"Check the appropriate bow I Type of pr.
o]'ect(r
4. am a contractor and I e�-
I.El I am a employer with ❑ $ 6- ❑New construcfiiu�t
employees(fort and/or Pat-time)-* have hired the sub-ca�actot's
2. I am a sole proprietor or partner
listed on theattached sheet .. 7. ❑Remodeling-
strip and have no employees These sub-contractors have 8. ❑Demolition
w for me in an capacity. employees and have workers'
or�ng Y � t3`- I 9_•❑Building addition
[No Workers' comp.insurance comp.msurancz-
required-] 5. 0 We are a corporation and its. 1f3..❑Electrical repairs or additions
3_❑ I am a homeowner doing all work of .havre exercised their' 11..❑Plumbing repairs or additions .
myself[No wcrkm'comp- fight of exemption per MGL 12..El Roof repairs
152,
insurance regrind_]i c_ §I 4�and we have no I3J®Other sj l gj 1 AJ Co
employees-[No workers';
comp-insurance required.]
*A3iy appbam that checks boa#1 toast aLw fll out the SECti a below showing then wodcen'con ge iaa policy ft&hMMfiO3
Hnmeasrnefs orb mbmit this affOr nt iifusti�g they r.doing anwmk and d ea him outside contractors—st sa'fmit a mw a5 davit mffirstig such.
ZCbutmclars th9t r1ma this box mast attach d',za 7dditianal sheet sboSliab the name of ihe�==actors md,State whether arnot those Mgitkslirm
avlayees_ If the sak-cont soon hose employees,they must p wv their workers'comp.policy a=ber.
I am an employer that is prvvidiag worirers'compertmulan.imurance for my angkTies. Belau is fftepaHcy aud}ob site
informadom
Insurance GompauyName: A I �A J.Q i 11 A l- ( 10 SO 9A A)GE:
Policy 4 or Self-ins-Lic-4- 6 D 1.610 2--O ! Z &.oration Date: , l 2 3
Job Site Address 2 I LU IZ L its CitylStatelZip_ 14 V4 1J A)l'S kA-. to Z 6®.n
Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of 1't<IGL c. 152 can lead to the imposition ofrriminal Penalties of a
fine up to$1,5t10.0D andJor one-Yearimprisoument,as well as civil penalties in the fb m of n STOP WORK ORDER.and a fine-
ofup to$250_00 a day against the violator_ Be advised first a copy of this statement may be ffirwarded to the Office of
Inve*gations of the DIA for mmman-e coverage verification-
I do hereby a thspains andpenatlias j... my that the informationpratidgtl above is here and correct
Sitmatare: Bate
Phone#:
l},f kiwi use only. Da not Ivrite in this area,to be camp&od by do or town o icia£ .
City or Town: Permituceuse
Issuing Autharitg(circle one):
1.Board of$eaI`th 2.Building Department 3.,CitF1I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
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 Iocal 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."
;4 Applicants
0 Please fill out the workers' compensation affidavit completely,b checkin the boxes that apply to your situation and if
P Y g PPY` J
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cer-incate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members og,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 induslaial
1
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit Tl e 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 pennitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The GOranonwcalth of Massachusetts
Depaj meat of Indnstdal Accidents
Office of jvestiptlans
600 wasbingtan Street
Bostous MA 02111
T(,-I.#617-727-4900 at 406 or 14 MASWE
Revised 4-24-07 Fax#617-727-7749
w_mass-govIdia
a .
■aaNsMEM
`""9' Town of Barnstable
Regulatory Services
Richard V.Scali,Interim Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barastable.ma.us '
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I. C LRI��fi fl. ���cl °`I I ,as Owner of the subject property
hereby authorize 'PA tLO PIA&I I OILZ to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
r .
Signature of Owner Date
C LAI I11I
Print Name
If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the
reverse side.
T-.UMVM D1Buildmg ChangeslOMRESS PERNMWORESS.dm
Revised 061313
r Office of Consumer Affairs&Business Regulation License or registration valid for mdividul use only
r HOME.IMPROVEMENT.CONTRACTOR before the expiration date. If found return to:
. mer Affairs and Business Re ulati onRegistration: 42802 Type: Office of Consf :.Y
I
Expiration 5/20/2014 DBA 10 Park Plaza-Suite 5170
_
_ Boston- MA 2___.___�_ 0 116 )
C VO BUILDINGEE REMODELING
I
PABLO MARTIN6
49 SMITH ST �J �F
f "HYANNIS, MA 02601 -
!- Undersecretary Not valid with t signature
Massachusetts -Department of Public Safety
Board of Building.Regulations and Standards
Construction Supervisor
License: CS-103617 "
Rj-
pABLO C MART],$EZ
49 SMITH ST - =
HYANNIS MA 02601 1
J � �� Expiration
11/17/2015
Commissioner l
.5 23 —r3
f Barnstable *Permit
�t"E -PRESS PEff ' o dare 6
O Expires 6 nths fro Lu e
Regulatory Services Fee
's tom. MAY 212013
MAS& $ Thomas F.Geiler,Director
059. ♦0
'FO MA
TOWN .OF BARN���►
ilding Division
Toni iRT O, Building Commissioner
.200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma us
OiBce: 508-862-4038 Fax:.508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address �/1 ✓G �6" l f�-! 'J A�I O
K]Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address UA12-E- I) 17I'l�i Rye i
3
Contractor's Namea \ `A t 4J ��- Telephone Number = 'p� Z �
e
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) co
❑workman's Compensation Insurance
Check one:
[ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name 0'L.-T t oV SU iZ A NCB CIO.
Workman's Comp.Policy
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to i��rt ► 1 P f� �1 �t�4�k L
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side #of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. .
Separate Electrical&Fire Permits required.
*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
e Hired.
SIGNATURE:
TURE:
The Ca mwofflreatth of Massachuse&
Department of In&istrial Acciderrtr
Off ice of Investigations
600 Washington Street
Boston,M4 92111 .
wrvW-was&gvvldia
Wnrkim' Compensation Insurance Affidavit:Builders/Contractnrs/Bectricians/Plnmbers
Applicant Information Please Print L.eziblv
Name(Busiu ffi l):��b�,o
Address:
City/State/Zip: tU N P S o 1 + 3� 3
Are you an employs ?Check the appropriate box Type of project(required):
1.❑ I am a employer with 4- ❑ I am a gem rA mrtractor and I
employees(fall and1w pat-time).
* have hied the sub-contractors6- ❑New consfrociioa
I am a sole grogsietai or Fartnef-
lashed on the attached sheet. 7. ❑Remodeling
ship and haxe no employees These sub-contractors have g- ❑Demolition
woddng for me in any capacity. employees and have mks' 9. ❑Building addition
[NO wod=s'comp.insurance comp.insurance
required]
5. ❑ We are a corporationapd its 101-1 Electrical repairs or additions
I❑ I am a homeAwner doing all work officers have exercised their I❑Plumbing repairs or additions
uryself[No workers'comp- right of exemption.per ivfGL 12-N Roof repairs
insurance required]T C.152,$1(4),and we have no
employees-[No workers' 13.❑tither
comp.insurance required.}
`Any appficWH that sheds box#1 zmisi also fill oat the section below showing the¢ ak woes'compensation policy infbms ian
Y Homeowners who submit this affidavit intlicatimg they amAmag 2Hvmrk MaA then hue outside cant m ma submit anew affidwit in&m mg such
lca3mctms that cherk this box must meshed am additional sheet dhawmg the name of the sub-ca oo actor and state whether or not(hose entities her.
emplmyees. If the ab-co at cos have employees,they IM, Psavide tbw wmkes'comp.police number.
I�a azi ennpItilsr that ispravvidirrg.reaar&t=rs'corisatiore i>*lssrt�ce far ariy emrpIn} Beirity is lee policy*a>�ri jab site
information. .
Insurance Company Nam: A t—V VA_UZ U PA- iJ Sy YZA NC r-- � M —
Policy g or.S&ins_Lis_ ® l "Z-o t 2- apimtion Date: 0 Z,0 (3
Job Site A dress: I :•r m L n> CitylStatelTp:ITN,�P �1 A O Z_(0 O i
Attach a copy of the workers'compensation policy duration page(showing the policy member and espIIation date).
Failure to secure coverage as required under Section.25A of Px+l:GL c. 15_can lead to the imposition of criminal penalties of a
line up to S 1,560-00 and/or torte-gear impriso>ment,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 mhised that a copy of this stdtent:may be forwarded to the Office of
Immstigations of t,e D1A for insurance cmmrage verlfla tacn-
I do lieu ce yjm&r
thhepams and jwnahlffs ofpedk47 Heat the informat&n p vided ahow is bnr-s and carrect
51 Date:
Phone q 3®) 03
official am only. Do not anrite in this area,to be campleted by cite or tmm ofciaC .
GSity or-Town: FermitiLicense#
Issuing Authority(circle one): .
1..Board.of H�ealtb 2.Burtdirrg Department 3.Ci.tyrTown Clerk 4.Electrical]nsp6cter S.P-hunbing]n-4rector
�.a.-----= Vlmne#
Wt
Town of Barnstable
RegWatory Services
Thomas F Geder,DaftUr
Binding Division
Twin"rercg,ciao
Commiss3aner ,
2W Min St[eet, Hyannis-&i 02W]
.ew.town barnsbble ma as
Oil 50&4W-4038 Fmc 508-79"230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I L Ld-Vt CUS C-71-71 N _,'as Owner of the subject property-
hereby authorize A r'\ Z to act on my, behalf,
in all matters relative to work authorized be this building permit application for.
SSG e,*z- LN z(0J-(Address of Job
S'�W' re.of OWner 115ate
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
+C"dCsa�eoetF�� �� m�'is�wT' yF�SCu�bu�'•�RE6zLB1=�Essaoc
Revised 053012
I
i. ��e [�omvrnarzuiea�l�uo ✓��aaaachraet�a License or registration valid for indiv'rdul use only
Office of Consumer Affairs&B mess Regulation before the expiration date. If found return to: .
HOME IMPROVEMENT CONTRACTOR Type Office of Cons[mer Affairs and.Business Regulation
. Registration: ;142802 10 Park Plaza-6uite 5170 l
Expiration_ ,510(2014 DBA Boston,MA 02116
C VO BUILDING- i EidIODELING {
PABLO MARTINEZ - 9
49 SMITH ST
` HYANNIS,MA 02601 .;:.,,-.,_,„;; Undersecretary i Not valid with t signature
eon v�,.,`
Re �� o C B l
str�cr cease. -
A,q ea,to cs ct�o 01
by MjO MqR . 70�s,>S`�ot,7
q�,Ni ysr Tip
r• �_ 07 VS'
Fxp��d7�o
o. .
T 77,
701%-7673
of r Town,of Barnstable ' ..Q f3 cz
' Regulatory Services 6m°" ` 1e
MASS
1659. Thomas F. Geiler,`Director
Buildilag Division
-.......
Tom PenT, CBO1,Building Commissioner
200 Main Street,Hyannis,MA 02601
www-town:barnstable.ma us
Office: 508-862-403 8 E.
Fax: 5 0 5-790-623 0
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Vaffd.without Red x--Press Imprint
Map/parcel Number - 69"
Property Address a S i l vcv (u4L �\\\y\ f�Vl✓�l
19 Residential Value of Work �2p0f7
Minimum fee`of S35,,00 for work under$6000.00
Owner's Name&Address C'7 IS �I {;/k �(? u S 1 4 S U-s1w_66 iy,N f
contractor's Name = w Telephone Number
come Improvement Contractor License#(if applicable)`
:onstruction Supervisor's License#(if applicable)
]Workman's Compensation Insurance4
Check one: MAR 11 S.2012
❑ I am a sole proprietor b '
(� I am the Homeowner 1
❑ I have Worker's Compensation Insurance OF .
LE
isurarice Company Name t
orkman's Comp. Policy# $.
opy of Insurance Compliance Certificate must accompany each per ;
:rmit Request(check box) -
❑ Re-roof(stripping old shingles) All construction debris,Will;be taken to
( f Re-roof(not stripping: Going-over existing layeis of roof)
Re-side r n
#of doors
` Replacement Windows/doors/sliders.U-Value (maximum,¢4)#of windows p Setfie- `
*Where required: Lssnance of this permit does not exempt compliance with other town depamaent regulations i.e Historic,Conservation,etc.
s
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License& Construction Supervisors License is
required.
, -
rIATIIRE:
TlierEa�n�rerin aft lrof- kssacliuse"� =_--- -
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information -: - _ Please Print Legibly
--- Name(Business/Organization/Individual): --,-------
Address: 22 t S LJ12 `LA_�,i C
City/State/Zip: 1'1A Q'2J_.0 L Phone.#: 50s z /F 7 za 4a
Are you an employer? Check the appropriate box: . ,Type of project(required)::
1.❑ I am a employer with .4. ❑ I am a general contractor and I
* have hired the sub contractors
6.-❑New construction .
employees(full and/or part-time). .
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. Remodeling
These sub-contractors have
ship and have no employees � 8. ❑Demolition . .
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.$• 9. 0 Building addition '
required.] 5. ❑ We are a coiporation and its 10.❑Electrical repairs or additions
3.[� I am a homeowner doing all work, officers have exercised their l l.❑PlumBing repairs or additions
/ myself. o workers'co right of exemption per MGL
Y � comp. 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers'. 13.❑ Other. '
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside.contractors must submit a new affidavit indicating such.
$Contractors 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$1,500.00 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 certify under the pains-and penalties of perjury that the information provided above is true and correct:
Signature: ! i 6 g1jt'Ls , Date
Phone#: d 2
Official use only. Do not write in this area,to be completed by city or town officiaL '
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person.in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the-'
receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced,acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work until acceptable evidence of compliance withthe 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
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 permiVhcense 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 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 ofJndustial A.ccldemts
Office of lavestigatkas
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax#617-727•-7749
www.mass gov/dia
t
'THE
Town of Ba
rnstable
Regulatory'Services
>anaxsz EIM : Thomas F.Geiler,Director. .
16.19. �� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us .
Office: 508-862-4038 1
Fax 508-790-6230
HOMEOWNER LICENSE EXEMPTION '
Please Print
DATE: ✓ 2
JOB LOCATION:
number street
village
"HOMEOWNER": �—
name home phone# work-phone#
CURRENT MAILING ADDRESS:.
5��4�►/�ilS /'lid--- �v2�Q/'
ty/town state zip code
The current exemption for"homeowners"was extended'to include owner-occupied dwelling 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;oiis iniended 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 thathe/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. R
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be iequired 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 lastpage of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:fomis:homeexempt
x
R
�TNEAt� Town of Barnstable
--:----
Regulatory Services
tMASS Thomas F.Geiler,Director
019.
ED IW�+} Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject ptopetty
hereby authorize 4 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
ate not to be filled before fence is installed and pools are not to be
utilized until all final inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORM&O WNERPERMISSIONPOOLS
w Y,'3j 91130 �
A�-Sesso� THE
ws map and -lot number ..E '0 O a of To
... o� y
Sewage Permit number ..
/�J Z EARNSTODLE. S
House number ..................................... ..1........v(Y. -........... 9� MAea
po,039. 00
'E0YP-ta,
TOWN. OF BARNSTABLE
BUILDING . INSPECTOR
APPLICATION FOR PERMIT TO ................ ..��...C.�.:!! ...:...... •.Q ";" ...'1� '�I .... � s.,...............:.......:..
TYPEOF CONSTRUCTION .......�kp.C,�.........................................................................................................
....................J// ......19.&
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ..............9_1......... .l fC .......... a mt.� ........:........:...p. ...... .....
ProposedUse ....... . v &.! .e .........................................................................
Zoning District ........... ............................. ......................Fire District ......... /.�/7/Yl4l.0 ....... ....................
Name of Owner .. .( .. v "�:......... :..... /"'.(<Address .............
/A` e... rf
�s!
Name of Builder V(5jA G_(1�...........................Address ....... ® ............................................................
........................ ..............
Nameof Architect ............................... ...............................Address ................. ...�.......................................................
Numberof Rooms ......................... .............................Foundation ..................-.........................................................
Exierior ...... .1 .....................................................Roofing ........ (.. .L".. .1• .....................................
Floors ,PC. ..(2-4 ...............................................Interior ..............................................
._ Heating . .. ... ...... ....Plumbing N.. ... . f..`.. .......... R........ ...... .. --
Fireplace ............... .................................................Approximate Cost ....... ......................................................
i
Definitive Plan Approved by Planning Board --------------------------------19--------. Area ........... ....... ...
Diagram of Lot and Building with Dimensions Fee l
SUBJECT TO APPROVAL OF BOARD OF HEALTH `% !
A
s�l
0 Ft f P
'I 9�
16
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. UUI
Name ...� `4C` :t .. ..... .....`..........
q
ZINC:, EDWARD A. ,
`, ;V 23369 ADD PORCH
No ................. Permit for .....................................
pnulinq...............
Location ....2.1...Si.�,VeW:..�slZl ...`.:......::..........
- r?
..., . w
HYaI}xlS..................... ............
00
Owner ......EdwZr:a..A...... inn. ..................
•w
r t _
Type-of Construction FXe
............................................................... '................. S ^T Y •J F aS
- s .
fi 7
Plot ............ k........... Lot ................................. r-t 1
Augut
F Permit:Gra ed ...................`... 13.........19 $1
,1 Date of Inspection,..........s............... .......19
Date o'Completed ....
c / - ....1. ....:Z.7. ...a.. . ....19
PERMIT REFUSED i
.:......... ................................ .....�.................
:................................................... ............ ..
Approved .....:.......................................... 19 � • t
..
E = 'ice" � • x
..........................................................................!< t
P
/ _ .'3 r)
Asses ^•'s map and lot number .. (�.�. � v _ '?
�f /3 H
Sewage Permit number
BJBH5TIDLE, .
House number ........................... ....nc /UL-.......... 9 S a�.................. 79• 9
�Ep MPY a�
TOWN OF BARNSTABLE
•
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .................,..pr (% ?!
ell
..... .......... .. Q ....... .. ....
f
TYPE OF CONSTRUCTION .......
............ ....... j.. .......19i
-TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies
/for a permit according to the following information:
Location .............91........sl l y......... .. ........:f....1..� l r rlJ
��++
Proposed Use ....... `,?„(1W• q'C P.........................................................................
Zoning District .......... /�L"a ......................Fire District l�......................................... .,..................................
Name of Owner .. !��.LQa V. ^.......... ... "'� .1�Address .. .f...AJ/f �' ...�.a �� ..........................t ff ...
Nameof Builder �!'..�- iA(I!T...........................Address........ ..... . .. . . .. ... ..... ............................................................
Nameof Architect ..........................'......................................Address ................. ..............................................................
Numberof Rooms ..................................................................Foundation ..-.....�.-.......................................................................
Exierior FYLt+Or ...................................................Roofing .....::.�t"..r...
?s.y.. j:: .....................................
Floors �.l?.cry . ...............................................Interior .......................................... .. .....................................
Heating ..... l r?.L!L.: ....................................................Plumbing .......... .`�&�"�............... ......
Fireplace .............. 1t/). .. ...................................................Approximate Cost ...... . ..............................................
Definitive Plan Approved; by Planning Board ________________________________19-------- . Area .. .. .`...;:.?,....
Diagram of Lot and Building with Dimensions Fee °`sue
SUBJECT TO APPROVAL OF BOARD OF HEALTH � � 12 -----��-------
ll!
- �7ru I " Icuje
r )R1
el
' . 1
� G
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. ?
Name ! ( rat. ..................................................
J
ZIND, EDWARD A. /' 268-159
/
` ��33G3 ADD PORCB `
No '/�----. Permit for --------..�--..
/ ^ `
1�^
I�onzily Dvvelli
----~---------------..-----
' 2l SiIv�r Lane
Locohon ,��--------________� ___..
_.__._.. ..........................
Owner ...E.dvvazd�..����—Oink
. . ________..
-
'. of Construction ..... .........................
.............. ^ o
Plot ............................ Lot ....................................
`
,
`
August 13' ' 81 '
Permit Granted -----------`�—..lV `
� .
( '
Date of Inspection --------�---.lq
�
Dote Completed ---------.]--]g
— '
'
`
PERMIT REFUSED
'
----- ................... 19
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Approved ---------------' lg .
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