HomeMy WebLinkAbout0030 SKATING RINK ROAD 3o S,-a-I%�
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Application number.
Date Issued.. O,.. [3.7ia.................................
Kos s . ` A 0 20 1 J9 Building Inspectors Initials...
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114FiIVSI�� Map/Parcel...zx22/ .l .........:................
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TOWN OF BARNSTABLE �s
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION
P.ROPERT)�INFORMATION
Address of Project: 30
NUMBER STREET VILLAGE
Owner's Name: ZCe ,�; Phone Number 5'y,9—Z3 7-,*7,5 o
Email Address: /1�� Cell Phone Number-'0 °-0737-476-0
Project cost $ —6",--9 Check one Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application for a building permit in accordance with 780 CMR.
.Owner Signature: Date: 6Amg
TI'PE`OFWORK�
0 Siding 0 Windows (no header change)# 0 Insulation/Weatherization
0JDoors (no header change) # Commercial Doors require an inspector's review
LYJ Roof(not applying more than I layer of shingles)
Construction Debris will be going to
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION NUMBER............................................................
*For Tents Only*
Date Tent (s) will be erected Removed on number of tents total
Does the tent have sides? Yes _ No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent
If food is being served at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval,
*WOOD/COAL/PELLET STOVES *
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
'HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name: W/M�
Telephone Number ® Cell or Work number 5t78--Z37—*7S, �b
I.understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures, specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature C�. Date
APPLICANT'S SIGNATURE
Signature Date
All permit applications are subject to a building official's approval prior to issuance.
6
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information // Please Print Legibly
Name(Business/Organization/Individual):
Address: 30 S f3%�� /Q//✓�( fib,
City/State/Zip: AII-< AP OZ a/ Phone#: 55$—Z 3 ---f7.S"U
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any caPaci n• employees and have workers'
$ 9. ❑Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. We are a corporation and its 10:❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ P 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#I 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.
lContractors 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:
I -
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
(Si ature:__1 6 C_Date:���(� ZO/
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#:
I
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in'the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
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 enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to 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 Accident
Office of Investigations
600 Washington.Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
r
Town of Barnstable *Permit# -/
s rom issue date
� Building Department Services Expires 6 mo fehe
HMMSTABM : Brian Florence,CBO
MAM
Building Commissioner
AIEo��r" 200 Main Street Hyannis,M 2 0a ,. �,
www.town.barnstable.m 5� ESS, VE
Office: 508-862-4038 SEP O7 20
17 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION
Not Valid without Red X-Press Imprint
.Map/parcel Number
Property Address'3 0 _QJW 110
Residential Value of Work$T Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address LEf" 6. j. 1117-A
70 SKR71" 91AI� H%/,�it/n//S, /;If, O Z<vo/
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable). Email:
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#
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
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value. (maximum.32)#of windows
#of doors:
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
QAWPFILES\FORMS\building permit forms\EXPRESS.doc
08/16/17
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.77te Commorn7veakh of-Mawachusetts
Department o,f rndustrid Accidents
— Office of brvestigadem
600 Washington_street '
_ Boston,MA 02111
n-mumas&govIdia
Warkers' ClUmpensation Insurance Affidavit;Blodldex-lCuntractarsMecb cians/Plumbers
Applicant Infurmatian Please Print
Name(13,ulnessfO�garlinfi ��,E' I�(/fr'/�/✓�
Address: 30 SMrMIK,
City/Sta� /9 /il/S P O� Phone 4'k- ,5'0 m-Z3 7—
Are you an employer?Check the appropriate bom ' Type of project(required):
I.❑ I am a et a to with 4. ❑I am a general contractor and I
P � 6. ❑New construction
employees(fo11 and/or part-time).* bzve]Tired the sub-contractaas
2.❑ I am a sole proprietor orparhmr- listed on the attached sheet. 7- [—].Remodeling
ship and have no employees '.These sub-cootractars have 8.,Q Demolition
es
moddag for me in any t3`- �I°� � #atdhavexwos�s' 9. �B.ui1dmg addition
[No W.06M.MS comp.rmsmanre comp-finuran-
.e
j 5- ❑ We are a-orporation and its 10❑Electrical repairs or a critions
3. I am a homeoumer doing all work officers have exercised their 1 L❑Plumbing repairs or additions.
myself[No workers' - c�2,f I ffidi�re ha(m per L 12_❑Roof repairs
insurance required.]B (
employees-[No worms' DID Other
cons?.insurance required-)
0AvyqTB=tdmtcbedsboxff1wm alsofluoucthesKd=beioardwvug&&workem*compenmso•poTicyinfnemsUmL
#Hameowners who sabamt dtis af6dmI mxScatmg they are doing&U wank and duen hire outside cantza s mast submit a new affidavit Wdiczda.-sUCTL,
fCoutcsc9=A=chendr this box must stterhedmadditionalshRetsha gtheazureofthe �dstatewhetherarnetthoseernitieshatre
emphryees.Iftbesub-caa�bweemplayea%they mustprvvAedeir warkess'camp.pGHUnumbm
I am au errtplapr tleat is pravging workers'compmsatiart iamirasce for my onWIal cal $efow is the policy and jab site
irrformatiora.
Insurance Company Name:
'Policy:g or Self-ins.l ic.4- FzpimtionDate: '
Job Eta Addrem- City/Statelyrp:
Attach a copy of the workers°coaupensationpolicy declaration page(shoving the policy-number and expiration date).
Failure to secure coverage as requiredunder Section25A of c- 157 can lead to the imposition of caimimal penalties of a
fine up to$UOD OD and/or one-ytear imprisonmesA as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250L00 a clay against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations offthe DIA€or insurance coverage verification.,
I do lieraby cgrdif}�Harder tbfapains artd psrtafties afpaeyury thatthe hzforma€wiprm d abmv is bare mid correct
Sit tattueJL� (i hate " S,6 P®ZO/
Phone ik .5�O •Z 3 7—'f75-0
o,ftcial arse artty. Do-tat write in dds area,trr be cornpteted by city artown o iciat
City or Town: Per€aitUcense#
Issuing Authmrity(circle one):
1.Board of Health 3.Building Department 3.City1rown Clerk 4.Dectrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
— - 6
Sarmatian and Instructions '
Massachusetts Geberal Laws chapter 152 regones an employers to provide wo6s'compensation far their employees.
` under com fro of
- defined as _.
dn.in$ie sceptre of another any b:1re,
P�tto this si�.nte,an�InyPe is svery Pray
express or implied oral or wriftczif
An.err player is defined as"an individual,partnership,associsiicm,omporation or other legal entity,or any two or more
of the foregoing engaged in a Joint eatmprise,and inchidmg the legal representatives of a deceased employer,Cr the
receiver or trasb=of an mdividaal,partnership,association or other legal entity,employing eurployees. However the
owner of a dwelling house having not more i3 an three apartments and v�ho resides therein,or the occupant ofthe -
dweIIing house of another who employs persons to do mair�anc. contraction or repai'wmk on such dwelling house
or,on the grounds or building a�puz�thereto shall not becense of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also sites that"every state or local licensing agency shall withhold the issaance or
renewal of a ficeuse or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compTance vPi-thu the ffis ranceL coverage required."
Ad.didonally,M(H chapter 152, §25CC7)states"Neither the comma nor lay ofits political subdivisions shall
enter into any conirad for the peafomance ofpubhc work until acceptable evidence of compliance with the ins*r2nce..
recfEnr=e¢f of this chapter have been presented to the coiftacting aofhouty."
A.ppHcan-& ,
Please fill out the wozkess'compensation affidavit completely,by check the boxes that apply to your sifination and,if
necessary,supply sub-.contractor(s)nam e(s), addres (es)and phone numbers)along with their=tEcafe(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees other than the
members or partners,are not required to carry workers'compensation insaran= If an LLC or LLP does have
employees,a policy is regnscct Be advisedthatthis a$tdaykinaybe submitted to the Depa.-(went of Industrial
Accidents for confirmation of msarm=coverage. Also be sure.to sign and data the affidavit The affidavit should
be retuned to the city or town that the application for the permit or license is being requested,not the Department of
Indastrial Accidents. Shouldyou have any questions regarding the Iaw or ifyou are rcgo±-ed to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license n=ber an the appropriate Ire.
City or Town Officials
f _
Please be sure that the affidavit is complete and primed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Invesbigatioas has to can act you regarding the applicant
P leas a be sure in fill in the permitllicemse mnnber which will be used as a reference nmnber. In addition,an applicant
that must submit multiple permit Ucensa applications in any given year,need only submit one affidavit indicafmg cogent
policy mfbii atioa Cif necessary)Emd under"Job Sim 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 fuinre'permits or licenses. A new affidavit must be fMr-d out each
year.Where a home owner or citizen is obtaining a license or permit not related in any business or commercial venture
(Le. a dog license or permit to buin leaves etc.)said person is NOT xeqndred to complete this affidavit
The.Office of Iuvest gaiions 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 f: mmmTMn of Maswchmsetts, '
Degarimmt cif 1adisftial Accidents
off!=of fvedikatio=
�Q4�ashin.�an Sty
-T(1L#617 T27-4 cxt 4-06 or 1-977 MA&AAA`
Fax#617 727 7M
Revised4-24-07 'WW Mas9 gomfdia
�t++E Town of Barnstable
Building Department Services
RARNST` XAB&" Brian Florence, CBO
►`� Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.maus
Office: 509-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I -
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job) Y
**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 .x Signature of Applicant
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOLS
Rev:08/16/17
Town of Barnstable
Building Department Services
Brian Florence,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
KAM www.town.barnstable.ma.us
Mla
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
DATE: 7 S,PT Z.o>7 Please Print
JOB LOCATION: -30
number street village
"HoMEowNw: - Cep ', WI�If�� 8 z 3 7 -7S0
name home phone# GEL L work phone#
CURRENT MAIIAJG ADDRESS: 30 R MA- R61
/-IY,19/VAlls OZ401
atty/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- .
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildingpermit. (Section
109.1.1) .
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
i&tature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control,
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in
your community.
Q:1wPFILES\FORMS\building permit forms\EXFRESS.doc
08/16/17