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HomeMy WebLinkAbout0100 SPRING STREET /a� SP,�;NG S r oFt r Town of Barnstable *Permit ExPirrs 6 monIsguin Regulatory Services Fee BARNSTAMZI Thomas F. Geiler,Director Building Division Tom Perry, CBO,-Building Commissioner " F r 200 Main Street,Hyannis,MA 02601 D ^ , www.town.barnstable.maus Office: 508-862-4038 ,50S-"7, Q,6230 = �, a EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY x: 2 �f Not Valid without Red X-Press Imprint Map/parcel Number Property Address �.�� S 1 N ' �( A-IV'V-/it S1 Residential Value of Work 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name &Address 0 CU "v Contractor's Name_ CAO 0 S jV OVA Telephone Number 9,11L Home Improvement Contractor License#(if applicable) a- Construction Supervisor's License#(if applicable) Ll , ❑Workman's Compensation Insurance Check one: . ❑ I am a sole proprietor ❑ .I am the Homeowner I have Worker's Compensation Insurance - Insurance Company Name D 1.4 Workman's Comp. Policy# l C D-0 40 —tr ry -y . Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping,old shingles) All construction debris will be taken to ❑Re-roof(not.stripping. Going-over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/dcors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not=mpt 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 rtquired. .GNATURE:J�— . MPFUMTORM permit formslEXPRESS.dcc. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation Insurance'Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Name(Business/Organization/Individual): ., o0--S . Address: 7O nervy _ CP City/State/Zip: �, vn��� I�'t'4 Phone.#: S Off; 3 7 � Ar you an employer? Check the appropriate box: Type of project(required):; 1 I am a employer with .4. KI 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 g, ❑Demolition working for me in any capacity. employees and have workers' . 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ ]red.re ui 5• ❑ We_are a corporation and its 10.0 Electrical repairs.or additions q . 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'co right of exemption per MGL �• 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. tContractors that check this box must attache&an additional sheet showing the name of the sub-contractors and state whether or not those entities have j 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 policyand job site information. q ," Insurance Company Name: �%� � f fJ✓ l'C--- Policy#or Self-ins.Lic.#: U'o O® -expiration Date: .J Lrr Job Site.Address: f, - SpM`""� City/State/Zip t//�G� Attach a copy of the workers' compensation policy declaration page(showing the policy number,and expiration date). , Failure.to secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of w 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 certi der thepains and penalties ofperjury that the information provided above is true and correct: Signature:'. c�1r Date. l �_ Phone . t so�a � a S .22 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.ElectricaI 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 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-contcactor(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 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"I:he 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 fo 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 Qf Massaehusetts Department of Industdal Accidents office of Investigations 600 Washington Street Boston„MA 02111 Te,1.#617-721-4906 ext 406 or 1-877-MASSAFE Revised 11-22-06_ Fax#617-727-7749 www.mass..gov/dia �THEr Town of Barnstable Regulatory;.Services BMMSrABLF, 9 MASS. $ Thomas F.Geiler,Director, Fa;A. & Building Division Tom Perry,Building Commissioner 260 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If UsinLy A-Builder as Owner of th e subject property authorize hereb . l/�.� \0'S. Y �' r -� ri�l to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Address of Job), Signature of t5mer Date 13c-- C6 l/ J Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. i Q`.FORM&O WNERPERMISSION t' Town of Barnstable Regulatory Services BARNSTABLE, Thomas F.Geiler,Director 16.19. A Building Division rFD MA't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 . www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION fPlease Print DATE: JOB LOCATION: too number t village "HOMEOWNER": name home-phone# work phone# CURRENT MAILING ADDRESS: T. � N S VA- A N N l S city own state zip code The current exemption for"homeowners"was extended to include owner-occupied.dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws; rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s),for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To.ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt vrivv BTS FAX 12/19/2011 2:48:47 PM ., PAGE 2/002 Fax Server Massachusetts Workers'Compensation Insurance Plan Acadia Insurance Company AL Administered by Berkley Risk Administrators Company, LLC PO Box 1100,Mpls,MN 55440-1100 222 S 9th St,Mpls,MN 55402 _ Acadia Insurances Phone(605)945-2144 Fax(866)215-8118 Toll Free (800)634-4589 NCCI Carrier Code 33391 _ CERTIFICATE OF INSURANCE 1.The Insured: WCIP Policy Number:WC-20-20-000092-04 Carlos Flgueiroa Tax ID#: F 01-8723094 dba: C N F Remodeling 20 Captain Noyes Rd Policy Period: From:5/1/2011 South Yarmouth,MA 02664 To:5/1/2012 Date of Mailing'.12f19/2011 a The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend,extend or alter the coverage afforded by the Policy listed below. This is to certify that the Policy of Insurance described herein has 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 Policy described herein Is subject to all the terms,exclusions and conditions of such Policy. _ UWI t u"`uinu !II..... trvn n . "'itreuuna n t _�Inn nunMrn.lit Mil Gilllflta1 i [Oyetd9e.',W� m Part One state(s) Workers'Compensation Statutory MA Part Two Bodily Injury by Accident $500,000 each accident. ' Employers'Uability Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $500,000 each employee. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. r' All Entities/Insureds: Certificate Holder's Name and Address: Flguelroa t Election Election Towriot Barnstable category Status' Name 200 Main Street + Sole Proprietor Include Carlos Figueiroa Hyannis,MA 02601 Date Issued: 12/19/2011 Leonard Insurance Agency Inc 683 Main St B OstervIII%MA 02655 Signature_ _. � .,. .... ... . .. BA 3140 Lrcease or viduuseltrton valid for mdiregis only I r before the esprration:'date. 3f found return to _ d� Uffce of Consumer Affars'.and Business.Regulahon 10 Park Plaza Suite'•5170 t� Boston,MA 01116: 15 ° - Not valid without signature f °NE RUM ' ._ —� aryreryrz°o� B smess Re � ptfiee� onsumer Attars& (RACTOR ` r CON ' TYPe: „t r HOME IMPROVEMENT Vi Regstration: 1537 32 pB.p i 1812 1 C g. REMODELIT� LOS FIGUEIFrO,I g h CAR YES�R � 1 20 CAPTAIN NO T Urdersecretar) - RMOU711 MA Q2fiUA g XA :. ' s: . k tchu.�ctt:� Board nl'Btrildrnl)clr.lrtpr , Re ' cntrrl'Ptrlili� Satet� Construction Super,;"III tions and License: CS 104,- isor LicenseFIndar d.�.a; CARLO r . 20 CAPT FIGVEIRO SOLI T H YA MOU7-OYEFS RD H, MA'02664 .. �J If. l Ilt i' Expiration: 8/25/2013 Tr: ,104107 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# ra_)b6, Health Division r M, Conservation Division Permit# C Tax Collector Date Issued Treasurer w Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 3 Historic-OKH Preservation/Hyannis Project Street Address V-! -e S Village a4 C Owner �r� d X? w Address Abo Sew. �7 i4v�v► �'( /-� Telephone S65ir V l (o L-ST Permit Request Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0^©O 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 LOo On Old King's Highway: ❑Yes VMo Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other S 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 Central Air: ❑Yes A No Fireplaces: Existing New Existing wood/coal tove: L*es .;�a No Detached garage:existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑a srie Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: j ^' Zonin Board of Appeals Authorization.❑ -Appeal# _=,<- = - — -= - Recorded 9_.._ pp , Commercial ❑Yes *No If yes,site plan review# �- r- M Current Use Proposed Use BUILDER INFORMATION h Name Crg � .t � Telephone Number Address O b v^ License# - ( Home Improvement Contractor# 17 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO wvi d 7— u yr S' e f vL SIGNATURE _ DATE FOR OFFICIAL USE ONLY p 1 r - 4 PERMIT NO. F I rA I i DATE ISSUED ' MAP/PARCEL NO. ADDRESSi VILLAGE OWNER DATE OF INSPECTION: r FOUNDATION k S + FRAME p INSULATION FIREPLACE I a ELECTRICAL: ROUGH FINAL i r PLUMBING: ROUGH FINAL c , GAS: ROUGH FINAL FINAL BUILDING � r 1 DATE CLOSED OUT , f , ASSOCIATION PLAN NO. I } pZF.'f Town of Barnstable p 1p� ' Regulatory Services yBARNSTABt.E, P" p Thomas F.Geiler,Director. y MASS. i639• �® Buildin-o, Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEMvNER LICENSE EXEMPTION Please Print DATE: .� 5 JOB LOCATION: I-on ,_ �� 44 (,4 number street village "HOMEOWNER": S CO)f g [�/_✓��22f 27 t G4 7 L'2S �f�7 7 name home phone work phone# CURRENT NIAMING ADDRESS: city/town state zip code The current exemption for"homeovmers".was extended to include u ner-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 HOMEONVNER 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 accessonj to such use and/or farm structures. A person rho 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"homeo%Nmer'' assumes responsibility for compliance-Mth the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner" certifies that he/she understands the Town of Bamstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Srgnatu�eo Wner 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 perforating work for which a building permit is required shall be exempt from the pro-,isions of this section(Section 109.3.1 -Licensing of construction Supervisors);proNrided 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-Supen*isors,Section 2.15) This lack of awareness often results in serious problems;particula-b . 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 Supen�sor. On the lasfpage of this issue is a for,currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrns'nomeex empt ' The Commonwealth of Massachusetts Department of Industrial Accidents 4 Office of Investigations a 600 Washington Street Boston,MA 02111 M s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): . Address:It-��,fl,,-� S City/State/Zip: Phone.#: S-08 77e' CLff Are you an employer?Check the appropriate bog: 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 sub-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 workingfor me in an capacity. employees and have workers' Y P t5'• 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised.their ❑Plumbing eir 11. 3.�I am a homeowner doing all work h i g repairs or additions myself. [No workers' comp. right of exemption per MGL 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. TContractors 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: Date: cSZS't57 _ Phone#: .S©cZ7,/ 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 lacceptable 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 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 AGeidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass.gov/dia Er, 'Town of Barnstable Regulatory Services ?sT'BLA ' Thomas F.Geiler,Director 9 MASS 16 ,. IN, Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax; 508-790-6230 Permit no. Date AFFIDAVIT. HOME MROVEMENT CONTRACTOR LAW _ 'SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: I Estimated Cosh Od.O Address of Work: 160 Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law OJob Under$1,000 Building not owner-occupied ROwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORD DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. Date 07 is Name Q:forms:homeaffidav f Tiaale JT.ZIa(CGn[tnAed� . . • prescriptive Packages for clue and Tw94X=D•Residential Ba3ldinp,�Nests$with'Fossil'�'Pe1a res . I44A7CfI4iilhY • M�IM� . • 4laxing GSaang Ceiling Wall Floor Basement Slab I;eatiag�CoolSng Area'(°!o) U-valuer R-value' ' R-value R-YWI Wall Perirae3es Equipment F.tSaeae}� R-valtie1 R value Pale 570I to 6500 Floating IIegrsx Days' 0.40 B 13 19 10 6 Normal IZYa O:i2 30)-- i 9 19 10. 8 Normal RB '•i57+FM 5 I3`a 0.30 3i 13 19 10 Isle 036 3i 13 25 .NIA NIA. Normal T v Nomsaf u 15% 0.46 33 19 19 10 6 �r 15% 0.44 31 13 25 NIA' � ' U AFUB w 13% 0.52 30 19 19 10 a >!5 AFUE ,fig . Ill'!. 03Z 31 I3 Zi. N/A rl/A Ydortrsal y TS°!a. 0.4Z 31 19 Z5 NIA NIA Narsr:al z 1 i°!a 6.41 31. 13 19 i 6 90 AFUE AA Id°!e G30 30 19 i9 TO 6 9.0AFUE 1, ADDRESS OF PROPEPTy: /d ® S v� �✓� T rye ,a 2, SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 7 e7 3, SQUARE FOOTAGE OR ALL GLAZING: -2' 4, c/o GLAZING AREA(0 DIVIDED BZ'#2): % o 5. SELECT PACKAGE(Q--AA o sea chart above): NC)TEc OTHER MORE INVOLVED I MTHODS OF DE iERMi3�FING ENERGY I{EQU[REMENTS ARE AVAILABLE. ASK.US FOP,THIS INFORMATION, BMI)ING-INSPECTOR APPROVAL: YES., N0; q-forms-f3i;Q343a ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel r. _ Permit# �- l 6 Health Division Qlaz 4-r tom Date Issued S Conservation Division �e �J a. Application Fee Tax Collector f Permit Fee y ; Treasurer Planning Dept: M'PLTCANTMW0BTA1NA9EWM CONNECTION PERMIT FROM THE Date Definitive Plan Approved by Planning Board ENGINEERING DIYJ$ION PRJOR TO CONMUCTJON. Historic-OKH Preservation/Hyannis Project Street Address 1 r—� U Village V\1 Owner C) A & Address A06 �S Telephone �,r � `7 7 Permit Request e t g c. cep( c, r. -e-- Square feet: 1 st floor: existing _N3 proposed 2nd floor:existing O 0 proposed Total new Zoning District R Flood Plain Groundwater Overlay Project Valuation Construction Type W Lot Size Z ad Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family )d Two Family ❑ Multi-Family(#units) - Age of Existing Structure 20 Historic House: ❑Yes A No On Old King's Highway: ❑Yes A No Basement Type: . Full ❑Crawl Cl Walkout - ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new - First Floor Room Count' Heat Type and Fuel: ❑Gas (XOil ❑ Electric ❑Other Central Air: ❑Yes ;'No Fireplaces: Existing New Existing wood/coal stove: 0 Yes ArNo Detached garage:0 existing JU new size/,6X20 Pool:❑existing ❑new size Barn:0 existing ❑new: size Attached garage:0 existing ❑new size Shed:❑existing 0 new size Other: Zoning Board of Appeals Authorization O. Appeal# S Recorded❑ Commercial ❑Yes ❑ No If,yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name .`s.`. i,� t` Telephone Number ,50? 77/ Address /(Z�,S/1 f- v\C License# Z Home Improvement Contractor# •4 Worker's Compensation# RR f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Ow O-P � a r v.4 tVots rft resc t.;t; S SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO. t DATE ISSUED MAP/PARCEL NO. 'F? ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION ,6 rO FRAME �/� �' d$ .�y�•ry O ,h i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING /�/M . DATE CL SED OUT. f ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents office ollnres1/9211817s 600 Washington Street Boston,Mass. 02111 Workers' Compensation.Insurance Affidavit � • name: ci h hone# '� I am omeowner performing all work myself. [� I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job �a 4'��+.�•k�`..�.'a'n'.n'c�57 RAW-,�W93�9,+�W cfia ��+r'�'''��+5`y,�7,,,,+"',�'`„t9rg''1��?��,���iv��'r4 y.���t a r�ya*5t'fv,zc.t.�+i)�,H,.rr4„j���'.tI.'�,�y.'�.:t tj'� n;:A�+:5y 1�#�t�ite,i�rr.r(s r,£��j�r�t,i�t f S r. 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".'�-TSY``,"`""+?,3 �,:� Tehl�r.N. _�T n�ttiy ur�.,��L�zy�.. 4�„ 4r.Yy„y..rY7�t�.�t>✓j"' ,.,..5'hk i F' S1.,r p � �,r r'r�"�'4'�."y.syti. x �`• �� ti..,e�� ,,}h..« !�, .r�nc�'4.,;,��4'r . �u`—�'�'` 2.f,.,�,�N�,�' �'� s�y�,(t�•+i"�F"••"'" �T,f'ru���•i` u -�,1.yF.P a .r t r�.k hx 5....�._sE .., 41.4S'�s•� -3 y x L G - � 3 � !�" n''�+� .r- h}�'y,i5_ '?`e'. ,• tTW? '+h n' Ne i,-.z ,t„f t/zs.Y*'�s s+:f T ` ti ^:"tr�'rY r+ 't;a...3+ �{r £`4 ..; •s�' F��kt, T ° `Sl.sy:'`f`ti i Ai. n ,: I ' a ' :r 'f eRY J!: zrr' ,+� z ti !r r�.Srj t Pw •a: t ,_Zty ::t�, n�•x:�.Ni kS�aµt � it f iXti6 r ^ r k i l'� f PbOn� 1F rr to itsWr 2� E ^rt�8 fi"v+r✓: CITY'`x 89 3w. ' �°s1 �2'+= F•"� r ,;4v ?1Ssh�'' '�'i r r,•aY c�"�.,��ca� �ryic. r it 4 Yv.•"P q -z. i :..r iy x { - r t� ✓r +1)� 3 1 k h�a Y.tSwSz��,._ ,7n��t*c' t ' t„`?=Y'.s.'c,,.;='' ��•.S•r"rn+'Si�� � aj,, ,, �tx'� a...,•+ �,.✓yada-v -., R ry l .;4 ,r 3, Y- OIIC,.i# ..'?N.�;�.': . -??... .+fixa' �')i:Y��e=.y��,ti ,C't�'-o��r,.'' -z Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi under thepains andpenalties ofperjury that the information provided above is true and correct Date �/z 037 Signature Phone# S::� 7 7 f Z 3 P t, Print name Official use only do not write in this area to be completed by city or town official city or town: permit/license# MBuilding Department ❑Licensing Board ❑check if immediate response is required []Selectmen's Office ❑Health Department contact person: phone#; r- Other (revised 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. WM City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out.in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406 Town of Barnstable ti Regulatory Services '` Haaxs�+s Thomas F.Geller,Director Kkn 9`bprF0;p.�04, Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. Type.of Work: \<J Estimated Cost. Address of Work: f® O S Owner's Name: * r Date of Application: r I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 Building not owner-occupied ',Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME RYIPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Nam RESIDENTIAL BUII.,DING PERMIT FEES APPLICATION FEE New Buildings;Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0031= plus from below(if applicable) GARAGES (attached&detached) V square feet x$32/sq.ft. J ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee The Town of Barnstable Regulatory Services ` Thomas F. Geiler, Director Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: sZ O 3 . JOB LOCATION: D Ayll ✓t 6 number street village "HOMEOWNER": SL a GCJ4 l.ti ✓` B�77 l J SP '- 8-62 Zz 77 name home phone# work phone# CURRENT MAILING ADDRESS: �>1'�✓�P S city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellin_Zs of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more-than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed•Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. � o LOT15 2 t IV e\y O. 1 t l LOT, 4 � 0 \ v L0. T, 13- , 00 LOT 12 6000, NOTES. PRE-EXISTING NONCONFORMING. " SHED APPEARS TO BE 0 VER LOT LINE. RES. ZONE.- "RB This MORTGAGE INSPECTION Plan is For FLOOD ZONE "C" Bank Use Only TOWN: _9Y_18W1S_ —'REGISTRY OWNER: RuTN F CHUTE' DuRWOOD U. & ROBERT N. MORIN DEED REF: _.,71Z �3 — BUYER-SC= ALAN�4I,UN _ _ DATE: _A,!�21193= __ _ PLAN REF: 37Z77 — SCALE:1"= c�O I HEREBY CERTIFY TO Spa'_I QL?_TGAGE--_--__--_—_ _-----THAT THE BUILDING ��`t-, Aass9� YANKEE SURVEY SHOWN ON "_!'HISS PLAN. IS LOCATEn ON THE GROUND AS � o� PAUL.. CONSULTA�v`TS SHOWN AND THAT ITS POSITION DOES ___— CONFORM a� A. TO THE. ZONING LAW SETBACK REQUIREMENTS OF THE MER�THEW N 143 ROUTE 149- TOWN OF F� RNSTABLE___ ___AND THAT, ? No. 32098 0� o a MARSTONS MILLS, MA. 02648 IT DOES NOT LIE WITHIN THE SPECIAL FLOOD HAZARD s S•TiF 9Fci �`° �``� , r TIrL: 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED 8�191� _._ s�c,NQ�'��Nos° Coy unit -Panel ' 250001-0_0_0_5-C '* FAX 420-5r�53 .> .. � THIS PLAN NOT MADE FROM AN INSTRUMENT PALL A MERITH PLS ----- SURVEY, NOT TO BF USED FOR FENCES, ETC. 11695 GGAf I 1 1� + 1 i i• LT- 11 R J R(2- -ec-e v-kn t,) —81�E�7 �1.'kV�477DA) _ o >a u u u il li Ll ti, u l I_ `T I /I` APPROVED HY: - SCALE: _,�ii DRAWN BY DATE: SED 5tltt/%-0w•' M�#-tF�N�t— —f��'��%a.." 7?�'f�L��'<Jr DRAWING NUMBER -0" o" -r-- ' r- '--------- -- �- I i I 3G" 20•� } FIX { 77) &i� a I d ° Mlnl, r3�wr,1 Co' 0 � GU/SO G/D �LD,GKI N6 M I CD Qt,-.5,L -b W PL Z7 O1 1-0 000 Q DOW � Of i i y I 1 91, 7 OU. .IkF. t7O© FnDNDA'77baJ �'r_aYa>J �l2�-r Lr Dori LL�1n1 _ aN� ��<� Pcg-n� � F15PN.�kt�7 r2.QOr" !/ Ifd P-I V6 e .�Si ..�UMJ3 7Z tY+ -D �P Gj� II Ot ax ax 6 FT y P-/6, .ou- HaR 3utt c�.tlA E our l'7- ._ a x F Rit K uJ� n �nG. 65t E_G LrE�,u T Flo_ l,vSoL,4-°rro,v P7$06 N4rLL. —No.�lN.ISP+ T_ IAT 12r�j� . ... 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