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0163 SPRING STREET
%�3 S�or;� ST � __ _ y ___ __ �, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 0 Parcel O Application # Health Division Date Issued Conservation Division Application'Fee so Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic- OKH _ Preservation/ Hyannis Project Street Address Village vmnncs Owner La c', [.B i IJ +ea Address _ Telephone 509 4 S b 55a Permit Request c L w'1A ceh\&1p,Se- Ca � Cj3 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total newer Zoning District Flood Plain Groundwater Overlay ' Project Valuation 2.a00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 0 Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes X No If yes, site plan review# Current Use Proposed Use _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ul11Nc,([vjke, t S, --IN Telephone Number S O 8 Address "� TT�� ' +� Ate License # I—< <d P �6 Uzi 6 q Home Improvement Contractor# IOU Email Worker's Compensation # WU n 13Q11 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Yprn;g„�Jt, SIGNATURE DATE FOR OFFICIAL USE ONLY ' APPLICATION # DATE ISSUED MAP/ PARCEL NO. f - '' ADDRESS VILLAGE OWNER i i DATE OF INSPECTION: FOUNDATION - FRAME i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ?PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING s . i` DATE CLOSED OUT ASSOCIATION PLAN NO. I.1 r ' } �,t• i .� ,,,.The Commonwealth of Massachusetts {. ` .:. ' ''Department of Industrial Accidents, '' ` 7,'" » • �' " 1 Congress Street,Suite 100 .ih-t "Boston,MA 021I4-201 ..'..:, rc•� n•. i ,.`.t r` 1 gi ..y,,--,:, .�=r �. www mass Opov/dia .'• R'orkers'Compen§ation.Iiisucance'Affidavif Builders/Contractors/Electricians/Plumtiers. w TO BE FILED WITH THE.PERMITTING AUTHORITY, t Applicant Information _."' Please Print Legibly Name (Business/Organization/Individual)-Cape Save Inc t _ Address 7-D Huntington Avenue , ? k k-, City/State/Zip:South Yarmouth,MA 02664 Phone# 508-398-0398 t Are you an employer?Check the appropriate bons 1 t _ _20 _ _ ,_ _ 1�pe of project(required) M_# 1.Q✓ I>am a employer with n employees(full and/or part-time)¢ :tit ` e. `r i' r i r ^ 7 :❑.New:construction .. r .r 1,JS'�. 7—, p ,Cx �' •o`i [ 2. 1 am a sole proprietor or partnership and have no a to ees workm" forme,n J f ❑ Y g , f 8. Remodeling t4 1 n , . s any capacity.[Noworkers'comp insurance required] , F - : .t , . O , n t A; •� . r • 9 ❑Demolition 3. I am a homeowner doing all work rt self.' * ' i ❑ g y [No workers comp..insurance requtted.J Y, - 4.❑I am a homeowner and wil be hiring contractors to conduct all work`o`n myy property..I will } 10❑Building addition ensure that all contractors either have workers'compensation insurance:or are sole 11:❑Electrical repairs or additions proprietors with no employees. ' .. 12,❑Plumbing:repairs.or additions 5.❑1 am a general contractor and I.have hired the sub-contractors listed on the attached sheet. 1.3:❑Roof repairs - These sub-contractors have employees and have workers'comp,insurance? E ' Q h ' 6.❑We are a corporationand its officers have exercised their right of exemption per MGL 14. Other Insulation c; _ ` 152,§1(4),and we have no employees.[No workers'comp.insurance required:) *Any applicant that checks box#1 must also.fill:out the section below showing their workers'compensations policy information_ �, ... t Homeowners who submit this affidavit indicating they are doing all.work and then hire outside contractors must submit a new affidavit indicatingsuch. { ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those;entities;haue 4 employees. If the sub-contractors have employees,they rttust provide their workers'comp:policy number: ' I am an employer thatris providing workers'compensation insurance for my employees. Below is the policy andlob site information. » . •. Insurance Company Name..Wesco Insurance Company -,Poficy#or Self-ins.L'ic #:WWC3136274 ;' Da Exptrafion te:04/09/2016 Aj- Job Siie Address': ' l S rip `Street-= kCity/S_tate/Zi ;. y ariri1S x. r- 5 Attach a copy of the workers"compensation policy declaration page(showing the policy number and expiration date)s Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a.fine up to$1,5.00.00 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.A copy,of;this statement maybe forwarded;to.the Office.of Investigations of.the.1)!A for.insUtance.—.a..._.,_.I i coverage verification. l _ I do hereby certify'under lh pains and penalties of perjury that the information provided above is true and.correct. ' - ae. { Siggattire. Date: 12/18/15 Phone#:508.-398 0398 = 1 I , L -Official use only.'Do not write in this'area;to be completed by-city or town'of j bial.." City or Town, _,.r, M .t w Perinit1kense# {>l Issuing Authority(circle one): :', Nt } 1.Board of Health 2.Buildin Department _ R' rtment 3.Ci , /To�. �„•�,�� m_; g :. pR _ . ty vvn Clerk 4.Electrical.Inspector 5.Plumbing Inspectoru*..:�, , t 6.Other.` ... _ Contact P `etson .«. �..�. ._.......,�.. � Phone:#: ` ....-... {'��}3�•.-s i{ • �:. 'i�. 'i'1 'is' C..-•yTl.. �-.i` :.� t:. 't♦s ;i�3 xC.l��'.� t}':'�f:,i►: . Ca�� DATE(MMIDDIYYYY) A CCO CERTIFICATE OF LIABILITY INSURANCE 10/14/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE'HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A•CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER - CONTACT NAME: Colleen Crowley Risk Strategies Company PHONE. WC.NoE (781)986-4400 NC No: (781)963-4420 15 Pacella Park Drive E-MAIL ccrowleyerisk-strategies.com. Suite 240 INS URER(S)AFFORDING COVERAGE NAIC« Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INSURER Allmerica Financial Alliance Ins Co 10212 Cape Save, 'Inc " " INSURERC:Wesco Insurance Company 7 D Huntington Ave INSURER D: INSURERS:- South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL15101402127 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED.OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER MP��ICY EFF MM IC EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEIF_ A CLAIMS-MADE Fx_1 OCCUR PREMISES Ea occurrence $ 100,000 ' S1994480 10/16/2015 1.10/16/2016 MEDEXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: -�. GENERAL AGGREGATE $ 2,000,000 POLICY�PEC°T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE I IT Ea accident $ 1,000,000 ANY AUTO ` BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS Ae9A46796600 11/6/2015 11/6/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS $' AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 4 AGGREGATE $ 1,000,000 DED I I RETENTION Hil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION officers Included for X STATUTE ERH AND EMPLOYERS'LIABILITY - - ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA Coverage E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? C ((MandatoryIn NH) WWC3136274 _ 4/9/2015 4/9/2016'- E.L.DISEASE'EA EMPLOYE $ 500,000 If yes,describe under ' DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD IOI,Addidonal Remarks Schedule,may be attached If more apace Is required) National Grid Corporate Services LLC d/b/a_National •Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER L CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance 'Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, M 02601 AUTHORIZED REPRESENTATIVE Michael Christian/CLC - 4 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) w HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. 1 hereb consent to and agree that weatherization hereby g fion work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping;air sealing; attic&basement insulation; exterior wall insulation;ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(sign$ture}_ W/Vj 61 A 6 k a� Home Owner email: Date: Agent:(signature} Date: J Weatherization Contractors: Adam T inc Cape Save All Cape Energy Alternative Weatherization Lohr Home Improvement Building Science Construction Resole ti;_Fin Energy Cape Cod Insulation Tupper Construction ( U J2�P Q2�0��1��12'�>?-f�ea�G��- Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664x --- --- ----- Update Address and return card.Mark reason for change. SCA 1 is 20M-05/1 t - ' E] Address [] Renewal Employment Lost Card �lltn��rii9iu•ituelLl��of�l�l�J:;iirl/iir6//�. • . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only AOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: WAM egistration: 171380 Type: Office of Consumer Affairs and Business Regulation ` 10 Park Plaza-Suite 5170 ?'Expiration�3AV2016 Corporation _ t.:. Boston,MA 02116 CAPE SAVE INC. 4�� .. ; .� : WILLIAM McCLUSKEY � y . 7-D HUNTINGTON AVENUE SOUTH YARMOUTH MA 02664 Undersecretary Not vali rthout signature I Massachusetts -Department of Public Safety \ Board of Building Regulations and Standards r_Sure, , 1:.1111111-111-Ui)11 fit\III-'JlILt171Ik_\' License: CSSL 102776 WILLIAM.J MC CCU 3.7 NAUSET ROAD !�Tvolt West Yarmouth MA cJ�•�..»:.:11f . ��t►; Expiration_ ; Commissioner 06/28/2017 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION J Map Parcel NP ` A lication #� E _ Pp Health Division " Date Issued Conservation Division Application Fee Planning Dept. Permit Fee " Date Definitive Plan.Approved by Planning Board Historic - OKH — Preservation/Hyannis (P-roject=Str-eet Address 4 67S San vac 5,+ d�1 ALI )kS tVillage 1� 4 RON VS cOw`ner L 0112 �t .5�' �Pr� Address Sa w6e- a!5 ivy. Telephone" Permit Request- --, 0 v� {- ( b down cal u�65 e I r�Sv�Gt �sr1. i►rt ; ski Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total now R Zoning District Flood Plain Groundwater Overlay P-ro(- -jeet-Valuations 2,Oaa Construction Type 14` Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting docum;etation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: W Yew❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - Nar me` r 1��(�trP.�-Prey Telephone'Number 336 ' k1l, Z823 Address, 6, 51As!_r3tSS6 License #-. _ 1 bZ-7-711 W�reff sw Mh- o2s" _Home,lmprovement,Contractor#_- I b0 �5 q Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE�-x w,, _, DATE 7,1 Q FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE {� OWNER . 4 e ' DATE OF INSPECTION: , FOUNDATION FRAME INSULATION } FIREPLACE t k ! ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL } GAS: ROUGH FINAL a FINAL BUILDING DATE CLOSED OUT - t ASSOCIATION PLAN NO. i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ;vivw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N1I7fe (business/Organization/Individual): -Piy"O T 1 E Address: _39 ON SE l City/State/Zip: ;/�1y1t b Phone312 Are you an employer? Check the appropriate box: Type of project (required): 1.® I am a employer with 2 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7 ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any workers'capacity. orkers' comp. insurance. q, ❑ luilding addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. } b Insurance Company Name: A\ 1" V -�c,,,l 1 Vx S 0 f G�v-1 c,? CC) Policy#or Self-ins. Lic. #: C> I6i �j !✓' � � ��0�L Expiration Date: 7 2-S / L� Job Site Address: f bS S V1Aoh City/State/Zip: EVNA ILS 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 hprisonment,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: &&Vt x Date: �Z��l0 Phone#: Yi S2 Z 3 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 Inspecto►- 5. Plumbing Inspector 6: Other Contact Person: Phone#: ''ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE-AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780.CMR 61.00) Applicant Name: Site-Address: � � �f g�(Z print Town: _A(T B ✓VI•A- Applicant.Phone: .5h - MZ -7U Applicant Signature: Date of Application: Cb NEW CONSTRUCTION: choose ONE of e following-two options) 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE-"AND TWO-FAMILY BUILDINGS MAXIMUM 5 MINIMUM Ceiling or Slab Basement ❑ Option 1: :Fenestration exposed Wall Floor Wall Perimeter AFUE HSPF SEER U-factor floors R-Value R-Value' R-Value. . R-Value and Depth R-Value National Appliance Energy FR-10, Conservation Act(NAECA)of 35 R=38 R-19 R=19; R-10 4 ft. 1987 as amended,minimums or greater as applicable Note: This form is not required if you choose either_of the two versions of REScheck as listed below. ❑ Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 REScheck-Web which can be accessed-at htt�://www energycodes.goy/rescheck/ ADDITIONS OR'ALTERATIONS,TO EXISTING BUILDINGS-:OVER.5 YEARS OLD*.. *Buildings under 5 years old must use option#1_or 42 in New Construction section above. Complete the,following formula to determine the% of glazing':', (a) Gross Wall &'Ceiling Area equals Formula: (100 x.b a) SF l 100 x %`of glazing t b Q (b) Glazing area equals , SF If glazing is 40% use the chart below. If glazing is >40.% roceed to "SUNROOM" section `780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM MINIMUM - Ceiling and Wall Slab Perimeter Fenestration Exposed floors'. u Floor Basement Wall R-Value U-factor R-Value•: R-value R-Value R-Value and Depth 39 R-37 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves.the full R-value over the entire ceiling area(i.e.not cons ressed over exterior walls,'and including any access o 'enin s): - SUNROOM ' An addition:or alteration.to"an'existing building/dwelling unit where the total glazing area of said addition exceeds 40% of-the.combined gross wall`and,ceiling area of the addition.. Note: Owner to fill out.Consurrrer Xnforrne tion Form (found in A endix'120.P) OF THE Tp ' Town of Barnstable o = e v Regulatory Services EARNSTAR9 M Thomas F. Geiler,Director ti p�a Building Division Tom Perry,-Building Commissioner y .200 Main Street,Hyaanis,MA 02601' 4 . www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 F. a Property Owner Must- Complete and Sign This Section. FIf Using A Builder f('S as Owner of the`subject property ,, hereby authorize L 1kr9dC&RAd to act on my behalf, in all-r atteis relative to work authorized by this building permit'application for V3 SP(LL(9"0- ST k ( .ddress of Job) i *nattir f CGer Date Print Name' ,, ' • .i. ' {ry ' 1,, !Y � � If Property Owner is applying for permit please complete the Homeowners License Exemption Form on.the reverse side.: QTORMS:OWNERPERMISSIM , Town of Barnstable oft►te tqk, , , Regulatory Services w sARNsrABte Thomas F. Geiler,Director MAss. 9q, 1639. ��� Building Division ArfD MPI A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess-a`license,Provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER,t 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:\WPFILESTORM S\homeexempt.DOC r,c, h v .. •. _.__.._,_p.�. - �� .�/00I7/IY000ZC(/C2GC/L 00�✓v(.cu!'�C�'LCLC[OCL�b .. �. _ ',�° _ �\ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registratiorf-160854 Expiration=9/812 10 �;.. TYP Supplement Card t t . 3 {' FRONTIER ENERGY%SOLUTIONS CONOR MCLNERNEY " r 239 PARKER ST yr INDIAN ORCHARD,MA 01.151 Undersecretary MIViassachus*etts- Department pf Public S�ftefi Board Of Buildinv Rey* COP,- 'dt Supervisor�Specialty Licenseandi . License: CS SL 102778`. l2estncted to IC 'CONOR MCINERNEY4 .., 39 SIASCONSET DRIVE <SAGAMOR4:4E'BEACM MA 02562. t' ^" �,✓ ,,� .. tin `� ,.�'� +� Expiration: 8/19/2012 ('uitinu�sioner Tr#:, 102778 JUN-03-2010 00:20 From: To:5087906230 Page:2,2 4/ 12/2010 1 : 1,6 -. 36 PM 8935 , ` . .� ® 02/03 CEWrIFICATE OF LIABILITY-INSURANCE DAIT`WV)Dp"`YY' Oai1V2010 THIS CERTIFICATE IH ISSOBD AN A MATTER OF INPORMATTOH On LY AND COHRER9 RO RIBHTS UPON THE CERTIFICATEBOLDER. THIS CERTIFICAT2 DOES HOT AFFIRMATIVELY OR DESATIVELY ARP,.EXTEND OR.ALTER THE COVERASE AF6o HAED BY THE POLICIES BELOW. THIS CERTIFICATE OF S0BvaNCE DOES HOT CONSTITUTE A CONTRACT EEVMMS THE ISSUING IBEVRER(6),'AUTSDRIZED REPRESENTATIVE OR PRODUCED, AHD THE CERTIFICATE HOLDER. - - IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Dolicy(ies) must be Ondorned. If SUBROGATION IS VAIVBD, subject to the, terms and Condition; of the policy, certain policies may require an endorsement., A statement on this, certificate does not confer ri hts to the certificate holder in lieu of such @pdorspmgnt{a)- eRaoucaa Rogers & Gray Insurance. Agency PNDD[ (6Y - Inc Ddj: F0 Box 1601 BADnAasS: " South Dennis, MA 02660 aw51wCEA zD•: . _ - zFsuDLPlet APfoADn1D cDvaRaae '' pale� . BEo - tltWM D: A.I.M. Mutual Lnsurance Co Frontier Energy Solutions LLC asmcw o_ 39 SiascOnset Drive - Sagamore Beach, MA 02562 �„�,D, - =u=r: _ - CaVERAC:ES CERTIFICATE NfIMBER: REVISION NUbMER: IS TV CEBTDFY TEAT THE POLICIES O@.DICUMCE LISTED BRIM HAVH WW ZS$V= TO TEE =S— AHOYB FOR THE POLICY PREIOD IPOW4TW- . H01VXTffs7 wC ASY BEQUTSS41M, T9W OR OOOrrZOd OF An CO81RAl•T O3.7fl=DOCOn=VITB RESPECT TO WHICHTHLS C3WTIP1f&,TR TAY DE ISSVB'D OR ZR7 PIRTASS, To IFIV HCS ABr==BY THE POLICIES DESCRISm BFJZM IS SUBJECT TO ALL TES THRgts, GSCLUSIOHS WD COUrnOSs OF 3VCB POLICIES. LILILI8 5809N MAY SAVE BEaD R mv= BY PAm CLFMM. . TYFH or =;vRaxrR U01IC1 OMER POLICY EFF POLICY=P cmroa/,,.*� LSH2T5 . . 68aE8Az zxAUa�t'r - - - ekCw 0CV=TKi ❑cagRAC IAI.66 RgaAi LIABCl[T[ - PALM TO'BwtCF ❑❑Q.\I M]IGDI ❑OCCUR _ _ PA�I56x(Ga•o.au[ill+D!) CEwbI1aL (1 RRY'L.�GGRDGI.TA iCh Ir/,DRIBS OR: - Iw:=ME ❑Pol[cC. 0e9wBCR DYOC vRwUCIs-�cDDr/w"s F - '^ RUTM 0BILE LIABILITY - CGKD 5twu.a Lu)AT - F :. ADAILT Wvn (Fee Pena,.) Y , []5CQADq.81D AUTOS _ DtaotLi W wr(Fe...cM—L) ... 7 6 . ram. aBIRBa 6YNA YRUYLATY OAUGb' . & loe.ewlaml)- e. �•�:' ❑COt7;tiCa,vlD AUTOO - '4' - ❑LREn A LUD O Q�C4OR PPCH DCCDUMCE . ❑S%CI°.II LGD ❑awiD MDREj v F7DOIC�8,5 t'ONPHW5A'd'ioE _ a sr DYlF. .. . AND 919w Ss LIAEZZTTY THE PROPF1CTOR/PAP.TNER3/ B.L• BAQI lCC IDIU� A EXECUTIVEorrlCEksARE _ .. ..6'- - 500,000 inCl ® eY.cl 6012959012009 e.L.'Dlsxnss -eseAPLomA e. 500,000 07/25/2009 07/25/2010 e,L Dlsusa-D��ID�c. a 500,000 coavwTY DYSaIIP•Iay DY aP[BAfIOvS oa LeCaxle=x: .. -. .. - -. '.- ALL MEMBERS ARE EXCLUDED FELON THE WORE EELS'COL�ENSATION POLICY.• - - CERTIFICATE BOLDER h: CANCELLATION NSTAR ELECTRIC &"GAS CoaP. NSTA& CORPO@ATE OFFICES SBOW&ANY OF ME MOVE DESCRIBED POT, MEL Be CAUC=,LED BEBDBE THE M E"TIOp'Awn 'THSREQI, Nor=V= HS DMIVERCD Is.RCCDRUAEca EM THE eoLtty'oaevxssoas. ONE.NSTAR NAY WESTWOOD, MA 02090 - AUSwoaRSYD RBR&ESR6fA1.Cvt a 2657 L 0f1KE Town .of BarnstabPerm.lei � q ,yam ti Expires 6 nionthsfront tssr date Regulatory Services Fee�� + BARNSTABLE, i v MAC Thomas F.•Geiler,.Director, ESS.s63Q. �m PER Q-r Building Division `t m.Perry, CBO, Building Commissioner PR 6 201® 200 Main Street,Hyannis,MA 02601 TOWN OF www.town.barnstable.ma.us Office: 508-862-4031gARNSrA13L Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Q (,, Not Valid without Red X-Press Imprint Map/parcel Number Property Address iC"3 Jp r i A9 5 � _ 14!1 Alup11 S5' 1' a - Eg/Residential Value of Work l 35b Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 1 Keiw 57 Oft d Contractor's Name ?e�f tz !gmltk Telephone.Number 56 36 2 " 3�CeAY Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 1 ' ❑Workman's Compensation Insurance Che 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 heck box) Re-roof(stripping old shingles) All construction debris will be taken to 7ooj,'J of V1q1zM aj(1-� ❑Re-roof(not stripping. Going over existing layers of roof) Re=side _ of doors 0 Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *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: . ��. The Commonwealth oflVlassachusetts Departineni.of Industrial Accidents .'' Office of InveStigktions 6OO Washington Street Boston, MA 02111 www,mass.gov/dirr Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indivi dual): ����/� SitZ`ti Address: D �Dx 4,w c71•� City/State/Zip: cco 41 v A M, 0a 6 3 Phone V' 156 F-36 2 3 sAP Are you an employer? Check the appropriate box; Type of project(required): A. 1 am a em to er with 4. I am a general contractor and I P Y 6 ❑New.construction �Jlanm loyees (full and/or part-time)•* have hired the sub-contractors 2. 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 y• 9. ❑ Building addition '[No workers'comp. insurance comp.insurance. required.] 5. We are a corporation and its 10.0 Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their 11.Q P11 bing repairs or addition' myself. [No workers' comp. right of exemption per MGL 12. oof 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 41 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 Addtess: 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 fin( r of up to$250.00 a day against the violator. Be advised that a copyof this statement maybe forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereb ce ify under the pains and penalties ofperjury that the information provided bov is true and correct. Signature: Date: 1 6 Phone# �d 7 2 " / a : 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 ofNealth 2.Building Department 3: City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector . 6. Other C 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-contractor(s)name(s), addresses).and phone number(s)along with their certificate(s) of in 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 pen-nit 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 insuredcompanies 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 permiAcense 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 futtire permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.inass.gov/dia i �IHET Town of Barnstable Regulatory Services ' BARNSrABLE, Thomas F. Geiler,Director 9 hues Ep - � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign Tl- s Section If Using A:Builder I, r)n J , as Owner of the subject property hereby authorize SM I to act on my behalf, ^in all matters relative to work authorized by this building permit application for. (Address of Jo Signa e of er Date I Lo r.1 Print Name Yf'Pr"operty Owner is applying for permit,please complete the' Homeowners License Exemption Form on the reverse. side: Town of Barnstable �pf"f t{F Tp� o Regulatory Services • Thomas F. Geiler,Director =nRrtsrest.E, M"S& i67.9• Building Division PIEo M�� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.m a.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: village number street "HOMEOWNER": work hone# name home phone# p CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-Occupied dwellings of six units or less and to allow homeowners to.engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF 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 andlor 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 d0 such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are as the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness oflen.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 helshe 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. n.wroFl� G(z\Pr)PM1\hnmeexemntDOC Massachusetts Departmcnt:of Public Safety" - Board of•Building Regulations'and•Standards Constrion Si'uct pervisor:Specialty License License:,CS SL.99486Y, Restricted to RF WSJ S� PETER SMITH 3925 MAIN STREET ', w CUMMAQUID,,.:, 37LL m Expiration: 11/1/2011 ('ommissioner Tr#: 99486 —.�•'-ter- .� ,t -- �ey ; Board of Building.Regulations and Standards } ' - t License or registration valid for md►vidul use only + ` HOME IMPROVEMENT CONTRACTOR f' before the expiration date.. If found return to;,. r Re-&tr tin 150950 Board of Buildmg.Regulat oits� nd Standards Expiration 5%8/2010 Tr# 267093 One Ashburton.Place Rm 1301 I tTYpe DBA I on,Ma.02'108 < 1- B �j ost PETER J.SMITH-,"HOME IMPROVEMENT _ PETER SMITH t 1 �� t ';f✓ # 3925 MAIN'ST. CUMMAQUID, MA 026375; �; Not id without signature i Administrator -1. -"- Town o f Barnstable *Permit Expires 6 thsfroni issue date Regulatory Services Fee BARNSrnsLE, v MASS. Thomas F.Geiler,Director sb39• AjF p�y a Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4638 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number —0 Y Property Address I ' ri [ esidential Value of Work f �0. I Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number_,5� / -455 � Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ®., ❑Workman's Compensation Insurance Check one: NOV El sole proprietor ZQQ4' Ukrarn the Homeowner "0 VVN ❑ I have Worker's Compensation Insurance ������ST��� Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request check box) Re-roof(stripping old shingles) All construction debris will be taken to >1Sbi An P ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors El Replacement Windows/doors/sliders.U-Value (maximum.44)#of:windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,'Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is ` r quired. ' SIGNATURE: Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 090809 Y6, The Commonwealth ofMassachusetts .. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02I11 wwm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Ileo Address: _� �(oa City/State/Zip: VA n r ts Phone#: Are you an employer? (f he&the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the s Lib-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y 9. ❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions q ] 3.,X I am a homeowner doing all work officers have exercised their 11.0 Plumbing 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 1 U l t _ Expiration Date: Job Site Address: IZA C City/State/Zip: zela Attach a copy of the workers' compensation policy declaf ation 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 certi under the ins and penalties o perjury that the information provided above is true and correct. Signatureaw. Date: Phone#: 7 7 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 S. 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 einployee 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,constriction 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-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 of 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia Town of Barnstable of�►�>�,, o Regulatory Services r >Axxsz.ABL Thomas F. Geiler,Director MASS 0.39. ,�� Building Division _ lED MA't a 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 Please Print DATE d'9 : / � ? JOB LOCATION: number street yr age j "HOMEOWNER": , J"v name —T home phone#/ �J r work phone# • CURRENT MAILING ADDRESS: city/town state zip code I 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. .t 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 require ents. Si nature otkMomeowner 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 hdshe 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:\WPFILES\FOPMS\bomeexempt.DOC �SHe T� Town of Barnstable Regulatory Services ' $" KAB& ' Thomas F. Geiler,Director 0.19. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02.,601 www.town.b arnstable.malus Office: 508-862-4038 Fax: 508-790-6230 Property er Must Co plete and S' n This Section If Usin A Builder as Owner of the subject property. hereby authorize to act on my behalf, in all matters relative to work au orize by this building permit application for: (Address o ob) Signature of Owner Date Print Name If Pro e Owner is applying for errnit lease complete the P �' p P P Homeowners License Exemption Form on the reverse side. Q:FO RM S M WN ERP ERM IS S ION ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel r� Application# ©� /V l Health Division Conservation Division Permit# Tax Collector Date Issued l� Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board ®f Historic-OKH Preservation/Hyannis Project Street Address 163 .S IV C- S / Village 14 I-1 ✓L i S Owner s •-f"J O z, L--wCL L 0 Address 52oq-iyr e Telephone S- S$ S' Z Permit Request H 1 Ct+ra 2/ -p" to Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay .'Project Valuation /l 6sO0 d Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family �E< Two Family ❑ Multi-Family(#units) " Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: S�Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing _ new First Floor Room Count f Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove;F ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing F❑new s ze �J Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: m Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ �L1 Commercial ❑Yes ❑No If yes, site plan review# ' Current Use Proposed Use BUILDER INFORMATION Name 06 0k,� -2k eec ICegC L 4 Telephone Number Address l G :? 3PA-'14 C— $ 7 License# y%y/4--0 H S Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 'IS GNATURE DATE O�3 ^ o r=+ 1 FOR OFFICIAL USE ONLY c PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE t OWNER r z DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL Y PLUMBING: ROUGH FINAL s GAS: ROUGH FINAL FINAL BUILDING i s DATE CLOSED OUT ASSOCIATION PLAN NO. 4 r t r The Commonwealth of'Massachusetts Department of Industrial Accidents Office of Investigations r 600 Washington Street ' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance A.ffidal : Builders/Con ct rs c a ]umbers A licant Information se Print Legibly a t ,c_ 6 P� Q Name (Business/Or,g ni zation/Individual): 1 �� � vl "'f` L.lS2 f� t Address: C(0 3 City/State/Zip: d/YVY0LA MN 6ab6i Phone#: St)S _T) �- Are you an employer? Check the-appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 El 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!: Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity.. 4 workers',comp.insurance. g. ❑ Building addition [No workers' comp. insurance S• ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.( I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or, additions myself.(No workers' comp. - c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees• [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' 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 their workers'comp,policy information. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy andjob 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct r"` Sienatur Date: F — _ o 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):' I.Board of health 2.Building Department 3.City/Town Clerk a.Electrical inspector 5.Plumbing Inspector � 6. Other iI Contact Person: Phone#: I FINE r, Town of Barnstable ti Regulatory Services B".NSTABLE. ` Thomas F.Geiler,Director 9 ASS. �ATf16 D 9. 16,0 Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 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: ? C14P_ g/4m I Estimated Cost Address of Work: /� 0 L '� S Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 OBuilding not owner-occupied wner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT 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 ot the owner: Date Contractor Signature Registration No. OR Date ,,,�wner s Signature Q:wpfiles.forms:homeaffidav Rev: 060606 . 1 P - r ZLP , I Oda —7p r c � S : i : i . r i p : P { 4f ! tl _ r y- it p • 4 w 6 v� IE � mmpi lies a I I r � ► I I —TY^k r — f{ ; r 'I r r " n I r , - E 41IN nalgim".M-n, —e-- � s :I � 9 ' _ r 1 r r AllI ._..._ {•J-- u kr w= ' y ZHE Town of Barnstable �OF Tp� "o Regulatory Services snxrs�ae . ; Thomas F.Geiler,Director v Mnss. g, 1 39• Building Division lfD MA'1 A 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 Please Print DATE: 5� 3 d p C JOB LOCATION: [ SO �2c C— 1 �nu`mbeer street g village "HOMEOWNER": V 014 N � O!` �E-6& L L 0 `�U 77S 4.SY Z .-69 SC name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF 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. ature of meo r 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 x _ y'_ bT�P �' — "r---t—II 1i'• —t—� y�.�.�— —tom- - 1 I L I. iLr vv d J { B { q Y nl Y I I ' '..o_. �..1 1 •. �� a II � I j 1 j '� pp' r - S a ! Y x P •' t ! ! l-,- & + � 71, le R a . F - �,.. a d e Ilk 1-7 It _.�. �Tfi M. .. �.__ •. ! 6 � � , _.. �I'wa. _ram.. � • � �. ',�i I ,�� 4 F • 1 � '�_�..__ f CA F PPCUPE -r' Y LINES Y E ACC ATE STANDARD LEGEND NOTE:not all symbols will appear on a map GOLF COURSE FAIRWAY < EDGE OF DECIDUOUS TREES EDGE OF BRUSH ORCHARD OR NURSERY ............_.. .. "'v`"""v' "'d EDGE OF CONIFEROUS TREES 19 .......... - . MARSH AREA EDGE OF WATER DIRT ROAD DRIVEWAY PARKING LOT AD PAVED R-. 0 I ------ DRAINAGE DITCH ----- PATH/TRAIL PARCEL LINE** _ MAP 326 E MAP# 021 E PARCEL NUMBER #367 E HOUSE NUMBER 2 FOOT CONTOUR LINE —E0— 10 FOOT CONTOUR LINE 328Elevation based on NGV029 4.9 SPOT ELEVATION STONEWALL -X--X- FENCE ® RETAININGWALL - RAIL ROAD TRACK STONE JETTY PuoL J SWIMMING POOL .0 . PORCH/DECK 0 BUILDING/STRUCTURE `.. - - --�;-r DOCK/PIER HYDRANT e VALVE O MANHOLE r o POST OFP FLAG POLE T O eW N O F B A R N S T A B L E G E O G R A P H 1 C 1 N F O R M A T I O N S Y S T E M S U N I T o SIGN ® STORM DRAIN N. PRINTED SCALE"IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimehics(man-made features)were interpreted from 1995 aerial photographs by The James a TOWER 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE " e 0 )0 20 National Ma Accuracy Standards at this do not represent actual relationships to h cal objects Cor oration. Plonimetrics,topography,and ve vegetation were mapped to meet National Ma Accuracy Standards - P Ps P Y� I Pg PPe P ry s 1 INCH=10 FEET* enlarged sca e. on the map, at a scale of 1"=100'. Parcel lines were digitized from FY2004 Town of Barnstable Assessor's tax maps. ¢ LIGHT POLE O ELECTRIC BOX