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HomeMy WebLinkAbout0052 SPRUCE STREET `7 v� S S41 3q _ �""7 Cj°mxf TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel _ Permit# �� � P Health_Division`� �a' Date Issued 40 Conservation Division Fee ` Tax Collector < i Application Fee do Treasurer- Checked in B ' Planning Dept. . Y t - Date Definitive Plan Approved by Planning Board - cs� et, Approved By Historic-OKH Preservation/Hyannis Project Street Address Village Owner Address 6 XNJE 4 CtWB /11 Telephone Permit Request ('8 NX,Q AT G(� V R OrM TO a �i�udZ2 ape,, 1 d.� c. al' ri AJU)0_V� t Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation J_ n e-). c-N Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size 6 4.o o Grandfathered: ❑Yes Cl No If yes, attach.supporting documentation. Dwelling Type: Single Family Z Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: 0 Yes RfNo- -On Old King's Highway: ❑Yes � o . 6- Basement Type: Z Full 9 Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) A,- Basement Unfinished Area(sq.ft) / r� r Number of Baths: Full: existing new Half:existing new 1 1 C-J Number of Bedrooms: existing_ new , Total Room Count(not including baths): existing new First Floor Room Counfu) Heat Type and Fuel:�A Gas ❑Oil ❑ Electric ❑Other f � Central Air: O Yes #1 No Fireplaces: Existing New ��h h Existing wood/coal stove: Yes eNo Detached garage:❑existing ❑new size Pool:Cl existing ❑new size Barn:❑existing ❑new size Attached garage:A existing 10 new size Shed:X existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number �) � Address Am /, a a et License# [OA MCA �12 Home Improvement Contractor# ANZ Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO en SIGNATURE;1 c DATE • 1 FOR OFFICIAL USE ONLY u, Y - t PERMIT NO. DATE ISSUED t r i MAP/PARCEL NO. ADDRESS ► VILLAGE ' r OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION ©/� � ✓" �� FIREP�L.ACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL . GAS: ROUGH FINAL FINAL,BUILDING - . J DATE CLOSED OUT ' ASSOCIATION PLAN NO. ?• 1 ne,t-ommonweatrn oI massacnusetts Department oflndustrial Accidents Office.of Investigations ' 600 Washington Street ,~ Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auulicant Information Please Print Legibly Name (Business/Organization/Individual): V. L` Address: a Iy nn L- City/State/ZiP:_ P6 Phone#: 5 S Are you an employer? Check the-appropriate box:. 1.❑ I am a employer with 4. ElI am a general contractor and I .Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7• Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. [:J 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.❑ Roof repairs •insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other '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 GContractors 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 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 Df ip 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. T do hereby certify under ains and penalties of jury that the information provided above is true and correct Si a `� l C%�/ Date: Phone#: Of,j`ecial use only. Do not write in this area,to be completed by city or town offieiaL City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspe 6.Other ctor 5.Plumbing Inspector 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 in on,Fo�poration 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:tlie 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 woik`on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if and under"Job Site Address"the applicant should write"all locations in (city or necessary) r 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-&enses..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 thus-affidavit. The Office of Investigations would ble 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 Washingfon Street- . Boston, MA 02111. Tel. #617-727-4900 ext 406 or-1-.877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia oFNE Town of Barnstable o Regulatory Services .' g rY qtO ' Thomas F.Geiler,Director MAM i p`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. i Type of Work: Estimated Cos# _0 __ Address of Work, U e L Owner's Name: 19 IV V Z--- L Date of Application: c.2 I hereby certify that: Registration is not required for the following reason(s): FWork excluded by law OJob Under$1,000 7Building not owner-occupied r [ Owrier.pulling own_p.ermi't—_J 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 of the owner: Date Contractor Name Registration No. cl OR Date 0 ewn is Name Q:forms:homeaffidav 4 40'•4" EMANUEL PACHECO l2'•11" 52 SPRUCE STREET SMOKE DETECTORS REVIEWED BARNSTABLE MA, 02601 _k SHED 774 930 7033 - 11'-5"x11'-a' BAR TABLE BUILDING DEPT. DATE FIRE DEPARTMENT DATE BOTH SIGNATURES ARE REQUIRED FOR PERhIITTING IMPORTANT UPGRADE REQUIRED STATE BUILDING CODE REQUIRES THE UPGRADING OF 9 SMOKE DETECTORS FOR THE ENTIRE DWELLING WHEN GUEST BDRM ONE OR MORE SLEEPING AREAS ARE ADDED OR CREATED. 12'-3"x 11'-9" NOTE:-A SEPARATE PERMIT IS REQUIRED FOR THE" R INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL REQUIREMENT. 2868 p Oo . 4'-1112" 9'J 1/2" 2446 3068 3068 4068 ._.4'.6 1/2 7'•30" O BATrl KITCHEN 0 .� 12'-6"x 10'-7' DO 0 STUDY 4 266E 7'-9"x 12'-0" D O Q 4'-1 1/2" " 00 MASTER BDRM 3'-4"-i 0 a 9'-3"x 16'-8" N N 4 IBaB 2868 2868 0 lV 9'4" LIVING o 25'-7"x 10'-7" o 41036 3068 V' 2436 2436 3068 2436 2436 74_1" 26'_3" 40'-4" EMANUEL PACHECO 52 SPRUCE STREET BARNSTABLE MA, 02601 v 774 930 7033 u 2"X 8"COLLAR TIES 2 R-30INSULATION ADDITIONAL 2"X 8"ROOF RAFTERS NAILED TO EXISTING 2"X 6" ROOF RAFTERS R-11 INSULATION MASTER BEDROOM WINDOW 2"X 4`WALL FRAMING 5/8"PLYWOOD SHEATING FLOORS CLOSETS WITH 1/2'SHEET ROCK W/PLASTER FINISH FOR WALLS AND CEILING 2'X 8"s NAILED TO PERPENDICULAR PRESSURE TREATED 2"X 8"s AT R-19 INSULATION ENDS OF SPANS W/JOISTS HANGERS - PRESSURE TREATED WOOD @ 16` CONCRETE SLAB CONCRETE SLAB y r, 'moo The Town of B ' arnstable Department of Health Safety and Environmental Services •'�� Building Division 367 Main Street,Hyannis,MA 02601 862.4038 790.6230 PLAN REVIEW Yer: ��I r7�L- .�- a"td��i Map/Parcel:_ �3 1") �"�� c G co ct Address: _4�`� S ��2 v c..E 5 Builder: following items were noted on reviewing: ------------------ wed by: 03/02/2006 09:38 FAX 5086767144 PACHECO INSURAVCF f 001 h PA" TtE T/O/V: ADD FA/ S �i 'OONtA I a CT : 70 33 le 3DVd ONI Qd3 BEESSE980S Z9:z9 966Z/zt/Z4a 03%02%2006 00:39 FAX 5086767144 PACHECO INSURANCF Zt002 9 RIDGE BEAM TJ.e aM#Oe.sosarW Numom 7o 301C103f, 1 3/4" xt 9 1/2" 1.9E Microllamiti LVL i �9 aao6 � 16 THIS PRODUCT MEETS Oft EXCEEDS 7H5 SET DESIGN CONTROLS FOR THE APPLICATION AND LOADS LISTED Mailtittier slope:Oita Poet Slope?A2 _ r x M dltsrerxelon*are tlori2erttal. Product Biagi-am is Conceptual, L2M& Arrllysis is for a Header(Fluch beam)Member. Tributary Load Width:V Primmy Load Group-Snow(pelf)-35.0 Live et 115%duratim,15.0 Dead Vorocal UNW1114. Type Caps; Lion Dead Location Application Comment Unlbrm(plf) Snov1(1.15) 174-9 86,2 0 To 10' Replaces Unl'ortrt(po` Snow(1.15) 174,9 W.2 0 To 10' Replaces S Input searing vertical Reactions iitts) Detail Other Width Larrsttt LlveMeWAIlptillUTotal 1 Stud wall 3,W 35V 1749 f SW 1012634 Lt.Bkscking i Ply 1 314"x 9 Miciat4wti}i LVL 2 PA well 3,5T 3,W 174918%1012634 L1.slacking 1 Ply 1 3W r 91.7 1.9E Micrvlarridi LVL -Se TJ SPECIFIER'S I BUILDFRS GUIDE fordetoii(s):Lt:Biocking ORION CCON1'810-LS. MOXIMtrfn rDeaisn Control Control Location *MW MS) 2546 -2W3 3633 Passed(57%) RI.end Span i under Snow boding MOnanl(Ft-Lbs) 6153 $153 6771 Passed(91%) MID Span 1 under Snow loading Live Load[W(in) 0.319 0,483 Passed OU) MID Span 1 under Snow loadinq Total LoW C4A(in) 0.481 0.544 Passed(1-1241) MID Span 1 under Snow loading -owedw Criteria:STANDAAD(Lt.V240,TL:Ul80). -Brack4l.u):All compression edges(top and bottorr.)must be braaeld at 3'5"o1c unless detailed otherwi6e. Proper attachment and positioning of lateral hViciry is regtdted to achieve memtrer stat>t'Nty -Dai(in a2surnes taldequa%rxu 0ucuus Lateral support of the ouvipressivn edge, M��nio�les• -IMPORTANT! The analysis:presented is output from sott►vare doveioped b'y Trus Jost(TJ) TJ warrants the suing of its products by this software vale be H000mpTitlhed In accordance with TJ product design enlace and code accepted design valued The specific prodLict application,input design loads.and stated dirne miaw have boon provided by the software user. This output Iras not been reviawAd by a TJ Assuckk. -Mat$It prodUC%WS needllY&dope*. Check with your supplier or TJ technical rapuese)nlwtive for product availability. -THIS ANALYSIS FOR THUS JOIST PROt7UCTS ONLYf PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. •AUOWabla Sham De6ibn methodology was used rot Buitda d Cade BOCA analyzing the TJ Dist,ibuticn product listed above, &2 SPRUC E INI`b1RMl►TiON: QaFRATQR iNFQR144-10N. E ST. DARTMOUTH BUILDING'SUPPLY BARNSTABLE,MA 966 REED PC). NO. DARTMOUTH,MA 02741 Phone:508-sso-9'wa Fax SO1!I--g90,e308 laguia(Qdarlmrauihbuildingaupply.corn copy:lgM.C A001) br 1rVe KocrQ1L4JW W q 1`6•11;N I �::1'[one as N l+r.\h:.:, .r..7-::i+,.: e.,,m\N.4lrke..n;:� V an. rinnrunl, I'/V'I:b. ,�. ,:. : : :�.r:::•:rr r, re: ;. r.r nrr,w,': I a� 3�hd CNI ad3 SCES9698a9 6_q:Z0 S0ETjZj/7L I L Town of Barnstable oFtHE r Regulatory Services A R A pL E BAMSrABLE, « Thomas F.Geiler,Director 1ss. `� Building Division Z7f�v��� 2� f'� 4� c� i639. �m ArFD�,t p Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601-- �-___ www.town.barnstable.ma.us D1VISlOA� Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number , street village C� HOMEOWNER":ZE� 110 W L L 1"/�/9 eH LaC C� .� 0Y C,3 6 S 3 � 3 name home phone# work phone# CURRENT MAILING ADDRESS: /I i� ! — r) e L) %.YOVqT- 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 requiremen i'gnature of 1oxleowner 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 J. Poll ------ h^ PI"1w s �: it �•' -" .�. * ,.,. °"tit!ae.� i -• • r � r�.y e;a�� ,':*� �... �• �.c" `'� ,� ��,:tw� -rua�.. :�a�. „fit, ?". � �,� n f JJ w a a a f e � 7 ke ij !fra Nt 3 � _ s �� h rt y e'- A y y awr,ww4 a r x�� 'a "y,. ' �, �•+�,: r ..'��^. ra Y' " ,. R" - I" "ate' ... �, a: e ° "�' r"�..0 d s F .. . -- a n r .1A Y 3" t P 4x 52 Spruce St. , Hyannis 2/23/06 r O� 77, ,,�� ;� F r 4 '' t S t -�,y ATOP r � ; DEPAR' ,M;ENT:O'F'HTEALT ° SAFETY AND , } fi} ENVIRONMENTAL SERVICES `, F t a BUILDINGJD?IVI°SION� 2 f i r �.s ! T WAYY y0! } , , 7 • rs rr ^ +..:,..•Ya;;-'�.,^'-� 1 k '°v 6� \\ti v i y t +rc�+-.�.r^-'•--�.'•--� ,,' +" v.r3; -�•CY .d rr 4 '-r 1 Zr;"v f ..y �.''y'V� r t ! ,-r- Y. "' a`,�, L .T Y. i. 7 3t°•rir�M:n , G ' ,+ f,� ,(, i is '� '} � �.. .r .}. ?a^v re Y- 'r•p � � 1K HIS STRV'CT AND/OAR P'.;REiMS1ES HAS,BE� N �� K �z ; 4 � `�r "", *°IO)tLA'THI,�IN�� �a x' yINSPECTED AND�THE FOLLOWING V�. � r OF THE BUILDaINGAND'/ORZON,IN�G a ti 1: 1 t` �•5f- +•':J'x t yon ORDINANCE HAVE BEEN,,F a, oil 04 77 f"r.. �I;11 ;.�f -a• � y'� t-5� ,,'�` ��y may, r-.�'F �'r are. �.2�. �rt, a L j g r7700 4 , �z • n 1 IIEORERTF- 1 CIA Id �D THAT ; j < &A �tolNO AD`Ill�I�TJI��� 4, w� �' � � r gE��v-�ISEps-r=°�'r• TIH�E iP��`E�M'aISE�S�,�.����. ;LTPON�THESEP�T TIL NOR!; V�E!,�ILATINrS; OCCUPIED IJly G L � G— � t s r ut Y "'ARE COR°RE EM �t 17AW alai J r ANY'�PE'RISO�N°RE, lOVI, G THISrNOTCEd ITH�OiJT T pR c'�PERAU HQ�R,IZM 1'N SSIIAr LfT.,BE1LIABL } >> ��L._ � , '{ rn FIEF TYN R, ; rA�F'IN�E OF tN�OVE"E''SO ��HANri r , ,�.�4 � d ; HU'N�D�RE�D� t' MORE THAN_ s { Address ,, ,> E r ' Date j P.t is- t ,r,..` a d •; _ is ,i ..,� L k. 1 �I K i.,',a t � •+ « � *�C `�,r f ,, BU1�'Cl�ing1 -ram� _ ? L24 � t { _'� � ! A.L. -t• -i - I S f .. L. �I-Z-oz Tr' 1 Town of Barnstable *Permit#* °� �\!2� Expires 6 months from issue date Regulatory Services - Fee , �S• oa Thomas F.Geiler,Director Building Division X-PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 NOV 2 0 2005 www.town.barnstable.ma.us Office: 508-862-4038 TOWIf QF5@�M§J�@LE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 3/40 r—?c;),R Property Address 67�, �r1 .Residential Value of Work Minimum fee,of$25.00 for work under$6000.00 Owner's Name&Address 211Y 434 ye- z x7 Sa Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: R..'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 be on file. 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 replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I ***Note: Property Owner must sign Property Owner Letter of Permission. Ho Improvement Contracto se' required. SIGNATURE: QTorms:expmtrg Revise071405 arm Lviisnsvnrveuun a/ Irlussucnuse"a; Department of Industrial Accidents Office.of Investigations, a 600 Washington Street Boston,MA 02111 S+•'� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A Hcant Information Please Print Legibly Name (Busmess/org=ationandividual): 0 Address: 02 N R L' ' : a S r��. S-E, ✓�n� s imp- City/State/Zip: •-Wl�_57'1' b A f 0­271 Phone #: o -C3. 6,_ .3 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 mein any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs equired.] officers have exercised their ❑. ep or additions 3.M I am a homeowner doing all work right of exemption per MGL 1 Tl.❑ 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' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: �F t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such " $1contractors 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. 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 ofci iminal 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 .p 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. I do hereby certify u pains and en ties o e ry that the information provided above is true and correct Si afore C --7 Z> Date:' Phone#: Official use only. Do not write in this area,to be completed by city or town officiat City or Town: Permit/License# Issuing Authority(circle one): j 1.Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6. Other LContact Person: Phone#• Information and Instructions Massa chusetts 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?p& dual,,:partnership,association, Corporation or other legal entity,or any two,or more of die 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 woikvn 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 en7er 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 1 sub-contractors)na ne(s),address(es)and phone number(s)along with their certificate(s)of ees other than the Companies LC or Limited Liability Partnerships(LLP)with no employ Liability Co (L ) . insurance. Limited L tY mP 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 serf-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 perroklicense 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 to•;vn)."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 permit to bum leaves etc.)said person is NOT required to complete this affidavit. : . ado license or (i.e g . 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 Jnvestigations : 600 Washington Slreet� . Boston,MA 02111.. Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia Assessorzp and lot number ...... THE THE TOWN ' OF �BARNSTABLE BUILDING INSPECTOR TO THE INSPECTOR OF BUILDINGS: The undersigned hereby ap lies for a permit according to the following information: ProposedUse ........q. ...................................................... Name of Architect - --- ---. ------AdJres ------.------.—..,—..--..------` Number of Rooms — Foun6ohun ......................................... ATExlo,io, ---- ----------------..RooHng —' ^'— ........................................... � Floors ................ ----------------.]nte,ov .----'--~~~_~_~----.,----.-----------. � Heating ..................................................................................Plumbing .................................................................................. � 1, --u��. Fireplace ------------.'---------------ApproximoteCoo .��..��.~~ � Definitive Plan Approved by Planning Board --------------------------------lV--------' Area ...... Diagram of Lot and Building with Dimensions ' Fee ___ �..v'. _�-- ___ SUBJECT TO APPROVAL OF BOARD OF HEALTH � --------------------- LA TV- \ I here 4 agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the 'above �._—ame .--..---_—._'—_�. ---..�--' ... � Construction Supervisor's License .................................... ' | GODFREY, EDNA A. l 28306 Build Shed No .................. Permit for .................................... Accessory to t.q..Dwe.11.i!!, k.f.................. Location .....52 Spruce Street . ......................HYannis........................................... Owner.....Edna A. Godf reY..........:......... . Type'of Construction Frame ...... �.................. ......... ............................. a L , r .Plot ............................ Lot ............:................... , Au Permif,Granted ..:............. ... . ' ` ust 9 85 Date of, Inspection „ Date ,Completed .Ge?:-.h�:............. 19 5S. ytA , Assessors map and lot number ....... � .....................4 cF THE to Sewage Permit numbe .1il !.. Z EAMISTADLE. i House number ' ........: .... . - 9 MAO& 1..... . .. �p 039. 6� CFO N TOWN OF BARNSTABL,E BUILDING' ��INSPECTOR APPLICATION FOR PERMIT TO r^ �`tr !��.:..�!. 'C7 : £ TYPEOF CONSTRUCTION ................. ... ..............+�,•...........�..... .................................................,.........:.......... ....... ......4>.. ...................199� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby op lies for a permit according to the following information: Location .............. ............. ........................ ......:.....{.. . M -...:............................. ProposedUse .... ge.ltA !?i/4.... . ............................ ............................... Zoning District .:.............................................:......... ..............Fire, District .............. ..Address Name of Owner .. ....... ... .......... ./........... . .................................................................................... Name of Builder ........Address .' Nameof Architect ..................................................................Address ...................................:...........?.................................... �'t� f Number of Rooms .... ,. ........... ........................................Foundation ` k e, t Exlerior .............I�L),::.;;I.��. ........................................:. .........Roofing fi'�!. a.All .. ......................................... Floors `°' / Interior `,........I ' Heating ................." :............... ` .l?lumi ng � ................` ............................................................. Fireplace ............... ...............................,........ .A roximate. Cost ..+ ...�!� .�.. r..............j!... p ..... .... ..... pp ...... Definitive Plan Approved by Planning Board ______________________________19_____'= Area ... ... ..... .. .:......... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH x OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations of-the Town of Barnstable regarding the above t I . construction. + f ; Name .... . ve . Construction Supervisor's License GODFREY, EDNA A. A=310-223 No 28306 permit for ,Build Shed ............... Accessory to Dwelling ............................................................................... Location 52 Spruce Street Hyannis ............................................................................... Owner .......Edna..A-...Cod£rey.............:............ Type of Construction Frame ................................................................................ Plot ............................ Lot ................................ r - Permit Granted .....August 9.:...............19 85 Date of Inspection ....................................19 Date Completed c s Qy � n ` Commonwealth of Massachusetts Official Use Only Department of Fire Services PermitN°. 3 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9105] leaveblank APPUCATION-FOR PERMIT TOPERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMA770A9 Date: . i;,-5 .7 Go 5 City or Town of: BARNSTABLE- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electric=66 Location(Street&Number) u L -r /� Owner or Tenant Telephone NO'. .V) Owner's Address 7 . Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. . Existing Service Amps 1 It er .d❑ Undgrd❑ No.of Meters a . New Service Amps. / Vo verhea Undgrd ❑ No.of Meters UNumber of Feeders and Ampacity Location and Nature of-Proposed Ery rk: a Completion of llowfng table may be w by the eeto>. Wires. No.of Recessed L aires .of Ce Su addl s o.of �� Transformers A No:of I,uminarre O ets No.of.Hot Tubs . Generators ZI ' o No,of Luminaires Swimming Pool A ove ❑ - ❑ o,o merg cy ig ng rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE AL S Nogg_.f Zo s No.of Switches No.of Gas Burners o.of Detec#on and'- Initiating and'- Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat ump um er. ons o..oSelf-Contained p Totals: Detection/Alerting Devices No.of.Dishwashers Space/Area Heating KW Local[] unrclp El Other Connection No.of Dryers Heating Appliances KW Security ystems:* Q o rY No.of Devices or Equivalent Q o ...� o.o ater Data Wiringr �._ o.o o:o V,t- z Heaters KW Si s Ballasts No.of Devices or Equivalent u, �, z No.Hydromassage Bathtubs No.of Motors Total HP Telecommunication s ' No.of Devices or E uiva.ent . ® o z OTHER: ,� Attach additional detail if desireA or as required by the Inspector of Wires. o «,~ g (When required Y P policy.) � Estimated Value°f.Electrical Work: � en b municipal olic . it 8. w Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. a g INSURANCE COVERAGE: .Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The Wo m a undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.. fiE CHECK ONE- INSURANCE XBOND ❑ OTHER.❑ (Specify:) o I ceiW y,under the pains and penalties of perjury,that the information on this application is true and complete. U_w w FIRM NAME:. LIC.NO.: ¢0a Licensee: UrIVA4f 1n14T Gs. Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus:Tel.No.• o — Address: I Alt.Tel.No.• �3 Y6 *Security System Contractor License required for this work,if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PE1R1t1IT FEE: $,g��j d 75 1 Z) Bpi THE TO TOWN OF BA1� NSTABLE EARNSTAEL • _ ° "6 9 JulY BUILDING , INSPECTOR a' . APPLICATION FOR PERMIT T ! v v� TYPE OF CONSTRUCTION ..........................��'.............. ..............:.................................... � l .......... ... .... ..19../...�3 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..................:........'......5...........C.`........:.. !�� ...........................................:.....:..:....::.................................... ProposedUse .................... /11 Aj�.........:5.��J...�........ .................. ................................................................ Zoning District .................. ......:.............................................Fire District ...14.1 Name of Owner .....ele0,"Jp... .... .....00-S'S...............Address ...........�....�..2... ��, (7'�Y ... Name of Builder ... ........................................... ...... ......Address �Y Nameof Architect .................... ®. "J......................:.Address ....................:.............................:................................. Numberof Rooms ..................................................................Foundation .................................... Exterior .Roofing .................. .......... �,� : Floors ....................u'`.....��............................................Interior .............. Heating /.:=X/*.�7 / /Jie6�zs7t1� . ..Plumbing !E7`'�c-fc:!Q .............:...................... Fireplace ................. ...............................:........:.............Approximate Cost ...................................................... Definitive Plan Approved by Planning Board ________________________________19________. Diagram of Lot and Building with Dimensions J SUBJECT TO APPROVAL OF BOARD OF HEALTH o d- "/ -'Af0'12.6 o /2 Lis C' R Ae 13 r1i z- I� I hereby agrele to conform to all the Rules and Regulations of the Town of Barnstable regarding' the above construction. Name ... ................................ .........: ...................... »000^ Brormx F. ' . ' . | } ' No —. . Permit for ..... . (___.±��±�y..��������.___________. | f Location ......... �2.. . ______. / � \ ' .......................... ..................................... . C�vvne, ---_. ..��..l�u»�� _______. � Type of Construction .................. ' --------------------------. ' Plot ............................ Lot ................................ April �^ is yq � Permit Granted ---��.��-------'lg ` - - Dote of Inspection --..�, -------.lV ' Date Completed x lg ��� PERMIT REFUSED ------................... 19 ^ --------.-----_-----------.. \ - .....................-----^-.......................... ............ \ � � ------------~--------.----.. . / ...................... � . Approved ................................................. lg ~ ----------------------^'---' . ^ � .................... .......... ^^'^'^~--^^---^^^............ ^ ( � > - - U i