HomeMy WebLinkAbout0065 STRAIGHTWAY � TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION
S
Map od �� Parcel:, E 'Application #
Health Division Date Issued P4 10
Conservation Division e.Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH — Preservation / Hyannis
Project Street Address (Q '
Village h Y\, 1 r
Owner Address G .
Telephone e�/ .5 )-D ,5 0 7 ) �7
Permit Request J
Square feet: 1 st floor: existing- proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation a b a 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 a No On Old King's Highway: ❑Yes Iq No
Basement Type: -9FFull ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing 1 new ! Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count -S
Heat Type and Fuel: &Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ® No
Detached garage: ❑ existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage:® existing ❑ new size _Shed: M existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ,
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
ZA
APPLICANT INFORMATION ry
(BUILDER OR HOMEOWNER)
Name Telephone Number
Address (0 S �✓ License #
Yy� Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE 3
! FOR OFFICIAL USE ONLY
APPLICATION#
• z
DATE ISSUED
MAP/PARCEL NO.
E ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION _
FIREPLACE
ELECTRICAL: ROUGH FINAL ' ,
.yf}
PLUMBING: ROUGH FINAL
_ y
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
1 .k p
ASSOCIATION PLAN NO.
The,Com' monwealtlz of Massachusetts
Department of Industrial Accidents , `
Office of Investigations
600 Washington Street
tY, Boston, MA 02111 t
y y� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Indivi dual): ,
Address:
" City/State/Zip: Phone M `tb D S
Are you an employer?.0 ck the,appropriate,boz: '. Type of project(required):
1.El I am a employer with 4• [] I am'a general contractor and I 6.,.0 New construction.
employees(full and/or part-time).
*- have hired the subcontractors
2.0 I am a sole proprietor-or partner-
listed on the attached sheet. 7 Q Remodeling
' These sub-contractors have. g. �] Demolition
ship and have no employees
employees and have workers'
working for me in any capacity. 9 Tj Building addition
[No workers' comp. insurance comp. insurance$
5.:Q We are a corporation and its
required.] w 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers,have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers comp. right of exemption per MGL 12.O.Roof repairs.
insurance required,] t 'c:;15.2, § (4), and we have no
R; employees. [No workers' 13.0 Other
-comp. insurance required:]
*Any applicant that checks box#1 must,also fill out the section below showing their.workcrs'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such;
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their•workers'comp.policy number.*
I am an employer that is providing workers'compensation insurance for my,employees. Below is the policy and job site
information
Insurance Company Name:
Policy#or Self-ins._Lic.#`. Expiration Date:
- "
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page'(showing the,policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in.the form of a STOP WORK ORDER and a fine
of up to$250,00 a day against the violator. Be advised that a copy of this statement.may,be forwarded to the.Office of
Investigations of the DIA'for insurance coverage verification.'
Tdo hereby certify a er the pains and-' ies of perjury that th information provided above is.true and.correct.
r - ♦, / ,per
• . , '
Si nature:
Phone# _ �l� y o / �/SZ d-
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
4
ENERGY CONSERVATION APPLICATION.FORMYOR ENERGY EFFICICIENCY FOR
ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (7$0.CMR 61.00)
Applicant Name: ; �- 1(��
Site Address:
print Town:
Applicant Phone:. 41,9 �/
Applicant Signature: Date of Application: -6
NEW CONSTRUCTION: choose ONE of the Ofowingjwo.o tions
780 CMR TABLE 6107A,
PRESCRIPTIVE ENVELOPE.COMPONENT CRITERIA FOR
NEW ONE,AND TWO-FAMILY BUILDINGS -.
MAXIMUM MINIMUM
Ceiling or Slab }
as Bement
Option 1:' Fenestration exposed Wall Floor Wall Perimeter AFUE HSPF SEER
U-factor floors R-Value- 'R-Value' R-Value R-Value
R-Value and Depth
National Appliance Energy
- R-10, Conservation Act(NAECA)of
35 R-38 R-19 R-19 R-1 O 9 4 ft; 1987 as amended,minimums or
reater,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.6107.32)
REScheck Web which can be accessed at http://www.ener ycodes.�ov/rescheck/
A DDITIONS OR ALTERATIONS,TO= XISTING..BUILDINGS:OVER YEARS OLD*
*Buildings under 5 years old must use option 41 or#2-in New Construction section•above.
Complete the following formula to-determine the % bf glazing:"
(a) Gross Wall & Ceiling Area equals Formula ,: .(1¢00 x b = a)s3 t
I
SF 100 x _ _ - % of glazing
b
(b) Glazing area equals
SF '
If glazing is:<40% use the chart below. 'If glazing is > 4.0 %o'pr'Keed to "SUNROOM" section
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BUILDINGS ,
MAXIMUM MINIMUM.
Ceilingand Slab Perimeter
Fenestration, . Wall Floor Basement Wall R-Value'.
U-factor :Exposed floors R-Value -value:: R-Value
>R-Value " and Depth
.39 R-37 a ,R-13 R-19 R-10 R-.10; 4 feet
a R-To 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 compressed over exterior walls, and includingan access o enin s).SUNROOM—An addition or alteration to an existing building/dwelling unit where It6talglazing area of said addition exceeds 40% of the combined gross wall and ceiling ar
addition.
Note: Owner to fill out Consumer Information Form (found in A endix 120.P)
a
Town of Barnstable
-- o Regulatory Services
Bnrtrtsrasi Thomas F.Geiler,Director
Mass.
1e39. ��� Building.Division
ATEp�,ta -
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 "
/ ^� I Please Print
DATE:
JOB LOCATION:
number street _ village
"HOMEOWNER": c7SZ� y D 7
name home phone# work'phone#
Atu
CURRENT MAILING ADDRESS:
ty/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 1i /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"ceriifie's 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
T
requirements. -
Sign re o r r
Approval of Building Official e
Note: jThree-familydwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 12.7.0 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:\WPFILES\FORMS\homeexempt.DOC
oUVE T Town of Barnstable �^
r r
Regulatory Services
MASS.r e$ Thomas F. Geiler,Director
16
1y 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
Property Owner,Must
Complete and Sign This Section
If Using A Builder`,,,'
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work autho ' d y this building permit application for:
( dress of Job
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
QTORMS:OWNERPERMISSION
Y
• P.O. BOX 839
NORTH KINGSTOWN, RI 02852
401-295-0669 • FAX 401-29,5-5760
R.I. 1-800-879-0669 NATIONWIDE 1-888-TRUSS20
TRUSSCO, INC. WWW.TRUSSUS.COM e-mail: Scott@trussus.com
JOB NAME: JOB #
LOCATION: SHEET OF
SALESMAN: BY DATE
i
I E
I V-11
I
t I i
I
I
i
I
i
I
University Co
nference Services
' University of Massachusetts o 5 (JDS
I� Amherst, MA 01003
413-545-2591
G
45
wk
741
-—---
• r
,.
r
1
v
° University Conference Se vices
8 University of Massachusetts . a p
Amherst, MA 01003 ` (�
413-545-2591
Y51 ✓�
t
r--
T"'r
.1 ILJ
znz
Ll
4
University Conference Services
University of Massachusetts
�I. Amherst, MA 01003
413-545-2591
YV
Pole tw
r Town of.Barnstable *Permit# ` ��� Z
Expires 6 months from issue date
Regulatory Services Fee
snxx ERM IT Thomas F.Geiler,Director
9� MASMI
2008 Building Division
Tom Perry,CBO, Building Commissioner
TOWN OF gARNSTAS(.E 200 Main street,Hyannis,MA 02601
www.townbamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint.
Map/parcel Number
Property Address
❑Residential Value of Work QCMinimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Narrie IkJ Telephone Number
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ a sole proprietor e
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)
❑YRe-si e
Replacement Windows/doors/sliders.U-Value (maximum.35)
*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 is required.
SIGNATURE:
QAWHILESTORWbuilding permit forms\EXPRESS.doc
Revise020108
t;.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations '
a 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
.Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): T�, ���
Address: � t% .
City/State/Zip: . , — one.#:
Are you an employer?Check the appropriate box: Type of project(required):
1 ❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-.time).** -have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or:partner- listed on the attached sheet. 7...❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• $ 9. ❑Building addition
workers'comp.insurance comp. insurance. 10. Electrical repairs or additions
equired.] 5. ❑ We are a corporation and its ❑ P
3. 1 am a homeowner doing all work officers have exercised their HE 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and i 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
Signafore: Date:
Phone#: t, .0
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall .
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in__(city or
town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
0mce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
-,Y Town-of Barnstable
snxNsrnsi.e, � '
"'"ES. Regulatory-Services
s6;q. ♦�
�E�►�`'�° Thomas F.Geiler,Director, r
Building Division
Thomas Perry,CBO Y
K
Building Commissioner
P
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us. ;
Office: 508-862-4038 Fax: 508-790-6230
Property Om>ner Must
Complete,and Sign This Section
-_If Using ABuilder
as Ownerof the subject property.
�
hereby authorize o act on my behalf,
in all matters relative to work authorized bythis building permit application for. ;
(Address of Job) r
Signature of Owner Date
Print Name,'µ ,
- _ £
Q:\WPFILES\FORMS\building permit forms\02RESS.doc 6
Revise020108
Town of Barnstable
o„ Regulatory Services
anantszy�ac� : Thomas F.Geiler,Director
KAM �.•� Building Division
rED ttAP't
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
p! Please Print r,
DATE: ��P� 0 _
c
JOB LOCATION: ��446 ju`c5
num er street village
"HOMEOWNER": � �5lloA !!g �0- —/n5e7
name -*� home phoonee## work phone#
CURRENT MAILING ADDRESS: (fAd L/J &U 1
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 buildin&Rermit. (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.
zg0ky2t,_"
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.
K. 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:\WPFILES\FORMS\homeexempt.DOC
c
TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION
Map Parcel'` Application #�
Health• Division '"""`� °- - `T' Date Issued l b b
Conservation Division G L Apo�cation Feed
Planning Dept. r Permit Fee `>
Date Definitive Plan Approved by Planning Board "V v
Historic:- OKH t Preservation/ Hyannis
Project Street Address -6 5 sSJTA� +w4q
Village G h Yl t Alh K'
Owner Address G4 ei o ,� �
Telephone ® t' '�(,7 �10, Q 04 2— - �I444.
Permit Request (!!�iWl AIW Z � �-- it-18 .dv
t . 0- JL�VI�J6
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District (WAl . Flood Plain Groundwater Overlay
Project Valuation 4:50 b, onstruction Type
Lot Size . �� Grandfathered: 0 Yes No If yes, attach supporting documentation.
Dwelling Type: Single Family =Two'Family ❑ Multi-FaJNo
ily(# units)
Age of Existing Structure Historic House: ❑Yes On Old King's Highway: ❑Yes No
Basement Type: JFull ❑ 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: b �Js existing Znew O =3
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: `O 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: 1
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 2
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use X `r
t.a
" - - APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
�Q �Z Name v I� Telephone Number L4 0 Jq
Address License#
Ala& LW h �T_ 0Z Z Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 0
a
' FOR OFFICIAL USE ONLY
_yam APPLICATION#
r .
DATE ISSUED
MAP/PARCEL N0:
ADDRESS ! I VILLAGE
I ti
OWNER i
DATE OF INSPECTION:
/ FOUNDATION i
FRAME
INSULATION
t
} FIREPLACE
t
` ELECTRICAL: ROUGH FINAL •
xPLUMBING: ROUGH FINAL ,
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
s
. r •
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
- 600 Washington Street
Boston, MA 02111
www.mass.gov/dia -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Appticaut Information Please Print Le ibl
Name(Business/Organization/IndividuaI):
Address: G � f
City/State/Zip: �� j�� Z�lC,a� Phone.#: �
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. ❑New construction
employees(full and/or part-.time).* have hired the sub-contractors -
2.❑ I am a sole proprietor or partner- listed on the attached sheet. - 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, Demolition `
working for me in any capacity.: employees and h$ve workers' 9. 0 Building addition
[No orkers'comp.insurance comp. insurance.
uired.] 5. We are'.a corporation and its 10.0 Electrical repairs or additions
�3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
XContractors 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.
Iam an employer that is providing workers compensation insurance for my employees. Below is the policy an djob site
information.
Insurance Company Name:
Policy#or Self-ins.tic.M 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 tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains"and penalties of perjury that the information provided above is true and correct
Date: .
signature:
—
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone.#:
Information and Instr'ncti®ns
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees:
Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s), address(es) and phone number(s) along with their certificates)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 pennittlicense 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 Iicenses. 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 washinpn Street
Boston, MA 02111
TeL #617-727-4900 ext 406 ar 1-877-MASSAFE
Fax# 617-727-7749
Revised 1.1-22-06
www.mass.gov/dia
HE
Town of Ba
rnstable
y�P Regulatory Services
* BARNHABLE, f Thomas F. Geiler,Director
S, MASS.
1639. A,�� BuiIding Division
TF�MA't
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
wwiv.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790=6230
-----------------------
HOMEOWNER LICENSE EXEMPTION
xPlease Print
DATE: O V
JOB LOCATION: 6 -h-c-I' ��""w Gh✓►l s
number stye t village
"HOMEOWNER":__14 li l �W_U77�S?,�
name 0 ;'home phone# work phone#
CURRENT MAILING ADDRESS: 6?
l
Afor 0 Z,
ci /towdi p
h' � 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.
Th".rrd'ersigned"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
requir ments.
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']09.1.1 -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
�oFZHETti Town of Barnstable
Regulatory Services
S^ MASS. Thomas F. Geiler,Director
1659. . 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
Compl and Sign This Section
If Using A Builder
I C7 , as Owner of the subject property
here authorize to act on my behalf,
in ll'matters relative to `work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Pr- ropedy Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORM&O WNERPERMISSION
University Conference Services
g University of Massachusetts
Amherst, MA 01003
413-545-2591
AIA
I f �--
I
Poe Gil
> c
CD
rt
U7
K w
CD
CD
f ID
6 / �
�� cn
- l J
tV N6. �Z
I
W A
CD
vJ
CD
l --�
31,
IQ
Ak "
"ET ti The Town of Barnstable
Department of Health, Safety and Environmental Services
CAB ; Building Division
43sT i63¢ Ak 367 Main Street,Hyannis MA 02601
Fa tuu►'t
Office: 508-790-6227 Ralph M.Crossen
Fax: 508-790-6230 Building Commissioner
Home Occupation Registration
Date: D-V7,
Name: Cy xc' Phone#: —VI V `` F16
Address: a V>Ilage: ,�iW Vt _75
U.
Type of Business: 'L.19yLy Map/L,ot: g (0-1 /Ogg
INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the
activity shall not be discernible from outside the dwelling there shall be no increase in noise or odor;no visual
alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,located
within that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and
there is no outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular
matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess
of normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There is no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up trick not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit.
I,the undersign d,have read and agree with the above restrictions for my home occupation I am registering.
Applicant: Date:
V� .e
Homeoc.doc