HomeMy WebLinkAbout0166 STRAIGHTWAY /66 J��
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Town of Barnstable *Permit#
Regulatory Servicesires6 ntHsjrome
�eie, t
039. p`b$ V.Scali,Interim Director
Building Division
Tom Perry,CBO,Building Commissioner
®VV 200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
j � ot Valid without Red X-Press Imprint
Map/parcel Number to-)
r
Property Address c cl /
(Residential Value of Work 0 0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Se t+h
-I C2 G S+ra�h�-`,v T—� ar r� S A- 0.QG
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
[YI am the Homeowner
❑ I have Worker's Compensation Insurance s`
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Re est(check box) q�
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be tak n
❑Rp.roof(hurricane nailed)(not.stripping. Going over existing layers'of roof)
e-side �.
Replacement Windows/doors/sliders.U-Value 5 1 (maximum.35)#of windows
#of door's:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
=�_��_
T:\KEVIN_D\Building ChangestEXPRESS PERMIr1EXPRESS.doc 3 '
Revised 061313
1"�xe�t�rnzrtxerntefersl#�rzf�asst�cFtus�tts
Degaarknmt o, bdksft d Accidents
- - f,Tce t�,f Imxestkafiorrs
600 Fay gton greet
Bastoq, 02
tufm mass go Mier ,
❑rker-s' Compensation Insurance davit:$i-iilders/Contractors/FAectricians/Plumbers
Applicant Infarmafion J Please Print,I�ibFy
Name(gusinesglOtganizationdndmdmo: InC
Address YC( t l.L.
City/Statp-/Zip C211i Phone
Are you an employer? Check the appropriate box: Type of, o'ect r
l_❑ I am a employer with 4- ❑ I am a dal contractor and I 6- [-]New amstrudim
employees(fall anvorpart-ime)* havehired-the sub-contracf m-
�_El I am a sole proprietor or partner- listed on the attached sheet; 7_ ❑Modeling
slip and have no employees These sub oozitrartors have
8_ ❑Demolition
and have workers'
working for me in any capa.citlr_ employeesl 9_ ElBnildsng addition
[No workers.'.comp_,'•,�t,�*,re; comp_msurant
ed] 5_❑ VIFe are a corporation and its
ME]Electrical repairs.or additions
3- homwi?nei doing all work officers have exercised(heir. '.' 1I-Q Plumbing mpayrs of addition.,
right of exemption per MGL
myself [No worl�rs'comp- 12_.❑.Rnafrepairs',
itrs=i ce required_]t c_152, §1(4),and we hnm no
employees-[Na workers' 1 _.❑Other
comp insurance required•
*terry ampHocut that checks boa fl nmst also fill out the section beIo ev showing fbek woolee compensation policy infflrrnarian
�Eomevwnen who submit this affidsvif inn xtmg ttiey ale doing an wc&and then bile outside contractors mast submit a uex amdavit rsf;.v sudi
CUnWacmrs thst check this burr must sttachad an additions)sheQt showing the name of the Mb-ems and stye whether oruut$arse have
employees_ If the st V<—taactdrs hate emplu,5-s,they ffiust piuvide their workers'comp.policy nimmb-
I am an empbayer chat is prmidhV workers'ro mpausadl n hmzrance for my,employees. Betotr is thepagry and job site
InsRrmce CompanyName:
Policy#or Self-ins-Ilc-;�- F.xpfration Date.
Job Site Addiess_ Criyl'Statel/Trp_
Attach a copy of the wGrkers'compensation polio de oration page(showing the policy number-and elation date).
Failure to secure coverage as regairedunder Sectiort 25A of MGL c 152 can lead to the imposition of criminal.penalties of a
fine up to s 1,500.Oa andlor erne-year m4r so ty as well as civil penalties in tite foTm of a STOP WORK ORDER-and a fine
ofup.to,$250.00 a day against the violator_ Be advised that a copy of this statement maybe forwarded.to the Office of
hweWZations of the DIA liar inviranrg-,coverage cation
Ida here c�rttfy_rtkrder tke pains - d enables Dfperjury thatfhe i jbrrrtar#tan prrxvidsd alien e istruer and correct
Signature: Date-
tl
Phan#_ _
Ofjir.-r�ai use anly. Ida trot write in this(ricer,#o bs cQuipleted by�'ar town o teial '
Cit .or Town: PermfitlLicense#
Issuing cgiuthoritg.(circle one):
1:Board of health 2.Building Department 3.Cityfl-dwa Clerk 4.EIectrical Inspector S.Plumbing Inspector.
6.Other
Contact Person: Phane 9-
6 ,,
information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto 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 imcludiag the l p
rPr. gaI representatives of a deceased employer;or the
receiver or trustee.of an Mi divid miners ' -association or other le enf , employingem to ems;. I owever the
P mP�
- , .. � tY,. R,. Y
owner of a dvvellrng house having not more,than,three apartments.and who resides therein,or the occ . t of the*
dwelling house of another who employs persons to do maintenance,consl uctzon or repair work oil.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 IocaI licensing agency shall withhold the'issuance or
renewal of a license or permit to operate a busm"ess or'to�const mct baildings'in the commonfvcalth for aizy
applicant.who has not produced acceptable evidence of cowpliance 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),addresses)and phone number(s)along with their ceri..ficaie(s)of
insurance. Limited Liability Companies(I,LC) or Limited Liability Partnerships(LLP)with.no employees otlier 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.. De advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofiasur rice 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 obt_in.a.workers'
compensation policy,please call;he Department at the number listed.below. Self-insured companies should enter their
self-Esurmc.e license number on the appropriate line. '
City or Town Officials '
Please be sure that the affidavit is complete and printed legrbly. 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 add i ion,an applicant
that must submit multiple pemitllicense applications in any given year,need only submif 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: ,
nt COMM.nnw�_alttl of MassacFiu t(s .
DegaAmnt of IndustrW Accidents
GMQe of kvestipfio s
600 Wasb__ n Ga met
Bastoia,MA 02111
Tel.W 617-727-4�00 i�xt 406 or 1-9 MASS.AF
Revised 4-24-07 Fax#t` 617-`27-�4
www.inass-gov/dia
Town of Barnstable
y Regulatory Services
�4opTHE roryy Richard V.Scali,Director
Building bivision
anxxsTas[E Tom Perry,Building Commissioner
nrnss
1639- .�� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
- Please Print
71
DATE: Lf
J
JOB LOCATI I-�n-� S+rQ'/�' /Cc�( �►r
t
&C/1,4/
/`' ( village
"HOMEOWNER'': S�- l T 77- �-j �C.�-/;2- CJ �
name home phone# work phone#
CURRENT MAII.ING ADDRESS: k-tvav A
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 interided 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.
re 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 Iast page
of this issue.is a form currently used by several towns. You may care t amend and adopt such a formlcertifica.tion for use in
your community. _
Q:%W FILESTORMS\building permit formsTXPRESS.doC
Revised 061313
f •
Town of Barnstable
Regulatory Services
W .SS Richard V.Scali,Director
1639. 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 OwnerMust
\'Compl&`t 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 authorized by this building permit application for:
(Address of Job)
"Pool fences and alarms are the responsibility of the applicant:-Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORMS:O WNERPERMISSI0NP00IS
Engineering Dept.(3rd floor) Map Parcel j& Permit# / �7
House Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee
Conservation Office(4th floor)(8:30-9:30/1:00,2:00)
Planning Dept.(1st floor/School Admin. Bldg.) tME
groject
Plan Approved by Planning Board
' - i • RARMASS.�
i t6sq.
TOWN OYBARNSTABLE.
Buildin/gPye�rmit Application
reet Address 11 ;a
Village
t
Owner Address
Telephone
*Permit Request /
t
..First Floor square feet Second Floor square feet.
Construction Type
Estimated Project Cost $ e '
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure E Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑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
No.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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size) -
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name Gy"� {"' �✓1 Telephone Number
Address 7/ �2e��a✓ C�L License#
Home Improvement Contractor#
Worker's Compensation# 6_0 /S/
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��eLI'74A
SIGNATURE DATE IS LlLt5
FOLLOWING REASON(S)
— FOR OFFICIAL USE ONLY _ ]
, {fit
PERMIT NO. .
DATE ISSUED -
t a .• t I 1
MAP/PARCEL NO.
a
ADDRESS VILLAGE
`Ro
OWNER ... ' �" r•
DATE OF INSPECTION:
FOUNDATION
r
{
FRAME
INSULATION y r :4
FIREPLACE r ,
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL —
FINAL BUILDING r
ti •
DATE CLOSED OUT
ASSOCIATION PLAN NO. -
{
table'The To n ®fBarns
.� .� -
. g1 Department of Health Safety and Environmenta Se�'Ices
�,. � °� BuiIding Division _
367 Main Street;Hyannis MA 0260I
Ralph C.TS-1 r.
Office: 508-790-6227 BuiIding Ccr
Fax: 508-790-6230
For office use oniv
Permit
Date AFFMAVIT
HOME IMPROVEMENT CONTRACTOR LAW
surruMFaNT TO PERMIT APPLICATION
I4ZA requires that the "reconstruction, alterations, renovation, repair, moderniz=tion.
MGL c.
conversion, improvement, removal, demolition, or construction of an addition to any pre-existi to
ng
owner occupied building containing at lest one but not more than four dwelling units or
P
structures which are adjacent to such residence or building be done by registered
certain exceptions,along with other requirements /
Est. Cost
Type of Work: '
Address of Work:
Owner's Name
AQ
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
_Job under SI,000.
Building not owner-occupied
Owner puiling own permit
Notice is hereby given that: UNREGISTERED
OWNERS PULLING THEM OWN PERMIT OR DEALING WITH
CONTRACTORS FOR APPLIG8iB GRAM OR G ROM �iJRA►RANTY FUND UNDER MGIrVEMENT WORK Do O I42�i�
ACCESS TO THE�rrRATION PRO
SIG,IED UNDER PENALTIES OF PERJURY
I hereby apply fora permit as the agent of the owner.
�c -L �. 6
l /f CjG�L Registrarion t`io.
Contractor Name
Dare
. . n
T114• C1I/11111U/I11'cult/r of:1tus aclruscin
Depurinte It Of Iudirstrial Accidents
ANC9alIZ`F9S l9aUvns
608 11'asllilrgtr»r Strea
Btuvi r..'11usa: U3111
Warkers' Compensation Insurance Affidavit
Anniir-nr inft Fn—m inn ' Plcnse PRIN71ENV
CIO
Inc-• nrt �
c' v (�n ` VVI� nimnr d
1 am a homeowner perfo m in^all work myself
r ! am a sole proprietor and have no one lvorkin= in any capaeiry
n/ an empiover providing workers' compensation pensation for my empiovees working on this job.
rnnrn••n.• n•r•nt•• ✓�
9(Irlr�cc• •
rife n mfinne 0'
C 7S,
r z.M a Soic rop,'Ic.,or. ,cncral contractor, or homeowner(circle o17ef and have hired tale conrmcmrs iistcai be:o«' '►'CC
:he oiiowin_ worker* compensation polices:
cam-1-.1% nnrnr-
9tl t'.rrc<•
Cl" •
nhnne d'
in• ,--•rr rn nailer >3 _ —
.. r -7. t�7 tom.—�.�. Tr^ -_ ���`•.---rnr...._�� ��rnr•.
ati:''r<c• �
rtT1•• fl�innC!�• _
Rn11C{•
in-rr-•trc n _
Att4C1 additionai sAeef 1f n[[cean.� �.•. -.c•a.r �.��...�:��•..... ._.. ..�..._.a...—.�.vs �.��`�� •• —.—
Fauurc 10 Securr covcrnce::s required u ucr-tectlon-'A of IGL 153;an iead to the smposttion of critatnai penaiues of a line up to S1.SOU.UU snu:cr
uric c.-,r5;ri imprisonment::. ,%cil as cis ii penaitics in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand th-t-.
copy •,f ehi.- ,micnient mai be furharded to the Office of Inrestizsttons of the DIA for coverage verif 2sion.
I rio:,rrr^1•Crr. i1 a rrr tllr put rs m arcs of pc uri that the information prorided above is true and correct.
Pr......-.. Cti� ! "�r't'`a�✓ Phone
1
1I��i u�c uni�• du not���ritc in dtis arcs to be completed by gin•ar totrn ofGciai -
:n1�n:
permitilicense -Buildintc Department
cite,�r ,
Cuccnsin_ Board
r — znccu ii immediate rrsnunse is reuuired CJeleetmen's Uffice
Cticaith Department r
phone F• Uttler -
Information and Instructions
4
Massaci;usettti Genumi Laws chapter 152 section 25 requires all employers to provide workers' cc it"
"1a��'". an cnrploree is defined as every person in the service of :norther unc�r;::
emnim ecs. As quoted from the :cor.imm of hire, express or implied. oral or written.
An enrpior•cr is cictincd as an individual. partnership. association. corporation or other legal enthy. or any rnv or
the �urc`_cinu en,_a_.•d in a joint enterprise. and inc!udina the leiz I representatives of a decczscd empiover. or:!:c
rccci�cr or tntstce of an individual . partnership. association-or other legal entity. employing emplovees. Ho •e•. c
mN'r:cr of a dwelling, house !raving not more than three apartments and who resides therein. or the occupant oft!:e
d�N c!!ine !rouse of another �%'ho cmplovs persons to do maintenance,construction or repair wort: on such
or on the __rounds or !wilding appurtenant thereto shall not because of such employment be deemed to be Zn em:p
10Gi._ ,Barer !:= scc:ion =5 also states that ever- state or local licensing agt•ncr shall withhold the issue ncc o.
1 of a license or hermit to ()per 11e a business or to construct buildings in the c:ommon'%ge h u rirca.d.
X:nit who lens not produced acceptable evidence of compliance with the insurance covera req
,c ..ionall�. ncilhcr :he commonwealth nor any of its political subdivisions shall enter into any contract for the
per:-1Jrr»c::ce of public ,%,ork until acceptable evidence of compliance with the insurance requirements ofthis
he=. Pre=,ted to the corttrnc:ine authorin•.
a{�(riic�nts
(lase :iil in the workers" compensation affidavit completely, by checking the box that applies to your situ= On c:
succi%�:ne _omcanv names. address and phone numbers as all affidavits may be submitted to the Department of
'n� for contirrnation of insurance cove—P. Also be sure to si;a and date the sfiidati'it. Zile
_hou!d be :o the cin• or town that the application for the permit or license is being segue=ted-
:;'C Deco tnle::1 J1 !Itdl:Si;ia! accidents. Should you have anv questions re-:rdine the "law-or if you are 7=q :
.J :C:Z::: c «•orkers' c:;,cc:aalion policti. please tail the Department at the number listed bolo«'.
C:n• )r T(::%-ns
P!e �e arc 'fin'. the is complete and printed legibly. 17te Department has provided a space at the bOM:7
the - cap it or %•ou to fill out in the event the Office of Investigations has to contact you re_ardin_ the appiic:n:. .
be _ . to till in the per-titiiicense number which will be used as a reference number. I7re affidavits may be sera:
'ne J:partme::t bN• Inzii or FAX unicss otlicr arrangements have been made.
Tire �fr;ce of lovesti_ations •,Would like to thank you in advance for you cooperation and should you have any quest
pie=e 24o rot hesit""te •o _!Ve is a call.
iiie Decamnerivs address. :eieriione and fax number:
The Commomvealth Of Massachusetts
Department of Industrial Accidents - .
Office n.f Investigations
600 «'ashin-ton Street
Boston. Ma. 02111
Ca,. 0: (6I i7 7 Z7-7,749
,ihune =. . 6 i -', --'900 e-:r. 406. .109 or _--
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HOME..IMPROVEMENT'�; CONTRAGTORS'�REGISTRATION 'l� '� t °1 '
F[(t' Board of :.Builds a lat.,,o"ns:-iaPd Standards�,�`
Ft 9u ,
One Ashburton P1acel=y`Roomt '1301
a'S.�s},a•Fx-i{tr �Y t.4`� :� ,�tJ,3trcB.oston',: .:Massa. ':hse. t •', �.. '. 9'
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to
� r � ;„ utsf °r r v�` ? HOME`IMPROVEMENT'CONTRACTOR .,
,, t r�, r ,,, _0 ,Registratiov*012536 X .
FF2ASER`CbNSTRUGTT0tj- � , ,�"�.� 4113 ;" r���� � �` `I' ` � ,
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COTUIT`NA 02635
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