HomeMy WebLinkAbout0043 SUOMI ROAD �f3 CSuam� Zd� 4
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel W 1 Application # bZ 0 1
Health Division Date Issued 3 .—lt-+ FF
Conservation Division Application F4 Iill
Planning Dept. Permit Fee l
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address l/✓� Oo
Village
Owner. Z1er&/ �/7'�� Address 4K,7-2 �wd
Telephone 91;1 a S79. 2'�1 51 0XZN r", AIA
Permit Request
2 yx ,A I'�s ice—
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District _Flood Plain Groundwater Overlay
Project Valuation �� Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Q
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wooclmo l stove: 0 Yes No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ exs):ing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: .�
a
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ,
Commercial ❑Yes ❑ No—' If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Telephone Numm�ber 917-57S,Z931
Address � �y�7o� License
Home Improvement Contractor#
Email Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
b
APPLICATION#
DATE;ISSUED
4
MAP/PARCEL NO.
r
G
x
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
' FRAME
r
INSULATION
s FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
t
DATFE-:.CLOSED OUT
AS,40 ION PLAN NO.
C
' 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
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): zfw dam, Y
Address: .' i5�77-
City/State/Zip: i—Ol .vim, Phone#: W;;Ze 370 , A9 3
Are you an employer?Check the appropriate box:,- Type of project(required);
1.❑ I am a employer with ! 4: 1 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
These sub-contractors have t
ship and have no employees 8: �Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.i 9.
'insurance comp, insurance:$ E]Building addition,
required.] 5. ❑ We are a corporation and its 10.❑Electrical'repairs or additions
3.qI am a homeowner doingall work officers have exercised their
11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.❑ Roof repairs
insurance c
required.]
t . 1.52 §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.
4;Contractors that check this box must attached an additional sheet showing the name bf 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:
�uo�a� ,��
Job Site Address: 72_ City/State/Zip: S/G��J/7/S�— �w C-V
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 g q of MGL c. 152 can lead to the im
position ositio p n of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties o perjury that the information provided above is true and correct.
Signature:
Date:
Phone#: ' _.
Official use only. Do not write in this area,to be completed by city or town of
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
Contgct Person: Phone#•
Town of Barnstable -_
Regulatory Services
�pTtiE lti Richard V.Scali,Interim Director
Building.Division -
3 mwisrasr.E, Tom Perry,Building Commissioner -
9� 1e ��� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
`- -DATE;. ��"�/�J/ -•
JOB.LOCATION:
number street village
g village
"I.OMEOWNER": �d 1/y 11? b. S . Z_9 j/
4 name home phone# work phone#
CURRENT MAILING ADDRESS:• 4 _,;7
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 regonsible 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"homeowne certifies that he/she understands the Town of Bamstable Building Department minimum inspection
procedures and requireme d„ at he will comply with said procedures and requirements.
Signature ofHomeowner -
Appioval 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.
n.�nrocn cc�rnn�,rc�1,..:7,i:.R no.mit fi,rmclFXPRFCR tine
�'ME r � Town of Barnstable
o� -
' Regulatory Services
• t na�vsr�scn, + .
MASS. Richard V.Scali Interim Director
Ea;A�•�� 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
I, Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work au tize y this building permit
ddress of
Pool fences and s are the responsibility of the applicant. Pools
are not to be filled o .utilized before fence is installed and all final
inspections are perfo d and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
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Y-81x 448' _ 2'-8 x 4••8
43 SUOMI RD, HYANNIS, MA
1 ST FLOOR PLAN
1ST BTH AS 0310112014 s
1 ST BDRM 5'-7"x 8'-3" b
�
11-1 x 9-7 46 sq.ft.
97 sq.ft. KITCHEN & HALL DECK
` 24-0"x 11-10" _ 8'-0"x 11,4 "
le
205 sq.ft. At 94 sq.ft.
b
k
4'•413118'x81•81SO L" 2'•8'x44' f'w 'w •?'•8'x8'-8' - -
1'- 4�-
CARBON/SMOKE
x 2'-1" 6sqk DETECTOR
12 sq.ft.
. - 2'•8'x4'• 2'•8°x88' B'•B1R8'x8'•8'Areh- - -
b `
CLT
0,1 x 8^
2d BDRM 8 sql, LIVING ROOM
10-11"x 11'41" 18'-7"x 11-11"
130 sq.ft. 219 sq.ft.
CLT
2- "sq.'x .2„
2'•8'x 4W 2'•B'x 4'.8' 8'x 81•8' 2'.8'x 08 7.81/18'x 4'&'' s'•8'x 4'•8'
ClUeP- en House wLah
2 6'x 4•P 2.8°x X2 112" 2'.°"x 44"
2d BTH 43 SUOMI RD, HYANNIS, M
8'-7"x 8=I" 2d FLOOR PLAN
62 sq.ft.
AS 03/01/2014
•1 11
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7 s .
_
3d IBDRM II C /SMOKE I ►►
91 -9 6 4th BDRM
x 20-5 TE' oR 8-5 x 3-7 92-1"x 20'-5"•
224 sq.ft. 30 sq.ft. 246 s ,ft.
q 4
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CL
3"x 5' I► r
9 s .
q CLT
-700x 8=9 7091,x 84 .+l
31 sq.ft. 4 sq
§ CLT
3"x 3, „
" 8 q°ft,
CRAWL SPACE
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/2014
DRMALL
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STORAGEROOM BOILER
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BASEMENT'S MECHANICAL ROOM DESIGN,43 SUOMI RD, HYANNIS, MA 02601
Mechanical Room Design and Combustion Air Opening Calculations
1. Requirements
All finished basement appliances(a Boiler and a Water Heater)and an Electrical/Communication Panel shall be
included in a confined space(mechanical room).
Appliances shall be accessible for inspection,service, repair and replacement without removing permanent
construction(see 780 CMR,6305.1).
Adequate combustion air shall be provided in the room for the boiler and water heater.(see 780 CMR 67,00).
2. Appliances
The follow appliances are installed in the Mechanical room:
1.. Boiler BLR 0 4`
Manufacturer:Weil-McLain
Model: CG-3 Series 9
Dimensions:46.875"H x 23.25"D x 10"W
Vent Diameter:4"
BTU/h:70,000 �-
e,r -
2. Water Heater(WH) '
Manufacturer: GE "
Model: GG30306AVG00
Fuel type: Natural Gas `
Unit Capacity:30 Gallon "
Dimensions: 19.75"D x 49.75"H (with Vent)
Vent Diameter:3"
Input BTU/h:30
3. Mechanical Room Dimensions
The boiler,water heater, its vents, piping and electrical/communication panel are already,installed in the
basement.The dimensions of the mechanical room: 6'-1"W x 10'-4"L x 85.5"H Will provide easy access(30")to
front and side panels of the Boiler and/or Water Heater as well to the Electrical/Communication Panel(see
Finished Basement Plan below, page 7). A +
4. Combustion Air Openings or Ducts Size Calculation
4.1 Total input of appliances in the room is
70000 BTU/h(BLR)+30 BTU/h (WH)=70,030 BTU/h
4.2 Required air volume(RV)from inside the basement is 50 cubic feet(cf) per 1000 BTU (780 CMR
6702.1)or RV=70.03 x 50=3502 cf.
Due to small the Mechanical room volume (MV): 6'x 10'x 8'=480 cf we cannot not meet the
above criterion RV(3502cf)for indoor air supply. -
So Outdoor Combustion Air shall be supplied to the Mechanical room via two openings or duds
(780 CMR 6703.2).
1
Prepared by Joseph Klebanov 4/17/2014
BASEMENT'S MECHANICAL ROOM DESIGH,43 SUOMI RD, HYANNIS, MA 02601
4.3 The Mechanical room (ceiling height 85.5" is located in the basement below the grade, so the
vertical ducts shall be used for combustion and dilution air.
• The Combustion air duct opening is located within 12"from the floor of the mechanical room
• The Dilution air duct opening is located within 12"from the ceiling of the mechanical room
Both vertical ducts are connected to outside via holes in a house wall above concrete basement's
front wall.
4.4 Minimum of the combustion air opening area size(COAS)and the dilution air opening area size
(DOAS)must be equal and are calculated according to 780 CMR 6703.2.1:
COAS=WAS=70030/4000=17.5 sq. inch
4.5 The combustion and dilution air opening area size must be equal or more than area size of the
common vent for the Boiler and Water Heater(a chimney connection):
• Boiler Vent(Db=4")Area (A=n*Dz/4)Size: 3.14 x 4 x4/4=12.56 sq.inch
• Water Heater Vent(Dwh=3")Area Size: 3.14 x 3 x 3/4=7.07 sq. inch
• Common Vent(Dcv=6")Area Size: 3.14 x 6 x 6/4=28.26 sq. inch
The combustion and dilution air opening area size shall beat least 28.26 sq.inch
4,6 To meet Clause 4.5 requirements and have a smaller space for the ducts accommodation the
standard size(3.25"x 10") rectangular duct will be used for the combustion and dilution air ducts.
In this case the opening area of 32.5 sq.inch will be provided for both vertical ducts(13%more
than required). -
S. Ductwork Construction
The vertical combustion and dilution air ducts will be made from the standard opening size (3.25"x
10") rectangular wall stacks,short(3",90°)vertical elbows and the weather hoods with the wire mesh
screen for outside termination (see sketches on pages 3-6 below). '
The small 15" long) horizontal parts will be used above the basement concrete wall toconnect
inside and outside parts of the combustion and dilution vertical ducts.
Both ducts will be extended outside and terminated 3 feet above grade to be.above a snow level.
Ductwork material:galvanized steel,28 gauge.,
All work will be done by a 5heet'Metal Worker licensed person(MA License No.'11793,expiration
date:01/28/15).
2
Prepared by Joseph Klebanov 4/17/2014
BASEMENT'S MECHANICAL ROOM DESIGH, 43 SUOMI RD, HYANNIS, MA 02601
BULK
HEAD
STAIR
WET Hall WASHER
CLT 40"x 40" &DRYER R-13 Insulation with 2"x 4"Studs and
CLOSET V D ryvall Sheetrock all around basement
Concrete
r D00 43 SUOMI RD,HYANNIS,MA alls
t 36"x78" FINISH BASEMENT with CONFINED MECHANICAL ROOM
e
PLAN y
COMBUSTIONIDILUTION AIR DUCTS per 780 CMR 67032:
:t Two Openings or Ducts to Outdoors
Duct Duct
Work Work
' Duct AC MECHANICAL
s Work FAN Fire-rated Drywalls G 30" ROOM:H=85.5"
1.BLR-BOILER -�48"
2.OWT-WATER HEATER ,.
Chimney
STAIRM 30
UPIDN . DOOR:
32"x78"
" Electrical
44
r' Carbon/Smoke 48" Panel
Alert Detector
SCALE: 51 DUCTS 10"W x 3.25"H x 1.5"L
THRUE WALL
3
Prepared by Joseph Klebanov 4/17/2014
BASEMENT'S MECHANICAL ROOM DESIGH,43.SUOMI RD, HYANNIS, MA 02601 .
Rectangular
Vent(3.25"x 12")w/Screen
1sT Floor Room
36"MIN
Basement
Mechanical Room ° s
FIRE-ATED H=85.5" OUTLET GRADE LEVEL
WALL& 48" DILUTION E
CEILING AIR N
T
C
0
48" N
49.75 C
D R
v -" E
B W T
H INLET ' E
30" R COMBUSTION
i W.
R
L AIR,
A
12"
BASEMENT CONCRETE FLOOT with CERAMIC TILE
4
Prepared by Joseph Klebanov 4/17/2014
BASEMENT'S MECHANICAL ROOM DESIGN, 43 SUOMI RD, HYANNIS, MA 02601
WINDOW
1ST Floor Room
15T Floor Room
- - 12„ GRADE LEVEL
C E IOUTLET
0 L DILUTION
M C AIR
i M T
Mechanical Room FIRE-RATED
Right Concrete Wall WALLS&CEILING
Mechanical Room
Back Concrete Wall INLET
Ceiling: H =85" COMBUSTION -
AIR 12"
` BASEMENT CONCRETE FLOOR with CERAMIC TILE
5
Prepared by Joseph Klebanov 4/17/2014
BASEMENT'S MECHANICAL ROOM DESIGN,43 SUOMI RD, HYANNIS, MA 02601
Legend:
90°DUCT ELBOW WINDOW
3.25"x 10"
Free Area:32.5 sq.in
_ DILUTION .
AIR VENT
VENT(325"x 10")
With Screen
Free Area:32.0 sq.in COMBUSTION
AIR VENT
r�„w
WALL STACK DUCT
3.25"x 10"
Free Area:32.5 sq.in
11 Floor
36" min
f '
Basement Cei ing
BASEMENT ---
12" CONCREATE - — -
WALL,12'W GRADE LEVEL -
MECHANICAL
ROOM - - - -
OUTLET
DILUTION
AIR
WATER ! a
HEATER INLET.
- --- COMBUSTION 12"
AIR
1 . .
BASEMENT CONCREATE FLOOR w/Ceramic Tile
6
Prepared by Joseph Klebanov - 4/17/2014
' BASEMENT'S MECHANICAL ROOM DESIGN,43 SUOMI RD, HYANNIS, MA 02601
.. r
B i
W.CLT
91"x
10 Sq.) , 22 sq.ft.
_�� r� ,a•�� 43 SUOMI RD,HYANNIS,MA
FINISHED BASEMENT PLAN
EXERWE ROOM AS O4f15/2014
V--0"x V-0"
461 sgfR
r,eo DRYWALL w1R-13 INSULATION
t
24'
FAN
COI
STAIR �.
STORAGE ROOM UPtoNa
9 ern�x
2rXID•
13-I"x 12'-1" __
151 Sq.ft.
WH
Im
4
48" MECH RM
6 RBON/SNNOKE 8:k10 E
CA ,
DETECTOR GFCI C
RECEPTACLE T
IN U 11"
T ,
32' COMBUSTION 8 DILUTION AIR WAYS
y
7
Prepared by Joseph Klebanov 4/17/2014
w -
-Commonwealth of Massachusetts
Map2`g c Sheet Metal Permit
Parcel .
�-PRESS PERMIT _ ,
Date: 2 2 e//r . Permit# t�01 3 a l
Estimated Job Cost: $ P /' �^, & 5 2014
7 �� Permit Fee: $ �'S
Plans Submitted: YES a/ TOM OF BARNSTAReviewed: YES NO
Business License# Applicant License# .117
Business Information: Property Owner/Job Location Information:
�) r `
Name: � �Qn �'`!r /� Name: b_;A & fPc�ooii' t'S/
Street: t� e l ��c Street: `7'3 �5U O rn f Rol,
City/Town: �� �(rn�h �n /Y/1 City/Town: 1�5 I�V A
Telephone: 8 Telephone: k7879— 0-5,l
Photo I.D.required/Copy of Photo I.D. attached: YES V NO
tartioitiai
,
J-1/M-1-unrestricted license
J-2 f M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less
Residential: 1-2 family V Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Fire Dept.Approval Institutional Other
Square Footage: under 10,000 sq.ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: V Renovation:
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
l�' S ' T��Y/ L�/Z��? vyjC?C•t✓
r
1
r
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L Ch.112 Yes a�'No❑
I If you have checked YLI indicate the type of coverage by checking the appropriate box below:
A liability insurance policy 66" Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
s
Check One Only
j Owner ❑ Agent ❑
i Signature of Owner or Owner's Agent ff)
` I
i�
4 By checking this box❑,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General laws. '
I �
Duct inspection required prior to insulation installation:YES NO
iProgress Inspections
{
Date Comments
Final Inspection
Date Comments #
I
i
i
Type of License:
3y 9Master
r itle
El Master-Restricted °�. ���•
i
:Ity/Town
❑Joumeyperson Signature of Licensee
Derrnit#
❑Joumeyperson-Restricted License Number /17 I
:ee$
Check at www.mass.aovldol
,
nspector Signature of Permit Approval
` I
The Commonwealth of Massachusetts
Department o Industrial Accidents
Office of Investigadoas
' . 600 Washington Street
Bostoi,MA 02111
www mass gov/dia.'
Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leeb1
Name(Business/organizationtb ividt4:.
•Address: S Ie M.iv,e/-
City/State(Zip:Vi///P-7//? /v,r IYA 04foo7Phone.#: 70v�•-0-5 7
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.LVJ I am a'sole proprietor or partner- listed on the-attached sheet 7. [1 Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.irorrrance - comp.insurance.t'
reed,] 5. ❑ We are a corporation and its ,10.0 Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 11.❑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.NrOther
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 most submit a new affidavit indicating such.
?Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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''ccoompensadon insurance for my employem Below is the policy and job site
information. lc?! / �r L
Insurance Company Name:
Policy#or Self-ins.Lic.P g SBA l fL li<V s6 Expiration Date: =0-5 0,
Job Site Address.`7� Su nm"I�W, �l`�Q¢'J/1 i 5 / 1 A 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 V 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 penaides ofperjury that the information provided above is true 2 and correct
Si attire: - Date: 212, 26 IIZ _
Phone# ��f �(��(^`,�Q 57
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#:
• t
- MMONW�
t ACTH OF MASSACt1}ItS _
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-=SHEET METAL WORKERS:`
=-AS A MASTER-UNRESTRICTED
Yevgeniy V Livshits 1SSUESrT1iE ABOVE LICENSE r0
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has been certified as a
Type-IFT =III YEVOENIY �V LIVS HITS
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technician as required by 40 C FR Part 82,Subpart F. a 6S U M M E R' S T
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rmdatationai 1=o ndatloh Approval:9130/93 j • `327853x
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g LI.VSHITS<<YEVGENIY<V«««««
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a
o Town of Barnstable
Regulatory Services
,usn�srs,
� Thomas F.Geiler,Director
+' Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
.w
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 Ae W� /Ile. l/(6W to act on my behalf,
in all matters relative to work authorized by this building permit
.(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be.filled before fence is installed and pools are not to.be
utilized until all final inspections are performed and accepted.
Signature of Own Signature of Applicant ,
r
Print N Print Name
Date a, .
Q:FORM&OWNERPERMISSIONP00LS
rr
Town of Barnstable *Permit#
Expires 6 mont f issue
Regulatory Services Fee
\ * BARNSTABM
- 9Q� 1639. `0� Richard V.Scali,Interim Director
A
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERNOT APPLICATION - RESIDENTIAL ONLY
of Valid without Red X-Press Imprint
Map/parcel Number W�l
Property Address ���� RA
W Residential Value of Work$ i' Q® Minimum fee of$35.00 for work under$6000.00
C
Owner's Name&Address l P
Contractor's Name Telephone Number &2�,JjI/#'_ge;r/
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one: Qj ,�'7-
❑ I am a sole proprietor ��/
N_I am the Homeowner
❑ I have Worker's Compensation Insurance FEg 13 2014
Insurance Company Name Tnl alp
Workman's Comp.Policy# F13ARNSTABLI
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side® AA Replacement Windows/doors/sliders.U-Value G`f1ff`//MJ`®!6(maximum.35)#of windows
#of doors:
❑ 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:
Q:\WPFILEST0RMS\building permit fbrms\E3WfrSS.doc
Revised 061313
The Cu;•nMOM of rgsad;±r�t r .
' Dot v fhrdshidAcudem&
.y .
ice ra,f' �:stigrrs -
' 609 Wmhingtoa Mreet
B asfor;MA 021H
! wt4n�r�ttrs�:go�Ir7rrx •
W-arke& Campeansataahsurance AffidavrL BuifdersfCan#ractursMecf icmnMumbers
Awficant Tnfarmatian Please hint Legihly
Name(Bnsmess! ;��t;t,��r►,�vi �Cl /
rev
G y/s at : /`� �l�/�� Phone 4-7 �� �-�c9
ElI am aemployerAm you aii deck veitTi $te spgr6p ate ba con6raciur and I T3�of P'oj��'��a}:
* have sob-co�actrns 6- El New iDa
ero¢tioyees{fnli a�orpazt-#ime). R�,,,����
1❑ I am a sole prop�ar orpartner- listed an the attached sheet'; - 7:-- g
ship and have no employees These sub-contw:tors have vg ❑Demolition
emplayees and have worms'
�vor3cing forme iu anycapact�� _ . Q_ ❑Building addition
LNO woz�s'army_insurance comp-"'sa""�`$
d 1 5. ❑ We are a corporaiiaaand its 10:❑Electrical repairs or additions
. I am a homeowner doing all wort= o±E=-s have exercised their II-R�Plumbing repairs or additions .
myse [No workers'cmp- right ofe emptiorrper MGL 12.❑Roofrepairs
insurance required-]y c_152,�I( ),andwe lia�*e uo
emplaystss_[No wodmrs' 13�Other
camp-insurance required:j
*�Y apPH�aat th:tchedcsbac�l mnst�Iso ffiovtt�sectionbclowshaceirc5�eiiwa3c��my�pa,�r;naspaTu=}- �
Ho-meawners vdw submit Eris xTIdsvff inffrsikg tbey mm daing vHim c au&Mjm bire aside coatxactD= salalk z aeW affidxvk inffirnfir sod ., .,
� s tbst beck this hint masti stiarhed s�idditinnzl si�eet shaming the nmme of ffie s�Es-oaa and sts�uhett�txnut ffsase have
v amplayees. Ifthe salrcnUUMEtMbat.`e empIoyees,theymust provide their worker'comp.palicymaflber..
I rani art employer thrttrsptmidiag tvorkers'compensation inviranca for nzy ertgAtoyees �e'wtr is the paficy rrrrd job site
nzforrrtadam
Insurance Companyldame:
Irolicy 9 or self iris.Uc- Expiration Date:
Job Si#ei Address: City�fState(T.rp:
Attach a copy of the workers'compensation policy aedarstiou page.(showing the gouty number and a rpiration date).
Fatlum to secure:coverage as mgaired under Sectica 25A o€MGL c I52 can lead to the imposition ofcriminal pemalties of a
fine up to$L,50U 46 andlor oane-yearimprisonmenf,as-wen as civil penalties is f e,farm of a STOP WORK ORDER-and a fine
of up.-to$250-00 a day agaimt the violator- Be advised that a copy of this statement maybe fnrvmded to the Office of
Investigations of fhe DIA fDr insm-ance,coverage verification_
I do Ftemby tort;fy ruuu/r tha�ptun�s nt alges atfhe irt,f orraatian pratu6id wham Es tam and-correct
( tore:
Phone#
02kial use only. Da not sprits in this area,to be compfetad by city or taWn afficiat
City or Toren: PermitlLiceuse 9
IssuingAuthoriig(=dr one)-
L Board of Health 2.BuMing Department 3.CItytrovn(irk 4.Electrical Inspector 5.Ph=bbg Inspector
6.Othrr
Contact Person: Phan:f:
_ 6
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers to provide workers'compensation for their employees. �.
Pursuant'to ibis statub-,as m pleyee is defined as `_..every person in the service of another under any contract ofhire, t
express or implied, oral or written."
An employer is defined as'an individual,partnership,association,corporafion 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 thann 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 Hcensing.agency,shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the common calth 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 ofpublic 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 cent ficatc-(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 inctn-ance. If an LLC or LLP does have
employees,a policy is required. $e advised that Ibis affidavit maybe submitted to the Department of lndustrial
Accidents for conf=ation of insuranc.6 Coverage.- Also be sure to sign and date the affidavit: The aiidavit 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-Tn su nce license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at ibe 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 ffiI in the peraiMicros;5 number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitllieense applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)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
(Le.a dog license or permit to burn leaves etc.)said person is NOT requited to complete this afftdaNdt
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 Departcaent's address;telephone and faxnumber.
the CoMMnuW(-'alth of Massach�tfs
Dspaztment Qf 7uclustdal AQc0=t&
Qffiee Of kv'E �patimli
��l�a�hzn�tan met
Bwon=MA G21 I I
TeL#617727-49 W W 406 or 1-9 E41% AFE
Revised 4-24-07 Fax# 617-727-" 4 a,
Town of Barnstable - -.
' - Re atory Services -
�yti Richard V.Scab,Interim Director
°-� Building.Division
i
'Tom Petry,Building Commissioner _
MASS.
16"5 ��� ' 200 Main Street, Hyannis,MA 02601
ED www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-750-6250
HOMEOWNER LICENSE EXEMPTION ;
• . ..~•� y� �1� Please Print .
`DATE:
1JOB LOCATIQIiT: 7> J 1, ' !-t�!OrX /5 �1 �
number street vglage
"HOMEOwNER�:
T name' /home phone# y work phone#
CURRENT MAILING ADDRESS: y b
6)24
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
Persons)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 stiuctures. 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 ciremen e/she will comply with said procedures and requirements.
Signature ofHorneowner --
Appioval 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 certdy 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.
�'ME Tj Town of Barnstable �
Regulatory Services
HAMS Richard V.Scak Interim Director
163g ♦�
Building Division
Tom Perry,Building Commissioner
200 Main Street;Hyamiis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 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 ray behalf,
in all matters relative to work authorized by this building permit
(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
Assessor's office (lst floor}i �7- ¢ L� X /� OF THE TO
Assessor's map and lot number �Cl
Board of Health -(3rd floor):
Sewage Permit number ......................... ... ................. Z B6Hd9Tl►DLE. i
Engineering Department F(3rd. floor): J� �S +o rasa e
House number ........................:........... U..r..::............ o t639. \em
0 YPY d'
Definitive Plan Approved by Planning Board ________________________________19-------- .
APPLICATIONS PROCESSED 8:30 9:30 A.M. and 1:00.2:00.P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ........Build
.....................................................................................................................
TYPE OF CONSTRUCTION New
.......................................................................................................................................
August 18 t 9.88..
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Lots 52 & 68 Sauna Roadj3axz"able, MA
Location .............................................................................................
-.Proposed Use New single family dwelling
................................................................................................................................................................................
, ,Zoning' District . P. .......................................................!..Fire District ..............................................................................
Name of Owner ice—. ,- 102 Seth Parker Road Centerville MA
.......s. ............. ...........T,...—::_....-.._................Address .............................................t.......................,.............
Name of: Builder n�,rnstable Holding Co., Inc. 10U..West Main Street,Hyannis, MA 02601
.... . ................Address .....
' Name of Architect .....Terry Luff.....................................Address ..................
Number of Rooms .....:.......5...................................................Foundation ......POured OORCrete.........................................
Exley for . Cedar shingles
.......................................................................Roof ng ............Asphalt shingles.........................................
Floors 5/.8 C.DX.... plywood...Carpet..............................Interior ............Drywall.........
Heating P1eCtiiC ..Plumbing
Fireplace .............N..................................................................Approximate Cost ...... ......................
Area
.................
Diagram of Lot and Building with Dimensions
Fee .............................................
5-
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
- construction.
C
Name
Construction Supervisor's License .......g....�
BARNSTABLE HOLDING CO. A=269-129
o?,& %aich
No ..JUI.9. Permit for ....I I...Story............
.........$iagle...Family..Dwe-11,4'.ng......
46 tx)om,
Location ..Lots...52....&...Ea., -n a...Road
.................Hy. annis............................................
Owner ....Baxrlsta-bla..Ho.lding..Ca......
Type of Construction Xrame............................
...............................................................................
Plot ............................ Lot ................................
Permit Granted ............I.............................19
Date of Inspection ....................................19
Date Completed ......................................19