HomeMy WebLinkAbout0225 WINTER STREET d�
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�t�T� �—�ea 1-�M v: D�- �1�3� �-1� -3�a
Application Number.............................. . ............................
MASS. 7 Permit Fee.......................................Other Fee.
Total
.......... ................................................. ......
TOWN OF BARNSTABLE Tt� PLit?Ap'poval by..... '".........on..;O:Z/�.f
BUILDING PERMIT 7'OWN 0
Map........................................P=el.............................................
APPLICATION
Section 1 — Owner's Information,and Project Location
Project Address_
TZS Wiktf�2.1` -- -Village .146�14IA 6
Owners Name— -1;!�c4l 4A-e S-sy
L00,
Owners Legal Address 2,22S Ut P' .izr Stv c�
city. l 41 k'Alt S State zip
Owners Cell# 291 222 E-mail S,IAvc?4he-s"Ui 16) VCJ\ob Cohn
Section 2 —Use of Structure
Use Group_f\ --
F-1 Commercial Structure over 35,000 cubic feet
Commercial Structure under 35,060 cubic feet
Single/Two Family Dwelling
Section 3— Type of Permit
F] New Construction E] Move/Relocate E] Accessory Structure ❑ Change of use
El Demo/(entire structure) El Finish Basement El Family/Amnesty El Fire Alarm
Rebuild 0 Deck Apartment El Sprinkler System
F1 Addition ❑ Retaining wall ❑ Solar
aRenovation El Pool El Insulation
Other—Specify
Section 4 - Work Description
P 0 40/ tc� e li, le
Last updated. 11/15/2018
7
Application Number....................................................
E
-Section 5—Detail
Cost of Proposed Construction ® ,,Square Footage of Project 0 y >�j z,
Age of Structure C% ���d' Dig Safe Number
# Of Bedrooms Existing Total# Of Bedrooms (proposed)
110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
(�Wiring ❑ Oil Tank Storage ❑ Smoke Detectors
Plumbing ❑ Gas ❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom
Water Supply Public ❑ Private
Sewage Disposal ErMunicipal ❑ On Site
Historic District [ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: � �� D_is4wd �d °° I am using a crane ❑ Yes f2f No
;a
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq. Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yard Required Proposed
Rear Yard Required Proposed
Side Yard Required Proposed
i
Has this property had relief from the Zoning Board in the past? ❑ Yes No
Last updated:11/15/2018
- Application Number...........................................
Section 9= Construction Supervisor
Name V e- ,' _ Telephone Number Sow- 3 67- 73 1�r
�� �. : city r p
Address / - ,;�� �. Ci �l'4^I�`� State �1- Zi
License Number( - 6 � License Type.Jv,rc % E ira 'on Date 0 q- -2 7 Z6/q
Contractors Email t; �� e �►' - r
/�' �.s�-Av � v Cell S�� `h� ``'-3/r
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 7 CMR and the wn f Barnstable.Attach a copy of your license.
Signature Date /
M
Section 10-Home Improvement Contractor
V p! C Name �. � ��" Telephone Number S ot`- 3 �7
Address l Z-41 (L&V City 0c,rvjj, State JAACA . Zip (?ZC µS
Registration Number I k Z S Expiration Date r,5,-7 (----) id()I
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation require by 78 CMR and the Town of le.Attach a copy of your H.LC...
Signature Date
i
f Section 11 -Home Owners License Exemption
r
Home Owners Name:
Telephone Number Cell or Work Number
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.
Signature Date
p
APPLICANT SIGNATURE
Signature Date
—
Print
n
Print Name TeleP hone Number Sc - M 7 '�3l
E-mail permit to:
Last updated: 11/152018
Section 12—Department Sign-Offs r
Health Department ❑ Zoning Board(if required) ❑
Historic District ❑ Site Plan Review if required) El( q )
Fire Department ❑
Conservation ❑
For commercial work,please take your plans directly to the fire department for approval
Section 13 Owner's Authorization
I, as Owner of the subject property hereby
authorize '' to act on my behalf, in all
matters relative to work authorize y this building permit application for:
22� WTAVV t k M3�C," own f
'A less of j ob)
I � I
Signature o Owner date
Print NaAe
�i
1
Last updated: 11/15/2018
}
ti---- -------------7
�ie��a�n�yaaruuea�C�C o�Gl�'lccaaac�Ca� f
Office of Consumer Affairs&Business Regulati`
/ HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
R`egisT tration Expiration
e 1$25b3 07/05/2019 *r
Max= ,
MATTHEW V CRED t
13,
z l;
" MATTHEW V.CREDIT
1229 ORLEANS RD
HARW ICH,MA.02645 `- undersecml -
Commonwealth of Massachusetts
Division of Professional-LicensMe—
c Board of Building Regulations.and Standards
Constr._u_ctionS'i9pervisor
f.
CS-086315 �� 'E�3ires: 04/27/2019,
MATTHEW V CREDIT ^1
1229 ORLEANS RD
HARWICH MA 02645 ti
Commissioner CI--
Construction Supervisor
Unrestricted-Buildirigs of any use group which contain
less than 36,000 cubic feet(991 cubic meters)of enclosed
space.
Failure to possess a current edition 8f the Massachusetts
State,Building Code is cause for revocation of this license.
For information about this license
Call(617)727-3200 or visit www.mass.gov/dpI
AML
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApipUcant Information. Please Print L 'b
Name(Business/Organization/Individual): ^4-eviV ("-Jt Mxvsf Ijx Lf �G �C?1!°� =fir•
Address: I•ZZ119 (1C'
City/State/Zip: `���Ul� ��_ o"C Phone#: ' go e6r-- 67 . -7-3/ K_
Are you an employer?Check the appropriate box: _ .; Type of project(required):
I.❑ I am a employer with- 4. 0 I am a general contractor and I
6. ❑New construction
ployees(full and/or part-time).* have hired the sub-contractors
2.lam a sole proprietor or partner- listed on the attached sheet. 7. FqRmodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp.insurance comp,insurance.
#
required.] 5. We are a corporation and its 10:❑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:❑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.
*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 thepolicy andjob site
information.
Insurance Company Name: '
Policy#or Self-ins.Lic.#: Vi c c sob ` Sd S �� _ I�� �/ Expiration Date: 1 f '
n
Job Site Address: �.�-� (`AJ/rfr City/State/Zip: 02""O/
Attach a copy of the workers'compensation policy declaration page(showing the policy nu her and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un a pains d pen of 'ury that the information provided above' trice and correct:
Si afore: Date: S
Phone 6
73
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): F
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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents..Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the penmittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington,Street
Bostua,MA 02111 -
Tel.#617-n7-4900 ext 406 or 1-877-MASSAM
Revised 4-24-07 Fax#617-727-7749
www.maw.gov/dia
Town of Barnstable
Building
g
�Po t This Card So TFi�at�t s;V�s�ble From the<Stceet-A rovedSPlans.Must be Reta ned„on Job and,this;Card;Must be Ke t ,
eAXNfi AA= ^'s ac, s ✓ ppk i Y �; r ? e •p 6
Mw 'Posted Until Final'Irs ection HasYBeen Made „• � g Permit
16gp .': 4 rx y a. �f';' p x: „a ' r.- ,' ,.:7. ,;k. �b , , Wu v p ,.
' V, " ificate of Oc u'anc is,Re u�re�d sucfi Buildm st all Not=be Occu ied untilsa Final lrt's'ection;`has been made. .
W,h. ea Cert p Y q s
.
Permit No. B-19-382 Applicant Name: MATTHEW V. CREDIT Ap
provals
Date Issued: 02/12/2019 Current Use: Structure
Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: '08/12/2019 Foundation`.
Residential Map/Lot 310 198 Zoning District: RB Sheathing:
.Location: 225 WINTER STREET,HYANNIS
ContractorNameMATTHEW.V. CREDIT Framing: 1
Owner on Record: SHAUGHNESSY TRACY E k w
ContractorLicense182563 .2
Address: 225 WINTER STREET < � •- �� �; ��� •
�� Est Project Cost: $40,000.00 Chimney:
HYANNIS, MA 02601
Permit Fee: $254.00
Description: Replace(2) Kitchen Windows.Replace the a4replace stairs to attic Insulation:
Fee Paid $254.00
s :
Project Review Req:
�Da e� ` 2/12/2019 Final:.
Plumbing/Gas
Rough Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Final Plumbing:
All work authorized by this permit shall conform to the approved application and theapproved construction documents-for whi h this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning bylaws;a`nd codes. Rough Gas:
i x
This permit shall be displayed in a location clearly visible from access sire�etor road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. Final Gas:
The Certificate of occupancy will not be issued until all applicable si nMures b"'the B�uildm and;Fire Officials are'`rovided on this) rmit. Electrical
P Y pP g <Y g P P
Minimum of Five Call Inspections Required for All Construction Work.,
ork
1.Foundation or Footing Service:
2.Sheathing Inspection Rough:
= �� - '`"
3.All Fireplaces must be inspected at the throat level before firest fluellinmg is installed ', •n _.�...
k•
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
7.Final Inspection before Occupancy Low Voltage Rough:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. tow Voltage Final:
Work shall not proceed until the Inspector has approved the various stages of construction. Health
"Perso cting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
'� Building plans are to be available on site Fire Department
� All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
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FEB 0 5 2019
TADLE
TOWN OF BARNS
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
• Ma P Parcel Application # 0 (-0 0 7(oZ
Health Division Date Issued
Conservation Division Application F
et—
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH = Preservation / Hyannis
Project Street Address +: a 5 lam) Te%z c C-�—
Village k4!d en-oso";s
Owner NAjcZc_:s 1�''.k� /i rc�Lq .%a ug�ne_J5L Address ,_SAdKk'
Telephone d - F 391
Permit Request Amtk-;o cry �P.T 4, VI ►M�(v i
Square feet: 1 st floor: existing ec'A proposed'7e-0 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay CD
Project Valuation 4.50 Construction Type " ryD
Lot Size / Grandfathered: ❑Yes ❑ No If yes, attachrsupporting'�documentation.
Dwelling Type: Single Family �9' Two Family ❑ Multi-Family(# units) p y r
I
Age of Existing Structure I!j 3&s Historic House: ❑Yes O<o On Old King's jHighwayP❑Yes'; ❑ No
Basement Type: 1A Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) 76 0 Basement Unfinished Area (sq.ft) �-
Number of Baths: Full: existing_ new Half: existing new
Number of Bedrooms: existing�2 new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: 216as ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes 306 Fireplaces: Existing New Existing wood/coal stove: ❑Yes U40
Detached garage: ❑ existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes. ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Ww�'v Telephone Number
\��
Address �" l0 '4 License #
/ O Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
,APPLICATION#
DATE ISSUED r+
MAP/_PARCEL NO.
ADDRESS VILLAGE
OWNER
t
i DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
= -GAS: ROUGH;?: .a. FINAL
F
FINALBUILDING.. .5 _
r DATE CLOSED OUT
ASSOCIATION-PLAN NO.
f
r
The Commonwealth of Massachusetts
Y ,Department of Industrial Accidents
Office of hivestigations
t500 Washington Street
t Boston, MA 02II1
r sy www.inass.gov/dia .
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information A A Please Print Legibly
Naive (Business/Organization/Individual):
Address:
City/State/Zip:
Are you an employer? C ' ck the appropriate,box: 'type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or paft-time),
* have'hired the sub-contractors.. 6. ❑ New construction
2_❑ 1 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 mein an ca aci employees and have workers'
Y P h'• 9. ❑ Building addition
o workers' comp. insurance comp.insurance.1
equired.] 5. ❑ We. are a corporation and its 10.❑ Electrical repairs or additions
3. I am a bomeowner doing all work officers have exercised their lq.❑'Phimbing 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.].e
*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 arc doing all work and then hire outside contractors must submit anew 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.
lam an employer that is providing,workers'compensation insurance foamy employees. Below is the policy and jab site .
information
Insurance Company Name:
Policy# or Self-Iris.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 S1,500.00 and/or one-year imprisonment, as wt l`as civil penalties'in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be foiwarded to the OfEce,'of
Investigations of the DIA for insurance coverage verification.
I do hereby aerti e der t pains nd enalties ofperjury that the information provided boNe is ere and correct.
m I v
Si nature: VT I VV VT
-��
Phone#: '
Official use only. Do not write-in this area, to be completed by city or town official
City o'r Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4', Electrical Inspector. S.Plumbing Inspector
6.-Other
Contact Person: Phone#:
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees•
• cl of hire,
Pursuant to this statute, an employee is defined as ".,.every person in the service of another under any contra
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
g engaged
of g the fore oin in ajoint enterprise, and including the legal representatives of a deceased employer, or the
er the
receiver or trustee of an individual, partnership, association or other legal entity,employing employees. Howev
owner of a dwelling house haying not more than three apartments and who resides therein, or the occupant of the house
dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling
t thereto shall not because of such employment be deemed to be an employer."
or on the grounds or building appurtenan
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-vvho has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any ofils political subdivisions shall
enter'into any contract for theperfoirhance ofpubliciYork until acceptable evidence ofcompliance with the inscuance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out.the workers' compensation affidavit completely, by checking the boxes than apply to your situation and, if
necessary,supply sub-contractors) name(s), addresses)and phone number(s)along with their certificate(s) of
LC)or Limited Liability Partnerships(LLP)with no employees other tha
insurance, Limited Liability Companies (L n the
members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees, e policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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
rn
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-msttred 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.permiUlicense number which will be used as a•refeTcnce number. In addition an applicant that must submit multiple permitflicense applications in any given year, (city or
need only submit one a davit indices tang current
policy information(if necessary)abd under"Job Site Address" the applicant should write"a11 locations in
_
town)."A copy of the affidavit that has been officially stamped or i.asked by the city or town y be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavilmust be filled mitt each
icense or permit not related to any busines`or commerci a 1
year. Where a home owner or citizen is obtaining a l venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this aJffidavil,
The Office of Investigalrons wou ike to lh�nkyom��a�+� r coa;eratin� and shou➢d y-0uhave any questions,
please do not hesitate to give us a call.
The Department's'address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dies
Tyr Town of Barnstable
�� 0 Regulatory Services '
` t t Thomas F. Geiler,Director a.�trxsrAst.E. �
".$� Building Division
Pr EDt
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA.02601.
www.town.barnstable.ma.us
Office: 509-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: �� 1
—A
JOB LOCATION:
number 1 JYOM � ' WtMIs(trmt Q 1 j village Q' j�
"HOMEOWNER": � Vl vW V QQ' �0�IQZ V' 1� 506 � Q Ot/ '0
name nQ�home h c# work phone#
CURRENT MAILING ADDRESS:
,I _
ity/town state zip ccdr
'ac 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_
DEFINMON 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 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.be/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
Equirements ,
S o a
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 cxcmpt from the provisions
Of this Section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a p=on(s)far hini to do such
work,that such Homcowna shall act as supervisor."
Many homeowners who use this exemption are unaware that they an assuming the responsibilities of a supervisor(sec Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hues unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homwer eon acting as Supervisor is ultirriatcly responsible.
To ensure that the homeowner is fully aware of his/hrr responsrbilitics,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:fonns:homccxcmpt
1 1,
Town of Barnstable
Regulatory Services
� DA.It?t6TASI.L, t
'r MAas $ Thomas F. Geiler,Director ti
16 Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign.Tl is Section
If Using ABuilder
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)
Signature of Owner Date
Print Name
If Property Owner is applying for pen-nit please complete. the
Homeowners License Exemption Form on the reverse side.
Q:FORMs:O WNERPERMISs1ON
r )2,
� `1 I
` 'OK u .q• " 'CARBON MONOXIDE ALARMS
MUSTBE INSTALLED PER
�c� MASSACHUSETTS BUILDING CODE `
. - z
IMPORT
ANT:
`\ ANY CONSTRUCTION THAT INCREASES>LIVING SPACE
� _ , a 4��' wt BEYOND 1200'SQ, FT. PER LEVEL MAY R�,. 49r�' REQUIRE THE
INSTALLATION•;OF ADD ;SMOKE DETECTORS.
ITIONAL
- NOTE: A. SEPARATE PERMIT IS REQUIRED FOR THE
INSTALLATION OF SMOKE DETECTORS--THE ELECTRICAL
PERMIT•DOE_NQ SATISFY THIS REQUIREMENT.
`pNio '
°
a � ,
_
a�
VJ"�,� ,
Po frc� k
F:i
I
1
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
M1
Map O Parcel ` U Application #
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/ Hyannis
Project Street Address W�
Village4AIAMM,_)�
Owner W i I ress
Telephone
Permit RequestMr
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 ti 1 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: I existing —new
Total Room Count (not including baths): existing C5 new First Floor Room Count
Heat Type and Fuel: WJ Gas ❑ Oil ❑ Electric ❑ Other I::; o
Central Air: ❑Yes iU No Fireplaces: Existing New Existing wood%coal stove: Ye's--❑ No
i I C>
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ ❑ex new size _ Barn: iting ❑�new es1'ze_
Attached garage: ❑ existing Ell new size _Shed: ❑ existing ❑ new size _ Other: �....
:2a 6.
h:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ._..
a.
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
_ kNo
- =- c
.Name Telephone Number
Address t% �' `� License#
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE �� vu
FOR OFFICIAL USE ONLY
APPLICATION#
i
DATE ISSUED
4
MAP/PARCEL NO. ..
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL - <Y
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL-.
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
k _ Office of Investigations
600 Washington Street
r Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: ,(fin (��p,, Q'
City/State/Zip: r, v l�Ulo(Phone #:
Are you an employer?Che k 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.El 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'
Y9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.]. 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.WI 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.❑ Roof repairs
insurance required.] t c. .152,'§1(4),and we have no
employees. [No workers' 13.1] 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. Lie.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 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 ce ify nder the sins d penalties of perjury that the information provided above is tru and correct.
Si nature: Date:
n.. V V T-VI
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 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
.Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax # 617-727-7749
www.mass.gov/dia
ENERGY CONSERVAT-ION APPLICATION FORM FOR ENERGY EFVICICIENCY FOR
ONE. AND TPVO-FAri1TL'Y DETACHED RESIDENTIAL'CONSTR•UCTION (78o CYIR 61..00)
Applicant Naive: Cj Site Address: 1 112 C�
prinl
Town:
Applicant Phone:
. �,,
Applicant Signature: Date of Application:
NEW CONSTRUCTION: choose O of the f6tiowing two•o tions
780 CNM TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE-AND TWO-FAMILY BUILDINGS
MA)C YMM MLhTIMUM
Ceiling or Slab
QOption 1: ' Basement
Fenestration exposed Wall Floor Perimeter
UE Wall AF HSPF SE
U-factor floors R Value R-Value R Value R Value
RTValue and De th
National Appliance-Energy
R-10) Conswalion Act(NAECA)
.35 R-3 9 R-19 R 19 R-10 4 ft.' a,1997 as nended,minimums
eaftr as a licable
Note: This form is not required if you choose either of the two versions of REScheck as listed below.
❑ Option 2: RESche'ck Version 4.1.2 or later variant software analysis must be completed
790 CMR 6107.3.2
REScheck—Web which can be accessed at http-//www.encrgycodes.goy/reschwk/
ADDXT OIVS.OR ALTERATXOI S.TO EXIS'T]1�IG BUILD11�iGS O VER 5 YEARS OLD*
*)3uildings under 5 years old must use option#1 or#2 in New Construction section above.
Complete the following formula to determine the %o of glazing:
(a) Gross Wall & Ceiling Area equals Formula: (100 x b a)
SF
100 x — _ % of glazing
(b) Glazing area equals SF b a
If glazing i <40%:i4e the chart below. • . If glaTin is> 40 % rgce6d to"SUNROOM" section
780 CMR'TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO=STING
LOW-RISE RESIDENTIAL BUILDINGS
h9TiIMUM
Ceiling and Slab Perimetl
Fenestration Wall Floor Basement Wall
Exposed floors P Value
U-factor R-Value R-Value R value . R-Value and Depth
.39 R-37 a R-13 • R-19 R-10 R-10, 4 fee
a R-30 ceiling insulation may be fised 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 including any access o enin s).
SUNROOM-An addition or alteration to an existing building/dwelling unit where the total
❑ g
lazin area of said addition exceeds 40% of the combined gross wall and ceiling area of the
glazing
adclitiou.
Note: Owner to fill out Consumer Information Form found in Appendix 120:P
Town of Barnstable
Regulatory Services
• Thomas F. Geiler,Director
+ saxxsTeBr.E, ,
MASS& Building Division
pTfDy a Tom Perry,Building Commissioner
200 Main'Street, Hyannis,.MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
— - —----HOMEOWNER LICENSE EXEMPTION
.orA Please Print
DATE: � �1 '
�
JOB LOCATION: ' " " ` cU+l�
nu be � street village
"HOMEOWNER':
name horn phone# work phone#
CURRENT MAILING ADDRESS: ' J -'
f.
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
SuT)ervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she,understands the Town of Barnstable Building Department
nimum inspection procedures and requirements and that be/she will comply with said procedures and
r ui
Signature of H meowner
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 constriction 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,
results in serious problems,particularly
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often p P
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
BIKE � Town of Barnstable
}
Regulatory Services
aAmirABm Thomas F. Geiler,Dfrector
Building Division
Tom Perry,Building Commissioner
- 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Pax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A wilder
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)
Signature of Owner Date
Print Name
-If Property Owner is applying for permit please complete the .
Homeowners License Exemption Form on the reverse side.
Q;FORMS:OWNERPERMIS S ION
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION..
Y"
Map Parcel Application
Health Division F`' Date Issued
y
Conservation Division Application Fee
Planning Dept. Permit Fee ��
Date Definitive Plan.Approved by Planning Board Vf�i
Historic'- OKH Preservation/Hyannis /
Project Street Address Z_--a
Village
Owner 5W
flu.uU1 Y Address
Telephone
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing , proposed Total new
Zoning District Flood Plain = Groundwater Overlay
Project Valuation �� �OC7 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting cumentation.
C:) ,
E7Dwelling Type: Single Family. Two Family ❑ Multi-Family (# units)
w.V
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'0�1ghwayLb Yes ❑ No
y
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Z(�
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
ca -
Number of Baths: Full: existing new Half: existing new `T'
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
._7�f Detached garage: ❑existing 0 new size_Pool: ❑existing ❑ new size _ Barn: ❑existing ❑ new size_
Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
1 APPLICANT INFORMATION_ (
(BUILDER OR HOMEOWNER) _ 790
Name Telephone Number
Address License #
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE Lo V
L
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED ,
a4
MAP/PARCEL N0.
ADDRESS VILLAGE
OWNER
' DATE OF INSPECTION:
C FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN'NO.
4.
k,
The Coininonwealth of Massachusetts
Department of Industrial Accidenty
Office of Investigations
600 Yfashington Street
Boston, AL4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Le ibl
Namo (Business/Orgmizationflndiviidduuall)^: 73
n�
Address• —��U\V���/ �� .
City/State/Zip: "���` ® Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6 ❑New construction
employees (full and/or part-time).* have hired the s'ab-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. 0 Demolition
working for me in any capacity, employees and have workers' 9 ❑Building addition _
[No workers' comp."imurance We arc
insurance.
required.] 5. ❑ W e are a corporation and its 10.0 Electrical repairs.or additions_
3.[ 1. qu a homeowner doing all work officers have exercised their It.❑Plumbing repairs or additions
yself. [No workers' comp. right of exemption per 1v1GL_ 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 tbcy are doing all work and then hire outside contractors must submit anew affidavit indicating such.
xConiractors that check this box must attached an additional sheot showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provid;their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information
Insurance Company Name:
Policy#or Self-ins, Lie.#: 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 Grimir;al penalties of a
fine up to 31,500.00 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 bIA for insurance coverage verification_
I do hereby ce u der p i s4d penalties of perjury that the information provided above Irr uYnd correct.Date:
Phone#: O '
Official use only. Do not write in this area, to be completed by city or town oftciaL
City or Town: Permit/License#
Issuing Authority(circle. one):
1.Board of Health 2.BuiIding Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing.Inspector
6.,Other
Phone
Contact Person: #:
Information and Ins' t °u.ct.ions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees:
e under an contract of hiie,
Pursuant to this statute, an enzployee is defined as ...every person in the service of another y .
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
g the legal representatives of a deceased employer, or the
of the foregoing.engaged in a 'oint enterprise, and including g p
g ,cn J g g
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 compliame 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 numbcr(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 Towp Officials
Please be sure that the affidavit is complete and printed legibly. The D epartmcat 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/lieensc 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 ortown 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 lice 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 Massachusa s
Deg eat of Indus al A ccidents
Offxco of IRVe'stigatious
600 Washington Street
Boston, ILIA 02111
Tel. # 617-727-4900 eat 406 ar 1-877-MA.SS.AFE
Fax# 617-727-7749
Revised 11-22-06
wvirw_mass.gov/dia
'Town of Barnstable
�Op 1HE rq�
Regulatory Services
t Thomas F. Geiler, Director
BARNSTABLE,
MASS.
0_19. Building Division
PlFD h1A't A
Tom Perry,Building Commissioner .
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
=_________-__________ —_
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
rr V
V
"HOMEOWNER": C/
name Q home p one# work phone#
CURRENT MAILING ADDRESS: L 'C�
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 structures, A
person who constructs more than one home in a tyro-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 inspectir a procedures and requirements and that he/she will comply with said procedures and
re e e S. /
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.,
ROMEOWNER'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.
oF�HErTown of Barnstable
Regulatory Services
�=wxHAS& .E,� Thomas F. Geiler,Director
Building ]division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.ba rnsta ble.ma.us
Office: 509-962-4039 Fax: 508-790-6230
Property Owner Dust
Complete and Sign This Section
Zf Using A Builder
1 , 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)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on th"e reverse side.
Town of Barnstable *Permit# do 0
Expires 6 nt s from issue d e
Regulatory Services Fee
L BAaxsrABLE, II Thomas F.Geiler,Director
,fA•� Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street Hyannis,MA 02601
y
r
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
(, q Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address 2Z`� WAVY Wiet %6MM V V l,1 � M V 1
Residential Value of Work 000 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address w v 4try ` �
� WA
Contractor's Name ��, Telephone Number
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name BAR;(+`S AB
IJE
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
F
Permit Request(check box) `
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side wl TRa>nS
❑ Replacement Windows/door's/sliders.U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
,t/***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required.
SIGNATURE:
Jv
Q:Forms:buildingpermits/express
Revised 123107 �!'
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
'Applicaut Information Please Print Legibly
Name(Business/Organization/Individual): RM
Address: L41 WMAA,
-City/State/Zip: O` � Phone.
#:
Are you an employer? Che k the appropriate box: Type of project(required):
1.❑ I am a employer with 4. Ej 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 8. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P tY t 9. ❑ Building addition
[No workers' comp. insurance comp.insurance. 10. Electrical repairs or additions
required.] 5. ❑ 'We are a corporation and its ❑ P
3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
I
yself. [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 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.
TSi
b/ cc / th pa' sand ena ies of perjury that the information provided bov is ue and correct
:W V Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
ICity 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 hue,
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 representative's 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 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 permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-774 9
Revised 11-22-06
www.mass.gov/dia
Town of Barnstable
�pF SHE rp��
Regulatory Services
r
Thomas F.Geiler,Director
BARNSTABLE,
MASS.
Building Division
PlFD �a Tom Perry,Building Commissioner .
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: S08-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: l�\J
JOB LOCATION:
nu bcr street village �f
"HOMEOWNER": W-vo < "
name C, ho hone# work phone#
CURRENT MAILING ADDRESS: ✓ w
ity/town state zip code
The current.exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
-
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on'which he/she resides or intends to reside, on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
um inspection ocedures and requirements and that he/she will comply with said procedures and
qr
r e
Signature of H meowner
Approval of Building Official
Note: Three-family dwellings containing 35,060 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_.l-Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to dosuch
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,
mligm
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.
�FTHE T Town of Barnstable
ti
0
Regulatory Services
g Y
�BARNSTABM
ass. Thomas F. Geiler,Di
rector
$p i639. �m
rF0.19ta Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.ba rnsta ble.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner st
Complete and Sign is Section
If Using A wilder
1 , as Owner of the subject property
hereby authorize to act on my behalf,
in all,matters relative to work uthorized this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the Homeowners License
4
Exemption Form on the reverse side.
114E r Town of Barnstable *Permit# W0046
Fxpi 6 months issue date
: `=- Regulatory Services Fe,
AIT g Y
v MASS&639, $ Thomas F.Geiler,Director
2007 Building Division
TOWN OF BARNSTABLE 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 PERMIT APPLICATION - RESIDENTIAL ONLY
J ,�� Not Valid without Red X--Press Imprint
310 Map/parcel Number
Property Address � C2 1
Q Residential Value of Work Minimum fee of$25.00 r work u der$6000.00
Owner's Name&Address M /
Contractor's Name r 1 �, �I�VCO\ �� Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on rde.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to I"✓����� V I 1/'e� �l�'�`
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property.Owner must sign Property Owner Letter of Permission.
` Ho pro em nt Co tractors License is required.
SIGNATURE:
Q:Fonns:expmtrg
Revise071405
-ti
' 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 41 Please Print LeLdbly
Name(Business/Organization/Individual): . n
Address:
City/State/Zip: ��1�, ��4r 1" ���� Phone.#:
gg�2n �
Are you an employer? Check the appropriate bog: 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. El New construction .
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance.
$• 9. ❑Building addition
,,p4quired.1 5. ❑ We are a corporation and its 10.❑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 MG!, 12. Roof airs
P
insurance required.]t c. 152, § ( ), re
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.
: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.
I do hereby certify under, ins. d penalties of perjury that the information provided abo efi�s true and correct
Sienature: Date:
Phone#: ap
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#:
r
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 emplpyer 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( )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-cont>actor(s)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'
number listed below. Self-insured
. compensation policy,please call the Department at theuxo 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 fo 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 Weshingtcri Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06
xvww.mass.gov/dia
«.✓ EVE
The Town of Barnstable
MASS9q� &6 .9. `eg Department of Health Safety and Environmental Services
prFD N►e�" Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
May 11, 1998
TO WHOM IT MAY CONCERN:
Due to a recent fire at 225 Winter Street,Hyannis,MA,it was discovered that 2 bedrooms were
located in the basement of this home. While the tenants were not a problem,the fact that emergency egress
was not possible, is a problem. Therefore,I had to order the discontinuance of those two bedrooms.
. If I can be of any further assistance,please call.
Sincerely,
r
Ralph Crossen
Building Commissioner
RC:lb
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[PAR] [R310 . 243 . ]
LOC] 0225 WINTER STROT CTY] 07 TDS] 400 HY KEY] 227702
----MAILING ADDRESS------- PCA] 1041 PCS] 00 YR] 00 PARENT] 0
MASON, MILDRED MAP] AREA] 63BC JV] MTG] 0000
255 WINTER ST SPl] SP21 SP31
UT11 UT21 . 28 SQ FT] 2582
HYANNIS MA 02601 AYB] 1955 EYB] 1975 OBS] CONST]
0000 LAND 28900 IMP 124200 OTHER
----LEGAL DESCRIPTION---- TRUE MKT 153100 REA CLASSIFIED
#LAND 1 28, 900 ASD LND 28900 ASD IMP 124200 ASD OTH
#BLDG (S) -CARD-1 . 1 124, 200 DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE
#PL 255 WINTER ST HY TAX EXEMPT
#RR 1866 0072 0966 0147 RESIDENT' L 153100 153100 153100 i
#SR MAPLE STREET OPEN SPACE
COMMERCIAL y
INDUSTRIAL
EXEMPTIONS
SALE100/00 PRICE] ORB11595/264 AFD]
LAST .ACTIVITY] 00/00/00 PCR] Y
}
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R310 243 . P P R A I S A L D A T - KEY 228097
MORIN, ALFRED C & DOROTHYP
LAND BLD/FEATURES BUILDINGS NUMBER ZN/FL=RB
18, 900 14, 900 51, 400 1 A—COST 85, 200
B—MKT 100, 100
BY 00/ BY ML ' 9/87 C—INCOME
PCA=1041 PCS=00 SIZE= 2272 JUST—VAL 85, 200
LEV=400 CONST—C 0 a
----COMPARISON TO CONTROL AREA 63BC ----------------------------- i
NEIGHBORHOOD 63BC HYANNIS
PARCEL CONTROL AREA TREND STANDARD
101 10 LAND—TYPE
189001 LAND—MEAN +00
852001 61720 IMPROVED—MEAN —170-o 200
] FRONT—FT
] 100 DEPTH/ACRES TABLE 02
10001 LOCATION—ADJ APPLY—VAL—STAT 1
LNR] LAND LFT/IMP]ADJS/SB/FEAT STR] STRUCTURE ARR]AREA—MEASUREMENTS NOR] NOTES a
COM] MARKET INC] INCOME PMR] PERMITS GRR] GRAPHIC
FUNCTION— [ ] STRUCTURE—CARD NO— [0 0 0] DATA— [ ] XMT [?]
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R310 243 . P E R M I T [PMT] ACTION [R] CARD [000] KEY 228097
000000001
PERMIT-NO MO YR TYPE VALUE CK-BY MO YR oCMP NEW/DEMO COMMENT
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UPC 68021 '
No. SH 1 SA 'o°CST•CONSJS� 1
HASTINGS, MN
bQ—
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°-1
' FIRE DISTRICT
MAC' NO. LOT NO. Hyannis SUMMARY
STREET 255 winter St. y
310 202 H 73 LAND sv
BLDGS. 3 A /U u
OWNER TOTAL p 0 S
LAND
RECORD OF TRANSFER• DATE BK PG I.R.S. REMARKS: BLDGS.
Ol
-'mason. Roger 3
'- TOTAL
• • B
LAND
Mason, Mildred 1 31 72 1594 264Aid 28a BLDGS.
LAND
BLDGS. -
rn
TOTAL,
LAND
Ol BLDGS.
TOTAL
LAND
z Z BLDGS.
/ �.- TOTAL
v/.7��� /�LJv HAS f %?:Ii�•f
LAND
BLDGS.
TOTAL
LAND
INTERIOR INSPECTED: ��� 0) BLDGS.
DATE: _ C_._ TOTAL
LAND
ACREAGE COMPUTATIONS BLDGS.
LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE TOTAL
HOUSE 3 /o .� d 7�: .�(� �j V LAND
CLEARECWONT BLDGS.
REAR TOTAL
WOODS&SPROUT FRONT LAND
REAR BLDGS.
WASTE FRONT
TOTAL
REAR LAND
O> BLDGS.
TOTAL
LAND
BLDGS.
LOT COMPUTATIONS LAND FACTORS TOTAL
FRONT DEPTH STREET PRICE DEPTH% FRONT FT.PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND
ROUGH TOWN WATER BLDGS.
HIGH GRAVEL RD. TOTAL
LOW DIRT RD. LAND
SWAMPY NO RD. BLDGS.
Cone.Wells Fin. Bsmt.Area Bath Room j Base / 5 BLDG.COST
Conc.Blk.WaIU Bsmt.Rae.Room St. Shower Bath gsmt. '
PURCH. DATE �'rr L
Conc.Slali Bsmt.Garage St. Shower Ext. Walls f 1 l
PURCH. PRICE. I3.00O. 1 ��
Brick Wells Attic Fl.&Stairs Toilet Room Roof RENTTWO �r0 �"w'yr`q., 2�.' 2�
Stone Wells Fin.Attie Two Fixt. Bath I14 r!trmmea 7 C, a��
� Floors R'e ma'1` "s01/n'tiy
Piers:': INTERIOR FINISH Lavatory Extra � J p n
Saint.; F 1 2 3 Sink t` `3 F.BR �•t) 01
Attic
aA 'A1/4Plaster Water Cie.Extra 2 r!J r i Nf Ir/ I ��
EXTERIOR WALLS Knotty Pine Water Only /Bsm!t.Fin.- '?/7 �� PARSTak FjpAd 3___,_._____
f`o X Qu-`>
1
Double Siding Plywood No Plumbing )60
cGIO' G °ui
;Single Siding Plasterboard Int.Fin. A/O
(/ dA hingles TILING �U
Cone.Blk. G F P Bath Fl. Heat a- /Q 'a
Face Brk.On Int.Layout Bath Fl.&Wains. Auto Ht.Unit {' -115-0
IID• /170 :S ,
Veneer Int.Cond. Bath Fl.&Walls Fireplace �- 8
Com.Brk.On HEATING Toilet Rm.Fl.
rTi'tlin,
mbing -f ?8�
Solid.Com Brk. Hot Air Toilet Rm.,FI.&Wains.
g
i' 'Steam Toilet Rm.Fl.&Walls
Blanket Ins.. - Not Water ;g/ ✓ St. Shower
Roof Ins: Air Cond.. Tub Area ,
Floor Furn.
ROOFING Z 0 A/-e— COMPUTATIONS `
Asph.Shingle Pipeless Furn. 8/ S.F.
Wood Shingle No Heat S.F. Q20 -
Asbs.Shingle Oil Burner 3 02 C/ S. F. / </(o
Slate Coal Stoker /g S F. /y_ 70 (o S '
Tile Gas S. F. 7,? OUTBUILDINGS
, _
ROOF TYPE Electric
S.F. 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5. 6 7 8 9 10 MEASUREDGable t/ Flat.
Hip Mansard FIREPLACES S. F. Pier Found. Floor ,-
Gambrel Fireplace Stack [/ Wall Found. 0.H..Door LISTED
FLOORS Fireplace ✓ Sgle.Sdg. Roll Roofing �-
Cone. LIGHTING Dble.Sdg. Shingle Roof
Earth No Elect. DATE
Shingle Walls Plumbing -
Pine
z;
Hardwood p! ROOMS Cement Blk.
Asph.Tile Bsmt. 1st y TOTAL 3 ?7 Brick Int.Finish CED
Single 2nd '/, 3rd FACTOR
REPLACEMENT
OCCUPANCY CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL.
OWLG. 7L /� 2 /i/ _ / S I — .3 Z 3277 :2, 3�/ Oo
1 _
2•
3
i
4
5 .
i
6
7
B
' g
10 -
i
TOTAL
s STATE
ROPERT'y ADDRESS I I ZONING DISTRICT CODE SP-DISTS.I DATE PRINTED I CLASS I PCS NSHD KEY NO.
0225 WINTER STREET 07 IRS 400 07HY 07/09/9.5 1041 00 636C R310 202
La
LANDIOTHER FEATURES DESCRIPTION ADJUSTMENT FACTOR$ T UNIT ADJ'D. UNIT 227702
no eyrDale size omenon LOC./YR.SPEC.CLASS ADJ. COND. P PRICE PRICE ACRES/UNITS VALUE Descdpron M A SO N i M I L D R E D MA P-
CD. FF De Ih/Acres ,, #LAN D 1 28,900 CARDS IN ACCOUNT -
1D 18LDG.SIT 1 x .21 =10 229 150 29999.9 103049.9 .28 23900 #+3LDG(S)-CARD-1 1 1240200 01 OF 01
1 #PL 255 WINTER ST HY OST 153100
BATHS 4.0 . U X C 100 14000.0 14000.0 1.00 14JO0 a #RR 1866 0072 0966 0147 MARKET 143900
FIREPLACE U- x C= 100 3100.00 3100.00 1.00 3100 U #SR MAPLE STREET INCOME
q USE
p I I APPRAISED VA
J . A 15.3olOO
a u ! PARCEL SUMMARY
LAND 28900
a T BLDGS 124200
mi S
E TOTAL 153100
_ IN CNST
1,11 I I 'DEED REFERENCE DATE
Zo mo R1-aea PRIOR YEAR VALUE
T 113-h Pay�lnsf MO -��D sales Pica LAND 28900
- S 1595/264, 00100 BLDGS 124200
jTOTAL 153100
BUILDING PERMIT A DJ:FOR•ECONOMIC
Number Dale Type AmOunl
LAND LAND-ADJ INCOME SE SP-BLDS FEATURESI SLD-ADJS UNITS
28900 1 17100
Class Const_ Tol al Base Rale AU Rale Y`e�ayr Built A Nefmr. OonO. CNO Loc %R G Repl Coll New Ad Re Value $Ipr�es Her nl Rooms Rms Belbe a Fia. Fl-,.11 F-
V�ils Unas I 9e p I P 9
04C 000 110 110 71.95 79.1.5 55 75 1980 90 70 177478 12420J 1.5 8 6 4.0 16.0
Descnplon Rale Square Feel Re DI.Cos' MKT.INDEX 1.00 IMP.BV/DATE. ML 9/87 SCALE. 1/D 0.3 7 ELEMENTS CODEI CONSTRUCTION DETAIL
6AS 100 79.15 316 64.586 IGROSS AREA 2582 FOUR FAMILY DWELLING CNST GP:00
FMP 55 5.50 180 990 *---
26---* STYLE _04CAPE CO_D 0.0
FSF 90 71.24 274 19.520 ! G20 ! DESIGN_ ADJM-T -JZD--ESIGN ADJU--ST--1-0.0
--- --- --- -- ---------- - - ---
G20 90 71.24 676 48158 24 ! EXTER.WALLS 11WOOD SHINGLES 0.0
--------- --- ----------------------
e 42 33.24 816 27124 ! 28 HtAT/-- TYPE 1D IL-H W-ZONED__- ---
*-13-* ! INTER.FINISH 07DRYWALL/PANEL 0.0
4 ! 1NTER.LAYOUT 11 DOD D.DI
Z **-13* IN7ER.3UALTY D2SAME AS EXTER. D.OI
18FSF! FLOOR STRUCT J2 -Cl JOIST/_BEAM 0.0
W ! 23 EFLOOR COVER J5CARPET 3 HDWD --0.0
- -- ------------- ---
E IToial A,eas iAus 130 Baso 1090 *--18--*--* ! 200E TYPE 01 GABLE-ASPH SH 0.0
T BUILDING DIMENSIONS *-FMP-34--*-* ELECTRICAL- _ _00 0.0
SAS W34 N24 FMP N10 E18 S10 W18 ! B15 ! fOUtVDATLON A JtCONCRET----------------
E BLOCK 99.9I
-- - -- -- - I
. SA5 E34 FSF N23 G20 N23 W26 ! ! -
-----
S2.4 E13 SO4 E13 .. FSF W13 S18 24 SASE 24
-------
L E05 S05 E08 SAS S24 .. B15 ! !
LAND TOTAL MARKET
N24 W34 S24 E34 .. ! ! PARCEL 28900 153100
*-----34----x AREA 2325
VARIANCE +0 +6485
STANDARD 20
I
IIII gECYCLfO
116
IIII � z
UPC 68021
NO. SF11 SA
HASTING.S, MN
�.ca1\ l4iaLi'StW.i"Z1'YY:ti_..,_+..,�..:,:�,.Am:i6fWHlfu-sxy� vi'+4y1�4.v
Z+6 TOWN OF BABNSTABLE
-1 REPOHT 7fLE3XENTARY/CONTXNUATlfj am
POBT
NAME (LAST, FIRST, MIDDLE) \'• %N4 e DIVISION
NOTE DETAILS i OBSERVATIONS-ITEMIZE EVIDENCE, SERIAL /S ETC.
Cc cj �
6
a L ��-- -
11/s/77 c� -W*f
LY / / PAGE 1 -t(5
/�
P 01,5. 196;. 696 4
Receipt for
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to ,
Street and No.''
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Return Receipt Showing .
to Whom&Date Delivered
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TOTAL Postage ` S
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ar
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WE
Ae" Town of Barnst 1
• BAMSTasr e.MAM
•
11659. `0$ Department of Health Safety and Environmental Services
ArED Me+A Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
April 11,1997
Ms.Mildred Mason
225 Winter Street
Hyannis,MA 02601
RE:225 Winter Street,Hyannis,MA
(M-310/P-202)
Dear Property Owner:
Our records indicate that your house at,225 Winter Street,Hyannis,MA,is currently being used as a four
family home contrary to Barnstable Zoning Ordinances. You must contact this office as soon as possible to
either:
1) apply for a building permit to restore the property to a single family home
2 apply to the Zoning Board of Appeals for a variance
PP Y g
3) prove that this is a legal four-family
You must contact this office immediately to tell us what direction you wish to take.
Sincerely,
.Gloria M.Urenas
Zoning Enforcement Officer
GMU:lb
CERTIFIED MAIL-P 015 496 696
f970311 a
CYCLED
116 Sono �J�aR 002�
UPC 68021
No. SF11 SA 'o OOgT-CONSJ���
HASTINGS, MN