HomeMy WebLinkAbout0245 WINTER STREET i
6
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map /&9 Parcel Application 60
Health Division v f.S" Is- Date Issued t l O
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address \,J
Village N
Owner Address_ � �ae--�otirz
Telephone 3 @(P
L
Permit Request ^ A0101 re
-T—svj !!Lk)2k, ekc- el
Square feet: 1 st floor: existing Wproposed Sa, 2nd floor: existing 3PO proposed SR—A Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size t 9 1kc- Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family(11 Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ANo On Old King's Highway: ❑Yes VNo
Basement Type: KFull ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) - --- Basement Unfinished Area(sq.ft) Ia?�v --
Number of Baths: Full: existing_ new O Half: existing new
Number of Bedrooms: H existing 0 new
Total Room Count (not including baths): existing new d First Floor Room Count
Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other
Central Air: ❑Yes Y,1 No Fireplaces: Existing 0 New O Existing wood/coal stove: ❑Yes Xlo
-4
Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: Ebexisting -nev 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# 4
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name n,r2 A � Telephone Number
Address � �_c�,.�c,��-� ��_ License #
Cd NA- G')L .3 s- Home Improvement Contractor#
Worker's Compensation # }�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 9116 /0!1
Y
4� r.
FOR OFFICIAL USE ONLY '
APPLICATION#
DATE ISSUED
fyy
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL x
PLUMBING: ROUGH FINAL
a
'= GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
(` Ri
N . r
S
The Commonwealth of 1{fassachcisetls
Department of Industrial Accidents
I Office of Investigations'
600 Washington Street
Boston, MA 02.111
��, ,� �°y• wwtt�.mass.gov/dig
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Pjnzxlbelrs
Applicant Information
in ip,,P�
Tease Print LeiblY
ess/Organization/Individua1): �r'�� Fv`
Name (Bus
City/State/Zip: 0v r A— `f °(0
Are you an employer? Check the appropriate box: Type of•piroject(required):
4. ❑ 1 am a general contractor and 1
I.El I am a employer with 6 New construction
employees (full and/or part,tim.e).* have hired the svb-contractors
listed on the'attached sheet. 7.. Remodeling
.2.[] I am a sole-proprietor or'partrler- Theso sub-contractors have g. Demolition
ship and have no employees
working for me,in any capacity.
employees and have workers' 9. Building addition
comp. insurance.$
No workers'.comp.•insurance WE Electrical repairs or addition
❑5• We are a corp
required] oration and its
3. a homeowner doing all work officers have exercised their, 11.❑Plumbing repairs or addition
• right of exemption per MGL 12,[]Roof repairs
myself. [No workers comp. c, 152, §1(4), and we,have no
insurance.required.] t 13.[� Other
employees:[No workers'
comp. insurance required-1
*Any applicant•that checks box#1 must also fill out the section below showing thcir workers'eompcnsa m
tion policy inforation..
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 providt thcir workers'comp,policy number.
X am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
lnsurance 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 crimui4l penalties of a
fine up to 31,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a day against the violator. Be advised that a copy of this statemerit may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi the pains-and penalties ofperjury that the information provided above is true and correct.
Si attire: Date-
PhD —
ne#:
Offccial use only. Do not write in this area, tb be completed by city or town offcciaL
City or Town: Pern-it/L.icense#
Issuing Authority(circle one):
1. Board of Health '2.BuildingDepartment 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
r.
. r
Format"i"on and Instrue IOUs
Massachusetts General Laws chapter 152 requires all employers to provide workef anotli Peundero any contracn'for their. t o Ihire,
Pursuant to this statute, an employee is defined as .".every person in the service o
express or implied, oral or written."
An employer is defuzcd 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 deedto emplH er, or the
cs. r the
rece trustee,iver or stee of an individual, partnership, association or other Legal entity,employing p Y
re than three apartments and who resides therein, or the occupant of the
owner of a dwelling house having not mo
dwelling house of anothr, who employs persons to do maintenance, construction or repair work on such dwelling house
e
thereto shall not because of such einployrnent be deemed to be an employer."
o'r on the grounds or building appurtenant
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 notp ro 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 Frith 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-contiactor(s)name(s), address(cs)and.phone numbers) along with their certifiicate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, axe not zegriired to carry workers' compensation insurance. If an LLC or LLP does have
xl
employees,a policy is zequired. Be advised that this affidavit maybe submitted to the Department h affidavit
ii t
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
stions regarding the Law or if you are required to obtain a workers'
Industrial Accidents. Should.you have,any que
compensation policy,please call the Department at the aurgber 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'aad 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 perulit/license number which will be used. s a reference number. In addition, an applicant
that gust submit multiple perxnioicense applications in any given year, need only submit one affidavit indicating current
city
or
policy information(if necessary)and under"Job Site Address" the applicant should write"all loca ba in rovided to the
town);".A copy of the affidavit.that has been officially stamped or marked by the city or town may p
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 pitizen is obtaining a license or permit not related Eo 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:
Tho Commonwealth of Massachusekt
Depar wont Of industrial Accidents
Office of Tavestigat-ions.
600 Washington Street
Boston, MA 02111
. Tel, # 617-727-490.0 ext 406 or $ 7 1- 7 - .MASSAFE
Fax # 617-727-7744
Revised 11-22-06 w-ww.mass.gov/dia
Town of Barnstable
ina ram,
Regulatory Services
• Thomas F. Geller,Director
! sAxrtsr�er..e.
1659- -Building Division
leis~ .�� . .
ATFo '� Tom Perry,Bulfding Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038 -
- - ^_---HOMEOWNER LICENSE EXEMPTION .
Please Print
DATE:
JOB LOCATION: . �� ` e�
street village
number gyp^
HOMEOWNER': r-`C �/Y1rt b
home phon # work phone# .
name ;. (y
CURRENT MAILING ADDRESS;, b �i SQ e--.'
city/town state zip co e
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'
o .
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
ptable to the Building Official, that he/she shall be
'homeowner"shall submit to the Building Official on a form acce
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 ' on procedures and requirements and that he/she will comply with said procedures and
re emen
Signature$ignature of�omeowner
Approval of Building Official
Note: Three-fanuly 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 m last page of this issue is a form currently used by
several towns. You.may caret amend and adopt such a fora crtification for use in your community,
,R
SHE Town of Barnstable
Regulatory Services
r 1AItN8TADLE, Thomas F+'. Geller, Director
hues.
i610).9 `� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis, hfA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 fax: 508-790
Property Owner Must
Complete .and Sign This Section
if Using A Builder
f
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,
f
Print Name
If Property Owner is applying .for permit please complete the .
Homeowners License Exemption Form on the reverse side.
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NOTE:PARCEL LINES MAY NOT BE ACCURATE. The DISCLAIMER:This map is for planning purposes only. It
parcel lines on this map are only graphic representations of may not be adequate for legal boundary determination or 0 5 10 20 Feet
Assessor's fax parcels. They are not true property regulatory interpretation. This map does not represent an +X i I
boundaries and do not represent accurate relationships to on•the-ground survey. """X physical objects on the map such as building locations. x+X^'.}( -..�(..•X�,,. / j 1 inch equals 20 feet
., ..._._.._.—..—._.._._._.._..__......._._.
I
s
0F1r Town of Barnstable *PermitXOG D 7a
E.Aires 6 uronths front issue dale
Regulatory Services ee 7
Thomas F. Geiler, Director
ya Building Division
Tom Perry, CBO, Building Commissioner
T ��(i 200 Main Street, Hyannis, MA 02601
0,/A/� 11 Zp� ®� www.town.barnstable.ma.us
Office:FS�, 4038 Fax: 508-790-6230
S'
T%ME,SS PERMIT APPLICATION - RESIDENTIAL ONLY
—� Not Valid without Red X-Press Imprint
Map/parcel Number `� (n ^ D-e, .
Property Address
%Residential Value of Work j�7>G Minimurn-Jee of$2S.00 for work under$6000.00
Owner's Name&Address a,r + . 1,cq VAt Wl
�, a�v d�' r� ®JL• 3 �'
Contractor's Name Telephone Number
Home Improvement Contractor License# (if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
I
❑ I am a sole proprietor -'
❑ I am.the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy It
Copy of Insurance Compliance Certificate must be on rile.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
Re-side
[Replacement Windows, U-Value (maximum .44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc.
***Note: ro erty Owner must sign Property Owner Letter of Permission.
inImprovement Contractors License& Construct Supervisors License is required.
SIGNATURE:.
Q:\WPF11 ES\FORMS1Express\E PRESSPERMIT.DOC
Revise06O4O9 -
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
+ d 600 Washington Street
Boston, MA 02111
s�•'� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: %- ( C ser
City/State/Zip: Cg�,d� AAA Phone.#: SVV
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction
employees(full and/or part-tithe).* have hired the sub-contractors
.2.[1 I am a sole proprietor or partner listed on the attached sheet. 7.. 0 Remodeling
ship and have no employees These sub-contractors have g_ Q Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers'comp. insurance comp. insurance.$
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.Q 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 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'compensation insurance for my employee's. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic,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 cri_minaI penalties of a
fine up to$1,500.00 arid/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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cer ' er the ains and penalties of perjury that the information provided above is true and correct.
I P 6
Si Date:Signature. —
Phone#: 7 �y`ld
F
only. Do not write in this area, to be completed by city or town official
n: Permit/License#
hority(circle one):
Health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
V
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 tiustee 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
persons to do maintenance,construction or repair work on such dwelling house
dwelling house of another who employs
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
"ire to carry workers' compensation insurance. If an LLC or LLP does have
members or partners, are not req
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" I.he 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 ofln:estigatiors 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
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
a
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
MASS .
Building Division
PrED A Tom Perry,Building Commissioner
a
200 Maiii Strrct,—`Hya:rmis,MA 02601 _.
wym.to wn.b arnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOl IEONNER LICENSE EXEMPTION
Please Print
DATE fI lD
JOB LOCATION: H-5— ,"- S4
number street village
•.HOMEOWNER": J`` Q c g ) 7� l U lob
name home phone# n work phone#
CURRENT MAILING ADDRESS:
city/town statt 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 be/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,Builc ng Deparhncnt
procedures and requiremtnts and that he/she will comply with said procedures and
re a e7tction
5ignatirr-ofeowner
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 horr=woer 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 peson(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 responmNlitics of a supervisor(sce Appendix Q,
Rules&Regulations for Licensing Construction Supevison,Section i.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 unlicenscd.person'as it would with licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responnbilitics,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the rrsponsnbilides of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may caret amend and adopt such a fmn/eertifi cation.for use in your community.
ITT ']Gown of Barnstable
Regulatory Services
puxx LE$ Thomas F. Geiler,Director
1639•
o a Building Division
e
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 509-790-6230
,
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
m all matters relative to work authorized by this building permit application for:
(Address ofjob)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please t
Homeowners License Exemption Form on e reverse side.