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HomeMy WebLinkAbout0311 WINTER STREET _. �I I -� *Permit# Town of Barnstable — J Building Department Services. o hsfromismedate S • snxxsr . • Brian Florence,CBO ,� Building Commissioner A(01 1 ft RFD nud 200 Main Street,Hyannis,MA 0260100/4 9 OIL www.town.barmtable.ma.us � Office: 508-862-4038 U '790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Valid without Red X-Press Imprint Map/parcel Number Property Addresszz Residential Value of Work$F C, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �/- Contractor's Name ' /a f Telephone Number C—(- C c / Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ck one: Ch I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each p m Permit a st(check box) y� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to_)?a eel� �. ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ' ❑ Re-side ' ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: &d' er must sign Property Owner Letter,of Permission. Home Improveme .Contractors License&Cons ructio- upervisors License is . SIGNATURE: Q:IWPFIL.ES\FORMSIbuilding permit fonnsEMRESS.doc 08/16/17 the Cor momveakh ref Massadirrselts Department&frnd=&ia1Accidews— Office of Lmmtigatiew 600 WashikVta<x,Street Boston,CIA 02111 wFvmmasLgvv1dia Workers' GompensatianInsurance davit:Builder-dC,uutractursMectr*cians(Ph mbers - Applicant Informafion Please Print Nee A,ddrew. G" �-- cityrstate _ e alwf/t, - Phan 6 V C/G Are you an employer?check the appra ' to b Type of project(redlniredi}: I.El am a employes.with. 4_ I am a general contractor and I 6_ [:]New eaasbrior! employees(fall andfor part-timer* ve hired.the sob-cont&actars 2.❑ I am a sole proprietor orpartuer- Tilted onthe attached sheet. I-❑Remodeling sh�p and have no-employees. These sub-coatractars have g. ❑Demolition woridng for me in any capacity- employees and have woxkers' 9. ❑Building addition [No Workers! comp.insurance comp-insarance l 5. ❑ We are a corporation and its 10.❑Electrical repairs,or additions 3.❑ I am a homemvner doing all work officers have exercised their 1 L❑Plumbiag repairs or additions myself o worms' right of exemption per MGL - . , ( 1� ofrepa rs iffcarramreil'd�0,1EEd.]T c 152 �1 �andwehaveno employees.[No modes' 13.❑Other comp_insurance required_j *Any app d mt cheds'6oa P1 Est also ffi oot the secdioa beIo sbuuiug dms woaere cangensadm paEcjr infnmmaga3- ffameawne s wba submit dais af�dat�t la g they axe dm�all track dad�FII h¢e artitride ron>ractais amst submit a new affidaest indicating 5L1CTL TCaatxsctM*st chedr this baud mast attached as additional sheet d um ag the name of the snb-c�sad state trhetha ar not those entities have employees.Ifthesub-c�'+�•+*= +�ha-etapIoyee%d Ley==pmvidedek srarltes'romp.policynumber. I am an employer that is pr4ni&kg ivarkers'comp 'lsadmi iu lrancefor my gnrphnjwes $etow is file ptrUcy and jab rite information. Insurance Company N": Policy-or Self-ins_Iic_ Fxpirdtioa Ike- Job Site Address: Cityl5tatd : Attach a copy of the workers'coanpensationpolicy declaration page(shaming the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MQL m 15-27 can lead to the imposition of aiming penalties of a fine up to$1,50a O0 andfor one-year imprisonment,as well as city penalties.in fire form of a STOP WORK ORDER and a fine of up to$250.QO a Clay against the violator. Be advised tixat a copy of this statement maybe forwarded to the Office of Iavedigations of1he DIA for insmz+ce coverage verification. Ida fiur7sby cent 5,aatci$r trepans andpenaMfes odfpetjury that the informa&m pt nuided abmv h bare aid carr,ct Sisnature: Date: 01 Phone ik �° 796 i O,()Wd arse onl. Da nut tsr&s in tfpis Brea,€a be catnpteted by dxty artolt n a,fjifciat City or Town: Peruri f kense R Lssuing Authority(circle one): L Board of Health 2.Building Depaartrumt 3.faty1rown Clerk 4.Electrical hupector S.Plumbing Inspector 6.Other camtect Person Phone#- 6 L 4f- formation and Instructions gacl mtfs Cyc a= l Lawsi ch M=gm-es all employers b provide woli='compersaion for feg e¢epIoyems. Mac i, Pm mmat-to this sf t te,an.M17loyre is defined as."_.every person m the service of another under any contract of hire, express or m¢plied,oral or wiifien.." An Moyer is defined as"an mcfividrA par(nemb p.associafi on,corporation or other legal etdifp,or any two or more of the foregoing engaged in a Joint eotaT6se,and mclndmg the legal rup. enta.fives of a deceased employes,or the receiver or t mstee of an in dividmL partnership,association or other Iegal entity,employing employees. However the owner of a dwelling house having not more than tie apartments and who resides therein,or the occupant oftha - dwelling house of another who employs persons to do mamteaaace,construction or irpai r woik on such dwelling house or on the grounds or building appurimnmtlheimto shall not because of such employment be deemed to be an employer." MGL cbaptEx 152,§25C(6)also stafns fh�at¢every state or local licensing agency shall withhold ffie issuance or renew2l of a Hcexase or permit to operate a business or to construct buRdings In the commonwealth for any applicant who has not produced acceptable evidence of cnmp£rance with the insurance.coverage repaired-" Additionally,MGL chapter 152,§25C(7)states-Neither the nor ELy ofits political subdivisions shall ewes into any coafzact forthe peafumnance ofpublio woricu�I acceptable evidence of comp�iancewith the ms�**�ce. reqturrzaerits of this chaptes.have been presented In the contacting auf1103*." Applicants Please fill out the worbess'compensation affidavit completely,by checking ha.boxes that apply to your sitaaiion and,if necessary,supply sub-conixactor(s)name-Cs), addresses)and phone m— er(s)along with then-certifl-cat*)of insrnance. Limited Liability Companies(LLC)or Limited Liability Parrft= ips(LLP)withno employees other.than.tine members or partners,are not mqui ed to cant'workers'compensation insurance- If an LLC or LLP does have employees,a policy is required. Be advised that this affdayitmaybe submitted to the Depaitment of Industrial Accidents for confamaiion of msurmce coverage. Also be sure to sign and dafm the affidavit. The affidavit should be-retzrmed to ih e,city or town that:the application for the permit or license is being requested,not the Department of . aidast1-L Accidents. Shouldyou have any questions regarding the law or ifyou are requm-ed to obtain a workers' compensation policy,please call the Depadme nt at the number listed below. Self-insured companies should ear their self-insurance license number on fhe appropriate line. City or Town Officials t _ Please be scam that the affidavit is complete and priofed 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 regaz the applicant Please be sure to fill in the permitlliceme number which will be used as a reference number. In addition,an applicant fhat must submit multiple pemitllicense apphtations in any given year,need only submit one affidavit indicating cma-ent p olicy in.fbrmation Cif necessa )and under"Job Site Addamss"the applicant should writes"all locations in ( 'or town):"A copy of the affidavit that has been officially stamped or marlre d by-the city or town may be provided to the ' applicant as proofthd a valid affidavit is on file for f�m*petmiis or licenses Anew affidavit must be filled oirt each year.Where a home owner or citizen is obtaining a license or pemzit not ic atE d to any business or commercial-Vaat -e (i.e. a dog license or peunit to bum leaves eft.)said person is NOT regaked to complete this affidavit The Of of Investigations would IEM to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Deparlme:nfs.address,telephone and fax number. Cm�Wwj*of Massachusettv , . Dega�ment 4f Izid�ial AGci�-�nis Of of jjt.Ve&tjgati0at3 Bin=MA 0�1II ` (,-L 4 6I7' -4 ext 4-06 or I--977-MA2SAFE Fax 9 617 727 774 Revised4-24-07 W M=If 9PVId V ` Town of Barnstable Building Department Services i R�V01R'�RI4 i - �ss Brian Florence,CBO Building Commissioner - 200 Main Street,Hyannis,MA 02601. www.towmbarustable.ma:us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must , Complete and Sign This Section - -If Using A Builder � T �G'✓,as Owner of the'subject property hereby, authorize ram/ / //C��/ G to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature o Applicant Coe Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16t17 Town of Barnstable " Building Department Services Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 �. • MAM « www.town.barnstable.ma.us 1639. Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: /d/ li0 � �' ? Please Print JOB LOCATION: numbers street village "HOMEOWNER" 9�`/ C.�l/� i��� name home phone# work phone# CURRENT MAILING ADDRESS: � '-- cityhown 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. DEFM1i TION 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. , dersi ed"homeowner"certifies he/she understands the Town of Barnstable Building Department minimum inspection ocedures is and that h she will comply with said procedures and requirements. gnahrre of Homeowner Approval of Building Official Dote: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building.Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a*supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed'persons. In this case,our Board cannot proceed against the unlicensed_ person as_it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. e t 0, - 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 this issue is a form currently used by several towns. You-may care to amend and adopt such a form/certification for use in your community. Q.\VJPFaM\FORMS\building permit fomu\M(PRESS.doc 08/16/17 r - JAEBUIL-01 MVAUGHAN ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/31/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO ACT ' MRogers&Gray Insurance Agency,Inc. PHONE FAX Rte 134 (A/C,No,Ext): (A/C,No): South Dennis,MA 02660 E DRESS: INSURE S AFFORDING COVERAGE NAIL$ INSURER A:Main Street America Assurance Company 29939 INSURED INSURER B:Associated Employers Insurance Company 11104 JAE BUILDING,INC. INSURERC: 12 DOROTHY'S WAY INSURER D: SOUTH DENNIS,MA 02660 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LJRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAMS-MADE ❑X OCCUR MPTS983N 06/05/2017 06/05/2018 DAMAGE TO RENTED 500,000 PREMIS MED EXP(Any one $ 10,000 PERSONAL SADVINJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ]JECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY Ea=SINGLE LIMIT $ ANY AUTO BODILY INJURY(Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ A PROIaYEAUTOS ONLY UMONNI� $ J I — $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY WCC50050134872017A .06/0512017 06/05/2018 5 ATU E ER 100,000 ANY PROPRIETOR/PARTNENEXECUTNE Y/N - E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 100,000 If yes di be under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LARRY NICKULAS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P.O.BOX 507 WEST BARNSTABLE,MA 02666 - AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .......................... . ... ................... ............ ... .. Commonwealth of Massachusetts Class A Large Capacity License to Carry Firearms(M.G.L.c.140,,§1S1) License.Number. Date otlssue ` nation Date5� 112499806A 01/18/2014 4414WOZO issuing,Crtyfrown: BARNST�� a Restrictions:None NICKULAS, 29.CEDAR STREET F. WEST BARNSTABL `k P s; { 4 } . , jsw of License or registration valid for individual use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: b HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 179703 Type: 10 Park Plaza-Suite 5170 /2018 IndividualEx Expiration: 8/28 Boston,MA 02116 LARRY NICKULAS .:.... LARRY NICKULAS 616 HUCKINS NECK RD CENTERVILLE,MA 02632 Undersecretary 4Noval' i out s nature r� Details Page 1 of 1 Licensee Details -:.. ..__ ._ ................ ............................ . Demographic Information Full Name: LARRY D NICKULAS caner Name: License Address Information City: W BARNSTABLE. _ - State: MA ipcode: 02668 Count United States License Information License No: CS-002265 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 1/25/2016. Issue Date: Expiration Date: 1/18/2018 License Status: Active Today's Date: 11/1/2017 ' econdary License Type: Doing Business As: tatus Change Reason: License Renewal Prere uisite Information No Prerequisite Information } . . a http://elicense.chs.state.md.us/Verification/Details.aspx?agencv_id=Wicehse_id=201832& 11/1/2017 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION.. Map Parcel `: Permit# Health Division Date'Issued Conservation Division S Fee' D 5. '50 Tax Collector Treasurer APPLICANT MUST OBTAIN A SEWER CONNECTION PERMIT FROM THE Planning Dept. + ENGINEERING DMSION PRIOR To CONSTRUCTION Date Definitive Plan Approved by Planning Board `-, Historic-OKH Preservation/Hyannis Project Street Address r Village �S Owner / vL . i' Address SGr J7� .tom Telephone 776 Permit Request 2 r Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost GUD- Zoning District Flood Plain Groundwater Overlay Construction Type —Ptarne Lot Size D X 0 0Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family Two Family ,❑ Multi-Family(#units) Age of Existing Structure Historic House:' ❑Yes Vo On Old King's Highway: ❑Yes XNo Basement Type: [Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other \/ Central Air: ❑Yes . �No Fireplaces: Existing W Z New Existing wood/coal stove: ❑Yes )No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size A a*ehed garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes to If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number - Address y License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �✓ l FOR OFFICIAL USE ONLY PERMIT NO. r> DATE ISSUED MAP/PARCEL NO. ADDRESS j,..f �, VILLAGE OWNER OWNER ` DATE OF INSPECTION FOUNDATION • .�J �r - _r) FRAME ' INSULATION _ FIREPLACE s ' . w z ELECTRICAL: ROUGH FINAL ' 1 'l -PLUMBING: ROUGH ." FINAL r • ` GAS: u ROUGH p FINAL - F FINAL BUILDING ; ! r c .��o t DATE CLOSED OUT K` ASSOCIATION•PLAN NO. ` �. � The Town of Barnstable • n�aHsrAsr.E. • Department of Health Safety and Environmental Services prEo '�' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 # Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: ce a G .Estimated Colt 6d Address of Work: Owner's Name-_kLd `t jejVI L) �(QS Date of Application: / I hereby certify that: Registration is not required for the following reason(s): pWork excluded by law [3Job Under$1,000 Building not owner-occupied 1ROwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. Date o IN. me q:fbms:Affidav fa UJJ aaaJ � + == Department of Industrial Accidents ' _ - Office affnlyestfgatfoos s: A 600 Washington Street Boston,Mass. 02111 L Workers' Com,pensation Insurance davit iiCZif 2f ITffQriImflFjR�f'.'', �/���+���/ name: location W ► h �e itv / /-/!I/If A A phone# '37 7 S - 2— I am'a omeowner performing all work myself. I am a sole proprietor and have no one workin in anv ca achy ❑ I am an employer providing workers* compensation for my employees working on this job. comnnnv name: address: city phone#� insurance co. 2nlicv# ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hued the contractors listed below who have the follo«ing workers' compensation polices: comnnnv name• address: city: phone#� insurnnce cn. oiicv# :•.. :..:..,.<: �� :...;... comnnnv name: address: cith- ... phone#. insarnnce co. ::;..:;:•;.. . . olicv# •;:::::•:.;::..... A ...... .. / FaIIure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andlor one vesm'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. I do here ify under the pains and penalties of perjury that the information provided above is tru,-and Co ed Si2mmre Date a Print tram Phone# official use only do not write in this area to be completed by city or town official city or town: permitNcense# [3Building Department L]Licensing Board ❑ check if immediate response is required ❑Selectmen's OMce ❑Health Department contact person: phone#; ❑Other�� ........ (rcvuca)o;9S PIA) zgrvaucss&LUX& sauu su016auLrry Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any coin;- 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 cr' the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receive: 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 c: building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewL 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,neitherthe . 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 in the workers' compensation affidavit completely, by checking the box that applies to your situatim and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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 as' questions regarding the"law"or if you .are required to obtain a wormers' compensation policy, please caU the Department at the number listed below. City or Towns 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 permitdicease number which will be used as a reference number. The affidavits may be rettaaed io the Department by mail or FAX unless other arrangement have bees made. The Office of Investigations would like to thank you in advance for you 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 Imlesduadoas 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 exL 406, 409 or 375 'ine 'lown .01 tiarnstabie .�' o Department of Health Safety and Environmental Services Building Division BARMABM 367 Main Street,Hyannis MA 02601 1639. rED MA'1� Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION ,L �y Please Print q DATE: `3 T/ / / r JOB LOCATION:QU GPJi h�ti, number street village "HOMEOWNER": Ao/G/dr,0 2 y"ta LV& -7 7S T( fiv name CC home phone# work phone# CURRENT MAILING ADDRESS: _:2z a" �- city/town state zip code The current exemption for"homeowners"was extended to include owner-occugied 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 underthe-buildiiig pertiiit. (SecUosl09 1.1). - -— _ -_--The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the.Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and irement . S' n of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with anlcensed 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 to amend and adopt such a form/certification for use in your community. Q:FORM&EXEMPT . ;sew Q a ww S' nib ; ` 7 757 SSG Z z , - ' 4P}Q,pS 6 ; I yvP „I 12erK- 5w wL e ..�. i ► -7 IN C i i d cA•v IBC"\\:S 3►l t,.►+ e�Sc- }� -r rHro 77S'- ys-6Z f* r - . t � x 6A►r5 v\ r IA IT f ?�e �a;pl�caQn; gvv. Galva g �X it w,e+Al PIA c its y Assessor's map and lot number 5 �0 r �.d! D.:!('• . ................ ...........v ypF TFI E Tyr J SehrMge Permit number .. . .t:)N.......:...G.w.c.r........ Z BA"STADLE, i 3 House number ........................................................................ yo MA86 4 t639• �0 MPY or, TOWN OF BARNSTABLE BUILDING INSPECTO APPLICATION FOR PERMIT TO / �. ........................... TYPE OF CONSTRUCTION ...... ... .� : .......................'V404 ....../....4'.:T mz.......................................... . ......�. . 19..d.,.S, r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...�./1.....`G 1..iJ.. y.....�2.1........................................................................................................................... Proposed Use .......74.kh.c.J.�/ ............. .........................................................................I......................... .�.(,�.,5'.��.................. ZoningDistrict ......................!..1.. 0.....................................Fire District .............................................................................. Name of Owner �.1.../.1..�.r1�c�Gt..... .V1!{..�k//� ;f.Address . A-1f...�N.[./ .................... :.... r.............. Name of Builder ..... ...Address ...... .4..i/. ?............................................... Nameof A"rchitect ...... v..?Z..e.......................................Address .................................................................................... Numberof Rooms ......::..........................................................Foundation .............................................................................. Exterior ......................................................................:.............Roofing .................................................................................... Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ________________________________19--------. Area ..,....................................... Diagram of Lot and Building with Dimensions / / (�, Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....... 'C ..................... f.[/ Construction Supervisor's License ...�J.......���.�............... KULLAS, RICHARD & JEAN A=310-209 No ..2 35 .... Permit for ...PD..PUZ............... ,uSin le Famil Dwel 'n .................Y..............i�...g................. Location ....311 Winter Strge ...................... ............... .....................HY.annis.......................................... Owner ....... ichard & Jean Kul A,9............. Type of Construction ......FKMP......................... ................................................................................ Plot ............................ Lot ................................ Permit Granted .....August 26, 19 85 Date of Inspection ....................................19 Date Completed ......................................19 Acct #2383 -TOWN OF BARNSTABLE SEWER RENTAL RECORD 53 l METER RATE AME AND ADDRESS OF SEWER CONNECTION BILL TO - NAME AND ADDRESS TYPE OF BUILDING REMARKS Kullas. Richard n N same Dwelling 311 Winter St Map #310209000 YEAR PREVIOUS READING PRESENT READING CUBIC FEET USED TOTAL CHARGE a 4- J; .sj / Assessor's map and lot number /.. ........... (.... . . . /�'•1 O" TH E 3 +,Sewage Permit-number .. ��N:..... e!_w`�.�....... d Z BARNSTADLE, i House number ...................3...........:................................ ..... 90 i639 00 TOWN OF BARNSTABLE NUILDING INSP-ECTO _ APPLICATION FOR PERMIT TO'.. ....... ` .TYPE OF CONSTRUCTION .... .Gr. ...................Gtl(.�G .... t ................ .: F.......:.:..:" -.::..TO THE INSPECTOR OF BUILDINGS: The undersigned' hereby applies- for a permit according to the following information: r./...... 1 .. �. :.:..Location ..... f[� . ProposedUse. ...., ...1/3i.r..f Ll.�'.:'..o.......... .................................................. _.._. ..... , .... i..... .. .- -- ZoningDistrict ................. . ..!................................::... ...........Fire District ............./.....�.... . Name of Owner ............. '....:.. ............... _. Name of Builder ..... ...Address ...... d. ................................................ _. Nameof Architect ......�`fL.)'tr�..,...:.........:.:..... .....,................Address..................................................................................... Number of Rooms .........."..._":............................................Foundation .........`w......(—.T�........................................... Exterior ................5-0'?. !!!�Lfi .......:................:...................Roofing ............. "`Z � .. ............................................. Floors ................................................Interior ....................................... ...................................... ............................................. Heating ...................... ..P.40. . ...............................................Plumbing ..................... .....d d!�.......................................... Fireplace .................................../J.. .............................Approximate Cost .......................�.�`5��........ .............. Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... -o, oe Diagram of Lot and Building with Dimensions X /(ell Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH &Ck A OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regar ing the above construction. Name . . . .... .................. ....................... Co struction Supervisor's License .............. -KULLAS, RICHARD & JEAN 2,8352 ADD DEC "'No ...... .......... Permit for .............................. §ingle Family Dwelling . ................................................................................ Location .....3 1.....1................Win ter...S.t.r.e.e t...................... . ......................Hyannis.......................................... Owner ......�Richard & Jean Kullas ........................................................... Type of Construction Frame .......................................... ........... .................................................................... Plot ............................ Lot ................................ Permit Granted ......August.-..26..............19 85 Date of Inspection .....................................19 Date Completed 4.17........ 19 4V