HomeMy WebLinkAbout0050 WOLLEY ROAD v� CUo/%
i �
( y 'own of BarnstableBuilding
490� Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept
1 Posted Until Final Inspection Has Been Made.
�fioi;�a+ Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a'Final Inspection has been made.
Permit
Permit No. B-17-3692 Applicant Name: Nathan Tissot Approvals
Date Issued: 11/06/2017 Current Use: Structure
Permit Type: Building-Solar Panel- Residential Expiration Date: 05/06/20.18 Foundation:
Location: 50 WOLLE,Y ROAD, HYANNIS Map/Lot: 270-166 Zoning District: RB Sheathing:
Owner on Record: CHAMBERLAIN,SANDIMAN&SHEILA Contractor Name: SOLAR CITY CORPORATION Framing: 1
Address: 50 WOLLEY ROAD Contractor License: 168572 2
HYANNIS, MA 02601 Est. Project Cost: $ 14,000.00 Chimney:
Description: Install solar electric panels on roof of existing house with,any Permit Fee: $ 121.40
upgrades,when applicable,specified by Design;To be Insulation:
interconnected with home electrical system. Fee Paid: $ 121.40
JB-0263731 9.3KW 31 Panels Date: 11/6/2017 Final c1s
Agin Alw-
Project Review Req: %; .v.-- Plumbing/Gas
Rough Plumbing:
Building Official Final Plumbing
:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas:
All work authorized by this permit shall conform to the approved application and the approved construction documents for which 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 by-laws and codes. Final Gas:
This permit shall be.displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. - r Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and fire Officials are provided on;this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work: Rough:
1.Foundation or Footing
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do•not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT UNtxr,)F
60A PIrz L. 5 CtJ
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map a 7o Parcel IM, Application #C;?"- L) L �� 5
Health Division Date Issued
Conservation Division Application Fee f
Planning Dept. Permit Fee ��p' `
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address
Village dyA N-1 s
Owner S'. M4W JW1(A lup"4UG4iN Address S �l / ►i9�v C�,
Telephone (JW) 771— �40 9
Permit Request
Xr Aelok, AM001,70*s AO m0f c WYW� AM&AIJ-P
Square feet: 1 st floor: existing I An.
/� roposed "'"' 2nd floor: existing propose . T� o
I new+
Zoning District /� Flood Plain — Groundwater Overlay ;
Project Valuation aTi ? Construction Type W , '
Lot Size �¢ Grandfathered: ❑Yes 2(No If yes, attach sgpporting,docurg ntation.
=� ca
Dwelling Type: Single Family ;ld Two Family ❑ Multi-Family (# units) ,fl
Age of Existing Structure �°Z /LS Historic House: ❑Yes No On Old Kin J Hi hwa._._.❑Yes No
g 9 X 9 9 Y'�
Basement Type: >(Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) IO�D
Number of Baths: Full: existing_ new Half: existing 6 new
Number of Bedrooms: 3 existing — new
Total Room Count (not including baths): existing knew First Floor Room Count �P
Heat Type and Fuel: XGas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes XNo Fireplaces: Existing/New Existing wood/coal stove: ❑Yes ANO
Detached garage: ❑ existing ❑ 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 /O/O Proposed Use-- -/0/0 y - - - — - --
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)- -
Name /�1�� y ' ►i Telephone Number
Address �0 � '� el$ *V� /V OW/License # 0M7�i
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO��
Alf
SIGNATURE DATE
[ f
<„ FOR OFFICIAL USE ONLY -
K s F
N .
APPLICATION#
' DATEISSUED
MAP/PARCEL NO. 1
ADDRESS VILLAGE
OWNER
I
DATE OF INSPECTION:
rFOUNDATION�
r.
FRAME — — — — — —
r INSULATION:! is
k FIREPLACE "
„ ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
P,
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT -
F ASSOCIATION PLAN NO.
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/P)umbers
Applicant Information Please Print Legibly
Name(Busi-ms/orpnizatiowIndividual): ��/�iV ' ��i�l� C� B/QS �/�j///1i/.P�//✓� �(fs9l�ist C
Address: 0 S//i 90
City/Siate/Zip: &4;V01 Phone LOGO
Are you an emplover?Check the appropriate boa: r Type of project(required):
1.X I am a employer with ZT 4. 0 l am a general contractor and I 6. ❑New construction
employees(full and/or pan-time). have hired the sub-contractors
p ) listed on the attached sbeet t 7. Remodeling
2.[] I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance: 9. Building addition t
o worker' comp..insurance 5• We are a corporation and its .
[N 14.❑ Electrical repairs or additionsrequired.) officers have exercised their .
3.El am a homeowne doing all work right of exemption per MGL 11. Plttmbiag repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12:❑ Roof repairs
insurance required.)t employees. [No workers' 13.R Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information:
't Homeowners who submit this affidavit indicating they are domg all work and then hire outside contractors must submit a new affidavit indicating such
tContractois that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
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.#: ke— eV Q J?7IJ Expiration Date:
Job Site Address: re A ,1It City/State/Zip:
Attach a copy of the wot kers' 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 de the ` I s and penalties of perjury that the information.provided above is true and correct.
Si attire: Date:
Phone#: 771—M70
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#:
Aim CERTIFICATE OF LIABILITY INSURANCE 9/20/2013
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 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 CONTACT F. Cordaro
NAME:
Andrew G. Gordon, Inc. PHONE_,,,,. (781)659-2262 FAX (781)659-4125
306 Washington Street -MAILADDRESS:bill@agordon.com
INSURERS AFFORDING COVERAGE NAIC#
Norwell MA 02061 INSURER A:Peerless Insurance 24198
INSURED INSURER B;Pil rim Insurance Company 1750
Lux Renovations, LLC, iNsuRERc:Star Insurance C ompany 18023
DBA Owens Corning of New England INSURER D:
60 Shawmut Road INSURER E:
Canton MA 02021 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:Lux 092013 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 DL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER M/DD/YY MM/DD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RE D 100,000
PREMISE Ea occurrence $
A CLAIMS-MADE Ex1 OCCUR CM8512851 /5/2013 /5/2014 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEMIAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY PRO-JECT LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
cadent 1,000,000
B ANY AUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED PGC10007161409 /17/2013 /17/2014 BODILY INJURY(Pet accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per a 'e
Uninsured motorist BI split limit $
X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED I X I RETENTION s 10,000 8511953 /5/2013 /5/2014 $
C WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LIABILITY..
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 11000,000
OFFICER/MEMBER.EXCLUDED? N/A 0428715 /24/2013 /24/2014
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
II pS describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,d more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Lux Renovations, LLC ACCORDANCE WITH THE POLICY PROVISIONS.
DBA Owens Corning of New England
60 Shawmut Road AUTHORIZED REPRESENTATIVE
Canton, 1dA 02021
F. Cordaro/CORWIL 7. W
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025(2oioo5),01 The ACORD name and logo are.registered marks of ACORD
Office of Consumer Affairsi/nd Business egu anon
10 Park-Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
f. Registration: 137943 1
`. x Type: Supplement Card
OWENS CORNING BASEMENT FI41SHN .' Expiration: 1/29/2015
ANTHONY METRANO t
,M
60 SHAWMUT RD
CANTON, MA 02021
Update Address and return card.Mark reason for change.
SCA 1 is 20M-05/71 - '
( Address j Renewal F-I Employment Lost Card
3
��le`�erieaettatuett���a�'C%l�aaJac•�tc�eC/.�
MCC of Consumer Affairs&Business Regulation License or registration valid for individul use only .
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 137943 Type 10 Park Plaza-Suite 5170
Expiration:-1/29 M15 Supplement and Boston,MA 02116
OWENS CORNING BASEMENT FINISHING SYS
4-
ANTHONY METRANO
60 SHAWMUT RD 4.
CANTON,MA 02021 L1, ._.�4ywT
Undersecretary Not vali without signature
iVlaSsacttuysetts Department of Public Safet�r `
Board v eiuf ing Regulations and Stanclatds
Construction Super%isur
License-CS-098078
'AN['HOMY P f TR 1NdP.
345 A+IEAMD STRIRT,a 7
CARVER 0=0
Expiration
-Commissioner 02102/2014
i
5
U Massachusetts -Department of Public Safety
Board of,Building.Regulations and Standards
Construction Supervisor x
License: CS-098076 "
ANTHONY P ME O
246 MEADOW STRIFE
CARVER MA 02330 1
` !ZZ...� w Expiration
Commissioner 02/02/2016
a
a _
r
rti . Town of Barnstable
o�
Regulatory Services
t
WASSg somas F.Geiler,Director
k Building Division
Tom Perry,Building Commissioner
200 Main St vee Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, >�/y�>M/9N C1ti9/�!/��/� /.t► ,as Owner of the subject property,
hereby authorize A-Vro Vis /`1'�f.>/d/��"0 to act on my behalf
in all matters relative to work authorized by this building permit
A04or Ad. 14�IAW-S
(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 Signatzir of Applicant
Print Name Print Name
Date
Q:FORMS.0WNEBPERMMSI0NP00L•5 62012
_._____........_.._._.-------___
BASEMENT .. Sr
..
FINISHING SYSTEM : ..
_ t
t�
DESCRoyION
The Owens Coming'Basement Fini;fbrtg =p r s ' s
System is cow of 6ghtweigtt fiber -;
part,PVC bleak which 5
( corurerrtiortai
and moldings 'k'�+t8) PVC trim
(whichreplace trim kmtber).The trim moldings
9W mW tip'lineak,Wding the panels in per.
MOldstgs and wall Pis are easily removed tc,
prw+de easy access to a hofttes tuxktiort ;yt Y 1 y 2F z r p V f
walls Because traditional wood
,{and
A st,Cam__
�d -wetlak aue'cV�w wit l ul er
AAS
and�s C materials.the BasemeI4 Finisttirag -
System fifers ethetent res*WKe to mciouse
mold and mildew.81The system is covered by
a lifetime limited trartsfi>rable wanwjty&* i
tram Owens corm.
USES
The Owens Corning-Basemen l7inishing
System is art intxwathe systern desgned to
cm4ate and finish basement walk.It hates,
acoustic*heats and aesthetically Swims
walls in a few sirtple steps.The system can be
uutalled over both masonry fotBtOdtm waNs PHYSICAL PROPERTIES
and interior partition walk bud with eidner
-ood or mend members "��� Test Mlettlrrod Value
For Piker Ghm In,
AVAILABILITY WaterVapor Sorption A5TM C 1104. <2%by wt: 12014f.
94"x 48'x 2-Ur Panels 95%RH
Lineals Compressive Sit ASTM C 165 .
@10%deforrreation 25 psf
W5`J6 deformation
90 pi
Ccm Mading Thermal Resistance A5Tk C 518 R-r 1
Vertical Battens Normal Densky ASTM C 303 3.2 PCF
Base Motdmg For sd AonelN •���••
Otfts+de Corner �e
Noise Rein COS ASTM C 423
lamb Exteixler _ Type A Month 0.95
Chair Rail Surface Burning Chrafteristics ASTM E 84+. Class A Flame Spread 25
C Ckeic�s -Mel is CAA Burn Rating Smoke Developed 450
r
bt enorTextde Firm Fire Clas'srFrcatroft NFPA-286 Meets Acceptance
Panels:'Linen Mist-woven fabric Crites
Trim:AN trim available in White. C 1338
'�'-` MOM a ASTMM C 33$ Pass
In additim vertical trim evader*in 1abr is bofc ASTM G 21 Pass
finish or fabrc wrapped to match panek,
*The Aafa +rung dbraco rA-of Ne kwmd cmPwe Pa"were d as acwsuKe wm ASTM.-E M The sta,
lard rats and dent A-ft m mcrtcs of mffiaa&Prodmu or msermim in remo m to teat arrd+time rattler
CODE COMPLUME « aea tabaratory con ions,Dam fipm RSTtrr a ea teRmg De uuc o r e or Ste fire hazed or foe
risk.:of r N t WL p`-kCU or a--bhes when cros duos$aof the factors Pert-art to an assesur era�of the fire has vd of -
2000 BOCA Evaluation#2 t•24 4.Pan4vW end use.Vakm are reported to the newts 5 fat,%
2004 ICC Report#NER-635
VA*the maermh and design of t►te Ow m Cartrtg
Bdse—NShN System resist mold and mddew the
System can not preaera or minute mold if vk condition
rwessay for mold VDAOth aher se eiia in.arbaserrerrt. .
'See acn+au warranty for detdds.Ianitations
- .vrA narrrrwxn -
Ir —
REScheck Software Version 4.4.4
Compliance, Certificate
Project Title: Finished Basement- Family Room..
Energy Code: 2009 IECC
Location: Hyannis,Massachusetts
Construction Type: Single Family
Project Type: Alteration
Conditioned Floor Area: 0 ft2
Heating Degree Days:, 6137
Climate Zone: 5
Permit Date:
Construction Site: Owner/Agent: Designer/Contractor:
50 Wolley Road, Anthony Metrano 'Owens Corning Basement Finishing Sys •.
Hyannis,MA 02601 Owens Coming Basement Finishing Sys. - 60 Shawmut Road
60.Shawmut Road Canton,MA 02021
Canton,MA 02021
Maximum UA: 45 Your UA:43
Envelope Assemblies
Doi
Basement Wall 1:Solid Concrete or Masonry 565 0.0 11.0 29
Wall height:7.0'
Depth below grade:6.5'
Insulation depth:6.8'
Door 1:Solid 20 0.340 7
Door 2:Solid 20 0.340 7
Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations
submitted with the permit application.The proposed building has been designed to meet the 2009,IECC requirements in REScheck Version 4.4.4 and to
comply with the mandatory requirements listed in the REScheck Inspection C list.
r Anthony Metrano, CSU
Name-Title ignature Date
t-
Project Title: Finished Basement-Family Room Report 12/04/13
Data filename: Untitled.rck Page 1 of: V
TOWN OF,BARNSTABL
CONTRACT Customer Name_.. J/ !7�� 9�11R C Id At14 AP
SKETCH Contract Date---_ ___._i/:r�A/3 __ _ __ _- y �[ _/N / !ems diy/9 Dm®;
ATTACHMENT Customer Phone��- 77/ '_' p� =� ��� Contract Price � _ __—
1 , a f ! , Y 10 la u „ „ ,1 ,0 ,6 A 1f :, A t. t btu-`
7 ad ar , t.,�,..�2 9, 3. x J6 1r JE 39 M N ., ,, +e fr •! ,i m 0: da 5, f� N 58 51 ,9 fa m
-I ----i - r NOME
l I
ICI-
` F-22box�i,. i }-
,
. ,`
01.1
P ,. If f (MOTES: p ne v �Qt C� Q r Ii� equals one torn unless otherw se noted.This sketch is a good faith
representation of the work to be done, it is understood the t all
dimensions
derived from this sketch are approximate,and that all locations of outlets.light
fixtures plugs,jacks andror switches are subject to change if necessary.
t ; pFiHr Tp�i
Town of Barnstable 'Permit#a�Sl ,��-
t rpires 6 months fronr issue dote
r Regulatory Services
Fee
)swRvsrA9[,E,
— '
ass. �,, •
Thomas F. Geiler, Director
"Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis,.MA 02601
www,town,barnstab le,ma.us
Office. 548-862-4038 - "
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY-
Not Valid without Red X-Press lmpriu!
Map/parcel Number
Pro er-ty Address �50 (/t/ ®h� /�/
�� U '� _
Residential Value of Work > Minimum ee of$35.00 for work under$6000.00
Qwner•'s Name& Address a
Contractor's Name TO q/
�— T lephone Number 50�'0 h� /Q�v2
Home Improvement Contractor License#(if applicable),
Const ction Supervisor's License#(if applicablea 7V 7 7
orkman's Compensation Insurance
Check one:
4 I am a sole proprietor PR+ES PERMIT
I am the Homeowner
I have Worker's Comperts tion Insurance SEP2 9
2010
Insurance Company Namefile-W *94k�_ STABLE1�
N OF BARN
Workman's Comp. Policy# �G jIt� 3 5"t; -
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request (check box)
❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed) (not stripping, Going over existing layers of roo
/Rs
#ofdoorsement Windows/doors/sliders. U-Value G. S (maximum .35)# of window_
1
*Where required: -Issuance'of this permit does not ezempCcompliance with other town department regulations,i.e.Historic,Conservation,etc.
1;.
I **FNote: Property Owner must sign Property Owner Letter of Permission,
A copy of the Home Improvement Contractors License & Construction Supervisors License is
i
t. re u' d. '
AIGNATURE:
I'WPFILESIFORMSIbNding permit rormslEX PRESS.doc
>vised 072110
I
4 _
- I'Iae Commonwealth of Massachusetts
Y: a
Department of Industrial Accidents
Office of Investigations
600 Washi310toaz Street
{)
y� StDn9 iV1-3,,11 0L 1 yll3,
� .
www,nl ass.go Y/{ {!l
Workers' Compensation Insurance Affidavit. Builders/Contractors/Electrieiarts[Plu ibvrs
Infarrrtatialt i
'lease Print Legibly
Alicatttig
s I
Name(Business/Organization/Individual):{
Ile pe or
Address: �� � /✓� ���
City/State/Zip: -1ej - &V .
Phone #:
Are you an employer?Check-the propriate b _ Type of project(required):
]. I am a employer with gW_k�V.0 4. l am a general contractorad I 6 ��construction
have hired the sub-contractorsemployees(full and/or part-time).* listed on the attached sheet. 7. eing
2.❑ 1 am a sole proprietor or partner- These sub contractors have 8. Demolition
ship and have no employees employees and have workers' ,
working for me in any capacity. 9. ❑Building addition
comp.insurance.$
[No workers'comp. insurance ME] Electrical repairs or additions
q
required.] 5. � We are a corporation and its
3.❑ I a homeowner doing all work officers have exercised their l I.[] Plumbing.repairs or additions
myself.[No workers' comp. . right of exemption per MGI. 12.0 Roof repairs
insurance required.]t c. 152, 1(4),and have no 13 ❑ Other
employees.(No'workers'
kers'
l 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.
r 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. y
mpensation insurance for my employees. Below is the policy and job site
/am an employer that is providing workers'co .
information.
Insurance Company Name: cc)
Expiration Date:
Policy#or Self-ins.Lic.#: 9 a J
Job Site Address: 1 City/State/Zip: 5�'
Attach a copy-of the workers' compensation policy declaration page(showing the policy nu her and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 tine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do hereby certify u pains and penal ' jperjury that the information provided 7ve is true and orreu
Date: 9
Si nature:
Phone# 5b� G 1E' L ! 9 —
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License# r
Issuing Authority(circle one):
Lof Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Person: Phone#:
The Commonwealth of Massach"setts _
— a`Department o/�•Industrial feeidents
Office of Investigations.
=4 r 600 Washington Street
Boston, MA 02111
r.,..... www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
{
Name,(Business/organization/individual): J coo
Address: S / CAl
City/State/Zip: v �e Gad hone#:
r2.
re you an employer?Check the appropriate box:
4..0 I Am a general contractor and I Type of project(required):
❑ I a employer with
mployees(full and/or part-time).* have hired the sub-contractors 6. 0�,ejN construction
I am a sole proprietor or partner- listed on the attached sheet. 7. odeling
ship and have no employees - These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'. a° '
[No workers'comp. insurance comp.insurance. 9• ❑Building addition
required.] 5. We area corporation and its 10.�Electrical repairs or additions
3.❑ 1 am a homeowner dorrl all work officers have exercised their
;$,. ,, . .; 11.�Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §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'com
pensation 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.
1 am an,employer that is providing workers"Compensa rance for my'employees. Below is thepolicy and job situ'
information.Insurance Company Name: `Qtmal
Policy#or Self:ins:Lic.#:: Expiration Date:
Job Site Address: •
/ �s-,�/�
City/State/Zip: /U1ls � V tf�1
Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber 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 cert' under the p ins and penalties of perjury that the information provided above is true and correct.
Si nature: Dater f�
Phone#: SO
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 unl`ier any contract of hire,
express or implied,oral or written."
An employers defined as"an uidividual,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 on 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 buildings4n 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
mor 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-Till oiit 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 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. Tbe.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. SelPinsured 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 bum 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
371.
Office of Consumer Affairs&Business Regulation ! License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: i
- Office of Consumer Affairs and Business Regulation i
Registration;>1�26893 Type:. 10 Park Plaza-Suite 5170
�,• Expiration 8 3/20112, _ Supplement Card Boston,MA 02116
The Home Depof,,j' Homy Services
DARREN DEMERS �7 I
2690 CUMBERLAND,PARKW/�Y
GA 30339 -'":,:` Undersecretary Not valid without signature 1
'..4. -
i
r
1
i
�EaQPTICo,il>Cdt?- ii1'IS:IYiiiil;tit • P'�iililii �:i9i't!
—'3ii;::'tl sst'�t:ilttittg dti lit tiwis an(I'St::nd:artl.
Construction Superviscr License
Ocense. CS 70077
Restricted to:
JOSEPH C OUARTE
15 FALL ST
WAREHAM, MA 02671
Expiration: 12/30/2010
t nnuri�.i„n�r Tra: 7662
. . 80o.n!of RriW�ogft�ket�ssad`es®dzrl. i.icrrasrue rr�isL' n valid `asP to®a'et4talusseSO1�`
i,rtoir Ikegn tioe+dm4r. If found n�eaasta:
t E II�tPRf3YEdIEldY�pa�C74t� {en trd of Viriho-2 pquhrtinns Hsu®staemdards
9balion 132349 041V Lshbustnn P>kar+c l$st L1tf�
E1tf6/i1bM1: 111 i)2011 `� ??tjyl �t1ltt11P.a4a.IPI1U�
Type: barinersttoQ
J i3 J Remodetnu9
j""h puette �. �,.w
i.Ei Fa!1.St r valid Wt�OVt1 fIR/lt►titrTt
Vnaren�tn. me 02571
�,tt7t1in3+tf;n8►
}
iHOMEIMMOVEl1TENT CONTRAG1
PLEASE READ THIS
Sold,Furnished and Installed by: "
Branch Name; Boston Date:�/�! D THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
345A Greenwood SDcct,Unit 2,Worcester,MA 016077
Branch Number:31 Toll Free(800)07-5182;Fax(508)756-8823
- Federal ID#'75-269846D,,ME lie#C 02439;RT Cont.Uc#16427
h/ � ) Uc#565522;MA Home Itoprovement Contractor Reg.#IZ6893
InstallationAddress: Cite
State Zip
Purchwxr(y): Work Phone: Home Phone: Cell Phone:
L [ t. 61 6 [
Home Address:
(If different from Installation Address) City State Zip
E-urail Address(to receive project communications and Home Depot updates):_ -
❑I DO NOT wish to receive any marketing emalls front The Home Depot
Project Information: Undersigned("Customer").the owners of the property located at the above installation address,agrees to buy,and THD At,Home Services,inc.("Ibe Home Depot")agrees to furnish,deliver and arrange for the installation("installation")of
all materials,described on the below and on the referenced Spec Sheet(s),all of which are.incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary au—bed hereto and any Change Orders(collectively,
"contract").
Job#: keR—) P ods: Spec Sheets#:- Project Amount -
Rtmfing[]Siding Windows ❑Insulation
3 OGuners/covers❑Envy Door.❑ 32
Roofing(]Siding❑Windows 0 Insulation $'
OGutterx/Covets []Entry Doors n
ORoofing OSiding Windows insulation $
OGuuers/Covers OEntry Doors❑ - - ...._ _OR ring Siding❑Windows 0insulation $
Ooutmrs/Covers QEntry Doors n - -
Minimum 29%DgWtofContractAnointmte upon rxuwti000ft6soott6rnct Total ContractAmount $:
Maine Putriwxn may not deposit more than oue•third of the Contract AnMnL -
' Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate Cob
(onc for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable;each Customer under this
Contract agrees to bejointl.y and severally obligated and liable hereunder-
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing etror_s or because
work required to complete the job was not included in the C'ntract
Payment Summary: The Payment Summary# / included as pan of this Contract,sets forth the total
Contract amount and payment.%required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs-of materials,labor,expenses
and services provided by The Rome Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOMF,DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTITFR PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEpOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Amwtance and Authorization: C.kustomer agrees and understands that this Agreement is the entire agrecmnnt between Customer
and The Home Depot wtrh regard ul the Products and Installation urvices and supersedes all prior discussions and agreements,either
oral or written,relating to said Products and Installation_This Agmwent cannot be assigned or understands,voluntarilywriting Q the
by Customer and The Home Depot.Customer acknowledges and agrees that Custuntar has read,
terms of and has received a copy of this Agreement.
# 4V&.-k
by:
AcceLA' Sign
O
Date
CDs c Date uhant's g��n((anne
(� Telephone
astomer's Signature Date Sales Consultant License No.
(sa applicable)
CANCELLATION: CUSTOMER MAY CANCEL 'TIILS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT- THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE .IS
SPEC'MCALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
.. NOTICE:ADDITIONAL TERMS,AND CONDITIONS AR&grwTF.D ON Tt11:RF,V 6RSLt Snrr AND.ARE PART OF THN CONTRAL
1,
Tel Wd9T:Z 40OZ T£ '-'?W LL'?Z9£80S: *ON XHJ Pe6ue(; W021-
ij
Op(NE Fry,
Town of Barnstable *Permit4 ' 0 t
Expires 6 nra+ths jrom lssrr me
,�s,,B� ; Regulatory Services Fee
M & 1�$ Thomas F. Geiler, Director
�pTEo �,A Building ]division
Tom Perry, CBO, Build ing.Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
"Office: 508-862-74038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
I—)
Map/parcel Number > L C
Property Address �� V 11U�1 t �
[WResidential Value of Work �O�o't Minimum fee of$25.00 for worlc under$6000.00
Owner's Name& Address —S�- e�A,10i 0,-\ 6 i,\ ah -F?1 4J�L'6C� Fti
Contractor's Name Telephone Number. �`e
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance -PRESS PERMIT
Check one:
❑ I am a sole proprietor; SE.P _ 8
01 am the Homeowner RNS r����
❑ T have Worker's Compensation Insurance TOWN OF BA
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on•file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will.be taken to
Re-roof(not stripping. Going over existing layers of roof)
E Re-side ..
❑ Replacement Windows. U-Value (maximum .44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission..
Ho e Im roven)ent Contractors License & Construct Supervisors License is required.
SIGNATURE: ��
Q:\WPFILES\FORMS\Express\EXPRESS PERMIT.DOC
Revise06O4O9
The Commonwealth ofMassachttsetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:. Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑,I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
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 11.0 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.
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 andjob 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 c rti under the pai sand penalties�ofperj�iirythat�the formation provided above is trcce and correct.
r
Si nature: Date: V
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,constriction 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 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,ttelephone and fax number: ` ,.'
1 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/dia
F�
r
Town of Barnstable
�t�
Regulatory Services
* Thomas F.Geiler,Director
BwaxsTABLE,
t►tnss.
9q, i63a ��� Building Division.
ATfpts 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
DATEA 1 e 1
JOB LOCATION:
number street village
"HOMEOWNER": JW V�I�— /� ' ✓ �`� C� —y �I77/��
name I� I home phone# work phone' 7# � L
U
CURRENT MAILING ADDRESS: 6,01`
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,+P'rovidedithat 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
minimum inspection procedures and requirements and that he/she will comply with said procedures,and
req r ents.
1. • t # ` ..£ A #
ignature of Homeowner
Approval of Building Official t-
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions.
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed'against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently-used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:\WPFILES\FORMS\homeexempt.DOC
�1HE Ta,� Town of Barnstable
Regulatory Services
9a►MSTTABIA Thomas F.Geiler,Director
fo;o•�► Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
' • f
Property Owner Must
Complete and Sign This Section
If Using A Builder
I,- l /v , 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 ate
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FO RM S:O W N ERP ERM I S S I ON