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Home My WebLink About0023 WOODLAND AVENUE 'oz3 ceJ �� C,��-- SHED REGISTRATION 3 eC ti�1� HOC . W��- Rm�-N\S , location of shed(address) property owner's name size of shed A Ul \ J ^3c) ^ signature date Old King's Highway Historic District Commission jurisdiction? THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN shed LIMIT OF LOT 55 USE 10 LIMIT OF ZONE LOT ; =�- .� LOT t� _7 j I 17 LOT 53 /l LOT !1Q1AAEFR:S' ?'AIt ',�,! ,r'/t'r'I,",f ;;"•: %?R ' RES ZO.,VE, 1-[, s - RB Thl:, MO R TGAGI E 1 % INS -..l'.. ian is o .r`T ( ,� IL0�0D 'O i L -: „ "0 j-YN: 3anit�c onl DEED RE REGS 0 NER: ��Z4LE "J' - - - flt�'S':/:+t.,A ) )T, r `r !%'i,r.• /V THAT 1'Eii, i3� 11.Di A`�K."'L' � ` f �I S H0 WIN ON TPLIS PLANiS LOCATEI (DX: 'j'y � l SHOWN AND THAT ITS >'GSI'i lUN DOES _ CQrdFnRM TO T14E ZONING i AW SETr�"I. R�Qt?IkE�'fENTS GF' THE 1/ ,. 406 (SUITE 0 : ` TG11';v OF �ARN,SLLIIEL ' _____AND THATy ^ .;,,,,, t 1�1.�tiT .:� RcY R`.. IT HE WITHIN ''HE-. SPFC]AL FLOC D 'i' � "' '- j. r�, 5 NS 2 UA AS 'ZHOWI\r ON T�•Ir, H.0 I) r TF , � tn�.A„D � �;'. �';. :1R_ i'o, �i(l.l.,S. � . , 0 j;.;t; 4F D,1, ..,f, _,� �—_ Tr"L 42 ,—C; ttt F1..AN`�'A�L !,. L ------- ;ti:�df \.• I' T4' E'J .';.� ,, , i liG L,;al: (: >;L' r". :, r "'E ETC. TOTAL P.Al CCARTHY RUCTION C O. sk',tial and Commercial Builder. 1 IZ�ITION SPECIALIST "4 CCARTHYC _ 9' r"VES:WWW October 21,2014 �r Town of Barnstable Thomas Perry CBO Building Commissioner , 200 Main Stret ZZ Hyannis, MA 02601 cr RE: Insulation Permits Dear Mr. Perry, This,affidavit is to certify that all work completed for permit application#201406299 at 23 WOODLAND AVENUE has been inspected by a certified Building Performance Institute(BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, Michael McCarthy McCarthy Construction (0 Assessor's office(1st Floor): y� Assessor's map and lot number "2- �� / Quo*TWE Toy,♦ Board of Health(3rd floor): eW p Sewage Permit number Engineering Department(3rd floorj: ]URrus Lt ? House number °o 'a)o Definitive Plan'Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE . BUILDING INSPECTOR APPLICATION FOR PERMIT TO ax� TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for permit according to the following information: Location (:32) cxnA, (2QE- Proposed Use Zoning District ?� Fire District Name of Owner 1�C `c�iL �.�� J IX(K� 17dd�essrWC� Name of Builder Address Name of Architect Address Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost VZ Area G Diagram of Lot and Building with Dimensions Fee T 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. Nam'41 III ` ) Construction Supervisor's License NEALE, DANA & LAURA LEONARDI iy 'F No 34205 Permit For , Demolish - r Garage' Location 23 Woodland Avenue ' Hyannis Owner Dana Neale & Laura Leoriardi Type of Construction Frame Plot Lot ! t Permit Granted March. 1.1 , 19 Date of Inspection 19 a i Date Completed 1 � • d i. is z: C ' w i 4 f t 4 �t ,- .+s,.�,.'a'r�e�rs�st�::4-«:i8f�°��rr +.t'F*�k....'.+."..�_.�a'-.a'.�5s1,.:Evan+v�'n""FyTxa"PN"w``M" '. ,lEy�"22' v��t, 5C4'4'r�.r�.^tr��.A�Rk��11dwM�'Yk;i-e.,,,+i;r,+tir^•y,�'!,t;ry.v��r�.•�r'Yti:.I Assessor's office(1st Floor): / s Assessor's map and lot number *THE >o Board of Health(3rd floor): ` ��Qyw�� ``� Sewage Permit number , Z aAUSTAnt,c S Engineering Department(3rd floor): rua House number +_ °o t639• Definitive Plan Approved by Planning Board 19 �0 MA-1 a• APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00 2:00 P.M.only a r TOWN OF B,ARNSTABLE BUILDING INSPECTOR * e APPLICATION FOR PERMIT TO ( ��= ' TYPE OF CONSTRUCTION QJ) 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for kpermit according to the following information: . Location Proposed Use Zoning District ` , Fire District Name of Owner _ z � Name of Builder {' Address t Name of Architect Address f ' r Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing i Fireplace Approximate Cost Area Diagram of,Lot and t�lding with Dimensions Fee F 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 Construction Supervisor's License NEALE, DANA & LAURA LEONARDI 11210 P�=269-054 No5 Permit/For Demolish Garage Garage Location 23 Woodland Avenue Hyannis , Owner Dana Neale & Laura Leonardi I Type of Construction Frame Plot Lot Permit Granted March 11 , 19 91 Date of Inspection 19 Date Completed 19 PERMIT COMPLETED TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel bo Application / Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village 41 Owner �� rycI?.- Address S`nt Telephone 77L1-13�'SYC` o „ Permit Request ►d' cc/l.,i..� ti �}� 3 Ii lG N A Lie �krre 2`� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 16r/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings HighwaL. ❑Yews ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other } Basement Finished Area(sq.ft.) Basement Unfinished Area ft. ) Number of Baths: Full: existing new Half: existing T rie�v Number of Bedrooms: existing _new ` Total Room Count (not including baths): existing new First Floor Room Cour ii l { C' Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No 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 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Mike McCarthy Construction Telephone Number PO Box 52 Address West Dennis, MA 02670 License # Cell (508) 280-6964 CS1 -58633 HtC-169393 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I �/ FOR OFFICIAL USE ONLY I!' APPLICATION# DATE,,ISSUED MAP/PARCEL NO. I t: ADDRESS VILLAGE w OWNER DATE OF INSPECTION: " �OUND_ATI.ONiv FRAME --INSULATION f t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL :a x FINAL BUILDING-! — L DATE CLOSED OUT t i ASSOCIATION PLAN NO. z 08/30/2014 10:55 FAX 5085683465 COOP BANK CAPE C00 NTG ®005/008 OWNER AUTHORIZATION FORM I, tom• (Owner's Name) owner of the property located at (Property Address , (Property Address) hereby authorize 1 (Subco tractor) an authorized subcontractor for RISE Engineering,,to act on my behalf to obtain a building permit and to perform work on my property. ' 4 Owner's Signature Date w Massachusetts -Department of Public Safety Board of Building Regulations and Standards . Cunstructiun super�isur License: CS-058633 MICHAEL J MCCR /;, f a, i PO BOX 52 ; W DENNIS MA 6264 .I A Expiration Commissioner 04/10/2016 _ — Office of Consumer Affairs and Business Regulation w _ r 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 238121 MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 WEST DENNIS MA 02670 / ' Update Address and return card.Mark reason for change. SCAT 20M-05/11 Address Renewal J�'Employment Lost Card 23 �!��/ ❑ The Commonwealth of Massachusetts Department oflndustrial Accidents Offlee of Investigations 600 Washington Street Boston,MA 02111 iviop.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrlcinmmlumbers `. Alpylicant Information Please Print Legibly Mike McCarthy Construction Name(Business/Organizagorulim ividuai): PO Bog 52 Address: • West Dennis, ]VIA 02670 City/State/Zip: CSLphM##.3 HIC-169393 Are u an employer?Check the appropriate box: Type of project(required): 1.&I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole propridtor or partner- listed on the attached sheet;= 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, watkars'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We arc a corporation and its 10.❑Electrical repairs or additions required.] officers have exerolsed their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. a 152,11(4),'and we have no 12.❑RP°f repairs insurance required.]t employees.[No workers' 13Q'Other comp.Insurance requital . *Any applicant that checks box dl must also fill out the section blow showing their worbeW cumpeasatton policy Wbrmmoon. t Homeowners afio submit this affidavit indicating they ara doing all work and then him outsido contractors most submit a new affidavit indicating such tContracturs that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy Information, lam mt employer that Is provla tg workers'compensation insurance for my employees Below Is the policy and job stte Information. Insurance Company Name: •n• M�� Policy#.orSelf-ins.Lie,M VWC, BVIrsdonDate: Job Site Address: W — l.�Jl City/Shutzip: 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 ofMGL c.152 can lead to the imposition ofcrtminal 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 time 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 ceri r! e apdkenallkr ofpedury that the Warmallon provided above is true and correct. Si MtUM, Date: Phone#: Offlictal rrse anry. Do not wrtte.ln this area,to be cotripteted by city or town q/ykla[ t Pcrmtt2tcense#City or Town.- Issuing Authority(circle one); r 1.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector f 6.Other Contact Person: Phone#t MIDD ,AcoRV CERTIFICATE OF LIABILITY INSURANCE DAo HO/2014m) 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 pollcy(les)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 01962-001 E21€j4CT Bryden&Sullivan Ins Agcy of Dennis Inc NC.tlo.Ext: (508)398-6060 ,No,: (508)394-2267 PO Box 1497 �S�Ess: So Dennis,MA 02660 INSUREW)AFF_OBOINS3�OL/ERAGE AIC A A.I.M.Mutual Insurance Company 26158 INSURED INSURER 8 ----- Michael McCarthy Construction Inc - P 0 Box 52 West Dennis,MA 02670 SULt _ 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 OTHCR DOCUMENT WITH RESPECT TO 'Al-IICH 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. IRR TYPE OF INSURANCE I yP� POLICY NUMBER AMM AWSM LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMSWADE El OCCUR MED EXP(Any one person) t PERSONAL&ADV INJURY S PREMISES(Ea occurrenw) GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ �OLICY [UEC _OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS - s UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE S DED RETENTION $ $ =1018apsEEChOr X I Ts3Iw-S I r A ANYIPRRMETQR/PARMSW&XECUTIVEr�, N/A VyyC-100-6017656-20,4A 7/17/2014 7/17/2015 E.L EACH ACCIDENT $ 500,000.00 (Mandatory IInnM NH) ReetrEXCLUDED? U E.L DISEASE-EA EMPLOYEE S 500,000.00 D��GRIPTION OF 9PERATIONS t.Iow E.L.DISEASE-POLICY LIMIT S 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) Workers Compensation Coverage applies to MA employees only. CERTIFICATE HOLDER CANCELLATION Thielsch Engineering 195 Francis Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cranston,RI 02910 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/66) The ACORD name and logo are registered marks of ACORD Town of B'alrnstable Permit: Regulatory Services ate: i'0� —7 P�opTHETgyy Thomas F. Ceiler, Director Building Division Fee: 3, B9RNSPABLE, - - Tom-Perry,'Building Commissioner y MASS. �A i639• 200 Main Street Hyannis,`MA 02601 IFD NU,`l a www.town.barnstable.ma.us Officer 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: Phone: Q .P Install at: AVj w lne �� Village: u l L � S Map/Parcel: �"I Q 45Ll Date f " ve ew Used - Type: Radiant 7 Circulating C. Manufacturer' ,Q-►/-F- CB '° Lab.-No. D. Model No.: : �. Chimney A.. New/ xistin (If existing,please note`date of last.cleaning) 9 2-0l� B. Flue Size � . F C. Are other appliances attached to Flue? D. . Pre-fab Type and Manufac z --t E. Masonry: Lined nlined Hearth _t y I�l'�� in C �G A. Materials: B. Sub Floor Construction. Installer izz Name: Address: Phone` Location of Installation: H.LC Registration# . Construction S pervisor. OR check Horneowner Installing, no license required APPLICANTS SIGNATURE`SW Or APPROVED BY: Please make checks a `able to the Town o Barnstable *This constitutes an official stove permit after inspection, photographed, and approved by the Building Inspector Q:forms:stove Rcv 103107 - The Commonwealth of Massachusetts Department oflndustrialAccidenfs Office of Investigations - 600 Washington Street Boston,MA 02111 wyvw.mass.gov/dia Workers} Compensation Iniurauce Affidavit: Builders/Contractors/Eleetriciaus/Plumbers Applicant Information PIease Print Legib� Name (Business/Organization/Individual): n—t) •Address eO93 u( >a V'_� City/State/Zip: V41 1 an.A I S V ��-G o 1phone.#: T�qb9 1,-76 -oqw . 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,[-1 I am a'sole proprietor or partner- listed on the,attached sheet 7. ❑Remodeling These sub-contractors have ship and have no employees S. '0 Demolition -working for me in any capacity employees and have workers' insurance,$ 9• ❑Building addition [No workers comp,insurance com` P• e aired. 5•.❑ We are a corporation and its 10.❑Electrical repairs or additions q ] officers have ekercised their 3. I am a homeowner doing all work . " 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c.152, §1(4), and we have no T employees, [No workers' 13.�Other �{�/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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornotthose entities have employees. If the sub-contractors have employees,theymust provide their workers'comp,policy number. lam an employer that is providing warkers''compensatinn"' surance for my employees. Below is.the policy and job site information. - Insurance Company Name: Policy#or Self-ins.Lic.# Expiration Date: lob Site Address: City/State%Zip; Attach a copy of the workers' compensation policy declaration page"(sbowing the policy number and expiration date). Failure•to secure coverage-as required iinder Section 25A of MGL c. 152 can lead to the imposition of criminalpenalties of a fine tip 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 statemeut'maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain dpp4lties of perjury that the information provided above is true and correct. Si ature: Date: 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# r Town of Barnstable Regulatory Services. t3�Rivsr,�ste ? Thomas F. Geiler,Director russ. . Building Division Tom Perry,Building Commissioner 200 Mairi.Street, Hyannis,MA 02601 www.town_barnstable.ma.us Office: 50 8-962-4038 Fax: 509-790-6230 HOIN7 OWNER LICENSE EXEMPTION Please Print DATE_ I e JOB LOCATION: d 1 CU) t number street A �j J / Zvi gage` "HOMEOWNER": —k t]'-7-7lS/'—'`1' l name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption.for"homeowners"was extended to include owner-occtipied dR'ellint?s of six units4or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFIN11ION OF HOMZO' NER Persons) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to- be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who cons"cts more than one home in a two-year period shall not be considered a bomeowner, 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 log,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 Barn stabie Building Department minimum inspection procedures_and,require�ments and that he/she will comply with said prbcedures and requirements. 1 , qi Hom cr Approval of Building Official f { 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 forwhich a building pemvt is required shall be exempt from the provisions of this scction.(Soction 109.1.1 =Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,:that such Homeowner shall act as supervisor. Many horireowncrs who use this ezerrrption are unaware that they are assuming the responnbilities of`a supervisor(see Appendix Q.. Rulcs&Regiilations 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 W ould"with a licensed supervisar. The homeowner acting as Supervisor is ultimately responsib)e. To ensure that the homeowner is fully awarc of his/her responnbilitirs many communities require,as part of the permit application, that the homcowncr certify that hdshe 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 forr /certification for use in your community, Q:forms:homccxcmpt I"rr Town of Barnstable ` Regulatory Services BARNMEf ♦p f .� MARL Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, Na�onboj, 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) tture 0 er Date � D,n Print Name If Property. Owner is applying for perTnit please comip'lete`the Homeowners, License Exemption Form on -the reverseside. Q:FORMS:O WNEPPERMISSION .&... + :• FA ��. , .. `� III _ � s N ter,•,,, `•1ti\ nd Ave, Hyanni Town of Barnstable .*Permit# a �D � 2 Expires 6 monNrs from is,e Regulatory Services Fee > anexsTaet.e, Thomas F.Geiler,Director MAM &.� Building Division Tom Perry,CBO; Building Commissioner 200 Main Street,Hyannis,MA 02601 P www.town.bamstable.ma.us 0ffice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number C�6 9O 16 Property Address ,3 Residential Value of Work ��(,� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address / �h Q3 0ood_ta,nrJ V� Contractor's Name " - Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor. •K I am the Homeowner X-PRESS PERMIT ❑ I have Worker's Compensation'Insurance Insurance Company Name SEP 2 ',1` 20.09 Workman's Comp.Policy# TOWN OF BARNSTABLE Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to }(� � ,f'c ill c'1 �lGl -h-b ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the-Home Improvement Contractors License is required. SIGNATURE-1YJ : ' Q:Forms:buildingpermits/express Revised 123107 �5 y The Commonwealth of Massachusetts Department of Industrial Accidents c Office of Investigations 600 Washington Street 1 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 95 City/State/Zip: Phone #: �0 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3*. 1 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I.am an employer that is providing workers'compensation insurance for my employees. Below is the policy.and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: - City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ti under the i a p lties of perjury that the information provided above is true and correct. Si nature: Date: 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#: .V- w Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise;and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct'buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been resented to the contracting authority." q P P g tY Applicants Please fill out the workers' compensation affidavit completely,by'checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or . town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia oft r� Town of Barnstable Regulatory Services BARNS.,BLF, ; Thomas F.Geiler,Director '� ,m� Building Division rED MA'I A . Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: Ot iz� 109 JOB LOCATION: &oilK) number stet_ village. "HOMEOWNER'':. d ! )EbS-�R l /I)OV name el-) r ;��(home phone /#� �/ work phone# - CURRENT MAILING ADDRESS: O( � L_<1) city/town. L state zip code The current exemption for"homeowners was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building-Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) . The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she undersiands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signaiur&f HoiK Swne—r— Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 Licensing of constriction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q 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 . � 6 Town of Barnstable °^ Regulatory Services ` as KAS&Le. Thomas F. Geiler,Director Mass. ' 9qj i6J9. � &639�0 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section ` If Using A Builder 4 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner Date ; Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERPERM IS S ION