HomeMy WebLinkAbout0202 ANNABLE POINT ROAD i
Y � Y.
I
` ��
`W Town_ of Barnstable
____
a Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Shed
raasa Posted Until Final Inspection HasBeen Made. •
bs� . p y. q Registration
..� __... ..��..� q� ng shall Not be Occupied until a Final Inspection has been made.
Where a Certificate of Occupancy is Required,such Building ilm
Registration Number: B-2-0-1515 Applicant Name: Tim Dussault Approvals
Date Issued: 06/22/2020 Current Use: Structure
Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 12/22/2020 Foundation:
Location: ,202 ANNABLE POINT ROAD,CENTERVILLE Map/Lot211-012 Zoning District: RD-1 Sheathing:
Owner on Record: DUSSAULT,TIMOTHY W&JENNIFER W Contractor Name Framing: 1
Address: 202 ANNABLE POINT ROAD Contractor License: 4 2
CENTERVILLE, MA 02632 •" `� Est. Project Cost: $3,500.00 Chimney:
y'
Description: Installing a 10x20(200 sq ft shed) on our property.Shed will be , Permit Fee: $35.00
Insulation:
placed 10+feet from rear property line &30 ft from right property Fee Paid:, $35.00
line. ,+ Date: 6/22/2020 Final:
Project Review Req: 10'x20'SHED located as shown on submitted plot plan
° i1
.meeting required zoning setbacks.' 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.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
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 Final Gas:
work until the completion of the same. ! q
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this;p'ermit.
Minimum of Five Call Inspections Required for All Construction Work: Service:
1.Foundation or Footing
2.Sheathing Inspection Rough:
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 Final:
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy
.Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
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).
Building plans are to be available on site Fire Department
Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT.
5
f _
�tHe, Town of Barnstable *Permit#
Expires 6 months rom issue Regulatory
e-
Regulatory Services Fee
BA RNSfABLE,
9eb 1 MASS.. ,0� Thomas F.Geiler,Director
' '0rl�p�►�a
Building Division Co J
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 1
;Residen
rtyAddress /►/1 /e ( ee Tl�rsl��!tial Value of Work �, 00 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) +a' ,;� �
❑Workman's Compensation Insurance
i c2 ri�z
PI
one:m a sole proprietor
m the Homeowner ` '"`` IN `1F -5aRNS BLE
❑ I have Worker's Compensation Insurance
Insurance Company Name * ;
1�
Workman's Comp.Policy# �
Copy of Insurance Compliance Certificate must accompany each permit.
Permit R;Re-roof
es (check box)
(hurricane nailed)(stripping old shingles) All construction debris will be taken to I` i, �'1 (-e SS
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
*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 ome Improvement Contractors License&Construction Supervisors License is
requi d.
SIGNATURE:
C:\Users\decollik\A Da ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 07211
y
T
The Corranaorrrotealth ofmassazchus,�
Department aff lndustr ral Accidents
_ t?fJrce 60. igaton
GQQ Washington-,street
fvivtu megov/
Workers'Compen a on Ytisuranee davit .Bvi ders/coli actor cctricians/Phkn ers
Applicant Information please Print Imbh�
:.Name(Ba�essl0t�izaf�n/Int!<vi _ ) w -
c; rsretztp_ t a e
Aee you an employer?Check the appropriate bas. --Type of:proSect{require
101am.a.employes>fvathd}
4- I am a general contractor and I
� � 1
empicsy-ees(istu`1 andtor pare-camel" have liied,the�� 6_ Aleva�nstTuction
1
2 ❑:I am.a.sole proprietor arpaduef- listed on:fe attached sheet Z-. .Remodeling
anti have no Thise sob-conhuctm have
ship employees- - 8:'0 D'eawhticm .
wr forme is c c employees and have tYo�ners : 9. 0 Building addifion
Y any-capacity:
[To wodbers'comp inAm=e Comp:iusura I i
€ 5.n We are a corpotadon'and its 10:{�Electrical repairs or additions
offtoers have exercised tleetr
3. I am a haanernfiner doing ail�i'oaic 11: Plnu�biag repairs ar additions;
myself•[No workers comp_ rxght.af exemption per MOL 32:❑Raof repass
insurance regziim&]I c. 152, 1( ),act c+sre httvvz nv
employees.[No u;nrkesm I. - i.E]flt&er
3 gip:ffii 3 f t t
'�Y aPPhs�t that checks box#1 msst also 51,
oat the Section below sbowing their wothe�s'compensation policy aafoa aeon.
1 Hom�em2rs wbu submit this offidasii mftoting,tbay:are gain aII wads.sad then like outside contractats mast submit a ueW SM&Vit iadicatigg sash
%Canttactnrs th$i tl,Ech dfis box.mast attached on additiowd..shed ebdveaog the ux"of dte sub`canaozmazs an&state wbetlM a;am ftse entities lin-e
employees. If the sob-connemts bane employees;they mustpxovi&der Wat'kws'comp:policy number.
I arts apt eragW"thongpmT -narrkers'.cot wansadou ztasurfiRCe for nty:eAVpiayees. .BdOW tS41wpvii�.afrdFarb-site
`` �.ertf®rvrttrtivte. _ -
Tasurauce CompanyNaure:
Policy#or Self-sos.11c.# F,xpuattore Date
Jot Sim Addr C�'ty/SfatelZsp
Attach a copy of the workers'compensation pot€cfdectaration page(shaving the policy number at►d`expl�on date).
Faijurer to secure covera~e as required under Section 2-5-4 of MCM c-I 52L can.lead to the inwosition es of a:
fine up to$1,500.00 andlor me-yen imprisonment,as well as civil penalties in.the fosa>:of ar.STOP WORK-ORDER and a fume
of up to$250.00 a day against fhe vidlator_Be advised that a copy of thiS states ed nay be forwarded to the Of ke of
In-Vesstigat sins of DIIA A._tumiptace core.-age:v ratim.
.1 do here a the. trtezf petea�"ss that dte information pt rnRded albow is&w arttd corrmt
Si Dats:
001,
Phon
tJJficanL.ttss only":Do.itcit write"its this.sr�a,to-be.couapleled,by city"ar lower�ffffldaL
Cfty or Town: Permit/License#
lrssaing :n#hors(.irel:oael
1.Board of Heap 2..Building Department 3.City,Il;own Clerk'4.Electrical Inspector.S.:l.'lumbing Inspector.
-6.Other .. _. .. -.-
Contact petsoa. Phone#.
_ 6
t ,
Town of Barnstable
Regulatory Services
BARMABMMAM " Thomas F.Geiler,Director
1659. • 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
HOMEOWNER LICENSE EXEMPTION
�j Please Print
DATE: 1 D '✓ 1) ^� P�
JOB LOCATION: 9(y CT L�1/1•/ �� u F (�?��C��'"''v
number street village j �,�j / j
"HOMEOWNER": ' ; — �'.� "[.v/�`�J v �C{Q 3
name j `/� home phone# ,p work phone#
CURRENT MAILING ADDRESS: . ( � Lt 1 z
A_
city/town I 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 un rsigned"h meowner certifies that he/she understands the Town of Barnstable Building Department minimum inspection
pro d es re rements?n�+ a*hP/she will comply with said procedures and requirements.
na of Homeo
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 ofawareness 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.
C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Ouflook\DDV87AAZ\EXPRESS.doc
Revised 072110
r
�Of1HEr � Town of Barnstable *Permit#
Expires 6 months from issue date
+ BARNSTABLE, Regulatory SerY1CeS Fee
vMASS.
39
1639 '
Thomas F. Geiler,Director
�� 11 Ojl
A�?FDMA Tom...PERMA ` ' Building Division d1G 6 I)o9
Tom Perry, Building Commissioner
MAY 7 2009 200 Main Street, Hyannis,MA 02601
3gNSTABLE
Fax: 508-790-6230
- EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property/Address OL i L,�t -9&6C_ eAv u I 't-�,
esidential Value of Work 5� QC7
Owner's Name&Address i L
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
I pea—sole proprietor
am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#
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 roofl
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
❑ Other(specify)
*Where required: Issuance of this pe t does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
Signature ,
Q:Forms:expmtrtg�\ "
Revised121901
,per The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name(Business/Organization/Individual):
Address: a C O 5:1, C t!
City/State/Zip: Q!��5 Cool b Phone.#: •
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the stab-contractors
2:❑ I am a sole proprietor or partner-' listed on the attached sheet 7. .0 Remodeling
ship and have no employees These sub-contractors have g•'❑Demolition.
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers- insurance comp. insurance.$
e ] 5. ❑ ❑Electrical are a corporation and its -10. lectrical repairs or additions
3.�I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑Other
employees.[No workers'
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 employers,they must providts their workers'comp.policy number.
I am an employer that is providing workers compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimirid penalties 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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby erti under the to -and penalties of pe ' ry that the information provided ab ve is tru and correct
Si e: Date _
Phone#
Official use only. Do not write in this area,to be completed by city or town offWaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health '2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r'
Information. and Instructions -y
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 foregoingg-engag in a jomt-en rpnse; i melu�n`gthe leg represenfaLive 6f- tiec�asetiempl�et�r he-_---'-
receiver or trustee of an individual,partnership,association or other legal entity,employing employees.'However the
tru
who resides there' or the occupant of the
three apartments and uP
owner of a dwellang house having not more than thr p m,
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
in the common ealth for an
o construct buildings � Y
renewal of a license or permit to operate a business or t g
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-contiactor(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 maybe provided to the
applicant as proof that'a valid affidavit is on file for firture permits or licenses. A neW affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture
(Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone-and fax number:
The Commonwealth of MassachuseM
Dtrpartment of ladustgal Accidents
Mee of Investigations
600 Washington Street
Boston,MA 02111
TO. # 617-727-4900 ext-406 or 1-977-MASSAFE
Fax# 617-727-774
Revised 11-22-06
www.massgov/dia
Town of]Barnstable
4
Regulatory Services
r r
RlRurcr�RTF Thomas F. Geiler,Director
�prED 06. Building Division
Tom Perry,Building Commissioner
. .200 Maiu�trce Hya=is,7 MA-02601 _. ..... ... _ . _.._. . . _._.._.....
,n w cp.town.barnstable-ma us
Office: 508-862-403 8 Fax: 509-790-6230
HOMEOWNER LICENSE EXEMPTION
Pleate Print
DATE: � � �
JOB LOCATION:
number stroet village
"HOMEOWNER�:
r)3 `3
name home phone# work phone#
CURRENT MAKING ADDRESS.
eityhown 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 HOMEOwR'ER
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 structur6s. A
person who constructs more than one home in a two-year period shall not be considered a homeov=r. 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 l09.1.1)
The undersignui"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations,
The.undcrsigned."homeowner"certifies that-be/she understands the Tpwn ofBar�stable:Buildin Department '
minimum inspection pro ores and requirements and that he/she will comply with said procedures and
r ents.
ignati=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 bomeowner performing work for which a building pernvt 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 ad as supervisor."
Many homeown=who use this exempti®are unaware tbat they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for licensing Construction Sup i-vison,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeown er hires unliccased persons. In this ease,our Board cannot proceed against the untiumscd person as itwould with a licensed
supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the bomoowner is fully aware ofhis/hrr responsibilities,many communities mquirc,as part of the permit application,
that the homcowncr certify that�dshe 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 foTri/certification.for use in your community.
Q:forrm:homccxcmpt
EKME Town of Barnstable
` Regulatory Services
Thomas F. Geiler,Director
4'�En 16 Building Division
Tom Perry,Building commissioner
200 Main Street, Hyannis,MA 02601
www.town_barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side. ,
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 2- Parcel l2 Permit# _ *y ?y
Health Divisio l� Date Issued r
Conservation Division T, 5, 9 7 4a Fee !fie
Tax Collector - ' �� �� (.!
' EEPTIC SYSTEM MUST E
Treasurer :-7 INSTALLED IN COMPLIANCE
Planning Dept. WITH TITLE$
ENVIRONMENTAL CODE AND
Date Definitive Plan Approved by Planning Board TOWN'REGULATIONS
Historic-OKH Preservation/Hyannis `
Project Street Address Aw- GD
,Village C"A Aq
.Owner �Qi �;�U^r1 Address
Telephone
ermit Request 7 r.
(�L.1
Square feet: 1st floor:existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost f Soo Zoning District Flood Plain Groundwater Overlay
Construction Type VJ ""-e
Lot Size - Grandfathered: ❑Yes ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure S -4 Historic House: ❑Yes MA(r On Old King's Highway: ❑Yes ClNa'
Basement Type: ull , ❑Crawl ❑Walkout . ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing l new 0 Half: existing new
Number of Bedrooms: existing Z new
Total Room Count(not including baths):existing new d First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Electric ❑Other
Central Air: ❑Yes UAo Fireplaces: Existing ( New Existing wood/coal stove: ❑Yes C9-No
Detached garage:❑existing ❑new size '— Pool:❑existing ❑new size — Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:Urlexisting ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# . Recorded❑
Commercial ❑Yes a-mo If yes, site plan review#
Current Use Proposed Use p
BUI DERIN FORMATION
Name; Telephone Number
Address Y r* 6 License# 044(('5~O
Home Improvement Contractor# 3�1 �-
Worker's Compensation# ( Y M6 o o
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6V .
SIGNATURE f DATE
FOR OFFICIAL USE ONLY
Y _
r
•,P&MIT NO. —
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE +
OWNER f -
DATE OF INSPECrim,: i
FOUNDATION _ s
FRAME _
• .
INSULATION _
FIREPLACE
ELECTRICAL: ROUGH', r FINAL
i -
PLUMBING: ROUG =~ FINAL -
GAS: F'OUdfiM Z F. i FINAL `
Adr " '
-FINAL BUILDING __ w
DATE CLOSED OUT #
ASSOCIATION PLAN NO.
��1-`
__-� The Commonwealth of Massachusetts
fir. -,
�= — ' Department of Industrial Accidents
A = Offlce of/firestioat/oos
600 Washington Street
- Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
�` J
name:v &L"J%-
location: O Z -F� " -
city e yll� vhone# 1L'(1--�--L 1 C1 s'._
❑ I am a homeowner performing all work myself.
❑ I am a sole r rietor and have no one workin in ca achy
///%%%%%%%%//G%/%%%%%%/O/ %%%% %%/%%O/%%%%%%%%/G%%%%%%%%%%���%%/O//%%%%%%%%%%%%/�%�%%///%%%%%%/%%/
❑ I am an emplo er providing workers'.compensation for employees working,on this job. :.:::. :::::: ..
K.*.'..":.......":........:...-......:.*...-....,
c- - an .name...... _. .._. _ ..
:..-......:...�......:.........:...u
......w,......
..t ..........-:.:::.:::::::::%:...........................................................
..... .. .
:::.;;;:::.. ..:..;':
. :..:.:..:::.
:-:
.....
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❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is truo and correct
Signature - .. Date � — -) —oo
Print name Phone#
official use only do not write in this area to be completed by city or town official
City or town: permit/license# []Building Department
❑Licensing Board
❑checkif immediate response is required ❑Selectmen's Office
• ❑Health Department
contact person: phone#; _ ❑Other
Ornsed 9/95 PJA)
Information and Instructions
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 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 section 25 also states that everyrstate 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,�geitherthe
commonwealth nor anyaof 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 situation 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 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.
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 permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been 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.
r
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investlgallons
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
Sep 07 00 02: 55p Peacock & Crosb!d Builders (508) 428-3399 p. 2
4
` W Wirilf/,IW"Iu(/Ei(.fiYG�li �V ��t
V 7
card of Building Regulations and Standards
One Ashburton Place - Roam 1301
3oston , Massachusetts 02108
• Horne Improvement Contractor Registration
Registration: 103582 Expiration: 07/09/2002
Type: private Corporation
PEACOCK & CpOSBY BUILDERS , INC .
Scott Crosby
PO Sox 151/ 1112 MAIN 'ST' UNIT 7
Osterville MA 02655
. {' 1
•
IBOARD OF BUILDING REGULATIONS
1 f License: CONSTRUCTIONSUPERVISOR:; . .. . 0
Number: CS O43556
Birthdate: 12/13/1962
Expires: 12/13/2000 Tr.no: 5485
Restricted To: 00
SCOTT E CROSBY _
62 CROSBY CIR
OSTERVILLE, MA 02655 Administrator
4 3«� ` "•� �i e�o�,imronc�ald.o�✓t�iiaawd.�aelA ��j ,
HOMEt:IMPROVENENT,CONTRACTOR2
;tt Registration A03582, �, Y
r >,k wExp rat10nA;k'07/09/00
PEACOCK CROSBY fBUILDERSt,
E
S,c,�,o��t,
D"`ftoxA51/-'1112MAIN ST
ADMWISTRATOR i
Osterv>lle`NA 02655 �, ter;
"
�p THE Tp�
The Town of Barnstable
saRtvsrnaLE.
9�A � Department of Health Safety and Environmental Services
1639.IF Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 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: l �'^ 91 Estimated Cost ��
�y
Address of Work: Za 2-
Owner's Name:s, �
Date of Application: ( ® a
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
❑Building not owner-occupied
❑Owner 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 V for a pe t as the agent of the owner:
C � 16 5� >
Date Con for Name Registration No.
OR
Date Owner's Name
q:forms:Affidav