HomeMy WebLinkAbout0069 BACON LANE f.
o
TOWN OF BARNSTABLE
CERTIFICATE OF OCCUPANCY
PARCEL ID 207 020 GEOBASE ID 12495
ADDRESS 69 BACON LANE PHONE
CENTERVILLE ZIP
f
LOT 26 BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT CO
PERMIT 62559 DESCRIPTION C/O FOR SFH/EXTENSIVE REMODEL UNDER 050596
PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY i
CONTRACTORS: Department of
ARCHITECTS: Regulatory Services
TOTAL FEES:
BOND
$ 00
CONSTRUCTION COSTS $.00 tNE
756 CERTIFICATE OF OCCUPANCY 1 PRIVATE ..
BARN
Mass.
BUILD D
BY
DATE ISSUED 07/23/2002 EXPIRATION DATE
ALDRE SS 69 BKON 11A N F PRONE
IDB�� 1 E, Ei,OP T+1i�T.,' DISTRICT .C`0
P PMIT 50596 DESCRIPTION REMODEL HOUSE INTER'OR•-KT1'C11/13A'T11
jPERMIT TYPE BR�`MOD TITLE RESIDE't�F'�1A,L AL'T/CONY
CONTRACTOR'S OR'S: YRbPERTY 0`WNE.R Department of Health; Safety
ARCUITEC and:-Environmental Services
TOTAL FEES. . $165.00 '
BOND - $.00 tME � 4.
CONSTRUCTION COSTS, : $pan,000.00
41 RE' :znnATiCi 1. k .VA° ► 3 ;,£ �,�
swMsrABIM •
MAS&
039.
BUILDING DIVISION
BY
DATE, ISSUED 3?/�.�/2000 ]�S�FIRt�`I'IGL3 ,0A""
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY.ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS THE ISSUANCE_-OF THIS '
—FEHMITDOES-NOT RELEASE THE APPLICANTFROMTHE CONDITIONS:OFANY'APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED "s
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE .APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR
2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU-
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH:
3.INSULATION. . OCCUPIED UNTIL FINAL INSPECTION HAS BEEN.MAD.E.
ANICAL INSTALLATIONS. ,
4.FINAL INSPECTION BEFORE OCCUPANCY.
POSTTHIS-CARD • IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
41,
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3 1 H A NG INSPECTION APPROVALS ENGINEERING DEPART
DMEN /
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p SIT L AN REVIEW APPROVAL
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W R S ALL NOT PROCEED UNTIL PEFAMq WILL BECOME NULL AND VOID IF CON INSPECTIONS INDICATED ON TS
THE INSPECTOR HAS APPROVED THE STRU TION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR`HI BY.
VARIOUS STAGES.OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS '.TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE. TION.
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BUILMWING
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r
Ma �i � �Z'4 � �,_� �: ^_1 ... ' r ..
p Parcel Application #
S
Health`Division ✓ 13
Date Issued v
Conservation Division Application Fee
Planning Dept. Permit Fee oZ 1
Date Definitive Plan Approved by Planning Board ,
Historic - OKH Preservation/ Hyannis
Aj
Project Street,Address ( �®
Village
Owner f-E/J C.0 g_(Z 1'-A) Address 5 �--
Telephone �'-3G Z- i�U
14
Permit RequestTj " Al
r
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatio f Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'` HighvW: ❑:Yes ❑ No
c:
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(� .ft) �<
o
Number of Baths: Full: existing new Half: existing newer
Number of Bedrooms: existing _new {
�o
otal Room Count (not including baths): existing new First Floor R om Cct
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑existing 0 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 V 6) /Vu Telephone Number
Address L� l�( ) �7��� License # 1-(
IVO 02- 1'4 Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE ` C�O
/
t
_ FOR OFFICIAL USE ONLY
1 !
APPLICATION# '
DATE ISSUED
MAP/PARCEL N0.
i
ADDRESS VILLAGE
r OWNER '-
w �
i
DATE OF INSPECTION: i
FOUNDATION
.r
's
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
{ FINAL BUILDING
y DATE CI OSED OUT
I
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/Plumbers
Applicant Information ` Please Print Le 'bl
Name(Business/organizationnndividual): U (1 L) l.L
Address:_ -7
City/State/Zip: AI 7V 5lrL)N3. A 1 L[ hone.#: 506 s-7 37 _3 Z y
Are an employer?Check the appropriate box: Type of project(required):
1.7L"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. ❑Remodeling
ship and have no employees These sub-contractors have g• E]Demolition
working for me in any capacity. employees and have workers' 9 E]Building addition
[No workers' comp.-insurance camp.insurance.t
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.❑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 chec}a box#1 must also fill out the section below sbowing their workers'compensation policy information.
t Homeownas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCantraetms that check this box must attached an additimral sheet showing the name of the sub-coniractnrs 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: OfIA Aj I S_-t� J
Policy#or Self-ins.Lic.M. 6 37- L1 Expiration Date: ( � /�� TO
Job Site Address: &q A,� � AJ City/State/Zip: A
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 c ri'mi'al penalties of a
fine tip to S 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 WA for insurance coverage verification
I do hereby certify er the p ' and penalties of perjury that the information provided above is true and correct
Si afore Date
Phone# , /-37--57L
Official use only. Do not write in this area,to be completed by city or town of xiaL
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#:
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 hue, .
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 fok 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 numbers) along with their certificate(s)of
insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LIP)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 Towp 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 cuaent
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 io 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 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 Ummonwealth.of Massachusetts
Depatt wnt of Iadustdal Accidents
OMce of Investigations
600 Washington street
Boston, MA 02111
TO. #617-727-4900 ext 4.06 or 1-977-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
C AMCITE STATE INSURANCE COMPANY 70285-0000 WC 638-88-43
i 34102 ------------------off 3 -- --
-66-11 -00
.-•.-• . - . PENNSYLVANIA
DOUG MULLEN j Member Companies of
PO BOX 1274 4'�j
MARSTOWS MILLS, MA 02648-0000 -• American International Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW'YORK, N.Y. 10270
SEE NAME AND, ADDRESS SCHEDULE - WC990610
I.D# MA UI#: '-•• ••
OCEANSIDE INSURANCE` AGENCY INC
WORKERS COMPENSATION ANDEMPL.OYERS 52 WEST MAIN ST
LIABILITY POLICY INFORMATION PAGE HYANN 1 S, MA 02601-0000
INSURED IS PREVIOUS POLICY NUMBER
INDIVIDUAL RENEWAL 008855933
OTHER WORKPLACES IUOT SHOWN ABOVE:SEE NAME -AND ADDRESS SCHEDULE - WC990610
ITEM 2 1 POLICY PERIOD 12:01 A.M.standard time at the insured's
mailing address FROM -1 1/21/07 TO 1 1/21/08
ITEM.3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA ;
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A,
The limits of our liability under Part Two are: Bodily injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ SOO, 00 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to.the states, if.any, listed here: J
SEE ENDORSEMENT - WC2010306A
ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification'and change by audit.
Estimated Total Rate Per Estimated
Remuneration Premium
Classifications Code Number $100 OF Re X Annual 3 Yeas
❑ muneration
Annual 3 Year a
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $150.
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $3 1 8 MA
MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $3,065
If indicated below, interim adjustments of premium shelf be made:
® Semi-Annually ❑ Quarterly El Monthly DEPOSIT PREMIUM
ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612
12/29/07 ASSIGNED RISK 66
Issue Date Issuing Office Authorized Represent ive wC oo 00 of
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Board of Building Regulations and Sla►iilards _
HOME IMPROVEMENT CONTRACTOrt f.be a or re istration val d for
ceus g i mdiyldul use only
j„ a fore the expiration date If found return'to Registratn�138368 �' Board`gl BttcldingRegulations and Standards;
E Pirat�on 3/27/�2009 ;.One Ashburton Place Rm 1301'
Pi T e D ..
Tr# 128181
,, YP B'A BPS,ton;'Ma:02108
MULLEN BUILDING'&REMOD,ELING
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+VEST YARMOUTH;MA 62673 ;
Not val rthout signature: r
1
°F�HEr�ti Town of Barnstable
Regulatory Services
BAR ASS. ThomasY. Geiler,Director
y Hues. $ �
'0lentiw.ca Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town,b arnstab l e,ma.us
Office: 508-862-4038 Fax: 508--790-6230
Property Owner Must
Complete and Sign This Section If Using A Builder
I, 3-0 ��iPc'" , as Owner of the subject property
hereby authorize to act on my behalf,
in all!ma.tters relative to work authorized by this building permit application for:
�A-)
(Address of Job)
S V ature of Owner Date
Print Name
If Property Owner'is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
�Qp1Ht:rp�
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
• BARNSTABLE, • f
y MASS.
4,,, l659• ,�� Building Division
TFD hlA�A
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of shz 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.
Thna-rrdersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
nunimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements,
Signature of Homeowner
Approval of Building Official r
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 EYSAIPTION
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 supenhsor."
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 oftearesults 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 thajjhe 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 fom/certification for use in your community.
4 — ------ — --— --.---- ----- -- -- _ --
I�
R A=ILL#'
I
SELECT
Please read all instructions completely before starting any part of the installation.
I" DECK JOI rs Each railing kit comes complete with all parts,hardware and installation guide to install
one complete rail section(excluding posts.)Railing sections have been pre-cut to 6 ft.or
NU AND WASHER .8 ft.lengths. Check to ensure that the kit is complete.Safety-Always wear goggles when
handling,cutting,drilling and fastening materials.Note:Check local code requirements.
MATERIAL -
n
1.POST SLEEVE INSTALLATIONS:
The Post Sleeve has been designed to slide easily over a nominal wood 4"x 4"
"°°°"°Sr (min.31A"x 31h",max.31/,fi'x 3'/,a")post'after the deck sub-structure is complete and the
deck board has been fastened.If the nominal wood 4"x4"post is twisted or oversized it will
be necessary to shave the post. Do not force the Post Sleeve as this may cause it to crack
CARRIBA6E ED, or split. The 4"x4"wood post should extend down to the bottom of the rim joist.for firmest
Figure t attachment,completely"BOX IN"the 4"x4"wood.post so there is support on all four sides.
(see Figure 1) The Post Sleeve is then slid over the wood post that has been mounted to
the deck or a concrete slab using the"SURFACE MOUNT BRACKET'.
t For more information see our website.
l Note:If optional Post Skirt is to be usedinstall over Post.Sleeve prior to installing railing.
I —� 2.POST SLEEVE HEIGHT CALCULATIONS
"""For Calculate and cut Post Sleeve to required height(see Figure 2). Slide Post Sleeve over ZIN4"
or � )I 38 For 36'
or ) wood post into position. For 36"rail cut Post Sleeve to a minimum of38". For 42"rail cut
42 minimum Post Sleeve to a minimum of 44".
(2)44"(For 42")
3.MEASUREMENTS AND CUTTING
i o ,
Measure between posts,top and bottom to obtain the rail length. Also check the rail
r r DECK,OMT ; opening to ensure the Post Sleeves,newels or walls where the rail is to be installed are
IL) GRADE LEVEL square and plumb. To obtain proper baluster spacing be sure to measure and cut retainer
I' ,x4-00MST/ and bottom rail equal distances from the center.Cut handrail to match retainer.
TIPS: See our website for 1)Optional cut technique to equally divide rail kits,i.e.make
I; Figure 2 2-4 foot kits from an 8 foot kit and 2)How to cut and position railing on the Post Sleeve
RETAINER AND BOTTOM RAIL at a 45°angle.-
I RETAINER OR
SO—RNL
4.RETAINERS AND BOTTOM RAIL BRACKET INSTALLATION(see Figure 3)
li l w Place the"U"shaped end of the painted stainless steel bracket on the underside of the
su— w I�•rAN"AD retainer and bottom rail. Be sure to place the bracket just slightly inside(7,,s')the cut edge
` OU
of the retainer and bottom rail. Mark and drill pilot holes with a'/,e"bit. Drill outthe two
N KNrIN� j
NR ADEti INs xr O a" ET mounting holes to 1/e. J
j Note: When drilling for the bottom rail,drill through bottom wall only-do not drill through I
�I Figure 3 the top surface.
Using the enclosed tool,screw the threaded inserts into the holes from the bottom until r
flush. Be careful not to over torque. Install inserts and fasten brackets with panhead bolts 3
IRE-oRILLEDRETAINER °R^Ro to the underside of the Retainer and Bottom Rail using the'/dI x 20 panhead screws.
I WOODO IOE50VER❑
SOREWSO RETAINER
(SUIIIIED) -
(I3 5.ASSEMBLE,FASTEN AND SLIDE
II — Align the ends of each Baluster with the pre-drilled holes in the.Retainer(see Figure 4). j
/ Using the t'/a"#8 wood screws,fasten the Balusters to the Retainer first,through the
j BALD RS HAND-1 pre-drilled holes. Do not over torque. Align the ends of the Balusters with the holes in the
Bottom Rail and fasten the Balustersto the Bottom Rail through the.pre-drilled holes using
IRE-DRILLED❑ the 3"#8 wood screws. Place the partially assembled railing against a solid surface and
I. BOTTOM RAIL '
slide the Handrail over the Retainer. Note: If the brackets cover any of the pre-drilled holes j
oo or there is not enough room for the baluster to firmly attach to the retainer,notch the
S<REwsD) I I(suIEUED) baluster so that it fits around the bracket and screws.
i
Also see our website for additional TIPS. Seal any exposed holes with a silicone exterior-
Figure 4 grade caulking.)
Revised Dec.7,2006
g�
SELECT
iflation Guide
I
- - - NOTE:LEVEL RAILING PRIOR❑
❑ TO MARKING&DRILLING '
13/4"WOOD SCREW - - -
0
C)1�\\
CENTER❑
SUPPORTO -
CENTER❑ BRACKET - -
SUPPORT❑ MARK&DRILL❑ ---
1 BLOCK HOLES
Figure 5a
1 1/2".LAG BOLT
BOTTOM RAIL" BALUSTERS -
i
IICI
Figure 6
�y CENTER SUPPORT SIZE
HOLPRE-DSILLE15B R CENTER SUPPORT❑ - US. Select-Flat 4Vid'
BRACKET
1"SELF- - -DRILLINGUS Select 4 5/8,I**
SC ..
CENTER SUPPORT -1 - US Reserve 4 3/81I "
BLOCK F—CENTER OF BOTTOM RAIL Figur5b iF*Indicates size supplied
e
Chart-1 I
I
. i
6.CENTER RAILING SUPPORT
Fasten center support in center of railing using 1"self-tapping screws. 8•POST CAP APPLICATION i
(see Figure 5a&b)Check Chart 1 for the proper cut length for your Apply generous amount of construction grade adhesive to top edges
lstyle of rail. of Post Cap and press Post Cap firmly into place.
7.LEVEL AND ATTACH RAILING(see Figure 6) 9.FASTEN HANDRAIL TO RETAINER. }.
Level the assembled railing prior to making any markings or drilling. Take-remaining self drilling screws that were used in Step 6 and install
Place assembled railing between Posts and level. up through the retainer into the handrail to lock it in place.
Mark holes. Space screws evenly over the span.
Remove assembled railing.
Drill pilot holes in the Posts with a 1'l 'drill bit. For care and cleaning instructions.
Re-position assembled railing and using a#3 Phillips driver bit attach to visit our website.
Posts with#14 x 2"stainless steel screws.
ET
IU$ -
COMPOSAT C`C-��11// Manufactured under Compos-A-tron Research&Development
� NAWLA- i
US Patent 6,702,259,
COMPOSITE TECHNOLOGY 62.
-
For more information call customer service at(416) 335-6500 or visit www.composatron.com
Under Strandex Canadian Patent#2153659 and Strandex U.S.Patent#5516742 Printed in Canada Trademark Railings is a trademark of CCPINC.
MORTGAGE INSPECTION PLAN
BOSTON
SURVEY, INC. 00-02839
P.O. Box 220 Charlestown, MA 02129
(617)242-1313 MAIN (617)242-1616 FAX
APPLICANT.- CURRAN
LOCATION: 69 BACON LANE DEED/CERP 7721-244
CITY, STATE: BARNSTABLE, MA PLAN REF: 21-133
tza.2s --------- —i... .--
LOT 26
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1994(c)Boston Survey Software
PREPARED: 04-24-2000
CERTIFIED TO: HARBOR MORTGAGE SOLUTIONS
SCALE: 1 inch = 30 feet
•tN M�,
The permanent structures are approximately located on the OF �Cy According to Federal Emergency Management Agency
ground as shown. They either conformed to the setback r JOHN �'
requirements of the local zoning ordinances in effect at maps, the major improvements on this property fall in an
�' area designated as Zone G'
the time of construction, or are exempt from violation en- RUSSE�L
forrenient action u p 38717 y 1 tinder M.G.L. Title VII, Chapter 40 A, v in Community Panel No:�ZS-66 00/6-1)
q
Section 7, and that there are no encroachments of major 4L�i/ Z Effective Date:
7'L !z
improvemenls either way across property lines except as p
shown and noted hereon. �qN 9� NOTE: one C is areas of minimal flooding(no shading). This
3U designation is not based on an elevation certificate.
I
NOTE:This is not a boundary or title insurance survey.This plan was prepared in accordance to procedural and technical standards for Mortgage Loan Inspections as adopted
by the Massachusetts Board of Registration of professional engineers and land surveyors,250 CMR 6.05,and use for any other purpose is prohibited.This plan is not to be
Assessor's map and lot number 2 '7
flitu s�,w�f d '
Sewage Permit number ......................�.....
TOWN OF BARNSTABLE
i BASB9TABLE. i
"6 9 BUILDING INSPECTOR
a M a•
APPLICATION FOR PERMIT TO ..... pa.�`j..lk'Q V.C.1....... ZbR-M..E R................................
TYPEOF CONSTRUCTION ......................................'A.A.r I...........................................................................
...........� ....................... 9'm
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a /permit according to the following
information:
Location ............. `�N.........`.!�. 1�� ... Q.fir..O..�:�en i .....................:: ...................................
ProposedUse ........O .E....... . .L .............��1`5 ...................................:...............................
Zoning District ............�.q .)................................Fire District .....C. T.'" Onmy
Name of Owner ......Q0.0v Address ....... A�. V L.N C
� ........................... .... ............
Name of Builder S .K► ......,i/.QAS...............Address ..........COT �............................................
Name of Architect `�� ................Address "—�
...................:.............................. ....................................................................................
Number of Rooms ........ Foundation ...ems
......................................................... ..............................................................................
Exterior .ii C... . .................Roofing ��1 QKq Lr
... ......................... ................... ................... .........................................
Floors -�!�.... �"� ..Vyl� � Interior ...............:.f .yW .L`...................................
Heating ........ ......................................Plumbing .......................... .....................................................
T
Fireplace ..................................................................................Approxi 11'mate Cost ..................1. �..01 .t. ........ . .....................
g-,� 'n'r-'r
Definitive Plan Approved by Planning Board -------------------_-----------19--------. Area ................... .......... ............
Diagram of Lot and Building with Dimensions Fee r '!..................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ...................... ............................ .............................
Gourley, Edwin A.
No ...16J�'6... Permit for ......dormer................
...............................................................................
W I
Location Bacon Lane
...............................................................
Centerville
...............................................................................
i
Owner Edwin A. Gourley
.....................
Type of Construction fr.ame 1
.... ...................... �t I
i 1
................................................................................
Plot ......................... .. Lot ................................ '
s
Permit Granted August...2.3.... .....19 73
Date of Inspection .............. ...... ............19 ,
Date Completed ... �........19
1C."Aw
PERMIT REFUSED
i
............................................... 19
...............................................................................
................................................................................ i fi
...............................................................................
...............................................................................
Approved "
...............................................................................
.................... ......................................................... I
4.
,a
TOWN OF BARNSTABLE BlAtLDING PERMIT APPLICATION
Map—, _Parcel�? Permit
Health Divisiou��,�% `av��� Date Issued 2 /
Conservation Division Feef�� '
Tax Collector OIL
Treasurer
SEPTIC SYSTEM MUST BE
Planning Dept. INSTALLED IN COMPLIANCE
Date Definitive Plan Approved by Planning Board WITH ITLE 5
ENVIRONMENTAL CODE AND
Historic-OKH Preservation/Hyannis TOWN
/ REGULATIONS'
Project Street Addre s C O L 1/1
Village
Owner �n P r U ka, l/L Address S_Qe i�(�_ /J Q CDh G`1
Telephone
Permit Request oe_t1 1b — Mo 61 G U CD U�U�
—16 Z�/ -S 7' F100t, 180(A—
e I
Square feet: 1 st floor: existing�__S�proposed 2nd floor: existing Z�y proposed Total new
Valuation 600 Zoning District Flood Plain /M Groundwater Overlay
Construction Type _k6
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ // Two Family ❑ Multi-Family(#units)
Age of Existing Structure+ � 16 Historic House: ❑Yes X No On Old King's Highway: ❑Yes No
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) /dS�
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing�� new d�
Total Room Count(not including baths): existing 7 new First Floor Room Count
• b
Heat Type and Fuel: If Gas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes 19 No Fireplaces: Existing ,� New Existing wood/coal stove: ❑Yes *No
Detached garage:16 existing ❑new size Pool:❑existing ❑new size Barn:O 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
A, BUILDER INFORMATION
Name 3NtLi A1 V'6&Ce M v shone Number
Address lu G h License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS P OJECT WILL BE TAKEN TO
SIGNATURE DATE
r _ FOR OFFICIAL USE ONLY
=emu:
lr MIT NO.
DATE ISSUED t
MAP/PARCEL'NO.
ADDRESS VILLAGE
OWNER
I
DATE OF INSPECTION:
FOUNDATION, '
FRAME
INSULATION
`4 FIREPLACE y
ELECTRICAL: ROUGH FINAL
.' PLUMBING: ROUGH » ` �t FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
,i +: �
w ASSOCIATION PLAN NO. r
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ESTIMA TED PROJECT COST WORKSHEET
LIVING SPACE � Value
(high end construction) b square feet X$115/sq. foot
(above average construction) square feet X$96/sq. foot=
(average construction) square feet X$57/sq. foot=
GARAGE (UNFINISHED) square eet 5 sq. oot=
PORCH square eet 0 sq. oot=
DECK square ee =
OTHER sgi-we feet X$??/sq. foot=
Total Estimated Project Value S � 0
The Town f o Barnstable
9 . � Regulatory Services
EDP Thomas F. Geiler, Director
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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: 'I Estimated Cost-0 060 od
Address of Work: CU/?
Owner's Name:
Date of Application:—* 021(06/,;�o�
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
ZlOwner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
Date Owner's Name
q:forms:Afdav
f
°F THE
The Town of Barnstable
enarrsTnar.E. -
9 M Regulatory Services
E16 p. Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
{/f /� Please Print
DATE: /Lr' 0&O&OV JOB LOCATION: 7 f7Xog L'
number � (� street village
"HOMEOWNER": cJQy1/`f ,Y' �IC� � Z /Z�
name home phone# C*U*+hnnr#
CURRENT MAILING ADDRESS:
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,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
the Building Official on a form acceptable to the
a homeowner. Such homeowner shall submit to g
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
Depent inspection procedures and requirements and that he/she will comply with said
pr ea
c4 2,a AS ger
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will.be required to comply
with the State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the
provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a
person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see
Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in
serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the
unlicensed person as it would with 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.
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t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel T/� a0 -b Permit# �� 1
Health Division 0 / Date Issued
Conservation DivisionFee )790. /Z
Tax Collector .�004
� ��" /
5 EPTIC SYSTEM MUST BE
Treasurer ".e ALLf D IN COMPLIANCE
Planning Dept. WITH TITLE 5
Es.VN�Fii0MHMENTAL CODE AND
a=„�
Date Definitive Plan Approved by.Planning Board �,�3��� R, TI
Historic-OKH Preservation/Hyannis UUU e-
/ LIU Ju .L t 400 I LJ .
Project Street Address
Village
Owner �h �L �' ���'t Address 7 164Coy (e4, G(/i'���
Telephone 316 `
Permit Request lice 4 O&al /Q47. eerw, --
Square feet: 1 st floor: existing . 8 osed 2nd floor: existing proposed �� Total new
ValuationA6 do
�dis9ict Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family GY Two Family ❑ Multi-Family(#units)
Age of Existing Structuren.) .
istoric House: ❑Yes 4-kd' On Old King's Highway: ❑Yes mot'Basement Type: ull alkout ❑Other
Basement Finished AreaBasement Unfinished Area(sq.ft) l6S%
Number of Baths: Full: existing new Half: existing new
.Number of Bedroom3-existing_ new
Total Room Count(not including baths): existing new D . First Floor Room Count 3
Heat Type and Z
ZGa ❑Oil ❑ Electric ❑Other
Cbntral Air: �/ex/istfing
❑ o Fireplaces: Existing New Existing wood/coal stove: ❑Yes NNo
Detached ara e: ❑
g g new size Pool:❑existing ❑new size Barn:El existing Cl new size
Attached garage: ❑existing ❑new size Shed:4 existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current„Use _ Proposed Use -- -
BUILDER INFORMATION
Name Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
s� ecc��e� S
SIGNATURE DATE
' FOR OFFICIAL USE ONLY
Al
PERMIT INTO.
BATE ISSUED 'r ,
MAP/PARCEL NO.
ADDRESS ate:sue, "~ VILLAGE
OWNER` +' r
DATE OF INSPECTION:;.
FOUNDATION
FRAME
INSULATION tie
e .
FIREPLACE
ELECTRICAL: ROUGH FINAL
• a
PLUMBING: ROUGH FINAL
GAS: ROUGH+ FINAL .
FINAL BUILDING
foe
DATE CLOSED OUT ctvQf
c•i . : )
x
ASSOCIATION PLAN NO M Lv! r
M1
f
FEE•VALUE WORKSHEET
LIVING SPACE
(2000 sq ft or greater) square feet x$115/sq.foot=
(less than 2000 sq ft) square feet x$96/sq. foot=
(affordable housing) square feet x$57/sq.foot=
(40B or low income)
GARAGE(UNFINISHED) square feet x$25/sq. foot
PORCH wt square feet x$20/sq.foot= vw
dt�
DECK square feet x$15/sq.'foot=
ALTERATIONS/RENOVATIONS
OF EXISTING SPACE . . . . . . . cost= . . . . . . . . . . . . . . . .
Total Project Fee Value $c®r)
Office Use Only
Permit Fee
projcost
° The Town of Barnstable
• L►artsresi.e.
165 g Regulatory Services
� .o
Thomas F. Geller,Director
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
- Date Z
AFFIDAVIT
f 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,alonith other
requirements.
Type of Work: /zee lkEstimated Cos
wo; 06
Address of Work:. �
Owner's Name: --37o-4 cl C&
Date of Application: K 11la-1
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
[]Job Under$1,000
❑Bui g not owner-occupied
g30wner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS R OR APPLICABLE HOMEARBITRATION PROGRAM IMPROVEMENT
ACCESS TO GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Contractor Name Registration No.
Date _
W
Date Owner's Name
q:forms:Affidav
M CMR Appends:!
Table J&Llb(continued)
Prescriptive Packages for One and Two-Family Residential Buildings Heated with Fossil Fuels
MAXIMUM MINIMUM
Glazing Glazing Ceiling Wall I Floor Basement Slab Heating/Cooling
Amy U-value] R-value' R value R value Wall Perimeter Equipment Efficiency'
packa$e _ R value° R value'
5701 to 6500 Hating Degree Days'
Q 12% 0.40 38 13 19 t0 6 Normal
R 12% 0.52 30 19 19 10 6 Normal
S 12% 0.50 38 13 19 10 6 85 AFUE
T 15% 0.36 38 13 25 N/A WA Normal
U 15% 0.46 38 19 19 10 6 Normal
V 15% 0.44 38 13 25 N/A WA 85 AFUE
W 15% 0.52 30 19 19 10 6 85 AFUE
X 18% 0.32 38 13 25 WA N/A Normal
Y 18% 0.42 38 1 19 25 WA WA Normal
Z 19% 0.42 38 13 19 10 6 90 AFUE
AA 18% 0.50 30 19 19 10 6 90 AFUE
.1. ADDRESS OF PROPERTY:
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: RZ6
3. SQUARE FOOTAGE OF ALL GLAZING:
R
4. %GLAZING AREA(#3 DIVIDED BY#2): �
5. SELECT PACKAGE(Q-=AA-see chart above):
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPROVAL:
YES: NO:
•
q-forms-f980303a
780 CMR Appendix J ,
Footnotes to Table J6.2.1b:
' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and
basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall
area, expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement.
For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area.
' After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with
the National Fenestration Rating Council (NFRC) test procedure, or taken from Table 11.5.3a. U-values are for
whole units:center-of-glass U-values cannot be used.
' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full
insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38
insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing (if used). For ventilated ceilings,.insulating sheathing must be placed between
the conditioned space and the ventilated portion of the roof.
'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include
exterior siding, structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER
by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to
wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction.
'The floor requirements apply to floors'over unconditioned spaces(such as unconditioned crawlspaces,basements,
or garages).Floors over outside air must meet the ceiling requirements.
'The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
described in Note b.
The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs.
e If the building utilizes electric resistance heating use compliance approach 3, 4, or 5. If you plan to install more
than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a
NOTES:
a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels.
R-value requirements are for insulation only and do not include structural components.
b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested
and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.
One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35).
c) If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
• _`_'�` The Commonwealth of Massachusetts
Department of Industrial Accidents
.._. . - office oflnsestiootioAs
_ t 600 Washington Street
_ Boston,Mass. 02111
Workers' C sation Insurance Affidavit
name 61, 4 0: Ct>
location: K 9 Ce Ile, /174
C
city
/ / ry. hone#
_
JF2
I am a homeown
❑ I a sole roprietor and have no one workin in anv ca achy
an employer providing workers' compensation for my employees workmg on this job
l ® t"
1 �
comaanv name
yhone#
insurance co. t y`f=, fit, '
❑ I am a sole proprietor, general contract ,or homeowner(cir le one)and have hired the contractors listed below who
have
the foll _ on olices:comPwo
com an .name:. l it? /h
....:....:
;iosnrant>e ca:
c an;:names :.....» ...::.
address. ,
h6ne#
CV
:..:..
of
insurance co..
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 s1,5oo.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue 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
1 do here11 by certify under the d pe of perjury that the information provided above is true.and correct
Signature Date �/ ��/��
Print name Phone#
official 1L4e only do not write in this area to be completed by city or town official
permit/license# ❑Building Department
city or town:
❑Licensing Board
❑Selectrnen'a Office
❑checkif immediate response is required ❑Health Department
contact person: _ phone#; ❑Other
Urvued 9/95 PIA)
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 or of
another who employs persons to domaintenance, construction or repair work on such dwellinghouse or on the grounds
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or 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,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 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 pe���rmit/license number which will be used as a reference number. The affidavits may be returned Tn
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.
EWE
The Department's address,telephone and fax number:
f
The Commonwealth Of Massachusetts
Department of Industrial Accidents
0111ce of Investigations
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
-ANA
B„�tsr" ns a e
5 ..Regulatory Services
Thomas F. Geller, Director
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601
Office: 508-862-438 Fax: 5 0 8-7 90-62-10
HOMEOWNER LICENSE EXEMPTION
j� nn Please Print
DATE: v� V
JOB LOCH ON: C(3 LA /1e /l�''
number street
/� /� / ) Qvillage
"HOMEOWNER": ®10Gtti i�• ( G L' �'�h2/"�/I�1 S1C�"O�l� �S�
came [�./ home phone work phone a
• CURRENT MAILING ADDRESS: ��eo Gl dJ
city/town state rip 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,grrovided that
the owner acts as supervisor.
DEFIMTION 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
proced d r i ents.
Si t Hom Kr
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 E7ff1 WnON
The Code states that "Anv 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:FORMS:EYEMFM