HomeMy WebLinkAbout0014 BEE LANE o K
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME In town (which you,
must do by M.G.L.-it does not give you permissiori'to operate.) You must-first obtain the necessary signatures on this format 200 Main St., Hyannis, -
Take the completed form to the Town Clerk's Offite;.1•st FI., 367 Main St., Hyannis, MA 02601 (Town-Hall) and get'the Business Certificate that is '
required by law.
DATE: Fill in'please
talmWz'rt ri3l?4sy.maalp ,j�'" s�I)�_ I' APPLICANT'S YOUR NAME S: e
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',����;F � BUSINESS YOUR HOME ADDRESS: U
TELEPHONE # Home Telephone Number
NAME O _ CORPORATION..."..
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When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town'of
Barnstable. This form is intended to assist you in obtaining the information.you,may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. &Main Street) to.make sure you have the appropriate permits and licenses required to legally operate your business in this town.
MUST COMPLY WITWHOME O; GUPAT'ION
1. BUILDING CO MI' SIO ER'S OFF E RULES ANUPEGULATION8. .FAILU..E TO-.' •.
This Indivi ual hI ice. e f any per, it requirement that pertain to this type of business: .
'.,0RAKy MAY RESULT IN FINES
Au horize ig
COMMEN r /` 6
2. BOARD OF HEALTH )'
This indivlduaihas been informed of the permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
S_ CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing.requirements that pertain to this type of business.
Authorized Signature**
COMMENTS: :
Town of Barnstable
Ki oFVE T� Regulatory Services
o Richard V. Scali,Director
Building Division
RARMN TAsr E,
Tom Perry,Building Commissioner
'°lFn rna t a 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Approved:,
Fee:
Permit#: . S Ug
HOME OCCUPATION REGISTRATION
Date:
Name:._ U Phone#:
Address: 1'14 Bee Llg4u f' e vTenuo Ue y4 Village:
.Name of Business:
Type of Business: P,o f &-I-i A,, (n Map/Lot: I-
EVITNT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 44.4 of the Zoning ordinance,provided that the activity
shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual alteration to the
premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;
and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,.located within
that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there is
no outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,
odors,electrical disturbance,heat,glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of
normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There are no commercial vehicles related to the Customary Home Occupation,other than one van dr one
pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot*containing the Customary Home Occupation.
0 No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit
I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering.
Applicant 12�V Date. 5,
i
Homeoc.doc Rev.103113
YOU WISH TO OPEN A BUSINESS. .
For Your Information: Business certificates [cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
necessary si
gnatures.natures.on this form at 200 Main St. Hyannis.
o e a e. You must first obtain the e Y
give you permission£o-�� Y g
. must do by M.G.L.-it does not gi y p p )
Take the completed form to the Town Clerk's Office, 1st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get :u-s•i•ftE��C- ifica hat is
required by law. �.
DATE: 3- F'I/please:
LICANT'S YOUR NAME/S:
BUS SS YOUR HOME ADDRESS: I A:,P.
T
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t' e eRIV►L e Mp � ' ivs o!
�6
°S' 5 TELEPHONE /Home Telephone Number ��- 5
y
NAME OF CORPORATION:
i
/ TYPE OF BUSINES
S
NA
ME OF NE
W BUSINE
SS
!1J
IS THIS A HOME OCCUPATION? YES N
ADDRESS OF BUSINESS. 0 2H� iLL Mi4P/PARCEL NU BER c� [Assessing) .
When starting a new business there are several things you must do in der to be in compliance with the r los and regulations of the Town of
a need. You MUST GO 200 Main St. - corner of Yar th
t you in obtaining the informati-n�• "u m [ •
form is intended to asses y Y
Barnstable. This f y 9
e the appropriate ermit and licenses required tole all operate our business in this to
.
Rd. & Main Street to make sure you have p q 9 Y P
Y
1.. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit req merits that pertain to this type of business. -•-
Authorized Signature**
COMMENTS: IV
r-
2. BOARD OF
HEALTH
This individual has been informe of the permit requirements that pertain to this type of business.
_Authorize ignature**
COMMENTS: `
3. CONSUMER AFFAI (LICENSING AUTHORITY)
This indivjdu.- as been informed of the licensing requirements that pertain to this type of business.
* Authorized Signature**
COMMENTS:
Town of Barnstable
Op1HE rqt, Regulatory Services
o Richard V. Scali,Director
saxtvsrnsr.E.
Building Division/
v MASS. Tom Perry,Building Commissioner
°Teo nnt►�a 200 Main Street,Hyannis,MA 02601
www.town.b a rnsta b le.m a.us
Office: 508-862-4038 Fax: 508-790-6230
Approved:
Fee:
Permit#: .
HOME OCCUPATION REGISTRATION
Date:��
Name: N 49#2k D S X y1 '2 S Phone#:
Address: p e L /9/t/E P.ti1&tzU/C P A4village:
.Name.of Business: p t t
Type of Business: f Map/Lot: 7 f> f
WFENT: It is the intent of this section to allow the rl sidents o Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provision of Section 4-1.4 o e Zoning ordinance,provided that the activity
shall not be discernible from outside the dwelling. th re shall be no increase in eise or odor,no visual.alteration to the r
premises which would suggest anything other than a r sidential use;no increase in traffic ove normal residential volumes;
and no increase in air or groundwater pollution.
After registration with the Building Inspector,a cost mary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the pe ent resident of a single family residential dwelling unitted_within
that dwelling unit.
• Such use occupies no more than 40 square feet of space.
• There are no external alterations to a dwelling which are not customary in residential buildings,and there is
no outside evidence of such use.
• No traffic will be generated in exce s of normal residential volumes.
• The use does not involve the prod ction of offensive noise,vibration,smoke,dust or other particular matter,
odors,electrical disturbance,heat,glare,humidity or.other objectionable effects.
• There is no storage or use of toxi or hazardous materials,or flammable or explosive materials,in excess of
normal household quantities.
• Any need for parking generated y such use shall be met on the same lot containing the Customary Home
Occupation,and not within the r quired front yard.
• There is no exterior storage or pl of materials or equipment.
• There are no commercial vehicl related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot'containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,.the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit.
I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering.
Applicant-,�✓1 f11� S �Ij 1 V P 5 Date• 3- Q^ 1 t0
Homeoc.doc Rev.103113.
f
c TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION.
Map Z 48 Parcel, 9 '18 �� - A lication # 6
pp
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 UN
Owner -50" 60t-1 M WA17-D i'- Address
Telephone s09) g5
Permit Request 'f 'L a*XSTT4& "(,fto UPDAM ?AP
Square feet: 1 st floor: existing vSm proposed 1OS� %�q g p 2nd floor: existing/ proposed Total new
Zoning District P3 Flood Plain Groundwater Overlay
Project Valuation " Construction Type
Lot Size! b US Grandfathered: X Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ilk Two Family ❑ Multi-Family(# units)
Age of Existing Structure a Historic House: ❑Yes It No On Old King's Highway: ❑Yes 10 No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ®Other Iyo��
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new I Half: existing O e w 6
Number of Bedrooms: I existing new
Total Room Count (not including baths): existing _new O First Floor� m Count b
Z
Heat Type and Fuel: ® Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ® No Fireplaces: Existing 0 New Existing woo /coal s#ove: U 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 11 No If yes, site plan review#
Current Use iks-votsoLz Proposed Use 51�a"�iL
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name 13OP k(41*41 Telephone Number OJ3 7-
Address License#
(k4 00tk wuazL)
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO UfM PSG
SIGNATURE DATE ( f Zoo i?
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL N0. T
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: i
FOUNDATION
FRAME d ? to
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL t j
k PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
4 _ I
FINAL BUILDING
DATE CLOSED OUT }
t
ASSOCIATION PLAN NO.
}
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
{ d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLibly
Name(Business/Organization/Individual): _1014A Go4''1m.011J9>J
Address: 14 Ui'c. l-"r-
City/State/Zip: L -V�Li , MA- Phone.#: ($00 q58 - 4 2 1
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner These sub-contractors have listed on the attached sheet. T. Remodeling
ship and have no employees 8. ❑ Demolition
workingfor me in an capacity. employees and have workers'.
y P t�'• 9. ❑Building addition
[No workers'comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs
insurance required.] t. c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp, insurance required.]
"Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy 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 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 statemerit may be foi:warded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby.certify under th s penalties o perjury that the information provided above is true and correct
i afore: Date:
Official use only. Do not write in this area,to be completed by city or town officiaG
.City or Town: Permit/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
[6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers.to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under.any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the-- -"--- - --
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,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 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-coutractor(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 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
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4 ,
ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR
ONE- AND TWO-FAMILY DETACPIED RESIDE NTrAL CONSTRUCTION (780 CMR 61,00)
Applicant Na1i1e: 30141 (30MMt. -_PT Site Address;
P,1,,r
Town:
Applicant Phone: �� qSg - y Zi
App 'cant Signatur Date of Application: D cC, f 2-00y
NEW CONSTRUCTION: (choose ONE of the following two options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW'ONE--AND TWO-FAMILY BTHLDINGS
MAXIMUM MINIMUM
Ceiling or S(ab
0 ti011 1: Basement
"_L Fenestration exposed Walf Floor Perimeter �_
Wall AFUE IIS11i SGIR
U=factor floors R Value R-Value R-Value
R-Value R-Value and Depth
National Appliruice Energy
R-10, Conservatiori Act(NAECA)of
35 R-34 R-19 R-19 R-10 4 ft. 1987 as amended,minimums or
reatcr as applicable
Note: This form is not required if you choose either of the two versions of REScheck as,listed below.
Option 2: REScheck Version 4,1.2 or later variant software analysis must be completed
(780 CMR 6107.3.2)
REScheck--Web which can'be accessed at codes.gov/reschecld
ADDITIONS'OR ALTERATIONS:TO.LXISTING B]Uf ,DfNGS:'OVER S.YEARS OLD*
*Buildings under 5 years old must use option#1 or#2 in New Construction section above.
Complete the following formula to determine the % of glazing:
(a) Gross WallCeiling Area equals I orlrula: (100 x b _ a)
sou SF
100 x 5 qo = foe-3 %-of glazing
(b) Glazing area equals. SF b a
If glazing is < 40% uae.thce chart below. If.glazin is> 40.% proceed to "SUNROOM" :section
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BUILDINGS
MAXIMUM MINIMUM
Ceiling and Slab"Perimeter.
Fenestration Wall Floor Basement Wall
- Exposed floors R- alue R-value R=Value. R-Value
U factor R-Value V and Depth:
3 9 R-3 7 a R-13 R-19 R-10 R-10, 4 feet
R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling
area(i.e. not Compressed over exterior walls; and including any access openings).
SUNROOM-An addition or alteration to an existing bui I dink/dwel ling unit where the total
0 glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the
addition;
Note: . Owner to fill out`Coiiscrmer Infornintzon Form (found in Appendix 120,P)
wr
�aF TKKE ray
Town of Barnstable
Regulatory Services
saxxsxAaLF Thomas F. Geiler,Director
Muse.
Building Division
rFD►M'I
Tom Perry,Building Commissioner
200 Main-Sireett Hyannis,]A 02601_
www.town.barnstable.ma.us
Office: 509-862-4038 Fax: 508-790-6230
HOTA EOWNER LICENSE EXEMPTION
Please Print
DATE: DFc. i t Zt3O
JOB LOCATION: `4-
numb er street village
"HOMEOWNER": SHIN ���1MHig(z-D'i= lJ�® � ��� 4z1
name home p one# work phone#
(::CURRENT MAILING ADDRESS? '
city/town state ap 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 understands the Town of Barnstable Building Department
m;nimum' oa procedures and requirements and that he/she will comply with said procedures and
require Dts.
igna of omeowner
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 fom✓certification for use in your community.
Q:forms:homeexempt
y,
WHET Town of Barnstable
Regulatory Services.
s"xxS. Thomas F. Geller,Director
019. Building Division r'
Tom Perry,Building Commissioner
I�
200 Main Street,Hyannis,MA 02601 E'
www.town.barnstable.ma.us /
1
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign Tl 's Section
If Using A Builder
as.Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work autho 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 WNERPERMISSION
Sep, 16. 2008 3: 15PM No, 4048 P, 1
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apt*tune oFcurtsm4aion with; msMcm horiakf d dtmQrts�'ona� scale: V 30_,
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ott on UnAer Mau. Gaur4laws Ou4p*W40A.-&cttinv7. File N0.-.QL:,J33;�
PLEASE NOTE. The structures: a% shown un this plot plant tire approximale only. An actual Hurvev iy nccex%ary for a precise
determination of the building Itx;.atipn end encroachment%, if any eximL. either wry ticroHx property lines. Thia plan MUHL not be
u%ed far recording purposes or for use in preparing deed deacripilona and must noL be used for variance or bullding plait
purpo�;es. This plea must not he uttrd ui locate property lint%. Verification of huilding locations, property line dimenpions. fences
or lot configuration can only he accomplished by art accurate in%trument survey,.which may reflect different information than what
Its %hown hrreon. Please note that .thiN is "NOT A BOUNDARY SURVEY" v4 ix "FOR MORTGAGE PURPOSES ONLY`
W COLONIAL LAND SURVEYING COMPANY, INC.
269 Hanover Street Hanover, Mess, 02339 Phone: 781-826-7186 • Fox: 781-8264823
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
TQOOC'® S/04-
Map 0 9) Parcel J Application #
Health"Division oo(g Z !/ Date Issued
Conservation Division Application Fee
Planning Dept. _ Permit Fee
F t
Date Definitive Plan Approved by Planning Board AW
Historic - OKH � t1�3a�o?
Preservation/Hyannis
e
Project Street Address �C
Village O L9 i F ZU6
Owner AT�c�W Address y� `_�(,4 2 ,--7- i!L. ;-Tom!-)Z CC
Telephone
Permit Request Xx^ r�(� au y
Square feet: 1 st floor: existing JZ91proposed SZ ' 2nd floor: existing proposed otal new
Zoning District Flood Plain Groundwater Overlay
Project Valuation m. Construction Type
Lot Size lC�, :�Q Fr Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout .POther �,
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing l new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: AGas ❑ Oil ❑ Electric ❑ Other
Central Air: dYes ❑ 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: ,
sv
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes )d No If yes, site plan review#
Current Use Proposed Use M
e-n
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) _
Name yl� � )fr 1 dL" Telephone Number Z37`164
2-
Address 1 ,X�5�� License # ICI D6 b
_r✓/u���v=�.U�� 1 (^�7�3� Home Improvement Contractor# 26q I/Z
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
I
FOR OFFICIAL USE ONLY
F AWPLICATION#
.�r DATE ISSUED
MAP/PARCEL N0.
f
.1 j ..; ..
ADDRESS = VILLAGE
OWNER
DATE OF INSPECTION: '
FOUNDATION
s FRAME
INSULATION
FIREPLACE
•% 10 ..
ELECTRICAL: ROUGH -' FINAL =y
PLUMBING: ROUGH FINAL ,
t
GAS: ROUGH FINAL
FINAL BUILDING
DATE,CLOSED OUT
ASSOCIATION PLAN NO.
1
r
The.Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
`' s�•'� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeFribly
Name(Business/Organization/Individual): 1Z AQ-T K l 17
Address: ��� c �Vmt�,i t.J S`
' City/State/Zip: Phone.#:
Are you an employer? Check the appropriate box: - Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.W 1 am a sole proprietor ro rietor or'P artner-' listed on the attached sheet. T. D Remodeling
ship and have no employees These sub-contractors have g. '❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• 9. ❑Building addition
[No workers'comp. insurance comp. insurance.t
required.] 5. We are a corporation and its 10.0 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 checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature• 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 S.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees.
Pursuant to this statute, an employee is defined as"...every person in.the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall notbecause 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 conThance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or mpensation insurance. If an LLC or LLP does have
partners, are not required to carry workers' co
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 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 Massachusetts
Department of Industrial Accidents
Office of Iavestig a'do'ns.
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-774
Revised 11-22-06
www.mass.gov/dia
' The Commonwealth of Massachusetts
Department of Industrial Accidents
I.: Office of Investigations
' 600 Washington Street
Boston, MA 02111
yy www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ��j�� � j
Address:9-C9- S.", 51//
City/State/Zip: aj '� 7-
1"(�9_tes�,s<e�- �� lJ?-6 % Phone #: , 8
Are you an employer? Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. 01 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. PgzRemodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.1
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=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 jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 certify under the pains and penalties of perjury that the information provided above 's 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#:
S
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-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 pen-nit 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 do license or permit to burn leaves etc. said person is NOT required to complete this affidavit.
( g P ) P q P
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
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
A FYC Guirle to Hlood Cojis•trecction in High 1 Yind.�r•ecrs: 110 mph Wh-1 l Zorl.e
Massachusetts Checklist for Compliance (780 CNIIR 5301:2.1.1)1
Check
Compliance
1.1 SCOPE
WindSpeed(3-sec. gust).................................................................. ..........:..................................... 110 mph
Wind Exposure Category..................................................................
Wind Exposure Category................Engineering Required For Entire Project .......................................0
1.2 APPLICABILITY
Number of Stories(a roof which exceeds 8 in 12 slope shall be considered a story)�_stories 5 2 stories
Roof Pitch ....................:.........:...................:........................(Fig 2) ........................................... _ 512:12
Mean Roof Height .....................................................:........(Fig 2)................................................. ft 5 33
Building Width,W ................................................:..............(Fig 3)...................:.............................ft 5 80'
Building Length, L ..............................................................(Fig 3)..................................................5ru ft.s 80'
Building Aspect Ratio(L/W) ...............................................(Fig 4)................................................. 153:1
Nominal Height of Tallest Opening2 ...................................(Fig 4)................................................ 5 6'8"
1.3 FRAMING CONNECTIONS
General compliance with framing connections....................(Table 2)...............................................................
2.1 FOUNDATION
Foundation Walls meeting requirements of 780 CMR 5404.1
Concrete.............................................................................................................................. ✓✓
ConcreteMasonry.................................................................... ......:.........................................
2.2 ANCHORAGE TO FOUNDATION".
5/8"Anchor BoltsTimbedded or 5/8"Proprietary Mechanical Anchors as an alternative in concrete only
Bolt Spacing—general ........................................:.(Table 4)................................................ —&-in.
Bolt Spacing from endTjoint of plate ................:............(Fig 5).... ...............................__j6—in. 6 .12"
Bolt Embedment—concrete.........................................(Fig 5).....................................:..........._in.>_7"
Bolt Embedment—masonry.........................................(Fig 5).....:......:............................... in.>_ 15"
Plate Washer........................... ..
3.1 FLOORS
Floor framing member spans checked ...............................(per 780 CMR Chapter 55)...................................
Maximum Floor Opening Dimension...................................(Fig 6)................................................... ft 5 12'
Full Height Wall Studs at Floor Openings less than 2'from Exterior Wall (Fig 6)...... ....I.........................
Maximum Floor Joist Setbacks
Supporting Loadbearing Walls or Shearwall................(Fig 7)..................................................... ft _<d
Maximum Cantilevered Floor Joists
Supporting Loadbearing Walls'or Sheanaall................(Fig 8)...................................................... ft .5 d
Floor.Bracing at Endwalls....................................................(Fig 9)...................................................................
Floor She Type ........................................................(per 780 CMR Chapter 55)...................................
Floor Sheathing Thickness .................................................(per 780 CMR Chapter 55)....................... in.
Floor Sheathing Fastening..............................................:...(Table 2).._d nails at in edge/_in field
4.1 WALLS
Wall Height /
Loadbearing walls...... ...:.............................................(Fig 10 and Table 5 ft :5 10,
Non-Loadbearing walls................................................(Fig 10 and Table 5)...........................7 ft 5 20'
Wall Stud Spacing ..........................:.............................(Fig 10 and Table 5)..................... in.5 247 o.c.
WallStory Offsets • .....................................................:..(Figs 7&8)............................................_ft 5 d
4.2 EXTERIOR WALLS
Wood Studs
Loadbearing walls......................................................:.(Table 5)..............................2x , -_2 ft E! in.
Non-Loadbearing walls.................................................(Table 5)..............................2x-_(,� . _ in.
r
Gable End Wall Bracing'
Full Height Endwall Studs............................................(Fig 10)..................................................................
WSP-Attic Floor Length..............:.::.............................:(Fig 11)............................................. ft zW/3
'Gypsum Ceiling Length(if WSP not used)....:............:.(Fig 11)............................................_ft>_0.9W -
and 2 x 4 Continuous Lateral Brace @ 6 ft.o.c. .. (Fig 11).............................................................
or 1 x 3 ceiling furring strips @ 16" spacing min. with 2 x 4 blocking @ 4 ft. spacing in end joist or truss bays_
Double Top Plate
Splice Length ........................................................(Fig 13 and Table 6)....................................AZ
cnlira r.nnnartinn (nn of 1Rd rnmmnn nail.-,)..............(Table 6)......................................................... E,-/
AWC Ctlirle to Id"Uod Col'stl'll t101! lil. Hi ,h I.-Viiid Areas: 110 inph Wind Zolte
Massachusetts Checklist for Compliance (780 Ci\11115301.2.1.1)'
Loadbearing Wall Connections
Lateral(no.of 16d common nails)................................(Tables 7).....................................................
Non-Loadbearing Wall Connections
Lateral (no.of 16d common nails)................................(Table 8).......................................................
Load Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9)
HeaderSpans ........................................................(Table 9)..................................IL ft in.<_ 11'
Sill Plate Spans ........................................................(Table 9).................................. 51 ft in. 5 11' .
Full Height Studs (no. of studs)....................................(Table 9)...:...................................................
Non-Load Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9)
HeaderSpans.............................................................(Table 9).................................. S in.-< 12'
Sill Plate Spans.... ..................:................................ ...(Table 9).................................. ift_in.5 12"
Full Height Studs (no. of studs)....................................(Table 9).......................................................-2—
Exterior Wall Sheathing to Resist Uplift and Shear Simultaneously4
Minimum Building Dimension, W E E
Nominal Height of Tallest Opening2 ................................................................ 6 5 6'8"
SheathingType..............................................(note 4)......................................................
Edge Nail Spacing.........................................(Table 10 or note 4 if less)........................_in.
Field Nail S acin ........... Table 10 ..........I.......... ...................... m.
P 9...........................:... ( ) .
Shear Connection(no. of 16d common nails)(Table 10).......................................................
Percent Full-Height Sheathing...................:...(Table 10).....................................................a%
5%Additional Sheathing for Wall with Opening> 6'8"(Design Concepts)....................
Maximum Building Dimension, L
Nominal Height of Tallest Opening2 1�
........................................................................ 5 6'8e
SheathingType..............................................(note 4).....................................................
Edge Nail Spacing .................... Table 11 or note 4 if less ........................ in.
FieldNail Spacing.......................................:..(Table 11)................,................................ in.
Shear Connection(no. of 16d common nails)(Table 11).................................................... .._
Percent Full-Height Sheathing.......................(Table 11)............................................:.......�%
5%Additional Sheathing for Wall with'Opening> 6V(Design Concepts)....................
Wall Cladding
Ratedfor Wind Speed?.............................................................. ...............................................................
5.1 ROOFS_
Roof framing member spans checked?........................(For Rafters use AWC Span Tool,see BBRS Website) e�
Roof Overhang ...................................................(Figure 19) ............. ft 5 smaller of 2'or U3
Truss or Rafter Connections at Loadbearing Walls
Proprietary Connectors
Uplift................................................(Table 12)............................................U= plf
Lateral.............................................(Table 12).............................................L= plf
Shear............................:..................(Table 12)............................................S= plf
Ridge Strap Connections, if collar ties not used per page 21... (Table 13)...............................T= plf
Gable Rake Outlooker..........................................(Figure 20) ............._ft 5 smaller of 2'or U2
Truss or Rafter Connections at Non-Loadbearing Walls
Proprietary Connectors
Uplift.......................: (Table 14).................. -
Lateral(no. of 16d common nails)...(Table 14).......................................L= . lb.
Roof Sheathing Type................:..................................(per 780 CMR Chapters 58 and 59) .............. LZ
Roof Sheathing Thickness.....................................:.....'............................................. e yin.->7/16'WSP
RoofSheathing Fastening............................................(Table 2).............................:..........................._
Notes:
1. This checklist shall be met in its entirety, excluding the specific exception noted in 2, to comply with the requirements of
780 CMR.5301.2.1.1 Item 1. If the checklist is met in its entirety then the following metal straps and hold downs are,not
required per the WFCM 110 mph Guide:
a. Steel Straps per Figure 5
b. 20 Gage Straps per Figure 11
c. Uplift Straps per Figure 14
d. All Straps per Figure 17
e. Comer Stud Hold Downs per Figure 18a and Figure 18b
2. Exception:Opening heights of up to 8 ft. shall be permitted when 5% is added to the percent full-height sheathing
requirenlents shown in Tables 10 and 11.
3. The bottom sill plate in exterior walls shall be a minimum 2 in. nominal thickness pressure treated#2-grade.
Y►,�T � Town of Barnstab4e
4
Regulatory Services
4 4
Thomas F_Geiler,Director
Building Division
Tom Perry, Building commissioner
200 Main Street, Hyannis,MA 02601
1VWW.town.barnstable.m2.us
Office: 508-862--4039 Fait: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subt ct property
hereby authorize Yl` ti to act on my behalf,
in all matters relative to work authorized by this building permit application for.
i�Y
(Address of Job
� 5
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
y
,
Town of Barnstable
�pF THE Thy .
o Regulatory Services
ttuvszwsr� Thomas F. Geiler,Director
tt�ss
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
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
'—""HOMEOWNER":
name home phone# work-pbonc#
CURRENT MAILING ADDRESS:
city/town sta� ap code
The current emption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow hpzneo ers to engage an individual for hire who does not possess a license,provided that the owner acts as
super Visor.
DEFINITION OF HOMEOWNER
Persou(s)who owns a p, el of land on which he/she resides or intends to'resid on which there is, or is intended to-
be, a one or two-family dwe g, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more one home in a two-year period shall not be considered a homeovmer. Such
"homeowner"shall submit to the . 'lding Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work erform under the building ermit. (Section 109.1.1)
The undersigned"homeowner"assumes resp ibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The undersigned"homeowner"certifies that_he/she under ds the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he e will comply with said procedures and
equrizements.
Signer of Homeowner
Approval ofBuildin Official
Note: Three- y dwellings containing 35,000 cubic feet or larger will be required`to comply with the
State Building Code Sech 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that "Any Qmeowner performing work for which a building permit is required shall be exempt from the provisions
of this sectign.(Section 109.1.1-Lieensmg eanstruction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supcm
Many homeowners who use this cxcmp are
unaware that they are assuming the responst'bilities of a supervisor(see Appendix Q,
Rules&Rcgulatians for Licensing Construction Sup ' ors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this cas , ur Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately sponstble.
To ensure that the homeowner is fully aware of his/her onsrbilitics,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities 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 fomJccrvfication use in your community.
Q:forms:homccxcmpt
ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR.
ONE; AND TWO-FAMILY:DETACHED RESIDENTIAL'CONSTRUCTION (780 C1YIlt 61.00)
Applicant Name: -1 Site Address: CAME
print Town:
Applicant Phone:
Applicant Signatur(-.: ' Date of Application: /`
NEW CONSTRUCTION: choose ONE of the following two•o Lions
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELv^PE CCMPONENT CRITERIA FOR
NEW ONE- AND TWO-FAMILY BUILDINGS
utvt 'MINIMUM
Ceiling or❑ Slab Option 1: Fenestration exposed Wall Floor Basement perimeter
Wall .AF'UE HSPF SEE1
U-factor floors � R-Value R-Value R-Value R-Value
R-Value and De th
National Applianc -F-mrgy
3 5 R-3 8 R-19 R=19 R-10 R--10, Conscrvalion Act(NAECA)of
q ft.• 1987 as amcndcd,minimums or
cater as applicabir,
Note: This form is not required if you choose either of the two versions ofREScheck as listed below.
❑ Option 2: RES check Version 4.1.2 or later variant software analysis must be completed
780 CMIZ 6107.3.2
REScheck-Web which can be accessed at http-//www.entrgyCDdeS.gDv/rescht--r-kl
ADDZ O1�T5'ORAX,T RA`I)DNS.TOEXISTZNGBUII,DXN S.OVER•5YEA.RSOLD*
*�3uildings under 5 years old must use option#1 or 42 in New Construction section above•
Complete the following formula to determine the % of glazing:
(a) Gross Wall & Ceiling Area equals Formula: (100 x b _ a)
`f-"-=—SF 100 x • _�V% of glazing
(b) Glazing area equals SF b a
If 'lazin i.s:�: o,.use the chart bblow. If giazing is > 40 % rocee,'d to "SUNROOM" section
780 CYIR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BTJH DINGS
MAXIMUM hOqIMUM
j Ceiling and Slab Perimeter
�J Fenestration -Wall Floor Basement Wall R_value
U-factor Exposed floors R-Value R-value R-Value
R-Value and Depth
.39 R-37 a R-13 . R-19 R-10 R-10, 4 feet
a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling
area(i.e,, not compressed over exterior walls, and including any access openings).
'
SUNROOM-An addition or alteration to an existing building/dwelling unit where the total
FJ glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the
addition.
Note: Owner to fill out Consumer Information Form found in A endix 120T
u
- it mLoN , riF ,vFverT .� nF +W:
i m T
lL P - D - 5
i'
s ''Board of Bu►tdmg Regulaho sand Standards
eivisor License f
_Xffl
I r �: Construction Sup,_
dens CS 99060
a ,.. Tr#''99060 I
Ex irat on -812011 v
�i - '
Restr�ic ton I >,
r r } 1
f KYLE rNICDEUITTr
PO BOX`541 .. t . oft r
MA 02 3 -
Commiss►o.
. � , CENTERVILLE �
Board of Bupdmg RegulatIons.;and Standards`'•
HOME IMPROVEMENT CONTRACTOR
( Regist (ram'Rn, ,159932> 77
Ex Craton 11/2010' TW 269476 '.
iYpB
f '
;K J MCDEVITT QUILDINGMEMQ ELING
KYLE MGDEVJTT o
2. 8 HUCKINS NECK,Rjj f E
CNTERVILLE MA 02632 f �
Admm�s(�ator } '
FLic
f, ense or registration,v , .
before the ex aLd for mdrvitlul;use on] t
'3 Board`of piration date ififound Y
Bmldin return to ;' gRegplationsand
Ashbu Standards
kJ ;-,One ; . rton,P1
.Boston,Ma 02108 Ce Rm 1301
i Not valid without si' r '
gnature
_,
O
t
REFERENCES:
Assessors Map: 248
Parcel: 018
Deed Book 231921260
ZONE:RB
Setbacks:
Front: 20'min
Side: 10'm in
Rear: 10'min
CB/DH
FND IVIF
Karl Kudenchok o
�m
�n►`` S8131'50
W 108.50'
Lot 1
Qj 10,456t SF
- New Concrete Block Foundation 24.3'
(Under Or/g/na/Add/t/on)
o � W
.4.2'
h
Q) o # 14 �o
WZ 1 sty Con c
Dwelling
n` Q5
W cj
,N
o
0
COt?C S/(7b
e
C81
w/f 1 D.9'
FND Shed
ND
N8131'50,,w
Qj
100.62'
Terri NSF
L Plifko 0
11.4' V
WHARD tiG
R PLOT PLAN
� uRrux
343t2 y At 14 Bee Lane
67//Wlvx/o
BARNSTABLE
Professional ) a Surveyor D to (Centerville)
NOTES: . MASS.
DATE: 07/MAY109 SCALE: 1"--20'
,,.) The structures shown were located on the ground 0 5 10 15 20 30 40 FEET
�y conventional survey methods on 06/MAY/2009.
PREPARED FOR:
2.) The property line information shown hereon was Elizabeth Bommhardt
compiled from available record information. 45 Swift Ave
Osterville MA 02655
3.) This. plan is not for recording and is not to be
used for .deed description purposes. PREPARED BY: CapeSury
7 Parker Road
Osterville MA 02655
DWG #: C735gl FIELD BY. RRL/MLL (508) 420-3994 / 420-3995fox
yati - 60sJ
C �75 � tial �
H OF MASSACHUSETTS
dustrial Accidents
n Street, 7th Floor
sachusetts 02111
1
JOHN C. CHAPMAN
Commissioner
A
fidavits per M.G.L. c. 152, §25C (6)
s
ual reminder that Massachusetts law requires that
a license or permit from any city or town agency
ensation Insurance Affidavit prior to receiving said
,� issue a license or permit without first receiving a
�� 1S REFERENCES:
Assessors Map: 248
Qk Parcel: 018
Deed Book 231921260
ZONE:RB
` Setbacks:
Front: 20'm in
Side: 10'min
Rear: , 10'min
CB/DH
FND m
N/F
Kori Kudenahok
S8131 50"E z m
108.50, o
Lot 1
10,456±SF A)0 AD DZ71 orJ AS a rJ yl/s
New Concrete Block Foundation ONLY 24.3
(Under Original Addition)
� 4.2'
O
o CO p
h
^� Z # 14
W 1 sty Conc
Dwelling
^\ s2.s
9
o
Cony S/ob
CB/DH w/f 10.9'
FND Shed
N8131 50»w
100.62'
N/F .
Terri L Piilko o 'I
11.4' U
SH OF
RICHf1RD yGN
R. a
IHEUREU.X PLOT PLAN
8302 v At 14 Bee Lane
e ,
B.4RNS1"ABLE
Professional 0n Surveyor D to (Centerville)
NOTES: MASS.
DATE: 07/MAY109 SCALE: 1"-20'
1.) The structures shown were located on the ground 0 5 10 15 20 30 40 FEET
by conventional survey methods on 06/MAY/2009. 71
PREPARED FOR:
2.) The property line information shown hereon was Elizabeth Bommhardt
compiled from available record information. 45 Swift Ave
Osterville MA 02655
3.) This plan is not for recording and is not to be
used for deed description. purposes. PREPARED BY: CapeSury
- 7 Parker Road
Osterville MA 02655 i
DWG #: C735gl FIELD BY RRL/MLL (508) 420-3994 / 420-3995fox
:�$ / ��--�— �� '�
lz � .: `
+rrr --
�� i;=t, >✓1 cti,:U, 1 �a x 1, � .�perr �.�,, ��� i i,'�-,
�c
,�I� /lid ��
10
.I� f `
f� 4-/ ,r l ..,ter !.
k O i
i
Is
re. 2(1 r.L, 2?.p r'_.._ -j-lood, zZ-0tic,-
FAUL.
I .9 � i . I red— fit o T.
tGFOVER
i! it e •'r•,. v 7/ 1'/� i �' -�;'^/�(�.4'?,��:: I .} Nn 1 J t i Y :
i J�''I�/JJv IVYLC� �.•j��L��ill .�.:C'' 'l�(�(� 4•:C�i 4h .� '."... I _ �� .
I cl"p+, afi1 l�dr 1C`11Vtt h CCt71i.,��'t�{JS �1.G% jG�+1. m a, .,pF:da
any wiliti an efFeotWe date, o fc?-b; anl1-dU l">cCLt1om I,� ;
the c�i,>=ac;i liter r,�:� confor- ?it to the lcx l ,u ng 6y-tM,0 t! C f We- i '
oFc,- 'tSt1"I.iawn With t e5peatc, li.(?D^1.?ot1�GT�yl���iSZL3YLSloC�tT�I St�tle: 1" 30 _
tr• ,e Dat
_
v�Gt LG',t. t iYt @r Mass, &cri-eraL � L?vQ5 L�'Ciaptrr,40 A C;�-1c�1Z '!. F' ie No
-----'- �
--- -- -•-.- --.-..— , dr: oU4[ ,,IiTlat( o':IV A7; ..1.'li sarvt;4 :S n('(.e„rn +or a p'ecise -
PLEASE NOTE: The ,trt c u s, hown on to plot plar, "
:ietermlu� lU'! l cross rr Opf }' lines. This nU,l not nC
( the location hn( 'e R7 1 F c t
1 used f)r rltL0rding purpose.. C••-; !ot u,e :n preparing deed (il crlpt.wn; land must ni`l he usco for vdr.anc( or buliding plan
i)urpo,: This slat, :i,ust nut : Y cd to locate pn)t;ert} !tn(, ctlflcatton of h,ildine lo(.atiorts, propert line dimension,, fences
c}r ;ot Co .!Jrdtum can 0M )c a+-.u-nplished h,; a,'; a(. u!ate It , ur;:ent survev wiich Inai reflect d:+ter(tnt t_tto:nattna tiara. what
s lul,r:n hereon. Please note that. tht> Is 'NOT A BOU',DARY SURVEY" and is "FOR MORTGAGE PURPOSES ONLY" --_ --
COLONIAL LAN L� fit;R d ��Y ING COMPANY
269 Hanover Street Hanover, Mass. 02339 - Phone: 781-826-7186 Fax: 781-826-4823 - ---
.� tl
O O
100- 25
shed
16.5 `O 34.01
o
10. t HOUSE-14LO
f
M
30
` V
Q) Q'
VI
M O 0
` 6
O
LOT l LOT 2
r
1
1
` /00. 00
BEE L A NE
NOTE: PRE-EXISTING NONCONFORMING.
RES.ZONE:RD-1 FLOOD ZONE:C
THIS MORTGAGE INSPECTION PLAN IS FOR
BANK * SE ONLY
TOWN:. CENTERVILLE REGISTRY OWNER: PE -
DEED REF: 3746 210 BUYER: FELIX & EMMA E. GARCIA
DATE:- 11/19/88 PLAN REF: 351/93 SCALE: 16=
hereby certi y .t at the building
shown on this plan is located on � �� Of VA N KEE SURVEY
the ground as shown and it �� CONSULTANTS
position does cantor= to the = PAVL� 70 RASPBERRY.LANE
MER
zoning law setback requirement of NNm320M y MARSTONS MILLS
MASS 02648
and d RARNSTARLE oes not lie within the special A9g`ESS1p�P�
flood hazard area as shown on �qNO SUR����
the h.u. . flood map dated
This Plan not Cade from an instrument 4809
Paul A. Merithew, RPLS survey, not to be used for fences etc
°PIKE r� Town of Barnstable
Regulatory Services
M it
■ M
* sa ASS. a
Mass.
Thomas F. Geiler,Director
Fc;pr"��� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
March 20, 2009
John Bommhardt
14 Bee Ln.
Centerville Ma. 02632
RE: 14 Bee Ln., Centerville Map: 248 Parcel: 018
Dear Mr. Bommhardt:
As you may recall, this office issued a building permit to remodel the interior of the
existing house on the above referenced property. However, upon inspection it was
observed that the work being performed has exceeded the scope of work approved.
Specifically, a new foundation has been installed. Subsequently:
In accordance with 780 CMR 5118.6 you are hereby notified that a stop work order
has been issued on the above property.
This foundation was not included in the approved application package and further review
of the property has shown that the foundation encroaches into the required setbacks. As a
result, a variance issued by the Zoning Board of Appeals is necessary to proceed with the
work.
Please call (508).862-4034 with any questions and this office will be happy to assist you
in the process. Thank you for your anticipated cooperation in this matter.
By Order,
aryL Lauzon
Local Inspector
Q zoning5
• °FIME A Town of Barnstable
Regulatory Services
* BARN Thomas F.Geiler,Director
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
March 20, 2009
John Bommhardt
14 Bee Ln.
Centerville, Ma. 02632
RE: 14 Bee Ln., Centerville Map: 248 Parcel: 018
Dear Mr. Bommhardt:
As you may recall, this office issued.a building permit to remodel the interior of the
existing house on the above referenced property. However, upon inspection it was
observed that the work being performed has exceeded the scope of work approved.
Specifically, a new foundation has been installed. Subsequently:
In accordance with 780 CMR 5118.6 you are hereby notified that a stop work order
has been issued on the above property.
This foundation was not included in the approved application package and further review
of-the property-has_shown.that_the_foundation encroaches into.:the required setbacks. As a
result, a variance issued by the Zoning Board of Appeals is necessary to proceed with the
work.
Please call (508) 862-4034 with any questions and this office will be happy to assist you
in the process. Thank you for your anticipated cooperation in this matter.
By Order,
f.
re L. Lau on
Local Inspector,_,,,.
Q:zoning5
i
1
l,,�6ci GLDR—
CoMPt-� w f� �
fi , 19E
{
1HE TOWN OF BARNSTABLE. Building ,
Application Ref: 200905107
BARNSTABLE, Issue Date: 11/30/09 Permit.
9 MASS.
�p i639- �� Applicant: MCDEVITT�KYLE
Permit Number: B 20092318
Proposed Use: SINGLE FAMILY HOME Expiration Date: 05/30/10
Location 14 BEE LANE Zoning District RB Permit Type: RESIDENTIAL ADDITION/ALTERATIO
Map Parcel 248018 Permit Fee$ 25'.00 Contractor' MCDEVITT,KYLE
Village CENTERVILLE App Fee$ 50.00 License Num 99060
Est Construction Cost$ 4,500
Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND
REBUILD PRE-EXISTING FOYER THIS CARD MUST BE KEPT POSTED UNTIL FINAL
INSPECTION HAS BEEN MADE. WHERE A
CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH
Owner on Record: BOMMHARDT, ELIZABETH 8i BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL
Address: 14 BEE LANE INSPECTION HAS BEEN MADE.
CENTERVILLE, MA 02632
Application Entered by: JL Building Permit Issued By:
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY`STREET,ALLY.OR SIDEWALK OR AN ART TH I ERTEMPO RILY'OR PERMANENTLY;:
ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING,CODE,MUST BEAPPROVED BY THE"JURISDICTION.
STREET OR ALLY-GRADES.AS WELL AS DEPTH AND LOCATION OF PUBLIC.SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS:
THE ISSUANCE OF.;THIS PERMIT,DOES NOT RELEASE THE APPLICANT FROM THE CONDiiIONSOF ANY APPLICABLE SUBDIVISION,RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK:
1.FOUNDATION OR FOOTINGS.
2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED.
3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION.
4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). -
5.INSULATION.
6.FINAL INSPECTION BEFORE OCCUPANCY.
WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS.
WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. i
PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF
DATE THE PERMIT IS ISSUED AS NOTED ABOVE.
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A).
.. � �.
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
2 2 2
3 1 Heating Inspection Approvals Engineering Dept
Fire Dept 2 Board of Health
0F1HE rot Town of Barnstable *Permit#
Q� p Expires 6 nronths from issi date
Regulatory.Services Fee
* BARNSTABLE,
639; Thomas F. Geiler, Director
ATfD MA'S A ���'2T�V
Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street,.Hyannis,MA 02601
www.town.barns table.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 �� j Ole)
� 1
Property Address j — 'Al IY e 7�5'0 V/X-L-'!� 0A '9-
Residential Value of Work «o0.w Minimum fee of$2S.00 for work under$6.000.00
Owner's Name& Address ALA A, qA✓4 �1�
Contractor's Name_ ���'!�� Telephone Number
Home Improvement.Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance �� IT
Check one: .
❑ .I am a sole proprietor
[ZI am the Homeowner
OCT 23 2008
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Req st(check box) o
Re-roof(stripping old shingles) All construction debris will be taken to7regulations,
F•M —
e roof (not stripping. Going over existing layers of roof) w❑ Re-side❑ Replacement Windows/doors/sliders. U-Value (maximu ,� r
*Where required: Issuance ofthis permit does not exempt compliance with other town departmetoric,Conservation,etc.
*'F*Note. Property Owner must sign"Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required.
SIGNATURE:
Q:'WPFIi..ESTORMS'.huiUng permit Forms\EXPRESS.doc
Revised 100608
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
' d 600 Washington Street
Boston,MA 02111
�,. ,.•�' www.mass.gov/din
Workers'- Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluirtbers
r p
Applicant Information
Please Print Le gib
Name (Business/Organization/Individual):
Address: /e L/l.,a ._s' OVA, 7F"g V/�-� �1 � 0�c5�
City/State/Zip: z Phone-#:
Areyou an employer? Check the appropriate box: .Type of project(required):.
1.❑ I am a employer with 4. ❑ I am a general contractor and I
have hired the sub-contractors 6, ❑New construction .
employees(full and/ox part-time).* 7. Remodeling
2.❑ I am a'sole proprietor or partner- listed on the'attached sheet. ❑ g
ship and have no employees These sub-contractors have g, ❑Demolition
w employe and have workers'
'working for me in any capacity. 9. [❑Building addition
comp. insurance.$
o workers comp,insurance 10.❑-Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
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 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 Homeowoers.wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
X 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:OR.DER and a fine
of up to$250,00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations.of the MA for insurance coverage verification.
X do hereby certify under the pains•and penalties of p. erjury that the information provided above is true and correct.
Si afore: Date: e.' d _
Phone#:
Official use only. Do not write in this area, to be completed by cty or town offcciaG
City or.Town: Permit7License#
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#:
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an em in the service of another under any contract of hire,
ployee is defined as "...every person
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 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 ehapter..152, §25C(7)states"Neither the commonwealth nor any of its political subdivi ions shall
enter into any contract for,the performance of public work until acceptable evidence of co:npliaaee wi#h 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), addresses) and phone number(s) along with their certificates)of
insurance. Limited Liability Companies'(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 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 then
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 fo 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 Depuiment's address,telephone-and fax number:.
Th(z C0MMQRW(,-an of Ma,ssaQhWetts
• �1��a�tmei�t of Ind�st�a�A.cezc�e�.ts
Office, of layestlgat.ans
60 Wash atop Street
Bostama_MA Q2111
TeL #617-727-000 ext 40, or I-S77-MASSAFE
Fax##6-17427»774
Revised 11-22-06
WWW.matsss .g0v/dia
v
J
I -
of z�
Town of Barnstable
H t ,
Regulatory Services
BARNSTABLE, : Thomas F. Geiler,Director
MASS.
9�A 019 a,�� Building Division
leQ � Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: S08-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: �C� �J: L 0 0 9,
JOB LOCATION: I—A A/' C a 1,446'
number street village
"HOMEOWNER': A/Dr V d .5� �ozc�'' 5�- Z%F .X-411 I A77:
name home phone# work phone#
CURRENT MAILING ADDRESS: .X
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. s
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures, A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The:undersigned:"homeowner"certifies that he/she understands the Town of Barnstable Building Department:
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements." `
?ignaturc of H eowner
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 5
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 fomilcertification.for use in your community.
Q:forms:homeexempt
VIE Town of Barnstable
Regulatory Services
EARNSIy MM sa $ Thomas F. Geiler,Director .
i634. ��,
Fo��a Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: S08-862-4038 Fax: S08-790-6230
PropertOwner Must
Complete;end Sign This Se 'on
Using A Build
j,
r
0�
I, i , as Owner of the subject property
hereby auth `' to act on my behalf, .
in all matters relati e, o work th d by this building permit application for:
(Address of rob)
S' na f er Date
CT• , i1
P tN e
If Property Owner is applying for pe it please complete the
Homeowners License Exemption Form on the reverse side.
n•PnPkAQ nUTMPT?PPT?X(TCCTnU
l- �TME
. "�. The Town of Barnstable
• aAMsrABU& •
9e� 'M .•� Department of Health Safety and Environmental Services
ArED5.tto Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
SHED REGISTRATION
Location of shed(address)
GL �� G C1y`CIyr1
Property owner's name Telephone number
X I0 0 . 8
Size of Shed Map/Parcel#
r �
Signature Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature required)
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
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