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Home My WebLink About1222 BUMPS RIVER ROAD eel77 .:... r .. ::'* ,...,-...,.). .. .. r.: .., w. ... �. . ,.,-...• a�'<,. "..3, �:! fR: � 49d.r ,: ,.r� w� 'r !+ [ Sx �3�, r � i .. c a - .. ��`e 41 �;�rZ �• 1ii{�• �,t��rY dr.. t.e �K,� � 3 . 3 ;F �. 5} it. t , � r 0 r; TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map, Parcel BARNSTABLE Application # Health Division "' ! #� ;. Date Issued Conservation Division Application F d Planning Dept. Permit Fee •��tj f Jy� pfi � Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address L)/—tj�!5 9/ VZ--;e Village Owner /-I Rt &u Ad >Rti 6-&t e> Address Telephone " .7 2 l - -33 0 _ cl q"Z S Permit Request (3 U r L--D 2a `�Ib 7 C�- C,l._-, 77 r_Z9 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District 1Z S Flood Plain Groundwater Overlay Project Valuation 0 Construction Type ,Lot Size h.w p c.4 r.1 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family 0 Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing i 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: ❑ Gas YOil ❑ Electric ❑ Other Central Air: ❑Yes JKNo Fireplaces: Existing LO New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: UYe'xisting ❑ 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 _ i,k��A� !-�L b l�r D Telephone Number - � �= ` -7 ,Address 111 56e/b[.c/n �' �vE t �J et,��_ License # Home Improvement Contractor# Email I (tu'i•c�2YL lei �� (29►1' . QM Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO D d R I SIGNATURE bt&`4- -'`" DATE ,,w FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. y ADDRESS VILLAGE Ir _ r; OWNER DATE OF INSPECTION: FOUNDATION 6r- P� °►"` F�ZS / II . { FRAME o►�` P(�a v►, z S6 a ;. INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDINGjo a - R~ DPoTrE�CLOSED OUT Ff AS SATION PLAN NO. r t j e . Vl ��g �� l SLY • . bo ' Ituems( co,Zr,L 12b`i Ltyq Fill 5 R I G G I G M P tit 22� FVVC �iC.0 V t LLC Zwstzmi�HA t2M Wm-ke&C'np Trrcrrr—"� avit:Bufldpts Cmxh��Fri�rralFlFmrr rg Dame Axe yEm an em*yer?Catckffm ajpxvpxiah�bcr rye of P7.0jectr I ❑ I am a empkurcrwiftri El'0 I�aaI rtxTf�rh sr��I I4Tew =gAOye=(fill andlor ).*' hay Sze the oss I am a soIe.prcpddar orparker- listed on The wed sbmt 7- E egg M ship and bare na emplayms sub-ao ha $- ❑ �me is spy ' : �e layeeshav�wa�ais' 4- ❑Bns�Cimg addifiau [Tb- `Comp_terra 1 5_ ❑ We ate a carpara�cnand its Ifl 0 EIPr Ec; �ar a---ms �_❑ I am a homwumr doing ail wmk' c fE=have emrvisea$itir IT 0 pig mpg w mans =Y-C-Sf INC),WC6 a'=mp- riOt cif cmmopfioa per MCN- i nce T, c-I5Z tI{4,aadwe�e� �$nt¢n pairs ; I. ICE Asher '�i2; • �°Y�-[Nam ' camp_msoxance nmFEre3 "13�g fina chedbar;�I amstalsn oytttmnbeIurPs �ffiei=wo�s>st mmnauped�- #S wnesubu srlb=-JM EmdzY;.i 6zy m m�--n b +*e o co n=R c m=amstsvbc as dsc�iian sucI� lC Etacnistairl-ckthL-bmc=astatmJudxM-9fHr;—lSbOd m xbdEvhEftwrw atfmsejsif h--e- �iay�s_ rft a SBhcm Iv^re rrmnT��,rhe�mmt paai&fadr tom erg-poiicy mob¢ • , .�vtrt'a�atatj�7�p�i�isgrxrsviza,�workers'cottgr�rsxdin�t arre,�rrr�a•fa{ rrz� y� BeiotF is ffte.pgi�used jeb sits. lob�am Adarzsx Cs fSta Tsg= • AjUzch a:cqPy Gft�vm�cDraP==tirm pall:�d.C�{1.OII Jsa$�(slxrtrmg.�F6Hy Ii'�ET aIIti D2i�3��: Fzpnxe to secmtt cage as mquirn6umcTer Sec&m-25A of lMCii.,r-152 as I mil to the imposifiaa a�criminal.pcnzl of$ file ap to LSOQ(}D audlaz 1 as veu ar curl P=Zlfies m ffm fod-of a MP VJDFK ORUER-and a E,21-- cd mp.fv$250-DG a dap agmint tint viol-stor_ Ike alivisad tat a copy of ffiis sly maybe fxwarded to the Of Fmd of' Eons of the DIA ihz msman_m couemga v=Et-afiaa F rya hWbY=46F wullr-tR- dpa abyl r r up$fatflre u irxza#rrta pravzd absve is hua�rt�ca srt z &,A/ f tcia:L trss a* Ir rsat wrar is 9r area,irr ba cad by#�F ar tam rrf c&£ ai y ar Town $ Pera h`r m ease - . LSaud�fl3eaT� �: �-�{��Fat�¢f�s� �..�Iec�ricallas�ecfar �_P�:n�I {-or. afhrr cater: pI N�G=Exal Laws cater l52 requires all mnployeas to provade worker'Comp—tenon fix their erdpIoy"sa PMM2Z t-•fD t3nis staff an mwp&T=is denned as -every Prier¢in.ffie sm-yim of mother under any Curtract ofTiffe, or fimp&ed, oral orwt>ttrn." �4n ernprvpea-is domed as 4aa m raT par=sbm,assoeiafion,c;orporatlnn or oflier legal enfify,ar any two or mare bf$ne fbregomg®gaged m aJomt eadmpuse,and m'gibe legal re ves of a deceased employeT,-or the receives or=nstee of an ma ' al padnembip,assorbon or other legal entity,emplayiag=:PloY( 3oVever the owner of a dwelFmg house having not mare$era i3nee apattmm:ds and who resides thea•em,cr tine occupant of the dwellmg house of another who ea:plo-ys persons to do ice,cons rucEm or repair work on such ftclI mg house or on the grounds or building app therdb shall not because of inch employm,-.1af be deemed to be-an employer." .NICE rhapte<r 152, §25C(6)also states that¢every st dB or local licensing agency shall wifhhoId ffie issuance or r=ewal 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 insm-ance coverage required A dditio al3y,MGL chapter 152,§25C(7)states-Neither the commonwealth nor any of itspolitical subdivisions shall ent:x into �y coitmat fbr,�petfinmance ofpubre�untl acceptable evidence of compliance With the;,,e rce rr-q= =e s of this chapter have been prescnti-,d to the contacting authority." A gplicants Please Ell or± the w-oikeas'compensation affidavit completely,by chug the boxes that apply to your situation and,if ne ss � �PPl3'srrb confracinr(s)name(s), addresses)and Phone mnmber(s)along with their ceadinca±e(s) of incrrrance. I:>mittd Liability Comliani�s(LLC)or LimiindLiab�.y Partnerships(LLP)w]thno emplo}lees other man the members or Partners,are notrequhed to carry workers' compensation ioMra m_ If an LLC orLLP does hate employe es;a policy is rcquued_ Be advisedthat this affi.davhmay be submitted to the Deparinnent of Industrial Accidents for confirmation ofm�ce covrrage:. Also be sure to sign and date the affidavit. The affidaYit should be mt=t-,d tD the city or town that the application far the permit or license is being rcquested,not the Department of Industrial Accidents. Should you have any gaBoas rtgarding the law or Hyou a e regnsed to obain a worlmrs' compmsatioapolicy;please call the Department at the number listed below. Self-msored companies should eutr-r ffie r self-msor� ce Iicense number on the appropriate Imes. City or Town Officials Pleasb be sore that ffie affidavit is complete and printed legibly_ The Deparhnenthas provided a space at ffie bol o cdlhe affidavit for you to fill out in the event the Office of lave sij tint has to contact-yon regarding th-e zpplicant Please be mare:tD tom.in.the penaitf kcnse number which' M be used'as a reference number. In addition,an applicant that must submit multiple p-TLYBcense applita ions in.any given year-,need only submif one affidavit indicating current policy information(ifneoessary)and imdea¢lob Siff Address"the;applic�t should write'all locations ia (city or town).—A copy of the affidavit that has been officially st raped or marked by the city or town may be provided tD the applicant as proof that a valid affidavit is on file for fry permits or license.& Anew affidavit must be tilled out each year.Where a home owner or cifi7m is obtaining a license or permit notreIated tD'any business or commercial vegtrnre (i.e,a dog license or permit to bum leaves etr.)said person is NOT rDquii tl to complete this affidavit The Office of FnvevEgations would hke to thank You in.advance for your mop r on and shouldyou have anY.questions, please do noth.esifate tD giveti§a caII_ The Departments address,tc:ephone and faxnmmbeat lh$ CoMmDa ltIz of Massachu: • .Dq�zfmt��f Ian A+�d-�.ts - _ .• I�agt MA(121 I1 ToL44 617-7V-4 Q�- 4-46 ur I-&77 F=4 617-727- 4-4 B.evised 4-24- 7 Town of Barnstable Regulatory Services V4E Toty� Richard V.Scali,Director r Building Division 4 iF :naxszABM Tom Perry,Building Commissioner ;`sas.S Y� %639• �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: —77 Vil1(f- T�( 0-01 J JOB LOCATION: J,2 2,,7+ AU,rY�12.5 Yei Ve-t P—L number street village "HOMEOWNER": �,c j L'� ,�� f� 44 !0 7S�(-a�3 s- �c�3 G l 7 - 7 - -7 name home phone# work phone# CURRENT MAIIINTG ADDRESS: I 3 5 Aa_-ham rz �T 6 a 4/ 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 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. Signature of Homeowner 0T 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 persou(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. Ou 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:IWPFILES\FORMSIbuilding permit forms\EXPRESS.doc Revised 061313 ' Town of Barnstable Regulatory Services 9BAMNSTABL g Richard V..Scali,Director i639' 'Drf 1 1. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Properly Owner Must Complete and Sign This Section If Using A Builder I, i e ei f v Owner of the subject property hereby authorizesr to act on my behalf, in all matters relative to work aXdffi�isuilding permit application for./ er— R. dress of Job) 2are ences and rms are the res onsibili o e a licant Pools P tY PPt to be * ed or utilized before fence is installe d all final tions re performed and accepted. Signature . Owner Signature of Applicant g ig App cant M c�Cc & 12�t90 r° Print Name Print Name Date Q IORM&O WNERPERMISSIONPOOLS Town of Barnstable Geographic Information System August 6,2014 188043 #2 W 188079 #12 188044 ' #1222 � • 188045 91245 m >s G 188078 #1241 �0 0 19 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:188 Parcel:044 boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:RIGGIO,MARIANNE. Total Assessed Value:$251800 Selected Parcel 1"-100'may not meet established map accuracy standards. The parcel lines on this map . are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.36 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:1222 BUMPS RIVER ROAD such as building locations. - Buffer `�' � €5=jc, . . -�sta�,�tom. .. � - . • - 1 , Am yen aim cxmployee Checkffiet-4��bc Type of Pipled(FcqIiTri): L❑ I a=a employer vrsdt 4 I ms gem rcnhm=br aud L . * II�uthe New es�fayers{fi7I1 and(orga �_ _ 7 ElI.2=a sole pr or arga�xer- list-d au the art 6mA shy �- ❑ ship and have na employeesT have $_ g forme m any mpa ly mahzve vas' I - Bnz�dmgaddit ; I 3- We are acarporaiicaiaadifs Elecbicdrepaimrxaddiiims 3_❑ I sties a hams doiug ail vu�L cis have ex•Pr=ed ffim II[]Pl=biog segaus or additions elf IND wade� > of t ge�> c�. Rnofn palm sssa�nce 1 F c I5Z�1(4=mdwe have.aD �.INo ` I3��t�ec- of-ecl'� camp_m.=arance , fl fdunes n 5mim t'is Ema.7-1 6zy am dam,-_u'%--�_a f--hLe omtiae comic=— SMb[IDL aaecr�dxck -C as tst 'h�Ythisbmcmgststh�rhedra �;h,,1 Shucs theaffineofffiess s am3sts�uh tcnar8�se 5� ' _ _Ifihe sahcm��hs��Sa�•rrs,rhegmmt gmaide 8�• 'gyp_per•�bez ' :- .�ir�ri•z�ar�rg'tIupt�r>zdtisprrrr�g•t�er�rrs'co�nu�rFruttctt jiar r8� 'ay�cs. Bdntr is�epa�and job szfs gDFsc�t�ceSeff�usllo_�' • • -. �tian:l}sai� - Job�Jie Addie Ci Ste !lP_ #ar copgf �s o-rkers`coz¢pensaiian pvIr�3sclaraon page t Fa3'aver aFs3pir on ds€'e}: Failnm to Secfmnk 25A of MGL c-152 caa Imif to the impa Rion of mmival pis of a fTxl P.up fo SL DU GD anUr oL-yearimp as wen as ciuR pe=lf m ff3e fnT of a SMP WDR7:ORDIM and a fine of op.to$250_00 a dey agafi3st fhe violatoL Ba advised that a copy offfiiS s maybe warded to the Of ki e of Inveffigatxiom of the DIA far ins cav=age v 1 e1.figraiT car*fF ander thirp us awlppmaha sr afpediuy that$fe current Pig� a3•s'— a� ' - use a.* Dc-trot wriirin fidr area,At bg cmpLeW by cdp ar tuaa aftcia£ City ar Tom: " ,��t�one; . • ' L II<o2rd of HeaH€t 3.Bmiffing DTzrt � I Caf�ffawa a=k 4PIedrical l ecfor fi.P Tutor -fi. r Cnct � Z�� I La-�vs aura 152 r, es aII employees to prove works s' for the eDiployccs . PM_=Mot_in fnis statute;an evp&yce is denned as=every person in the,service of another des any contract ofhue, e:pr Cr implied, anal Orwr>tt - Y An em-�;&ryar is defined as 4an individual,partaershm,s,z o cm,corporation or Other legal=±±3r,or any,two or more offfie Ercgoiog=.gagrcI in g3o�m±=ttF es and inlln fhe�leg�l rCpTMS=tdi7M of a d=eased employer;-or the recei ctr trustee of an mdvidna�partnm:sh� asz!a, n or other legal enW,employing eauployeM HovTever the owner of a awelling hawse having not mare than three apartm�and who resides ti=iI3, the occupant of the won or repair work on such dwelling house dweIfing house of another who employs peasans to do ma� r-e an , _ e to rr." be derm..ed to b an not 1D employ or an�.e grounds or building appurtrnar�fhemtn shaIl no �p y�� MaL dmptsr 152, §25C(6)also st=that¢every state or local licensing agency shall wi hold t$e issuance or reuewaI of a or permit to aperate a business or fD construed buildings in the commonwealth for a-ay appficaat who has not produced acceptable evidence of compliiaace with the ham-ance.coverage require' . Additionally.MM chapter 152, §25C(7)stars'Neither the commons,eahhnor any of itspoliiical subdivisions shall enter iito any contract far Ihe plan ce of pnblic woikuatsZ acceptable evidence of compliance vrith the;n�Tce requ�ements of this chapter have been pmseated to the cordrar�R aoffioriiy Applicants ; the boxes that to 'OL siirnBtinn and,if Please f M oat the wnzLers compensation affidavit campletn ly,by chec dog apply S necessary, sa?ply alb-contrac Dr(s)na-e(s).addresses)mdphone nvmber(s)along wY�their=-i ca(s) of insaiauce. Limited LiabiEfly Companies(LLC)or Limited.Liabili y Partnerships(LLP)ono employees other ffian the members or partners,are not req�to cagy workers'compensation If an LLC or LLP does have employees;a policy is required Be advised that this affidavitmay be submiliz=d ti).the Department of Industiial Accidents for conf nr.afion ofm=ance Coverage. Also he Saxe to sign and date the affidavit: The atfiaavit should be retumed t r-the city or town that the application for the pemnit or license is being requested,not the Departn ent of Industrial'Accidenfs. Should you have any T cst-tons ffiie lour or you are r$gPu�d to obr�in a workers' compemafion policy,please call the Department at the number listr1T below. Self insured companies should eater their self-m ice license number on the appropriate line. City or Town Officials The De arimenthas rovided.a ace atffie bot . Please be stn�tliaf tide affidavit is complete sndpri�legibly p p o f foe affidavit far you to fll orXt in the event the Office of InyW6gHfi=has to contact you regaling e applicant ' Please be see to fill i a the pacmit/Iieen se nr>mberr which-�ii]l be used as a refer-code number. In addition-an applicant that must submit multiple pennit/Iicense appliratons is any given.year,need only submit one affidavit indicating cw.rent policy iafaIIn anon(ifnecessary)and finder'Job Site Address"the a�pIic�t should write¢all lotions in (city or town)."A copy of file affidavit that has been of-r_ially stamped or marked by$e city or town maybe provided the applicant as proof that a valid affidavit is on file for fatam permits or licenses A new affidavit must be plied D•±each year.Where a home owner or citizen is obtaining a license or peamk natreIated to-any business or eonnmeatial Teat re (i.e.a dog license or permit to bun leaves etn.)said person is NOT req�to complete this affidavit The Office of Invesisgations Ewald hke to thank you in a&M=for your cooperation and should you have any.questions, please do not hesitate to give cis a call_ The Deparimerfs address,telephone an-d nmnbtz- aa a OfMamach :s - tit cif In�a�At�d-�n . - o �gn� I�a MA G21II wised 4-24-0 . i of l Town of Barnstable ,f `� � Permit# ig f } Regulatory ServiceseEzp 6n`°nr °Mu�date } auss f 201i i639. �b Thomas F..Geiler,Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office; 508-862-4038 Fax: 508.790-623 0 EXPRESS PERMIT'APPLICATION - "SIDENTL4L ONLY Not Valid without Red X-Press Imprint Map/parcel Number n `t Property Address ` Z [Residential Value of Work 6-z CAS Minimum fee of$35.00 for work under$6000.00 Owner's Name&'Address ��'r�/1�-�✓�✓� �� E.�y� Contractor's Name ) 3 Z— . rn Telephone Number ---------------- Tome Improvement Contractor License#(if applicable) :onstruction Supervisor's License#(if applicable) J ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I'have Worker's Compensation Insurance surarice Company Name orkman's Comp. Policy# )py of Insurance Compliance Certificate must accompany each permit . mit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to 77) ❑Re-roof(not stripping. Going over.existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders:U-Value #of doors (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License required. & Construction Supervisors License is IATURE: FILESIFORMSIbutlding permit formslEXPRESS.doc ed 070110 I The Commonwealth of Massachusetts Department of Industrial Accidents,. Office of Investigalions, 600 Washington Street Boston, MA 02111 www.mass,gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leglbly Name (Business/Organization/Individual); Address: City/State/Zip: We_,by) 6a.)��3 Phone#: 79/ -a 3�--3 0 3 72.OF ou an employer? Check the appropriate box: am a'employer with 4. �'I am a general contractor and IType of project(required): employees (full and/or part-time),* have hiredthe sub-contractors 6. ❑New construction am a sole proprietor or partner- listed on the attached sheet, 7. Remodeling ship and have no employees These sub-contractors have working for me in any capacity, employees and have workers' 8. ❑Demolition [No workers' comp.insurance comp.insurance.# 9. []Building addition required.] 5. 0We 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 insurance required.] t C. 152, §1(4), and we have no 12.Sf Roof repairs 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 aman employer that is providing workers' information. compensation insurance for my employees. Below is the policy and job site Insurance Company Name:= I la 55 �ybp4 10 2'- ,! Policy#or Self-ins.11c. #: Expiration Date: Job Site Address:_ i �j-Cc�npsc�� City/State/Zip Attach a copy of the workers'compensation policy deciai'ation page(showing the policy number and expi I ration date), deb 32, 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 is true and correct Signature - - Date Phone#: " '7?1 d 3,S7' 30 3 Of use only. Do not write in this area, to bd 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#: The Commonwealth of Massachusetts Department of Industrial Accidents Once of Investigations ` 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi icians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organizatiom4ndMdual): f��Gl��i'�/2A <!L L,4— Address: A-/ City/State/Zip:f. f0��iv r�� wl/L Phone#: 5---7 Are you an employer?Check the appropriate bog: Type-of project(required): .. 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors F7. ❑New construction 2.12 I am a sole proprietor or partner- listed on the attached sheet [(Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' o workers' co c insuran # 9. ❑Building addition [N comp.insurance gyp. • � ce, required.] 5. ❑ We are a corporation and its I0.❑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 'eC r va insurance required 12]t c. 152, §1(4), and we have no ❑Roof repairs employees. [No workers' 13.[:J Other /'[s✓'J IyfA comp.insurance required.] *Any applicant tbat checks box#1 must also fill out the section below showing their worke c rsopnation poli cy 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. xContractors that check this box mast 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 mast provide their workers'comp,policy number. I am formation.an employer that is providing workers'compe infonsation insurance for my employees. Below is the policy and job site 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify under the p and pen es of perjury that the information provided above is true and correct signature: / Date: /lJ / 2 1 Phone#: r Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# - Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/fndMdnal):_� Address: ln1 t,nJ IU 5 iA I City/State/Zip: r av e ry i f le M rq Phone#: 906 cb l 5 6 -7 -7 -? Are you an employer?Check the appropriate bog: 1.❑ I,.,=a employer with 4. ❑ I am a general contractor and I Type of project(required): . loyees(fvIl and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.tZ I am a sole proprietor or partner- listed on the attached sheet [7. Remodeling ship and have no employees These sub-contractors have g Demolition working for me in any capacity employees and have workers' [No workers' comp,insurance comp.insurance.$ 9. 0 Building addition 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 req ired.]t _ c. 152, §1(4), and we have no ,� employees. [No workers' 13•U Other / Mave_ comp.insurance required] UU1=1 *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 isproviding 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:_ 2 Z_ R O M fJ e P,i J a( V� City/State/zip:CE_n i 2 r y i C I iL d 3 Z Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under th pains andpenaMes'ofperjury that the information provided above is true and correct Si afore: Date: b—Z t^-Z. O f f Phone#: 0 Official use only. Do not write in this area, to be completed by city or town offzciaC City or Town: PermitlUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: y'Y^ THE r, Town of Barnstable ' Regulatory Services • a " * iaatMs ABM Thomas F. Geiler,Director y Mass. 039. .�� Building Division rFD MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: (2).� g( , oZ 0/( JOB LOCATION: );' % /3te_ - .J$ ✓ems 1�0� t P�rtf"G�Vu t tC�[ l�(f� 6 (� 3 Z— number street u village p �p "HOMEOWNER": + 6&. f 4t,o'l.Yt>;' s��ci�C� —Z��' �� 1�17` l 7 2 7 Z' (P 7 name c home phone# work phone# CURRENT MAILING ADDRESS: �.63 �ji Q/�u�r—s] <2-y— 6 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 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 u minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner 9 f 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. Q:forms:homeexempt 1 tR �WE ,,, Town of Barnstable Regulatory Services R+xxsrABLE, Muss Thomas F. Geiler,Director s63q. 1�g Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862403 8 Fax: 508-790-623 0 Property Owner Must Complete nd Sign This Section If sin A Builder as Owner of the subj ct property hereby authorize to ct on my behalf, in all matters relative to work authorized b boil y ding pertuit (Address of Job) **Pool fences and alarms are the respon ' ility of the applicant. Pools .are not to be filled before fence is in d nd pools are not to be utilized until all final inspections ar erfor ed and accepted. Signature of Owner Signature of Ap licant Print Name Print Name Date Q:FORM&O WNERPERMISSIONPOOLS