Loading...
HomeMy WebLinkAbout0033 BUTLER AVENUE ��.� ���..-�Lam. ��t ,,. i I I�'� �, '�i q �, *. TOWN OF BARiNSTABLE BUILDING PERMIT APPLICATION Map 1;91 �2 Parcel 0 Application# Health Division Conservation Division 3 11-41& Permit# d Tax Collector Date Issued Treasurer Application Fee 6 Planning Dept. Permit Fee q L�_� Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 5, ki ey " , i Village Owner ' Address Lf dLP AAA- '9A . `Qy_'6"Vm Telephone � (e t Permit Request 'EA op. V d, 6Z..D0 vvvt S Square feet: 1st floor:existing f 50® proposed 154 2nd floor:existing � �°` proposed � Tot aI new" Zoning District Flood Plain Groundwater Overlay =t Type Project Valuation �3 Q' � M 1®6Construction yp Lot Size Grandfathered: ❑Yes A No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure YES Historic House: ❑Yes XNo On Old King's Highway: ❑Yes XNo Basement Type: )4FUII XCrawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Al/AEI Basement Unfinished Area(sq.ft) 1500 Number of Baths: Full:existing 0 new /� Half:existing IJ new Number of Bedrooms: existing new Total Room Count(not including baths):existing 15 new AI A First Floor Room Count Heat Type and Fuel: )(Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes Xo Fireplaces: Existing New Existing wood/coal stove: ❑Yes *No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size '�• I J ./ Attached garage: existing ❑new size Shed: existing ❑new size RX49 Other: �✓" e tq Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ -- --Commercial.-❑.Yes--- o—If_yes,_site-plan review#._ Current Use 1AA f, Proposed Use t I_ BUILDER INFORMATION Name �C��1,y1 �0L'�� Telephone Number 5_6 Address License# sV ,! 9 Home Improvement Contractor# Worker's Compensation# AA ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 3 11 �,(a6 FOR OFFICIAL USE ONLY x PERMIT NO. DATE ISSUED , .A MAP/PARCEL NO. } C ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME ©bC 1310LO- INSULATION s FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ` GAS: ROUGH FINAL FINAL BUILDING I Z) DATE CLOSED OUT . ASSOCIATION PLANNO. °pTNETp,, Town of Barnstable Regulatory Services BAMSTABM " Thomas F.Geiler,Director Mass. 9q, 16;9. ``� Building Division pTEO MA'S a g Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. .�o�mf'o ? � Type of Work:Sww� 5 • 1 Estimated Cost 131 1 0106 Address of Work: 33- Owner's Name: coa'cn Date of Application: I hereby certify that: Registration is not required for the following reason(s): QWork excluded by law ❑Job Under$1,000 OBuilding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. 3WI —O"J&h-6&CV,� OR Date - Owner's N Q:formslomeaffidav The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston,MA 02111 ',M 5�• www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Legibly Name (Business/Organization/Individual): Address: C)U j CDA-(_ Z D City/State/Zip:�0 Phone#: Are you an employer? Check the appropriate box:. Type of project(required): I.❑ 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 El New construction 2.❑ I am a sole proprietor or partner- listed on.the attached sheet I ❑ Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. 9, `'Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have,exercised their 10.❑ Electrical repairs or.additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have no 12.[l Roof repairs. l' insurance required.] t employees. [No workers,- 13.❑ Other KOQtt(� 11)/� comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: �r 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-contraetors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. asurance Company Name: 01p, 'olicy#or Self-ins.Lic. #: Expiration Date: ab Site Address: City/State/Zip: ►ttach a.copy of the workers'.compensation policy declaration page(showing the polity number and expiration date). - ailure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is t e and correct: 4. ature: _ Da I 40 hone#: Ojicial use only. Do not write in this area,to be completed by city or town official, City or_Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined a$:`_`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. Howev.,er: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 .n 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, §25 C(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 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 their— self-insurance license number on the appropriate line. City or Town Officials f 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 permivlicense 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 9f Investigations 600 Washingfon Street Boston,MA 0211 L Tel. #617-727-4900 ext 406 or 1,877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia • TehieJ12A(cost ved) •thi~on#I �' prssr.#Iptits PdekaEed for di►e and 7wo4andly Re�id=tW ZvJldiatp NOW�d NiJl7�BiUM � .H�n�Caaling Cflis3ag 01=1 �g. VAR Floor .Basemeat Slae� FOPmMA md�q Ar�ea��'l.) Ling R..yxivax A nttsei R•i•aivas R e 37g1 to toga 11ghtin jD3 Di 10N-INVIA Norcaal383g 13 23 ?VA 19 . 19 is3a ' 33 A0ARMIMA 0.3k• 3a19 ia•'IS ZS ?ylA38 19- 3'! I�lA:1$Y. . aaz• a •' .18y. 0,42. 3a 13 i9 IO . XA ta��. o.sa as . 19 ii to a sQ.�i:t T.•ADDRESS OP PROPERTY; .. . un F OTAC�E OF 2 gQUARE Q 3, gQVARE FCOTAGE'OF ALL'CttAZING. '` •.. o11 AREA ##3 DNIDRD BY#�2): GLAllNC ( ' 5, SELECT PACKAGE(Q 'See chid above), .. •Nt*j ;. 07M Mon WVC)LVBD METHODS OF DETERIvIININ�s EI;iBRC�'RFQC ME'riTS ARE AVAILABLE, ASK US FOR THIS INFORMATION,. . BLJ�,,DTNG INSPECTORAPPROVAL. , NO, , ti • q.ac�ns�f�Sfl393a f OF1HE TpN, Town of Barnstable Regulatory Services BABNSTABLE, Thomas F.Geiler,Director 9 MAS& �A 0.19• Building Division rE0 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: 0 c T � JOB LOCATION: a�= C1V CSC v C number r street ') �j r , villa J�] "HOMEOWNER":�J C�)k V� V G�lil. �v ^ J `E�6 r9 � name �f home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of 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. i ature f 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 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 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a� JParcel O Application'# Health Division Conservation Division .3I22- 1�06 OV, Permit# q ( '3 10 Tax Collector ' `a L1;4 Date Issued q 4_0 EXISTING SEPTIC SYSTEM > r Treasurer LIMITED T0�_*OF BEDROOMS Application.Fee J Planning Dept. Permit Fee Date Definitive Plan Approved by Planning.,Board Historic-OKH Preservation/Hyannis Project Street Address Ic— Villag > V\- 'F Owner waky-r� l° G � Address Telephone t V$ 3 6 6 -3 Y Permit Request 11h,e— Square feet: 1 st floor:existing I WO proposed /4 20d floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes,attach supporting documentation. Dwelling Type: Single Family X Two Family ❑ Multi-Family(#units) Age of Existing Structure i Historic House: ❑Yes XNo On Old King's Highway: ❑Yes XNo Basement Type: XFull XCrawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing �' 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: 1 Gas ❑Oil ❑Electric ❑Other Central Air: O Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:0 existing ❑new size Barn:❑existing 0 new size Attached garage:O existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name��( �` � Telephone Number Address rCL License# Home Improvement Contractor# L� Worker's Compensation# ° ALL CONSTRUCTION DEBRIS RESULTI G FROM THIS PROJECT WILL BE TAKEN TO In SIGNATURE DATE FOR OFFICIAL USE ONLY ` t PERMIT NO. DATE ISSUED , MAP/PARCEL NO. 3 ADDRESS VILLAGE % f OWNER ` DATE OF INSPECTION: FOUNDATION FRAME G��v)5/31o6Ur r} In' INSULATION rr IN FIREPLACE v M ELECTRICAL: ROUGH' FINAL PLUMBING: ROUGH ! FINAL r 1 GAS: ROUGH / FINAL x FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. _f- -Town of Barnstable Regulatory Services BARNsrnBLE, Thomas F.Geiler,Director 9 MASS, sa39• .� Building Division 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 b Please Print DATE: l �� JOB LOCATION: c 2� � eACL� huMlf_ nu er street vill l "HOMEOWNER! name home phone# work phone# CURRENT MAILING ADDRESS: �,�I Y V e,rl 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 Arequirnts. 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 form/certification for use in your community. Q:forms:homeexempt The Commonwealth of'Massachusetts Depailment of Industrial Accidents Office of Investigations 600 Washington Street • Boston, AM 02111 \ ,v www w.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: q (0 V Co C _ ' City/State/Zip: `_ e-5V6V-b ' VA - Phone#: j(1� ' 3(e�G?" 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- listed on the attached sheet 1 7Remodeling ship and have no employees These sub-contractors have S;. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' romp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3 I am a homeowner doing all work right of exemption per MGL I I.[]-Plumbing repairs or additions Xmyself,[No workers' comp. c. 152, §1(4),and we have no 12.❑ hoof repairs insurance required,] t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 certK under the pains and penalties of perjury that the information provided abo a is true 617.d correct r. Signature: Date: Phone•#: Official use only. Do not write in this area,to be completed by city or town official. 1 City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Realth 2.Building Department 3.City/Town Clerk e.Electrical inspector 5.Plumbing Inspector �I 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-contractors)name(s),address(es)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 their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, IAA 02111 Tel. `617-727-4900 ext 406 or 1-877-MASSAFE ax �; 617-727-7749 Revised 5-26-05 w-w-w.mass.zov/aia Town of Barnstable Regulatory Services �RAM i'& Thomas F.Geiler,Director MA'� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. c-� Type of Work: Rim/2� Estimated Cost, Address of Work: G-V v4 � Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑JQb Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. Dat ' Owner's Name Q:fomns.homeaffidav OAK � p' Froyv � }k pr, ,� y Y OvIn Tz i r Avg 1, " 33 �d az 53 ON Prof C6 8 ` - r .33 iAer - - 5 �.. , c R. � xy , r .3 t t, ll ` z [t......... t jn no boo 1 i t €� �1u i — s `q� AN }r t � � ` i � �i F w . Y � 1 5 � � t i t`r U OVA \ ; - us �� V _ ° : I ANC dew fence w&fl v � 641 0,Lou e'\r-- � r♦ .W - as PL'J s�5s b.�c�s A,w vik e, Yz CAA , ¢ � m _ jam' ( 5't IA o6, a ' Y �Q C " y n •.wu .aw n f f 5U� 4o I ` Froe - i�' r. Ne b P� A 33 Nil o /p g' ✓ ! C �" ) d �f�� IIII sm I II � 1��111 III r 6 i ialll �II'I''ill 11 IIII',II ' � -r;�0. !&.A .. � y _:� � • '. .. '1 . \ - d��'I it Ill l'�I III ` ! �I IIII ' C:7 I nt lIl II''S id ,,,Ili �Ilu ii�i�l r.11il, lir�jiill,llirTI �III�II�I11�r It � •. � ., � P to �- � � �I'I I���Iliulitll r I IIII �141 J II' e uil� II 9� ,� h k . t ,I11�U�III, r. f MII a5 ' _ 6U112 fi�rl +Pro os -. o aky s / e l iIIIll lk lira NA to - ��� ;r IIil�lill^lul 55 hp loll qvr • t ° P I �� IiIlll4�r III fiV4 x �JI 6 � IIII F yIl II �U I 'PI;IIiII� nil ' I r v" c 7 , 1w AGE on � 149 s �9 gg�� -�P'ktQ - _�. - ° �© � Ill li�l�ll II IIII I' n � ^`=li4�l� IIII IIIr Iu I lUl • } - . -. ,,. .. • _ , ., -�i�rl IIII j'�I _,�. - - . �� s _. v v. '' - _. ° • .- �I IIII 'III - - z 4,,. ,gg a�! r••y !, � ti l i uj, II I r a c% mew - { j II 'IS it l w I, - ��. .�' •_ - ..,. .:.:.. _ .' - .... ,. .. _ , IIII I � I a1ti1l,l J � , it uQl I I ,i rl c fl 11 5T � t G, d. • x � v � 30 IIII •ry'ry /y � .,�"- � � - III I a kil I I � J MWE , o I 4 t.. YI —VA d� f 0 C?1 Pz, i G) � lc0• ' ram, .,. �� .1:.�.�rAC-JL--.�_...�...._..�W?...._ 'C'f,feK�'.�'.�. ' ! f r ' !; T-'Ie -fie trvaskr - I Jodi —40 �� ! ` �►�Su,a.�'i.�� tQ[�� J�eCC+'. �blhs�l�?�°- Le.)�1� ' y L _ (- e&CA 'TRY'O V �O t s I 14 ISI.r Vial��Ilil�il 1. iy,` -��, ..-�is �� III I�Ip I��ilh� .-_� ���I it r.,•;�.. Iti 1 AltSUS -��6 �. ,I . I .A �NIII I�1 III���)i INI�I�I�i III. i1� •� J , 4 VI II .�. Ilu,tf j•- I 1 � I,, � —........_—..._,__....—.._.�..�,,.-�_.+.��.e...s .,._ _ I Ill .+ rt. '.. � ., � �, ^ ).:.; ,,�„' � I'i. ;..ai,;_. I. t,....1:=•n .n:.�...,� 1 �'1M,A..It L,) �.ii..{ �({, I�...I(G In I} l,dlh4�(,Yl ,l��I�.PI!I' YlNil"r':..,.�,��. ' .. .:I"all � u ri eL ; : �. 30 y rt. 5Va I ft?X et Cbni��® esr� Vey wood Mk Ali I� !I ��All�lll''llll�� �IjI1li as .....__ 4 END II III jl!�LI 11I�Ilw llljl SINS 0 •¢ :�� .. _ %���Ui!pl Y. . a •-n � rplf I� fl Y,��PIII III II illl ii; III Ny Illlglll II I `-`, l �!!�IIVIIIII 1 I� 1 1 f� I. it� I Ike- jo�r\ Gf ce e- Y `'�"� ' AD � wo ON S t a S�uv'vrs•�l�'� _i ,I y � vv� 11, it Q�I 1 i - : rn �. - , - L��,: gt 'ffI tl III III 'ii.Ipl 14V.o vY., ` V, ::? •,... ,,:,. ;`: lul 111, - $ ' ^ III �I!� „A r.y IW�NIIIII�IIuVli�l!mm!imllµ;u�ti,m 4h Roo l z . f t 1� M i 1 � : c x X L �l 6 �5h d c : F - - - --- - � y!lillj��lltrgg j III i+. ---.............. --- - - - uliillhi I�yl l 'I�uN X jo, v k P Jr ) t' �ll�II�II J�rr' I R 71 wt 'Jowa 1� y, U III 4 1 [ �] pa II C I III III r I I I r 7 I i II I i s t 5 I L is I III I I. 'I lil �4xt 33v k_ t .. ,.-.. r. •.•-Y.. ''.: y ,-:: :la�.: -,-..: _... .' y .�I: „i.i. I I�d .i. � I,.�!'t:. {IUI IiilV'll f �'�JI �.�r'.f,�ili.i{ I I :!V.gg II'� ti.i..i'. I � _� / : . ,�� ..®- t -.,...�.• gip.,-.,...,..�.. �: fw � a �{��f�,���lll Y . I - � � p �a✓� � �, ,�l a'` IIIII l �1' I t ce OLq e l a I .�- 1 , y` I I AA.. i II i { I � - .�,���• � " �� , III j I - r � f r vd �v J��tP _ r r r. r I "Ay �. , 1 414 -- w till i.. t I Ao ZZ710,06al- aI � Ave- C I 1 ,•. ., - ".:.. '- r ,, I Pam'.:.:::.. '4".in.n�Ni I1�11�"I,AN�NI �'.11 lfh^1,'"�tY:�?1,rc°r�r'm p .... _ -_, z- ,.: ,., � • �,_- . - •x� ,ill Yi'( ,':.. .y. - :. _. :, F n �_ '. .. .��:I: 1- III��ivl�ij X I! ::�;r •;..,,. "��III 1;1�xl, I. ,r - . „ . .�°. :-... -. J I �: { iN?y7MIN.0:N III „n: ., .::...:.. ::,.,.:.:.. �.:.ems:I1..N i•'o JW�, ,. .. ;✓. „ .v. ry nlNl,_. i r 11111l slllalilli . f ' � Vrn--`M^OeP �' • � � + � .. v' : I o2 X I-L �"�; � �' 1 a�Ily III II ��k,yrlIIIII.,I I qNl IN a � I mL I i r! i 1 , V .. , � ' I I t r1n I ., s. .. ,: vk r :.:u .0 :...n nu.r..d.. -��!..:::o: ...... J.::..'J..... : :-:.:.f.i•... .. r ,».. ._. NA fib.'.i :^�:I ..f. � ,r i� ,:,;;.� ._,- ':. ::. .. ..,. „. "� ..��n�,, s rsi�:�.�• +14,�. I ks�u.4�.� x �Y d . ';.:u, �.... � .:,. r -.-:. +le•+ -i ME it „u r F.�d 14J I I, ::� ::::.L. �l(:r',f �l,)II' l Ifs' yu '1 It �.vaJ