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HomeMy WebLinkAbout0050 HARRISON ROAD n t } t r �u W �' ��:giix.•ns s Id 4l �� ajY }a, •.�: ^. ' ipi"R; i �_ '":"ff r.. o.,.t,a .. �}I,.RRy�I."`.."' M1"fw ., <„',3 4 - - �' - r {s tlF.rk 7a l IP r• -,'� a.:$°N„4 �,"' J;r. �, n _der. , ' hK Y a , , e r fir � - F c .. n. p a s n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel N.J Application D Health Division Date Issued 10 t ILI Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board i Historic:- OKH _ Preservation/ Hyannis Project Street Address Cfi&ZM- AU� Village t Owner Fix M '(11 Address �!T) 0"�O Telephone ) 1 Permit Request o 'I ey '- ' '� A011101, &i' e ...AY�MAA —imehr. 4 S" ` �1 Square feet: 1 st floor: existing proposed 2 d floor: existing proposed Total new Zoning District Flood Plain_ _Groundwater Overlay Project Valuati onstruction Type C> _ Lot Size Grandfathered: ❑Yes ❑ No if yes, attach s pporting-doc entation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) _7M can Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' Highway ❑Pbs ❑'No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other r 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: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ 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: Zoning Board of Appeals Authorization ❑. Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name V _-�\ � Telephone Number c�� T� Address License 1CQr)W v = Oc Home Improvement Contractor# u � C Worker's Compensation # Y_0­ U 55�1-003- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE qP� f FOR OFFICIAL USE ONLY Q { APPLICATION# r DATE ISSUED ,,MAP/PARCEL N0. � €r 4 F ADDRESS VILLAGE OWNER F e - DATE OF INSPECTION: µ_ `a FOUNDATION FRAME F { INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r . ;GAS:, ROUGH -, FINAL FINAL BUILDING DATE CLOSED OUT '� ASSOCIATION-PLAN NO. Die-Cemmomv_ealth-a, -Massachuset&s _ ---- -- = -- -- - Department oflndustrried Ai cidents Office of Invadgations '600 Washington Street Boston,MA 02111 www.massgov/dia ' Workers' Compensation Insurance Affidavit: Sunders/Contractors/Electricians/Plumbers A•PPHeant Information Please Print Le2b Name(Business organizatio vhavu4: _,TM of New Bedford CO. , Inc. Address: 423 Coggeshall , St. City/State/Zip: New Bedford, MA 02746 phone.#: 508-992'5770 Are you an employer? Check the appropriate bos of i•o ect(required):: •4. I am a neral contractor and I -Typee r ( Q �::1.�I am a employer with ❑ � 6. ❑New construction . employees(full and/or part-:time).* have hired the sub-contactors 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling Ship and have no employees These sub-contractors have 8. Demolition working for mein any capacity.- employees and have workers' [No workers' camp.incu=, a comp.insurance.$' 9'. ❑13;iffic*addition required.] 5• We are a corporation and its 10.0-Electrical repairs or additions officers have exercised their '3.❑ I am a homeowner doing ill-work 11:0 Phimbing r airs ar additions myself[No workers' COMP. right of exemption per MGL c.I52, �•❑Roof repairs T t,.arrrance required.]t §1(4), and we have no . employees.[No workers' . 13UX)ffier Insulation comp insarawc required.] *Any applicant that checks box#1 must also fill out the,section below showing fheeir workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing aIl work and then hire outside contractors must submit a new affidavit indicating such. Conhacton that check this box must attached an additional sheet abowing the name of the sub-contractars and state w.bofi=or not those entities have employees. If the sub-conhactoz have employees,they must providr their workers'comp.policy number. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Iusntance Company Name: Continental Indemnity Policy#or Self-ins.Lic.# 4 6-8 5 5 6 3 7—01 —0 3 Expiration Date: 6/2 2/1-5 Job Site Address: 50 Harrison Rd. city/StatelZ .Centerville, MA -02632 Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Farlure,to secure coverage as required under Secti.an 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 m4Msomnent, as well as civil penalties in the form of a STOP WORK.ORDER and a foe of up to$250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veafication. I do hereby erti under th p sand penalties of perjury that the information provided abov is tr e and correc4 Si tore: .•Dater Phone# 508-992-5770 Official use only. Do not write m this area,tb be,completed by city or.town offcci¢l City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Electrical Inspector. 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 06/27/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Applied Risk Insurance Services, Inc. PHONE FAX 10825 Old Mill Rd A/C,No,Ext: (877)234-4420 I(A/C,No): (877)234-4421 Omaha, NE 68154 E-MAIL ADDRESS: PRODUCER (877)234-4420 CUSTOMER ID# INSURER($)AFFORDING COVERAGE I NAIC# INSURED INSURER A: Continental Indemnity Co. 1 28258 JM of New Bedford Company, Inc. INSURER B:INSURERC: 423 Coggeshall St New Bedford, MA 02746-1758 INSURERD: CTL 1273 891374 INSURERE: INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLCYEFF P LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER 1 M/DD EXP ' MM/DD � M /DD GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY �^ I EACH CCURRENCE $ i ! I DAMAGE TO RENTED CLAIMS MADE�OCCUR $ D EXP n on $ PE NJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I j GENERAL AGGREGATE $ PRO (�, S-CO $ 17 POLICY C LOC I $ AUTOMOBILE LIABILITY ire I COMBINED SINGLE LIMIT ANYAUTO i�L_: I Ea ac' $. ALL OWNED AUTOS I 1 BODILY INJURY Per erson $ SCHEDULEDAUTOS � BODiPerILY $d HIRED AUTOS I I j PROPERTYDAMAGE i I Per accident $ NON-OWNED AUTOS $ ' r I I I $ UMBRELLA LU\B IOCCUR i ; EACH OCCURRENCE $ EXCESS LIAB 77CLAIMS MADE DEDUCTIBLE AGGREGATE $ LEI�� I $ g RETENTION $ I $ WORKERS COMPENSATION X WC STATU- ! OTH- AND EMPLOYERS'LIASILnYYIN i A OF ICER/MEMBERFJANY �(CLUDED?ECUTIVEFVI�N/A ( 46-855637-01-03 '06/22/2014106/22/2015 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) L+� I [fps describe untler E.L.DISEASE-EA EMPLOYEE $ 1,000,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I(ALJtta Ich Acord 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Town of Barnstable BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 200 Main Street IN ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 0.2601 AUTHORIZED REPRESENTATFVE �I783118 ACORD 25 (2009/09) ©1988-2009 A ORD CORPORATION. All rights reserved Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet (991M )of Massachusetts - Department of Public Safety enclosed space. Board of Building Regulations and Standards Construction Supervisor License: CS404088 ELWELL H PER13-* 1454 MAIN ST , . Failure to possess a current edition of the Massachusetts Acushnet MA 02 443 '? State Building Code is cause for revocation of this license. For DPS licensing information visit: www.Mass.Gov/DPS �' lJ )I "` Expiration Commissioner 05/20/2015 � C?'/�n 1!r,.rn.ri�anu�rc<�/�of�C.-�.�l�rJilnc•�r�dc//3 � ._. •__ Office of Consumer Affairs&Business Regulation I License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ;Registration: `103195 Type: Office of Consumer Affairs and Business Regulation P 10 Park Plaza-Suite 5170 Ex iration: 7/6/2016 Private Corporation Boston,MA 02116 z'= JM OF NEW BEDFORD.CO.4NG, .:tll ELWELL PERRY 423 COGGESHALL ST: NEW BEDFORD,MA 02746 Undersecretary Not valid without signature a r f BIKE Town of Barnstable Regulatory Services t BARN&r"LE, _- MAS& g Thomas F.Geiler,Director Fn i 61% 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 -Property Owner Must Complete and Sign This Section If Using A Builder I, , as Owner of the subject property hereby authorize �l f ! I y ,�� ' ( to act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. ti Signature of Owner Signature of"Applican Print Name • ' Print Name S�� Date � I Q:FORMS:O W NERPERMIS S IONPOOLS Town of Barnstable a Regulatory Services &ARNST"LE, : Thomas F.Geiler,Director y orris. �p 1639• Building Division lED MA'I I► 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: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of 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 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 you-community. Q:forms:homeexempt OWNER AUTHORIZATION FORM TI I, , (Owner's Name) owner of the property located at b o � l � (Property Address) (Property Address) hereby authorize ; (Subcontractor) - an authorized subcontractor for RISE Engineering, to act on my,behalf to obtain a building permit and to perform work on my property. Thomas Tiger TTE (Oct 3,2014) Owner's Signature Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a Q-9 Parcel 0-7 J Application #, t a q�_j� Health Division Date Issued Conservation Division Application Fee Planning Dept. Perrriit Fee � (o.• 3z� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 6_0 PAU I S0 0 RD Village e%r-ol[J1~y1 t-�f=_ Owner HARVCC� 71 Address Telephone &17 - —7-77 r 3©_69-- Permit Request 6lic l Au- Tv%a) 4AS goml�Lr 0, or-Li bpi)(T-V � � � �—/C Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1�1 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ] Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes J66No On Old King's Highway: ❑Yes Basement Type: Full ❑ Crawl ❑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: ❑ Gas ❑Oil ❑ Electric ❑ Other o Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood�m!oal stov(g� ❑ ❑ No o Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ekisting Wnevgsize_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: . q Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use v ----- - Proposed Use APPLICANT INFORMATION i. 1 (BUILDER OR HOMEOWNER) I Name wlL-1-/APJ Y Telephone Number 9-N Address 016 ZU4!�H -D License # 76T Z ©Z.(p 3 Home Improvement Contractor# 13'cZ/00 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE t FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r, ! DATE OF INSPECTION: FOUNDATION r � FRAME ` INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 4 DATE CLOSED OUT ASSOCIATION PLAN NO. Town of Barnstable . oF1He T Regulatory Services �y' o Richard V. Scali, Director EARNSfABLE, w Building Division BASTABLE MASS. - OnPNS &E CHrtEPY1LLE VNR•1(Y.iW115 A 79. Thomas Perry, CBO 5 1�«� 639-LLE.Kf5 8 MT10F Zb � -" 139-2014 Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790=6230 December 18, 2014 William Murphy 95 Slough Rd. Brewster, Ma. 02631 . RE: 50 Harrison Rd., Centerville, Map: 229 Parcel: 073 Dear Mr. Murphy, This letter shall serve as notice that the permit issued under permit application number 201102944 has not been completed. To date this office has no record of successful completion of final electric, plumbing and building inspections. As the contractor of record, one of your responsibilities is to obtain all of the required inspections. Please contact this office as soon as possible to arrange for inspection or explain the status and do not hesitate to call if you have any questions. Respectfully, re L. Lxuzon�on� Local Inspector 'e� ffrey.lauzon a,town barnstable.ma.US (508) 862-4034 } �1G2 7:5rR,S-r' F::�Lo© ��s ib�.ti1G 5-o iso L IA w i2 s16)re 3�3 �- �S�\ i j -rl fs� ►i l L00 Gr-o-r�.- VI L-C uur7 1 +� F✓µ d D054 � Locooli J The Commonwealth of Massachusetts IUL Department of Industrial Accidents rr Office of Investigations ' '' 600 Washington Street ! Boston,MA 02111 c l" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i. AlBLL1A'm 6 Address: City/State/Zip: 1W.J �t A Phone#:' Sag. ;z7q 41S-2J. Are you an employer?Check the appropriate box: +Type of project(required): 1.❑ I am a employer with 4. ❑ 1:am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2-M I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑ Remodeling \ship and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. •g, ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its , } required.] ! officers have exercised their .' sIO.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1l.0 Plumbing repairs.or additions myself. [No workers' comp. c. 152, §1(4), and we have no I2.❑ Roof repairs insurance required.] t. employees. [No workers' comp. insurance required.] 13.❑Other 'Arty applicant that checks box#I must also fill out the section below showing their workers'comparsation 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 their workers'comp.policy information. ram an employer that is praviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t. M(,( I+L- Policy#or Self-ins.Lic.#: QC 2,31S131 733 0®2Q Expiration Date: f 1 '] / Job Site Address: IS 1) City/State/Zip: Z 1�106�ea� �r Attach a copy of the workers'compensation polic 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 pen of perjury that the information provided above is true and correct � j Si ature: Date: ;5 l Phone#: Official use only. Do not write in this area,to be completed by city or town official CityT or Permit/License# Issuing Authority(circle one): L Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical InspecEbhng1nS]A 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 wotk 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 certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the rsembers 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 Iocations 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 Name owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The.Commonwealth of Massachusetts Departnent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia r tAgNStt^r s - : Town of Barnstable prEo��k Regulatory Services Thomas F. defiler,Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www:town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230. Property Owner Must ,,Complete and Sign This Section .If Using A Builder as Owner of the subject property hereby authorize to act on my behalf,; in all matters relative to work authorized by this building permit application for: (Address of Job) Signature f Owner Date Print Nartie If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. C;lUsersldccolliklAppDatzV-ocaAMicrosoftlWindomlTcmporzry 1nLcrnct Files\Content.outlooklDDV87AA-7TXpRESS.doc Revised 072110 of .Town of B arns~taWe THE Regulatory Services Thomas F. Geiler, Director RARKSTABr.H, _ '' Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, kA 02601 www.t6wn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of 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 intrndbd 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 fit! responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for dompliance.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'corriply with-said•procedures and requirements. Sign an m us ofHoeowncr 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 hbmc*wner performing work for which a building permit is required shall be exempt liom the provisions of this section(Section )09.1.1-Licensing•of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such x work,that such Homeowner shall act as supervisor." Many homeowners who use this cxemption'are unaware that they arc assuming the responsibilities of a supervisor(sec Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2-15) This lack ofawarcnrss often results in serious_problrnu,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. Thc homeowner acting as Supervisor is ultimately responsible. To cosurc that the homeowner is fully aware of his/her responsibilities,many communities rzquire,as part of the permit application, that the homeowner certify that helshe 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 formh/eertification for use in your community. Q:forms:homccxcmpt r Office of Consumer Affairs&Bdsine s Regulation License or registration valid for individul use only !:1 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:_. .132160 Typie: Office of Consumer Affairs and Business Regulation Expiration: -*,'/29/2012 Individual r 10 Park Plaza-Suite 5170 WI IAM G. MURPIdY s Boston,MA 02116 E WILLIAM MURPHY4= r, ( ` 95 SLOUGH RD , BREWSTER, MA 02631 j Undersecretary l i Not va d witho signat re R9aSSaCliuSCttS- Department ttI'Public Sa1'et, Board Of Building Regulations ',nil Stand ~ Construction Su ads Pervisor License License: CS 76917 Restricted to: 00 WILLILAM G MURPHY " P. 95 SLOUGH RD BREWSTER, MA 02631 Expiration. 8/8/2011 . (ounn„siuncr Tr#: 20497 j M ��Q�ofTHETo�4o� 4 TOWN OF 'BAR.NSTABLE li BABB9TOBL&,.M 9 BUILDING ; INSPECTOR APPLICATION CrL Gt. LIGATION :FOR PERMIT TO ................................................. .. ......�....... ........ ....... .............. ........ . TYPEOF CONSTRUCTION ....... ................:.................................................................................................... ......... ............9...........,9:73 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies :for .a ermit according to the following information: Location .. `. ..................?...... 3, .. .................................................................. .. .. Proposed Use ....... .. :. ., ....... :...........,...............!.. .... ...... \J Zoning District ........ ....... 1 .................. ...............................Fire District ..............� > � Nameof Owner : ....\.V.. Address ...�.. ............. . .. ...... ................. 1...................... Name of Builder .....,... . `� ......Mdress / .. ,� .... Name of Architect .................... ......... ..........Address ......... .............._...................._....... ........_ .........Number of.-Rooms .......... ............Foundation ...C: ►.-.- ...... -. Exterior ......�....,., ... "��`��'� .Roofing ...... X Floors ........ .. ...............................................Interior ..................................................................................... Heating ........... ..........................................Plumbing ...................... .. ....................................................... Fireplace ...... ......... ......_. ....... ..._........................_.Approximate Cost ........ ... ...................... :Definitive Plan Approved by 'Planning 'Board ----------_-------____________19________. Diagram of Lot and Building .with Dimensions se SUBJECT TO APPROVAL OF BOARD OF,HEALTH . y t- wZ ^ p V � t m Z Uj + � >11 U Q 0 U U ® ` V Q g �- _ z0 w Wz < W , ° V) U) o y v G I hereby agree to �farc�.to�Ja, he u es and Regulations of the Town of Barnstable regarding the above construction. Name` ..........P :.. .. ... ...... .... ...... \ . ` . ' ` . � ' i � ( � ' } � | � � - ' - ` - ' ` Bailey, Gordon family dwelling Harrison Road �e ffia;r;v:�11 1 e Date Completed ...../O/JA Z;,d A7. ......19 PERMM REFUSED ' -- ' --' � - --^—' � � . . 19 . ! ----------------.. . --------------^-- � -4 i - 1111 ufkr4to UP. )5, 04M.Fe M,PfAC'- 1�1167 p r,F. IH woo P,v" (JMlT, 1APrV 47 ---------- (pr,�jvioa cawe;.4 q,PLO,K: Vr.-, A,-a""P c0. i�T,;f C. lf-Y4iF,,PLAt*Il4 TL.,F,.0 011 nl\ T'll U-1 4�vl I I F to ILI Tll I IT, a. j� .......... 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I '; �� I� a�1 I,Ial' f.Kl Nt^17 j LINtP'r7 TI,A&1 �.�'�YI67 J4147 ; 'I (•'1��.., I��..� ., a ,a. -- _ ___ . I 1, I� , j u a I .....H..._ 15"dPP6CT.y� ill I In °CAP lh.'�'C (7 YJK j�S'Dri�N I a L... I e v aF ImAjD !7F.CAfGy of T ra y "G1CaFR.RFy _ 1 I � r � I I _ I .!�. ( -! I I, � ` .F' 1 I° -'2:H•.StkuMaN kL�ce�T` I -14 92 i \ N t �I. •X�L. ... ..�'.-..1., r._...YTS' .. '�"_ •` �� . _... '-Z�. .. _ �. i - i. ..,. � .. . - ... I Assessor's office(1st Floor): �a _ G SEPTIC SYSTEM U Assessors map and lot numb INSTALLED IN CoTW Conservation J, V9 TH TITLE e„ Board of Health(3rd floor): !ENVIRONMENTAL O • ��L Sewage Permit number ;7-e Fe Engineering Department(3rd floor): Fos TOWN RE0U6� 639. House number �o Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ' (�C�G cu d _ n OC TYPE OF CONSTRUCTION �O 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: �= f Location 5 A`C T\ �o kA 2�� \P 0 \ � �� S, ri' 6 & Proposed Use ` ` \ Zoning District Fire District Name of Owner �'� \ (:.,A �'(` Address Name of Builder _ \ C Address 5 �,�,. V\14 Name of ArchitectC()L\V CA `R 0 M A Address--.-"%C 0` Number of Rooms \`. Foundation Exterior S Y1 N ��. Roofing 1\A- Floors -5 \` Interior Heating \� p\ Plumbing 1/4 Fireplace �-- \�e d Y� Approximate Cost Area Diagram of Lot and Building with Dimensions S Fee � t 'T Yd1 ,z•�z ,yo � d OCCUPANCY PEI WITS REQUIRED FOR NEW EL NGS I hereby agree to c 3ntorm to all the Rules and Regul ions the Tow of Ba nstable regarding the a ove constr Qb ame Construction Supervisor's License 3 TIGER, HARVEY J. No 35194 Permit For BUILD ADDITION a Single Family Dwelling Lot #6 50 Harrison Road Location � i"* �.• r"�. _ Centerville Owner kHarvey J. Tiger r' F Type of Construction Frame Plot f t' Lot Permit Granted July 13 19 92 1 Date of Inspection 19 Date Completed 19 IL 41 °,. •ter ,t r1 _a" .e { i I „tia + � '. . i y .xL i