HomeMy WebLinkAbout0060 HIGHLAND DRIVE t h r
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TOWN OF BARNSTABLE Bulfding , -
Application Ref: 201000694 BARNSTABLE, Issue Date: 03/01/10 Permit
MASS.
1639• �� Applicant: CRAFT,TANIKA M ET AL Permit Number: B 20100338
prFO M1►l a
Proposed Use: SINGLE FAMILY HOME Expiration Date: 08/29/10
Location 60 HIGHLAND DRIVE Zoning District RC Permit Type: RESIDENTIAL ADDITION/ALTERATIO
Map,Parcel 190139 Permit Fee$ 25.00 Contractor PROPERTY OWNER
Village- CENTERVILLE App Fee$ 50.00 License Num OWNER
Est Construction Cost$ 6,000
Remarks fl APPROVED PLANS MUST BE RETAINED ON JOB AND
REMOVE GARAGE DOOR,BUILD A WALL AND-INSTALL A WINDOW. 1NHIS CARD MUST BE KEPT POSTED UNTIL FINAL
STALL SUB-FLOOR,INSULATE WALLS/CEILING;ELEC BASEBOAD HEANSPECTION HAS BEEN MADE. WHERE A
CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH
Owner on Record: CRAFT,TANIKA M ET AL BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL
Address: 60 HIGHLAND DR - INSPECTION HAS BEEN MADE.
CENTERVILLE, MA 02632
Application Entered by: JL Building Permit Issued By:
THIS PERMIT CONVEYS NO RIGHT'TO OCCUPY,ANY STREET,ALLY OR SIDEWALK OR ANY/PART TH-t QF,E i HER TEMPORARILY OR PERMANENTLY.
ENCROACHEMENTS ON PUBLIC"PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDINd CODE;MUST BE APPROVED BY THE JURISDICTION.
STREET;OR ALLY. AD GRES AS WELL DEPTH AND,LOCATION OF PUBLIC SEWERSMAY BE OBTAINED FROM,THE DEPARTMENT OF PUB LIC WORKS.
THE ISSUANCE OF THIS PERMIT. 6ES NOT,RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDiV]SION RESTRICTIONS:
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK:
1.FOUNDATION OR FOOTINGS.
2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED.
3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TOTRAME INSPECTION.
4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY T'O LATH)-'
5.INSULATION.
6.FINAL INSPECTION BEFORE OCCUPANCY.
WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS.
WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION.
PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF
DATE THE PERMIT IS ISSUED AS NOTED ABOVE.
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A).
1 G D D
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BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
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3 1 Heating Inspection Approvals Engineering Dept
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Fire ,gpt 2 Board of Health .
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SMOKE DETECTORS REVIEWED
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w TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 1 Parcel 021 Application # :;0 1Q W0 fl
Health Division ( _ 37 N� � ? -� Date Issued 3
2c0�11a S ` A
/�ils•���
Conservation Division Application Fee F
Planning Dept. Permit Fee.
Date Definitive Plan Approved by Planning Board
f,0
Historic - OKH _ Preservation /Hyannis V
Project Street Address
ftvit ffinh IQ r�cl by-
Villager
l Owner ro Addressm—niem Jk
Telephone(5t�S) 7I-75" Oq
Permit Request rd(')O-(-, 1QWAd - Wa I I OOJ
mrdow. ld,qoll
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Peh e � rVIP^,H S n
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new `
Zoning District Flood Plain Groundwater Overlay
Project Valuatio*._
000, Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ,& Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes k No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) ,,��-yy�� Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing_ new 0 Half: existing new
Number of Bedrooms: existingQ new --TC. T1 z = 3
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# i
Current Use Proposed Use
e
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APPLICANT INFORMATION -�
(BUILDER OR HOMEOWNER) �c3��-15 b KQ ��
�
,,--Name J Telephone Number n�o I ���n��
""",Address g) License #
C -6 62 Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
,SIGNATURE X DATE l
FOR OFFICIAL USE ONLY
(APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
4
r FOUNDATION
g FRAME 3�3f p f 1 I u
s INSULATIONCO
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL t
GAS: ROUGH FINAL
FINAL BUILDING y1 uJJD
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of lndttstrial Accidents
71
Office of Investigations
� 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/,Contractors/Electricians/Plumbers
Applicant Information Please Print Leibl .
/ Name (Bu siness/organi zati on/fndivi dual): l Q I 1 I VQ MQ S
Address: nci r'
Addr _
/ ll
City/State/Zip: .
C2rrt-e.ry I I� MA Phone #: �� -7 75 ��o
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4.. [ am a general contractor and 1 6. ❑ New construction
employees (full andlor part-time).* have hired the sub:contractors
2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling
ship and have'no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
o workers' com . insurance comp. insurance.$
required•]
p 5. We are a corporation and its lo.❑ Electrical repairs or additic
3.El I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additic
myself. [No workers? comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we.have no
q ] employees. [No workers' 13.❑ Other.
comp, insurance required,]
*Any applicant that checks box 41 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 ind then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins, Lie,M 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
fine up to $1,500.00 arid/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a
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 h by c under the pains and penalties of perjury that the information provided above
(r is true and correct
Si nature: Date: V
l`Phone.#: d J
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
Phone#:
Contact Person:
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 Linder 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-contractor(s)name(s), addresses)and phone number(s)along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners,'are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be-advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit.. The affidavit should
be retumed to the city or town that the application for the pen-nit or license is being requested,not the Department of
Industrial Accidents.'Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pemnit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the.
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617.-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-774.9
Revised 4-24-07
www.mass.gov/dia
r
ENE•RG'Y CONSERVATION APPLICATION FORM FOR.ENERGY EFFICIC>ENCY FOR
ONrP-- AND TWO-FAMILY DETA.C1_SED RESIDENTIAL.CONSTRUCTION (780 CMR 61.00)
Applicant Nai LjCj r)I VQ r S Site Address: (2 }�
print Town: vI 10 .
Applicant Phone:
r Applicant Signature: Date-.of Application: a
NEW CONSTRUCTI choose ONE of the following two-o tions
780 CMR TABLE 6107.1.
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE- AND TWO-FAMILY BUILDINGS
MA QMTIM. 'Mam4uM
Ceiling or Slab.
QOption I: Basement
Fenestration exposed Wall Floor Wall perimeter ATUE HSPF
U-factor floors R-Value R-Value R Valua
R-Value
R-Value and Depth
Nalional Appliancc-Enu
.3S. R-38 R-19 R-19 R-10 R-10� conscrvA6nAct.(NAE(
4 ft.. 1987 as amcndcd,minim
raTrr as applicablo
Note: This form is not required if you choose either of the two versions of REScheck as listed below.
❑ Option 2: RES check Version 4.1.2 or later Variant software analysis must be completed
780 CMR 6107.3.2
REScheck—Web which can be accessed at http_-//www.energyCDdCS.gov/rcschf_-ck/
D X� O1VS OR AST RA`TZOI S.TO TJXIS`* J;N: JLLDSI�IGS:O ES25 YEAT�S OEM*
*puildings under 5 years old must use option#1 or 42 in New Construction section above,
Complete the following formula to determine the % of glazing:
(a) Gross Wall & Ceiling Area equals Formula: (100 x b_ a) '
SF 1.00 x - % of glazing
b a
(b) Glazing area equals SF
If •lazin i <�0%.use the chart belpw. If glazing is >40 W , rpceed to "SLNROOM" section
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIAADDITIONS TO EXISTING
LOW-RISE RESIDEN'ZUL BI7SS�pINGS
MAXIMUM ' MINIMUM
-Ceiling and Slab Peru
Fenestration Exposed floors -wall Floor Basement Wall R-Vah
U-factor R-Valuo R-Value R-value R-Value and Dc
39 R-37 a R-13 R-19 R-10 R-10,. 4
a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling
area i.e, not com ressed over exterior walls, and including any access openings).
SUNROOM—An addition or alteration to an existing building/dwelling unit where the tot
glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of t
addition.
Note: Owner to fill out Corzsurner b1formatiog.Form found in Appmdix 1.20T
0'
Town of Barnstable
��of srte row o Regulatory Services
STAB Thomas F. Geiler,Director
p i6� k,� Building Division
rLED Tom Perry,Building Commissioner,
200 Mald.StrCet._Hyannis, MA 026.01
?rww town.barnstable.ma.us
fi c e_ SO8-862-4038 Fax: 508-790-6230
Of
ETOT,MOwNER LICENSE EXEMTTIOTI
( Please print
DATE:
J � �-re rV� l l-� •
JOB LOCATION:
number streetho
• v llage
—""HOMEOWNER":
name home pho c# worlCpbone#
CURRENT MATLING ADDRESS: U 1
e v � � MR
city/town statL rip coat
The current exemption for"homeowners" was extended to include otvmer-occupied dwellings of six.units or less and
to allow hoineownurs to engage an individual for hue who does not possess a license,provided that the owner acts as
s up eryis o r.
DDFI MON OF HOlYLEO VXFR.
pergon(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, of is intended to•
ssory to such user and/or farm structures;
be, a one or two-family dwelling,.attachcd or detached structures acce A
person who constructs more than one borne in a iwa-year period shall not be considered a homeowner: Such
"homeowner"shall submit to thc.$tulding Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed trader the building permit. (Section 109.1.1)
The undcrsigncd"homeowner'assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations,
The uzndcrsigned"homeowner"ceres that be/sbc understands the Town of Barnstable Building Dcpartrpcut ,
um inspection procedures and requirements and that he/she,will comply with said procedures and
re Cuts.
Sign Luc o omcovencr
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.
HOMEDWNER'S E)CEMTTION
The Code states that "My homeowner performing work for which a building poTnit is required shall be exempt from the provisions
truction Supervisors);provided that if the homeowner engages a pQson(s)for hire to do such
of this secGon.(Section 109.1.1 -Licensing of cons
work that such Homeowner shall act as supervisor."
Many horncownas who use this exemption arc una 're that they are assurrung the responn'bi)ities of a supervisor(see Appendix Q.
Rules&Regulations for Licensing Construction SuperYisors,Section 2.15) This lack of awareness born results in serious problems,particularly
when The homeowner hikes unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting ss Superrisor 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 homcovrner certify that hdshe understands the responsibilities of a Supereisor. On the last page of this issue is A.form currently used by
community.
several towns. 'You may care t amend and adopt such a forrr)certification for use in your
YHEr Tawn of BarnstaWe
Regulatory Services
vx .RNS-0', Thomas R Geiler, Director
�. Fo,�,� � Building Division
Tom Perry, Building Commissioner
200 Main Strcet, Hyannis, MA 02601
www.town.barnstable.ma.us
Office; 508-862-4038 Fax: 508-79(
Property Owxi_erMust
Complete and Sign This Sectxoa
If Using A Bnrlder
4
I, a as Owner of the subj"ect.propert.y
hereby authorize to act on my behalf,
in all matters relative to work autho y this building permit application for.
. , ale
ffin
nrir �
(Address of ob)
ign tune of er a
� varauou-
lani
Print Name
complete fete the
'n for eat lease o
If Property Owner is, applying p p P
Homeowne
rs License Exemption Form on the reverse s,rde.
I
i,.
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s�•�' www.mass.gov/dia
Workers' Compeasation'Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): -j� / /'[�'a�-
Address: /,� ���E� AeJ,.
City/State/Zip: Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-.time).* have hired the strb-contractors
.2` II am a sole proprietor or partner-' listed on the attached sheet. T. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
in for me any capacity. employees and have workers' ❑ addition
[No workers'comp.-insurance comp. insurance.$ ❑Building 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -zo^t'—Ze2 S° PLt70E7W`2..
Policy#or Self-ins.Lic.M t l — 0 7.5nv 2 ac?—O`i Expiration Date: cY3-22'2c7 i v
Job Site Address: 6 0 S7-- 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 WA for insurance coverage verification.
I do hereby certify under the pains an penalties of perjury that the information provided above is true and correct
Simature: X ::i� Date:
Phone#: Lam'-,360' �22%.
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#:
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 tinstee 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
PIease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-conti-actor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address the applicant.should write"all locations in (city or
town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to-thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations.
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
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60
oF�►tE Town of Barnstable *Permit# 4q,�2,,
EVIres 6 montha froin issue date
11AJIZ4S?AJ= ; Regulatory Services Fee 6 -��7 60
MAM
%63 Thomas F.Geilert Director
Building Division
Tom Perry, Building Commissioner -
200 Main Street, Hyannis,MA 02601 NOV-
Office: 508-862-4038 2, 9 2004 •�I Fax: 508-790-6230 •
EXPRESS PERMIT APPLICATION - RESIDEr � '��Rf�STf�,�Lr
Not Valid without Red X Press Imprint
V1ap/parcel Number
Property Address C e� , f V 2(P J 2—
aResidential Value of work�120 Minimum fee of•$25.00 for work under$6000.00
Owner's Name&Address l
LD ffi011l0 w-v) 1 6A�13 a
Contractor's Name an Telephone Number n/rCJI
Home Improvement Contractor License#(if applicable /
Construction Supervisor's License#(if applicable)
❑Workmaes Compensation Insurance
Check one: .
❑ I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to_DLrmp
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement windows. U Value (maximum.44)
*Where required: Issuance of Oa permit does not exempt compliance with other town department regWations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home rovera=t Contractors License is required.
Signature
Q:Forms: g
Revise063004
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