HomeMy WebLinkAbout0092 LIETRIM CIRCLE 4
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OpTFibT Town of Barnstable *Permit#
Expires 6 months from issue date
awRN5rABCE.
Regulatory Services Fee � d`�
� - .
Thomas F. Geiler, Director
�_F Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601 .
www.town.barnstab le.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address y �_ ; , 7 Yh �a t'c'1r' ��'�: v' e H
R Residential Value of Work. �j 9b ' .minimum fee of$25.00 for work under S6000.00
Owner's Name &Address T.( t
Cluc-Q
Contractor's Name P6�`ic � up,0c�'�Y't' r(o4ft^ v>zId�.Ss!-�tc Telephone Number ����; ? 's_ _
Home Improvement Contractor License#(if applicable) y�!
Construction Supervisor's License#(if applicable) of -�
❑Workman's Compensation Insurance X-P,RESS PERMIT
Check one:
[ I am a sole proprietor JUL-2 112009
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box) /��
Re-roof(stripping old shingles) All construction debris will betaken to [Darn:� I-Cl4 = �-unfr
❑ Re-roof(not stripping. Going over existing layers of roof)
[ Re-side
Replacement Windows.. U-Value (maximum .44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Ftistoric,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
e Imp eme �ractors Lice- & Construct Supervisors License is required.
SIGNATURE: -
Q:\WPFILES\FORMS\Express\EXPRESS PERMIT.DOC
Revisc06O4O9
The Cornmonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
:�•� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information j _Please Print Legibly
Name(Business/Organization/Individual): jA kz(�-,� y e ael/m� P�'�giakwas
Address: /f o/ �47 d14a I UU)Lid 400r
Phone.#:
o
City/State/Zip: � �94-u, J'' �i� a �4 ?S _ —�d� � S
Are you an employer? Check the appropriate box: Type of project(required):
❑ I am a employer with ❑
4. I am a general contractor and I
1. 6. ❑New construction
employees (full and/or mel.* have hired the sub-contractors
part-ti
..2. I am a sole proprietor or partner-' listed on the attached sheet. T. ❑Remodeling
ship and have no employees These sub-contractors have g. '❑Demolition
employees and have workers'
r me in an capacity. addition
worlang for y p ty9. Building
[No workers'comp. insurance comp. insurance.$
required.] 5. (] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Other �ro►i S tGt'Pie /
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. 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 a
fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine.
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the WA for insurance coverage verification
I do hereby certify under the pains and enatties ofperjury that the information provided above is true and correct
Simafore: Date:
Phone#' 15 d k" .a `2 9 7 a 0
Official use only. Do trot 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#:
f
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 tiustee 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-coutcactor(s)nanie(s),-address(es)and.phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
.Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" (.he 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 roof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
p
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 brim 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 IaVestigatians
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-72777749
Revised 11-22-06
www.rnass.govldia
�j► To�ti Town of Barn-stable
Regulatory Services
t t
9 " �B $ 'Thomas F. Geiler,Director
1634- ��'
�Eo a Building Division.
e
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town-barnstable.ma.us
Office: 508-862-4038 Fax: 509-790-6230
Propexty Owner Must
Complete and Sign This Section
If Using A Builder
I, k� g , as Owner of the subject property
hereby authorize NI Cc r'e l 144 per ke to act on my behalf,
m all matters relative to work authorized by this,building permit application for.
4, C
t
4av � OZCo32.
Address of rob
7 _ zd _ Zoo
S tur of Owner Date�!t�f -
1
10
P Name +
If Property Owner is applying for permit please complete the
Homeo�rners License Exemption Form on the reverse side.
Town of Barnstable
�IHE Y,
do Regulatory Services
Thomas F. Geiler,Director
16' BuHding Division
�PrFD Tom Perry,Building Commissioner
_ . __ . ._ ... - - -200 Ivfain=Street—Hyannis;IvfA 0260
w"Jown.barnstable-ma.us
Office: 509-862-4038 Fax: SOS-790-6230
HOMEOWNER LICENSE EXEMT'TTON
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The ctu-rent 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
Persons)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 axYd regulations.
The undersigned."homeowner." certifies that.he/she understands the Tpwn of Bar.astable;Buil&g Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signatirrc of Homeowner
Approval of Building Official
t
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 pcnrrit 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 persons)for hire to do such
work,that such Homeowner shall act as superosor."
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 2.1 S) 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 persori as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the bomcowner is fully aware of his/her responsrbilitics,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 currmfly used by
several towns. You may care t amend and adopt such a fomi/ccrtifi cation.for use in your community.
122 U/67!YI)ZlYI2l!/CClGLfL, ,��
Board of Bwldi,g Regulations and tandarifs License or registration valid for individul use.only
HOME IMPROVEMENT CONTRACTOR before the expiration date if found return to:
Board of Building Regulations and Standards
Regt06 ion:\ 153440 One Ashburton Place Rm 1301 1
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E, pirat►on 12/1/2010 Tr# 27814fi Boston,Ma.02108
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�. MICHAELAUPPERLEEREhtOVAfIONS "• i
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MICHAEL AUPPERLEE, i {
1 i9 SANOALW00D DR ✓f �pZ, Q
`�Y Not valid wit outs' afore !
COTUIT,MA635 -,' Administrator
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BAB.B9TIlDLE, it
"b 9 BUILDING INSPECTOR .
°mopY
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APPLICATION FOR PERMIT TO .... ......... .................. ...syE
TYPE OF CONSTRUCTION .*F„s+ - .. v. .............. . ....CL ..........................
........ .. ..... ... 191/
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according o the following information:
Location. �.
ProposedUse .: / . ..........................................................................................................................
Zoning District ...... �...................................................Fire District ... ' ....41........................................................... .
Name of.Owner ..W..l .. .: .1:.:...... .........AddressTJ 4- �'�.`. .... �....!..Y...��
.................. ......
Name of Builder ....................................................................Address y
Nameof Architect ..................................................................Address ...................:................................................................
Number of Rooms A....... ..............................................Foundation .... .�...1'(.. .....................................
Exterior .`.. .. ............Roofing .........
. . ..................... ..... ................... .. . .. .................. .................................................
Floors ............................................................Interior ..A.......... ....................................
Heating ......... 1 . ..........FA),It..................................Plumbing ............�.. ....................................................................
Fireplace . ..............................Approximate Cost .......
Difinitive Plan Approved by Planning Board ________________________________19________ .
Diagram of Lot-and Building i .ion.
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
�i✓ . C�
Name ... ............... ..... .................
Dacey, William E. Jr.
14048 DEC 3 trp7st ory
No ................. Permit for ....................................
single family dwelling
. ...............................................................................
C?a Lietrim Circle
Location ................................................................
Centerville °
William E. Dacey, Jr.
Owner ..................................................................
Type of Construction frame
................................................................................
Plot ............................ Lot ........ ................. t -
Permit Granted ........July 1 j 19 71
Date of Inspection .....................:..............19 L
Date Completed .....04.7. ......W........19
PERMIT REFUSED ^�s
................................................................ 19
.................................................................. ......
..... .......................................... ........................ j`��
............................................................................... ✓
Approved .................................................. 19
...............................................................................
...............................................................................