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HomeMy WebLinkAbout0054 MONOMOY CIRCLE 3 4 Town of Barnstable .. *Permit#a6 C �oyvl gulatory Services Fe MASI . l. 9ibp 163¢ ��� ?' is",Y Thomas-F. Geiler,.Director 7hJ/y oft, -Building Division Perry,CBO, Building Commissioner, 00 Main Street,Hyannis,MA 02601 ' www.towmbarnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - .RESIDENTIAL ONLY Not Valid without Red X-Press.lmprint Map/parcel Number Property.Address ®Residential Value of Work `��cle)o.0,0 Minimum fee.of$35.00 for work under$6000.00 Owner's Name&Address �,' f�� ,'A, xP4 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑workman's 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 accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing-layers of roof) [�.Re-side #of doors g Replacement windows/doors/sliders.U-Value Xf (maximum.35)#of windowsET -�- Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission., A copy of the Home Improvement Contractors License&-Construction Supervisors License is i required- SIGNATURE: QAPRUSTORWbuilding permit formslEXPRESS.doc The Commonwealth 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 Please Print Legibly Name(Business/Organization/Individual): Z4 7?,.1 E Address: 32 City/State/Zip: C'�..f nor;`���, aO1 32 Phone.#: .�®O 7 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 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. T ®Remodeling ship and have no employees These sub-contractors have g;"❑Demolition workingfor me in an capacity. employees and have workers' Y P t3'• $. 9. ❑Building addition [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 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 and job site information. Insurance Company Name: Policy#or Self-ins'. Lic.#: 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 c/er�tif�y under the pains and penalties of perjury that the information provided above is true and correct Signature: //�`� /y' / = �" 'Dater 02 f+f Z Phone#: Official use only. -Do not write in this area,to be completed by city or town official J_ � City or Town: ft Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employ 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, artnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterpri ;and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partners ,association or other legal entity,employing employees. However the own--r of a dwelling house having not more th three apartments and who resides therein,or the occupant of the .,dwelling house of another who employs perso to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto hall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every ate or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a busine s or to construct buildings in the commonwealth for any applicant who has not produced-acceptable eviden a of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Nei r the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public w is until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the ntracting authority.". Applicants Please fill out the workers' compensation affidavit complet ,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s),address(es)and one number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Lia ' 'ty Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compe tion urance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit ma b submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure t sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit o ense is being requested,not the Department of industrial Accidents. Should you have any questions regarding a la l or if you are required to obtain a workers' compensation policy,please call the Department at the number ted b ow. 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 legi,ly. The Dep\han t has provided a space at the bottom of the affidavit for you to fill out in the event the Office of vestigations ontact you regarding the applicant. Please be sure to fill in the permit/license number which be used as ace number. In addition,an applicant that must submit multiple permit/license applications in - given year,nsubmit one affidavit indicating current policy information(if necessary)and under"Job Sile Ad ess"I:he applic d write"all locations in--(city-or town)."A copy of the affidavit that has been officially s mped or marked c or town may be provided to the applicant as proof that a valid affidavit is on file for fu a permits or lice n affidavit must be filled out eachyear.Where a home owner or citizen is obtaining a lice a or permit not rto business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said pe on is NOT requirmple a this affidavit.The Office of Investigations would like to thank you' advance for your tion an should you have any questions, please do not hesitate to give us a call.. The Department's address,telephone and fax number: Tl�e eorru7a� ealth aMassacbusetts Departmenn of Industrial Accidents UMe of Investigations 600 ashingtoli Street B ton, MA 0.2111 Tel. #C 17-727-4900 ext 406 or 1-877-MASSAFE � Revised 11-22-06 Fax#617-727-7`749 www.mass.gov/dia I � •.�' oFTHE r, Town.of Barnstable °* Regulatory Services 4. snaxsreBr.E • y Wins. � Thomas F.Geiler,Director i639• 1� ' �Eo yq.1• Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 ' www.town.barnstable.ma.us Office: 508-862-4038. Fax: 508-790-6230 Property Owner Must omplete and Sign This Section If Using A Builder I, 1 "` / ' '%� s Owner of the subject' roperty. hereby authorize to act on my behalf, in all matters relative to w rk authorized.b this building permit: ( dress of Job) *Pool fences and . .rms are the responsibility of the applicant- Pools' are not to be fille r tilized before fence is installed and all final inspections are rfor ed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QFORM&OWNERPERMSSI0 1OLS 62012 THE Tp�� Town. of Barnstable P.� Regulatory Services zwBxsrABM Thomas F.Geiler,Director nsass. a Building Division �A 039. rFD MA't - Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 r HOMEOWNER LICENSE EXEMPTION Please Print ' DATE: �� (�•/y C JOB LOCATION: y✓ n/O o C',' �.e--V4 e 2 Vr I/e //rn��u��mber. stre village U"HOMEOWNER": V''/z4,in 12/i !/e.y '1/ name / home phone# work phone# CURRENT MAILING ADDRESS: �L/ /1�JC/i✓y'A�!©c/ ( /�%L 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 re/q/uiirem nts. Signature of Homeowner ell 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 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 4„ when the homeowner hires unlicensed persons. hi this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt 1. ^.'� :y.', ,1Alj. 1' f 1 , - 7' Ia e _ r•: S .1 t^ ,•14, $11`a�,y� w i .t`a 1. L.',Pi ,( {}'� - n rb .,r..a d, ,;; J�' ( d t r 1 4 y� t t r x ( rti. X; ) p lk w{ i s JIl♦4 �.- . 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Y - k C� R it 3.` R. % t Sfe "f;i Alt , �� �_ ;mom.. +r•" vS ,. ' X.� s +s }t"' �' f1 7, �* JALA' ' r+ v x � s� I , n p� } h G/�/%L -=./G%A/�EeG$ 4a r i a7 d f t if � 1 '.:1 rG�7 Al a St/e1�61✓O BS A` 'i j ., ", y iI, ' 3©r:'✓7'1E 6A rY�.2MOcJT<,I, "�i SS. f�TE 'E r Q l� y�F 4 'w•r'w f. is 4'. s9� v r xt v � a �I r, Assessor's. ma and lot. number -77 SEPTIC SYSTEM MUST BE- 70 1 Sewcge'Permit number 1.rl.. INS;i LED IN COMPLIANCE WITH APT;CLE I! S` .ATE r S I TA y COO 'AKIP `�'fl1iVt°� Q�OF?HE?��y -! E TOWN OF, BARNlS e-,: ,.BLE c1 Z BARMTAItLE. '1 i'i639• J �_ UI L,D I N G INSPECT-OR y A9 . 1 APPLICATION FOR PERMIT,TO ........:. .. .... ......................... ............................ ........ ' TYPE OF CONSTRUCTION .................. :.�/. � ... ... ........... .................................... ........ ...........) TO THE INSPECTOR OF�. BUILDINGS: The undersigned hereby applies for a. permit according to the following, information: Location ......�4.0.....A/................../`�C�/�!C�/•'7 G?.Y...C.jAC A_Cw CE/I/7-EAVIL.I-E..t. .1'�'1 hSS. ........... ProposedUse .. S/At/Ui—1,Q.�.............. ............ .............................................................................. Zoning District C 67rvTE�U 1L._kE Fire District .............................................................................. Name of Owner !.! ot"1'rs s��c�e�l �t3��OdEY W !�i�!fAddress� ............................E/aS JnJ P/etfl�S.. v'� C•�N� _ p Name of Builder S ....Address 7? RA I��RSTCII/ I....g ,,�,•, ............................ �........................... Nameof Architect= J ,5A. ...............:.................Address .................................................................................... r • ��C �1� . Numberof Rooms .:.........................................:......................Foundation ... .....��........C...o....ru....C...R.......................................... Exterior l�/ov0 SHINGI-E.3 3—' Cl- Pc3079RD.....Roofirig .....ASPH�.II .................................................... Floors Interior -� T......C.?�.................................................................)................................................................... Heating ..................................................................................Plumbing ..�....8A.TH ......................................................... Fireplace I..................................................................Approximate Cost .... .�1 C} OC).............:.................. .... .. . Definitive Plan Approved.by Planning Board ________________________________19________. Area ...../..... . ...'.. 0 Diagram of Lot and Building with Dimensions Fee 3 / . a _-- ............... . . SUBJECT TO APPROVAL, OF BOARD OF HEALTH l 9, 3 � n 41�V� d� 0 Oct k o I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. l� �" Name r� `^ -'. .... ................................ - ` ' . ^ ^ . ' " . . . . - . . . . . ' ^ . . 19084 one story rY single family dwelling pmoy Circle Locdtislv�!.................................................... Centerville ' Walker . . frame 00 PERMIT REFUSED' ' ' ~ ` - . .. . ' . ~ ° . . . - ^ ` �...~-----..---.........----.....—...' -------.�.—...—..---,.—.—..------. . ' Approved ................................................. lV ,. . , �-------------......—...--~--'. ----------------.----.---.,.. , . | ' ' | - . . -1 TO V! 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