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Geiler,Director 59 b CT _4 2012 Building Divis10n Tom Perry' CBO, Building Commissioner TOWN OF gARNSTABL90 Main Street,Hyannis,MA 02601 www.town bainstable.ma.us Office: 508-862-4038 Fax. 790-6230_{= MRESS.PER ftT'APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number'' /.-7/ Property Address 33 a:..N-y!no kaA"1✓t J'JSZ C�✓l T G0.111 ll e-. D 2-63 2' IV Residential Value of Work__ _ Minimum fee of$35,00 for work under$6000.00 Owner's'Name&Address 3 a � v_V1 Contractor's Name (�(,y(�,Q Telephone Number _bp"7 76 6 ?Q Home Improvement Contractor License"#(if applicable) , Construction Supervisor's License#(if applicable) (]Workman's.Compensation Insurance Check one: 0 I am a sole.proprietor. I am the Homeowner M I have Worker's'Compensation Insurance I Insurance Company Name' Workman's Comp:Policy# Copy of Insurance Compliance Certificate must accompany each permit, Permit Request.(check box) f ,KRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to []Re-roof(hurricane nailed)(not stripping. Going over existing'layers of roof) SLRe-side #of doors " $eplacement Windows/doors/slide'rs.U-Value 7ma 35)#of windows `5= „El 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: t Property Owner must sign Property Owner Letter of Permission. A copy Wf the Home InAovem nt Contractors License&'Construction Supervisors License is equire SIGNATURE: n•1nroL•rraetomn�io�t._ave_-= --..�� ,,� .... . I r . The Commonwealth of Massachusetts Department of Industrial Accidents , r Office of Investigations + d k 600_Washington Street Boston,MA 02111 , www.mass.gov4ia ti Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information $• Please Print Le ibl Name(Business/Organization/Individual): L -T_t.Oaj6L)L�� : Address: City/State/Zip:( ,,��I�I�. 10'(?� �22h6ne.#: 740 Are you an employer?Check the appropriate bog: ' . Type of project(required):. 1.❑ I am a em to er.with 4..❑ I am a general contractor and I . P Y 6. ❑-New construction . employees(full and/or part-time).* have hired the stab-contractors-, ry 2.❑ I am a sole proprietor or partner- `listed on the attached sheet. 7.g ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• s $. - 9. ❑.Building addition [No workers' comp.insurance comp.insurance. r required.]- 5. ❑ Wetare a corporation and its 10.❑Electrical repairs or additions fficers have exercised their 11.❑Plumbing repairs or additions 3.�I am a homeowner doing all work o V myself. [No workers'comp. right of exemption per MGL 12.EgRoof'repairs C 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 theirworkers°compensation policy,infomiation. 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. Iam 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 dedaratiowpage:(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 covierage verification. I do hereby certify un r the s and p alties o 'rjury that the information provided above is true and correct _ p Signature: i Date: Phone#: �W) Official use.only. Do not write in this area,to be completed by city or-town official - - 5 . t 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 a Contact Person: Phone#: ormation and Instruct'one Massachusetts General Laws ch ter 152 requires all employers to provide workers' ompensation for their employees. Pursuant to this statute,an employ is defined as"...every person in the service of other under any contract of hire, express or implied, oral or written." , An employer is defined as"an individu 1,partnership,association,corporation or ther legal entity,or any two or more of the foregoing engaged in a joint ente rise,and including the legal representati es of a deceased employer,or the receiver or trustee of an individual,parts ship,association or other legal entity, mploying employees.-However the owner of a dwelling house having"not mo than three apartments and who resid s therein,or the occupant of the dwelling house of another who employs p sons to do maintenance,constructio or repair work on such dwelling house or on the grounds or building appurtenant ereto shall not because of such em oyment be deemed to be an employer. MGL chapter 152, §25C(6)also states that' very state or local licensing ag cy shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildi gs in the commonwealth for any applicant who has not produced acceptabl evidence of compliance with c insurance coverage required." Additionally,MGL chapter 152, §25C(7)stat "Neither the commonwealth or any of its political subdivisions shall enter into any contract for.the performance of ublic work until acceptable r 'dence of compliance,%vith the insurance requirements of this chapter have been present e to the contracting authori Applicants Please fill out the workers' compensation affidavit ompletely,by chec ' g the boxes that apply to your situation and,if necessary, supply sub-conti;actor(s)name(s),addres es)and phone numb r(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or L' 'ted Liability Pa rships(LLP)with no employees other than the members or partners, are not required to carry worker compensation' ance. If an LLC or LLP does have employees, a policy is required. Be advised that this a davit maybe su witted to the Department of Industrial Accidents for confirmation of insurance coverage...Also a sure to sig and date the affidavit. The affidavit should be returned to the city or town that the application for the ermit or lice e is being requested,not the Department of Industrial Accidents. Should you have any questions regar ' g the law r if you are required to obtain a workers' compensation policy,please call the Department at the numb r listed be w. 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 De artment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investig4tions has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be use as reference number. In addition,an applicant that must submit multiple permit/license applications in any given yei eed only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the app.it ant should write"all locations in _(city or town)."A copy of the affidavit that has been officially stamped or mark I by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or lict ases. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not lated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT req to complete.this affidavit. The Office of Investigations would like to thank you in advance for yo co peration and should you have any questions, please do not hesitate to give us a call.. The Department's address,telephone and fax number: The,GomrnonweaM of sac setts ` Department of Industrial Acci_eats Office of Investig. 'an 600 Washington Boston, MA 0 11 Tel. ##617-727-4900 ext 406 or 1-877--MASSAFE Revised 11-22-06 Fax#617-727-7749 v.mass.gov/dia Town of Barnstable Regulatory Services Thomas F.Geiler,Director 1639 �0 Building Division Tom Perry;Building Commissioner. 200 Main Street,Hyannis,MA 02601 www:to wn.b a rn sta b l e.m a.u s Office: 508- 2-4038 Fax: 508-790-6230 Property Owner,Must Complete and Sign This Section ' If Using A Builder as Ow er of the subject property hereby authorize to act on my behalf, in all matters relative to rk authorized.by this boil permit: (Address of Job) **Pool fences and alarm are`the re possibility of the applicant. Pools are not to be filled or utiliz d befor fence is installed and all final ' inspections are performed a d acc pted. Signature of Owner Signature of Applicant t Print Name Print e Date Q:FORM&OWNERPERMISSIONPOOLS 642012 THE tj Town of Barnstable P 4i O ,. Regulatory Services g rY * snxxsrASLs Thomas F.Geiler,Director yL MASS. `DA 1639• Building Division .. rfD MA'I A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 5 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION r Please Print DATE: JOB LOCATION:- p1 3 �D r/ �hG��GvrK t�i 4(/ number street - village _ "HOMEOWNER": k 47 6 C_4L2t I d.1/Gt q:G 45 4 Z e_s name h6me 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 Persou(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 t1kat he/she understands the Town of Barnstable Building Department minimum' spection proced s and requ' ents and that he/she will comply with said procedures and requireme ° Signatur owner 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 persons)for hire to do such work,that such Homeowner shall act as supervisor." t Many homeowners who use.this exemption are unaware that they are assuming the respoy sibilities 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 ul6mately;responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communitie 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 ' t. Town of Barnstable tHE Regulatory Services ' OF Tp� ti Thomas F.Geiler,Director w &MMSrna[.e, Building Division y MASS. g Tom Perry,Building Commissioner 39.i6 ♦0 '•�pp 39. a 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Approved: -(�r��DS J Fee: "— fermit#: HOME OCCUPATION REGISTRATION Date: l Name:.-Jeo �etZ 1 ( GC 1� ��1�-- - Phone#: J`Z) —q2to Address: 6R3> d � � �� village: Name of Busmesb'S cl-:2Y10Ct) Type of Business: JY�L�C�f Map/Lot: hT INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit, located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration, smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials, in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Hcme Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No pers "be ed iAbv ary Home Occupation who is not a permanent resident of the dwell'I,the undersigned with ictions for my home occupation I am registering. Applicant: Date: d Homeoc.doc Rey.5 3 /03 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter. DATE:2-1-1-O 7 Fill in please: _ Y APPLICANT'S YOUR NAME: a U rAV1CJl�� S - 5 � BUSINESS YOUR HOME ADDRESS: 2�h EtaG,r�✓�'! lIe TELEPHONE # Home Telephone Number. - 112-0 NAME OF NEW BUSINESS ob 5 ono TYPE OF BUSINESS Ltw1ouj IS THIS A HOME OCCUPATION? S N Have you been given approval from the bw ding division? YES NO ADDRESS OF BUSINESS 5� AS abOyie- MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S FFICE This individual has been in or ed of,any permit requirements that pertain to this type of business. FOLLOW HOME Authorized Signat ** AT I O N RULES COMMENTS: 2. BOARD OF HEALTH This individual h been inf med of the rmit uirements that pertain to this type of business. AA A- Authorized S' nature** '* M CMftyWRHALL ��'� ��° COMMENTS: HAZARM 13 ue�Q�■•.r,s I �•�wr.wyo mvr 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual h, een inf. d of the i g equirements that pertain to this type of business. . 2. ! Authorized Signature** 7 COMMENTS: t Er. ineerin Dept. 3rd floor Ma 17 Parcel9 # �so � 7 g P ( ) p ` House# Date Issued m -F-,7 Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) Fee �.dd Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) DIME Definitive Plan Approved by Planning Board 19 ' - RARNSTARLE. °rEn�9. TOWN OF BARNSTABLE Building Pe it Application Project Street Address a , Village Owner t Address Telephone d Permit Request First Floor 170 square feet Second Floor square feet Construction Type ' Estimated Project Cost $ � 200• O y Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family C�/Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No 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 No.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 Garage, ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) " ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name I L-Qr Plephone Number Addres . ( ' License# Home Improvement Contractor# ay! _ 00 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTR ION DEBRIS RESULTING FROM THIS P OJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED F W THE OLLOWING REASON(S) V FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. i ADDRESS " VILLAGE _ OWNER DATE OF INSPECTION: 1 FOUNDATION FRAME INSULATION FIREPLACE - 3 ELECTRICAL: ROUGH ' FINAL PLUMBING: ROUGH FINAL GAS:' ROUGH ; FINAL ` 4 FINAL BUILDING . DATE CLOSED OUT ASSOCIATION PLAN NO. THE The Town of Barnstable • a�sxgrasr� • 91619. ,0�' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissione For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling, units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: O �- Est.Cost Address of Work: B Owner's Nam Date of Permit Application: /9-7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law .lob under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: -. OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I ere pply for a permit as the a Ont of the owner. // Contra or Name Registration No. OR AIN Z-497\10