HomeMy WebLinkAbout0300 NOTTINGHAM DRIVE t
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map _ Parcel dJ i Application # J
Health Division Date Issued
Conservation Division Application F
Planning Dept. - ``Permit Fee
Date Definitive Plan Approved by Planning Board ' &p
Historic - OKH _ Preservation /Hyannis
Project Street Address 300 No fh h 66 r N Or-
Village CZ+n4-tM 1 11.e_
Owner Gordq,n L o Ui 5 v Address_p&_OX LI y 3 �6v mma q L'i c1
Telephone OaC 3 7
Permit Request F� n 1 -,)k 1 ✓1 enY qr of coop S2Gl Vo f'C,�\ - 3 5ewso-n
no hea4 1(0x 12. Shee 4 Ou+d car- cc roe '.
/10 eX4e4ar
Square feet: 1 st floor: existing proposed 2nd floor: existing_ proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 2 y 0 D _Construction Type -
Lot Size 3 L( ftirc5 Grandfathered: ❑Yes q No If yes, attach supporting documentation.
Dwelling Type: Single Family 3_ Two Family ❑ Multi-Family (# units)
Age of Existing Structure I q I a Historic House: ❑Yes 140 On Old King's Highway: ❑Yes ❑'No
Basement Type: 21 ull ❑ Crawl ❑Walkout ❑Other_
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing 2- new Half: existing new
Number of Bedrooms: 3 existing _new
Total Room Count (not icluding baths): existing _ 1 new First Floor Room Count
Heat Type and Fuel: SIG/as ❑ Oil . ❑ Electric ❑ Other
Central Air: 19'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: lSrexisting ❑ new I 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 I�pehrr�l I �I , Telephone Number �� ' 5 7 7�-7a S8
• 1 u
Address _R� Sun�nn� � License #
b a�(o 0 tome Improvement Contractor# (- 1 2_ 3 0
Worker's Compensation # .2b4 f 3�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
(Jw��ec� c✓4 s k
SIGNATU ��._ DATE 3/Z0I12 -
i
FOR OFFICIAL USE ONLY t
APPLICATION#
}
j ':DATE ISSUED,,,,,k.:
_ •.MAP/PARCEL-NO.
1
Y
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: r
;_FOUNDATION:
' FRAME
_INSULATION► ^,l
FIREPLACE
ELECTRICAL: ROUGH FINAL
f
PLUMBING: ROUGH FINAL
GAS'- t:.� - ROUGH;.=M FINAL
.1-j.i:E:I.NAL BUILDING`' 4 r
c
a--,DATE CLOSED OUT.
ASSOCIATION PLAN NO.
I -
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/din
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le_ibiy
Name (Bnsiness/organizzetion/Individual): K�j�'�C L U C.
Address: 4 SuMM I �G P�H v ✓ ✓�4� Da',>(oC7 -.
City/state/Zip: P—lq rnoU dY11q C A Q Phone
Are ou an employer?Check the appropriate bog:.
4. Iam a general contractor and I' Type of project(required): .
1.�I am a employer with 3 ❑
employees(fiM end/or part-time).* have hired the sub-contractors 6. ❑New construction
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'
[No workers'comp.mi sl ce 9.comp.insurance.t ❑Building addition .
required.] 5. ❑ We,are a corporation and its 10.❑Electrical repass 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:
insurance required.]t c. 152, §1(4), and we have no ❑Roof repairs
��
employees. [No workers' 13.R Other
comp.insurance required.]
*Any applicant that checks box#I must also fin out the section below showing their workers'compensation policy informadoo.
t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have
employee. If the sub-contractors have employees,they must provide their workers'c policy number.
omp•p c3'
Jinn an employer that isproviding workers'compensation insurance for my employees Below is the poFzcy and job site
information.
Insurance Company Name:_ (, )/,�Q,,r Wrl �4xs
Policy#or Self-ins.Lic.# �47le) ,30 ✓a Expiration Date: L' S! <
Job Site Address: 3co Pe Ifi im T)r, City/State/Zip:_ (on EMA
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 fom7 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
Ida hereby c nder the sins and penalties o erjury that the information provided above is true and correct
Si lure: Date: 3 Zo I Z
Phone#:
Dfficial use only. Do not write in this area to be completed by city or town gfficiaL
City or Town: Perm%t/I,icense#.
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#•
laoftta License or registration valid for individul use only
Office 6 o sumer airs smess egu a on before the expiration date. If found return to:
HOM
E IMPROVEMENTOffice CONTRACTOR of Consumer Affairs and Business Regulation
Registration: .-171230 Type:
-LLC 10 Park Plaza-Suite 5170
Expiration: 3/1(2014. Boston,MA.02116
tI-C.
:- 4
DENNIS KERKADOr= r t Ir
96 SUMMIT RD
PLYMOUTH,MA 02360 Undersecretary _ Not valid without signature
1 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction SuperN isui-_
License: CS-093445 '
DENNIS KERKADO
96 SUMMIT Rb
Plymouth MA 02360
Expiration .
Commissioner 02/26/2014
t
ISSUE DATE
;;CERT'TT C" DF.IN�SURANCE: 2/24/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATWELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. '
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policylies)must be endorsed.If SUBROGATION IS WANED,subject to the
terms and conditions of the policy,certain policies may require an endorsement.A statement on this certbicate does not confer rights to the
certificate holder in ileu of such endorsement(s).
PRODUCER CONTACT
DOWLING&O'NEIL INSURANCE AGENCY INC' NAME:
P.U. BOX 1990 PHONE FAX
(A/C,No,Ext): (AIC,No):
HYANNIS MA 02601 E-MAIL
ADDRESS:
PRODUCER
CUSTOMER ID "
INSURED INSIIRER(S)AFFORDINC COVERAGE NAIC#
KREC LLC INSURER_ A HARTFORD UNDERWRITERS INSURANCE.
945 CONCORD STREET - COMPANY
FRAMINGHAM,MA 01701 INSURER B
INSURER C
INSURER D
INSURER E
INSURER F f
COVERAGES _ CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TFIE 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.LM=SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER" POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WV]) (MMOD/YYYY) (MM/DD/YYYY)
GENERAL LIABILITY EACH OCCURRENCE S
O COMMERCIAL GENERAL LIABILITY DAMAGE( RENTED I
PREMISES(Ea
occurrence)
CLAIMS MADE OCCUR MED EXPENSE(Arty me I
person
0 ' PERSONAL&ADV S
INJURY
0 - _ GENERAL AGGREGATE S
GEN'L AGGREGATE LIMIT APPLES PER
' -
0 POLICY 0 PROJECT 0 LAC' , PRODUCTS-CONIF/OP S -
AGG
AUTOMOBILE LIABILITY - COMBINE)SINGLE S
LIMIT
(Ea accident)
0 ANY AUTO BODILY INTURY S
. - (Per Person)
0 ALL 010 ED AUTOS - BODILY INP-MY I
(Per Accldeni)
0 SCHEDULED AUTOS - - PROPERTY DAMAGE S '
(Per accident)
0 IIRcEL AUTOS S -
0 NON-OWNED AUTOS S
0
0 UMBRELLA LIAR 0 OCCUR + _ EACH OCCITT:RENCE S
0 EXCESS LIAB 0 CLAIMS-MADE AGGREGATE S
0 DEDUCTIBLE s 1 _ S
0 RETENTIONS. _> - - S
WORKERS'COMPENSATION - WC
A AND EMPLOYERS LIABILITY NIA S'I'AM TOR Y
YIN LRAFS
ANY PROPRIETOR/PARTNER/
EXECUMTsOFFICERlt-EMBER Y - N/A 5047P30A ' 02/iS/2012 02115/2013 L EACH ACCIDENT - 11,000,000
EXCLUDED9
(MANDATORY IN NIA _ .L DISEASE-EACH S1,000,000
EMPLOYEE
Eyes.describe=der DESCRIPTION OF E LDISEASE-POLICY 51,000,000
OPERATIONS below M41T
DESCRTP'17ON OF OPERATIONS/LOCATIONSNEIIICLES(Attach ACORD 101,Addwonal Remy ks Schedule,if mere space Ls required) -
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE,
GERTTFIATE.HQI DEA CANCELLATION
TOWN OF BARNSTABLE
200 MAIN.STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HYANN[S MA 02601 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
. AUMORUM REPRESENTATIVE
br-aav MacLeaav
ACCORD 25`(2009I09)" da 19W2009 ACORD CORPORATION.All rights reserved.
y. IKE Town of Barnstable
Regulatory Services
=ARNbTABLE, f
ass. Thomas.F.Geiler,Director
16.19. ♦0
Ennu�� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038. Fax:-- 5087790-6230-
Property Owner Must
- Connplete-and Sign:This Section
If Using A Builder - ~
I � '
as
�' yt Owner of the sub'ect, ro e
p .p rtY
hereby authorize �2 h��'� x kctAo to act on my behalf,
in all matters relative to work authorized by this building permit
N
(Address of Job)
Pool fences 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.
lgnature.of Owner
/)/V
Print Name Print Name
Date
Q:FORM&OWNERPERMSSIONPOOLS-
I
'THE . Town'of Barnstable
Regulatory Services
BARNSTABLE, Thomas F.Geiler,Director
MASS. g
16
� Building Division
Tom Perry,Building Commissi ner "
200 Main Street, Hyannis,MA 0 601
www.town.barnstable.ma. s
Office: 508-862-4038� Fax: 508-790-6230
HOMEOWNER LICENSE EXEM TION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
ci own state
zip code
The current exemption for"homeowners' as extended to inclu eowmer-occupied dwellings of six units or less and
to allow homeowners to engage an individu 1 for hire who does otpossess a license,provided that the owner acts as
supervisor.
DE INITION OF HO EOWNER
Person(s)who owns a parcel of land on which /she resides or intends to reside,on which there is, or is intended to
be,a one or two-family dwelling,attached or det ched structur s accessory to such use and/or farm structures. A
person who constructs more than one home in a -year perio shall not be considered a homeowner. Such
".homeowner"shall submit to the Building Official a form a ceptabl6 to the Building Official,that he/she shall be
responsible for all such work erformed under the b Ly De t. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for co �Iiance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understan s the T wn of Barnstable Building Department
minimum inspection procedures and requirements and that he she will omply with said procedures and
requirements.
Signature of Homeowner
(
Approval of Building Official_
Note: Three-family dwellings containing 35,000 cubic feet or larger will a required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER' EXEMPTION j
The Code states that: "Any homeowner performing work for Which a building permit is require hall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);Aided that if the homeowner enga es 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 ervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2." This lack of awareness often results in se 'ous problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board can of proceed against the unlicensed person as't would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsi ilities,many communities require,as part of the ermit application,
that the homeowner certify that he/she understands the responsibilities of a upervisor. On the last page of this issue is a form,currently used by
several towns. You may care t amend and adopt such a fora/certification f r use in your community.
Q:forms:homeexempt
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fA141 '� LOCATION OF STFIUGTURE(S)
SASEC C,iJ L NEg OF 9'XUPATION
30 1 ' WILL REQUIRE AN INSTP.I MEN TATION
NQ
SURVEY.►
�2' lrl$ ..Scale: i3D
S. LAURFANI
_ IROFESSIONAL LAND SURVEYOR, AMERICAN SURVEYING COMPANY
HEREBY CERTIFY THAT THE
OVE MORTGAGE INSPECTIONJ 1264 Main Street, Waltham, MA 02451 (781) 893-6477
AN WAS PREPARED FOR
c. a MoRr�A�EIN
-NNECTIONWITHA NEW MORTGAGE Mortgage inspection Plan
D IS NOT INTENDED OR REPRE-
NTED TO BE A LAND OR PROPERTY A S 13f-& COUNTY REGISTRY OF DEEDS
IE SURVEY NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDEp AT PAGE
I 1 G 7(o Soy L.C. Corti
T. IT �QI BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK rL gV 1q7 Py 84
BLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: ASSESSOR'S
ILDING LINES.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF• DRAWN PER TOWN OF
FECT WHEN CONSTRUCTED WITH RE- MAP S --PARCEL S — DATED
REON IS BASED ON CLIENT FUR- voo A)07—riNV tFAM DR1vC-
.HED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: - G�TAR I IJ.L ii A
EJECT TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT
<INGS,EASEMENTS ANDRIGHTSOF FROM VIOLATION ENFORCEMENT AC- BORROWER: f?AAliFI
,Y. Na RESPONSIBILITY IS EX- TION UNDER MASS.G.L.TITLE\111.CHAP. I L.
T DWELLING LIES IN FLOOD ZONE
VDED HEREIN TO THE LAND OWNER 40A, SEC. 7, UNLESS OTHERWISE SUBJEC
OCCUPANT, IT IS NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSURANCE PR GRAM FLOOD
FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED
BE RECORDED. o I , CtUt�s —
}; IS ADVISED WHEN STRUCTURES ARE COMMUNITY_PANEL S
.TE t SHOWN TO BE V-OR LESS FROMI FIELDED DRAFTED CHECKED
IENT�:r_K; tEWt DAW C) PROPERTY OR REQUIRED ZONING BY T w
IENT REF.N Q SETBACK LINES. :. r._ r.i -
T- - 13]
I IH
Town of Barnstable
Regulatory Services
saxxA e
M � Thomas F.Geiler,Director
1639. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
February 9, 2012
Gordon&Louis P
yY_
PO BOX 443
Cummaquid, Ma. 02637
RE: 300 Nottingham Dr., Centerville. Map:. 171 Parcel: 041
Dear Property Owner(s):
It has come to the attention of this office that the above address_has had alterations done
without the benefit of a building permit. Specifically, the room in the back of the house
was finished. You are hereby ordered to bring the property into compliance by taking the
following actions:
a) Remove the unpermitted work, or
b) Obtain the building permit and successful.completion of all required inspections
(including electrical requirements).
You have until March 9, 2012 to obtain the proper permit(s) and the required inspections
or further legal action may be taken. Thank you for your anticipated cooperation in this
matter.
By Order,
f
YJ6e L.Lauzon
Local Inspector'r
(508) 862-4034
n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 1 -7 / Parcel 0 Cff Application#
Health Division �— 7
Conservation Division Permit# 1
Tax Collector Date Issued I f D
Treasurer < Application Fee 5-0
Planning Dept. _ Permit Fee ?J 5
Date Definitive Plan Approved by Planning Board - _,4
EXISTING SEPTIC SYSTEM
LIMITED TO_-L_#OF BEDROOMS
Historic-OKH Preservation/Hyannis
Project Street Address w NJ'f+1 An Dr.
Village O 5lll 4—eJy 1 e
Owner 5S1e;d + .T0Q h r a" Address S�
Telephone +5-()&- c-ld0 ! 7d G/ <`—e�� 5_y,�3- - 0//6 —
Permit Request A4/ 41011 3 S P. oodpi.s 4
( Uh ke W )
Square feet: l st floor:existing� 6 proposed / a 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 0? 0®a Construction Type R/4-
Lot Size Ag d. Grandfathered: ❑Yes Flo If yes, attach supporting documentation.
50
Dwelling Type: Single Family LK Two Family ❑ Multi-Family(#units)
Age of Existing Structure L r 5 Historic House: ❑Yes I- lb On Old King's Highvy: ❑Yes"' im6
c'
Basement Type: Vull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 146 0 d Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing S� 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: was ❑Oil ❑Electric ❑Other
Central Air: ❑Yes k o Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:Vxisting ❑new size l' X-2 Shed:❑existing ❑new size Other:
F
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes kNo If yes, site plan review#
Current Use, Proposed Use
—BUILDER INFORMATION
Name - Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO f
SIGNATURE( DATE Ge
FOR OFFICIAL USE ONLY
G _
PERMIT NO.
DATE ISSUED.
MAP/PARCEL NO
ADDRESS VILLAGE'
OWNER I
DATE OF INSPECTION:
FOUNDATION (Arm- tS 4)yf vb�
FRAME;q &
INSULATION 1
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH a FINAL
C
GAS: ROUGH s 1 FINAL
ro tI
FINAL BUILDING in I
0 d
tU rr
?- R7
DATE CLOSED OUT 3N- m,
r
` ASSOCIATION PLAN NO. c n
I.
i
i
oFfwtoh Town of Barnstable *Permit#
�t;
Regulatory ,Services EFC2e'-'r1°'`11991,�"e(late
zQgAR�ABA � � S
1639 � Thomas'F. Geiler,Director
2 �� )11A_
OF 0/0 Building Division
Tom Perry, CBO, Building Commissioner
ST,4 ` 200 Main Street, Hyannis, MA 02601 -
www.town,barnstable.ma.us.
Office: 508-862-403 8
EXPRESS PERMIT APPLICATION = RESIDENTIAL ONLY Fax: 508-790-6230
Not Valid ipithoat Red X-Press Imprint -
Map/parcel Number j 10 j r
Property Address O A)o pl,d `j6,,,y, `
Vesidential Value of Work ' 10 Minimurh fee of$35.00 for work under$6000.00
Owner's Nam e & Address
Contractor's Narne Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) f
❑Workman's Compensation Insurance
Vsole proprietore 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)
Ve-roof(hurricane nailed) (stripping old shingles) All construction debris will be.taken to Val i +-e
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .35) #of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulati6ns,i.e. Historic,Conservation,etc.
***Note: Property Owner must sign Pro erty Owner Letter of Permission.
e Home Improvemen ctors License & Construction Supervisors License is
requt
SIGNATU E:
Q:\WPFILESIFORMSIbuilding permit f PRESS.doc
Revised 072110
The Cannnomveal h nflM ssachzrsetts
-- DepartznenI of Industrial Accidents
k— Oft ce o,f lirvestigations
_ 600 Washington Street
k Boston, .,IV4 02111
t wfv.rnass.gov/d`�`a
AV,arkers' Compensation Insurance Affida-vit: Builders/Conti,tctors✓Electrici ins/Plumbers
Applicant Information Please Print LegibIN
Name, (Bumnes&''Orgaui_?ationlu&vidnai):
Address: �o CiMn�L�n�--, �•
City/State`/Zip. �— Phone #: S 7 -7 -7 a,
Are you an employer?Check the appropriate boa.: - Type of project(required):
l..❑ I am a employer with 4, ❑ T am a general contractor and I
employees(full and/or pert-:time).
+ Have hired the s-ub-contractors 6- ❑New constniction
2_❑ I am a sole proprie#or orpartt er- listed on the attached sheet_ 7. ❑Remodeling
shipand have no employees These sub-contractors have
P y 8. n.Detnolation
working :for me in any capacity. employees and li-ave workers'
o workers' comp.insurance comp_insurance..
1 9. O.Building addition
equired-] 5. ❑ We are.a corporation.and.its 10.❑Elec.tric:al repairs or additions
3. atf.cers have exercised their
I am a hotne. oti� er doing wank 11..0 Plumbing repairs or trdditions
mysel€. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] c. 152, §1(4),and.we have no
employees. [No workers' 13.❑Other
coup_.insurance required.]
*Any applicant thst checlrs box C.must also fill out the section belota,showing their worlters'compevsati:ou policy in€urnnvtian_
Y Homemmers who submit this affidavit indicating they are doing all wwk and then hire outsidecontra€tors must submit anew affidavit indicating sach-
tC'antracturs that check this:box must attached au additional sheet showing the:name of the sub-contraetxnrs and stare whether or not those entities have
employees. Ifthe sub-contaactars1ave empltrgws,they.must provide their workers'comp.policy number.
I ant azi ezztp2r7y ar fhrzt is pravidiztg ttrorkars'cortrFerzsrzlrart iztszerrzrzca for zrEt'ettrpIoy'iras, Below is the policy aad.,joh site
informiad it,
Insurance Company Name: '
Policy#or Self--ins.Lic_#: E:xpiratian Date:
Job Site Address: City/State/Zip: `
Attach a copy of the workers'compensation policy declaration page(shmiring 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 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250M a day against the violator. Be advised that'a copy of this statement I may be forwarded to the Office of
Investigations of the D.IA for insurance coverage verification.
I do ha y cer m z s nfpa uty that Me informatzon prot4rlid above is trite and correct.
Si Date:
Phone#: •5�7'7
Official use only. Do►tot.write in this area,to be completed by city or town.ofciaL
City or To-"m: - Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Ioivn Clerk 4,Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#.
6
I .
JHE Town of Barnstable '
Regulatory Services
snjyAss. •x Thomas F. Geiler, Director
$-era;E,. A11b Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable ma.us
Office: 518-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: 3cx—�) A)o/-%'I j k4o,, 4f 6V--c—
number street -village
".HOMEOWNER"_P-9 r—f� LC.ac �� 7�J 8
name r o�me
/� —phone# work phone#
CURRENT MAILNG ADDRESS:-
��JiJbil S �U►�"1 60C
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.
bEFINITION 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.
Th at he/she understands the Town of Barnstable Building Department,minimum inspection
pr ures and requ ents and that he/she.wi I with said procedures and requirements.
Signature of Homeowne
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 ofconstruction 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 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 your community.
Q:\WPFILES\FORMS\buildmg permit forms\EXPRESS.doc
Revised 072110
I -
�p 1HE 1p�
+ BARNSTABLE, * .
MASS.
ib39•. Town of Barnstable
��
�IFD MP'�A
Regulatory Services
Thomas F. Geiler, Director
Building Division
Thomas Perry, CBO
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 Biuilder
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 of Owner Date
Print Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
QAWHILESTORMSIbuilding permit formslEXPRESS.doc
Revisec 072110
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 131 i = Parcel Permit# 5
3
Health Division .$" �_ - Date Issued ��
Conservation Division '5 / G �_F, Fee
Tax Collector /r '/DI SEPTIC SYSTEM MUST BE
�I 6 IId�STALLED IN COMPLIANCE
Treasurer WITH TfTLE 5
Planning Dept. ENVIRONMENTAL CODE AND
Date Definitive Plan Approved by Planning Board
TOWN REGULATIONS
Historic-OKH Preservation/Hyannis r
Project Street Address 30.0 6oAAa n 1�k
Village
Owner Lc.G it Address Zoo
Telephone D
'Permit Request m 04- ra ��_
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size a5' Y _�)-Q Grandfathered: ❑Yes Cl No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#,units)
Age of Existing Structure ;�� rG Historic House: ❑Yes l�'No On Old King's Highway: El Yes �o
Basement Type: C5"tu/Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Fj$ 1) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing / ' new
Number of Bedrooms: existing - new �1/G
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: VGas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes Y No Fireplaces: Existing New Existing wood/coal stove: ❑Yes' tf'No
Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size
Attached garage: b'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
BUILDER INFORMATION
Name iG-•i Telephone Number � !'-/ ;7'a
Address'0 J +� �.i �-.�- � �•� �_ ��J� License#
c
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO :�► - _'
SIGNATURE DATE c:Dr,"�
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
.. MAP/PARCEL N0.
- _ -
ADDRESS; - VILLAGE
OWNER. '
DATE OF INSPECTIONc
FOUNDATION �•� '�"I3 ''t,
FRAME"
INSULATION n
FIREPLACE '
ELECTRICAL: ROUGH'—' FINAL -
PLUMBING: ROUGH- FINAL
GAS: >. ROUGHS = FINAL
FINAL BUILDING
DATE CLOSED"OUT c '
ASSOCIATION.PLAN NO.
t 1
r
C-0
1
r In I r
36 '
LOCATION OF STRUCTURE(S)
BASED ON LINES OF OCCUPATION
/ r JOHti 3. . ACCURATE_. WILL REOUIR At NSTRUM LOCATIONLAIP
ENT
SURVEY.
t - ''
Scale. I�
J HN
F`nOFESSIONAL I-AND SURVEYOR, AMERICAN SURVEYING COMPANY
1 11FREBY CERTIFY THAT THE
30VE MORTGAGE INSPECTION 1264 Main Strei2l, Waltham, MA 02154 (761) B93-6477
AN WAS PREPARED FUR
2A/%Cy `4 IN
)NNFCTIQNWCTHANEWM()RTGAGF �:or�tgga Inspection plan
,JD IS NOT INTENDED OR REPRE•
N T EI; TO FIE A LAN;)OR PROPERTY ___ 1'� - ' COUN IY REGISTRY OF DEEDS
NF :il1RVEV. NO CORNcRS WERE THE LOCATION OF THE ORIGINAL RE( ORp'D AT
'p I .� _LC C(_
-T IT ► f� BE L:SED FOR ES DWELLING SHOWN HEREON EITHER 130 K �__PpLEy�,, T ''
43 Q PLAN REFERENCE:
WAS IN COMPLIANCE WITH THE LOCAL
ABLISI-IING FENCE. H:_DGE OR ASSESSOR'S
_IILDINGLINFS.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF DATED
FELT WHEN CONSTRUCTED WITH RE- MAP p PARCEL st
=PEON IS RASED ON CLIENT FUR- "��� '-' � �J(-'
ISHED INFORMA T ION AND MAY BE SPELT TO HORIZONTAL DIMENSIONAL ADDRESS:_ (u J
REQUIREMENTS ONLY),OR IS EXEMPT
1.18JECT TO Fl1RTI-IER OUT SALES. —
AKINGS.EASEMENTSANDRIGHTSOF FROM VIOLATION ENFORCEMENT AC BORROWER
1AY b[Q Ri-SPONSIBILITY IS EX- TIONUNDERMASS.G.L.TITLE VII,CHAP.
FNDEDIIERFIN"TOTIIELANDOWNER 40A, SEC. 7. UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE
OCCUPANT. I-1 IS NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSURANCE PR_ OGRAM FLOOD
FIRMATORY INSTRUMENT SURVEY INSURANC-F RATE MAP DATED
O BE RECORDED
----- -- IS ADVISED WHEN STRUCTURES ARE COMMUNII'r ._PANEL a
)ATE ---- -- SHOWN TO BE I' OR LESS FROM T it t OE0 DRAFTED �EC. D
:I IFNT --- PROPERTYe OR RE01.IIRED ZONING
!..AI I:JI" J11.{H {p=1?{_{ AT :--'I :-,IzEd.I cif 11-1
L .ASNsre.r.� ;
e Town. of 13arnstanle
MAM e$ Regulatory Services
Thomas F. Geiler,Director
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601 r'
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the`reconstruction,alterations,renovation,repair,modernization,conversion,
F 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: 4`—' v►n&v 1 Estimated Cost—;)- d UU
Address of Work: v J IVy � ✓�11N Ivn '" ` I
Owner's Name: SI Gt / 4i-i CA v
Date of Application: OL or v
I hereby certify that:
Registration is not required for the following reason(s):
OWork excluded by law
❑Job Under$1,000
[]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 hereby apply.for a permit as the agent of the owner:
Date Contractor Name Registration No.
—l7 OO /
Date Owner's Name
q:fomis:Affidav
The Town of Barnstable
� r
Regulatory Services
Thomas F. Geller, Director
Building Division
Elbert Ulshoeffer, Building Commissioner
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6=:0
HOMEOWNER LICENSE EXENEMON
Please Print
DATE: kav 17 a0o i
JOB LOCATION:F>o V Vc)J4ti✓1�� O"t't 1 lam'' Ce _�eV CJ t 6 5&
number street villa-r-
"HOMEOWNER _� t!il_� 2ai r''f'�► a me- �/�y-/7d-Y"
�y
name home phone re work phone rt
CURRENT MAILING ADDRESS: 00 kd±- 1jA_CJkesW1L .
6.A-•er
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occuoied dwellings of six units or
less and to allow homeowners to engage an individual for hire who does not possess a license rovi p tied that
the owner acts as supervisor. P
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 utrements. i
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 perforating 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 j
form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:FORMS:EXEIMM N
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Av
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