HomeMy WebLinkAbout0483 NOTTINGHAM DRIVE .s
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map J Parcel Application# L
Health Division
Conservation Division Permit#
Tax Collector Date Issued d�
Treasurer Application Fee 00
Planning Dept. Permit Fee it
Date Definitive Plan Approved by Planning Board G h��
Historic-OKH Preservation/Hyannis
�Pr e t Street Address LlX3 NOtt%NG 4 a /Y p R f tl c
Village, C F A11XA f/o{/L4
e-Owne�11e1VA V f B ifi /_a c"'�"Address��-/�3 IYO_tt iNC, Q�4 /I!�
' Tel"ephone-z-3 9-4 0SaY 6 Permit Regaest �� lVa�1 G P R A 11—P�� l�/"91i1 T� 4 (4o' Ze /o 9Li4C4e-
/y/67
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
�Project-.Valuation� �� o/voa- 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 ❑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
Number 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
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new e
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: ,f
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial 0 Yes ❑No 1f yes,site plan review#
Current Use Proposed Use
r��B_U�LDER_IN��FOR ATION� ''� ,
Name p �o� y o-��KYd
G�/V�� LT, E�a Telephone Number
Address t /N6 a Pf b 4 License#
C EN7'FIf ViLI E H 2 O.L Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO gaRA15727JI E Z ?,V d ELL
.SIGNATURE'S cDATE /yN r 15`,� 7
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FOR OFFICIAL USE ONLY
r
i PERMIT NO.
3 DATE ISSUED
1 MAP/PARCEL NO.
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} ADDRESS VILLAGE
OWNER
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DATE OF INSPECTION:
FOUNDATION
FRAME
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INSULATION
j FIREPLACE
ti
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH �+ FINAL
FINAL BUILDING
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DATE CLOSED OUT '
> ASSOCIATION PLAN NO.
3
S
The Commonwealth of Massachusetts
Department of Industrial Accidents
�, Office of Investigations
e 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors(Electricians/Plumbers
ADMicant Information Please Print Le 'blv
N✓me(Business/Oiganizationllnd vt�):
., ddrgss: AgY3 Noft llyrpkaM DR 111t
City/State/Zip CFiVT6!{di<l k o G I-,VY Phone.#: J oly^ UVO: t9
Are you an employer?Check the appropriate box: 5 Type of project(required):.
1.❑ I am a e to er with 4. ❑ I am a general contractor and I
mP Y 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. 7. ❑Remodeling
These sub-contractors have Demolition
ship and have no employees # , 8• ❑
workingfor me in an capacity. employees and have workers'
Y P tY• $. 9. ❑Building addition
comp.insurance.
[No workers' comp.insurance
5. We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their 11. Plumbing repairs or additions
3.[ .I am-a-homeowner doing-all work ❑ g eP
myself-[No-workers"comp right of exemption per MGL 12.❑Roof repairs
.�
� ��n u once se uued: `t c. 152, §1(4),and we have no
.13.❑ Other
'— �•�> , employees. [No workers'
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: i
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 covera7e verification. t
I do hereby certify,under the pains-and penalties of perjury that the information provided above is true and correct
1 - DatetJ v•vE /b� 007
�Si afore:
Phone#• S-6L W-fi5W
Official use only. Do not write in this area,to be completed by city or town o jiciaL
City or Town: �PermitfLicense#
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 In ' tructions
Massachusetts General Laws chapter 152 requires all employers to pro "de workers'compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in a service of another under any contract of hiie,
express or implied,oral or written."
An employer n,",defined as"an individual,partnership,association,c oration or other legal entity,or any two.or more
of the foregomg�engaged in a joint enterprise,and including the leg representatives of a deceased employer,or the
receiver or trustee,,of an individual,partnership, association or other egal entity,employing employees. However the
owner of a dwellinghouse having not more than three apartments d 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 bLding appurtenant thereto shall not because f such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local ' ensing agency shall withhold the issuance or
renewal of a license or perrnit to'operate a business or to cons uct buildings in the commonwealth for any
applicant who has not produ\ced-acceptable evidence of comp ce with the insurance coverage required."
Additionally,MGL chapter 152 §25C(7)states"Neither the co nwealth nor any of its political subdivisions shall
enter into any contract for.the perrgrmance of public work until ac ceptable evidence of compliance with the inz ante
requirements of this chapter have been presented'to the contractin authority."
Applicants
Please fill out the workers'compensation a davit completely,b checking the boxes that apply to your situation and,if
necessary,supply sub-contiactor(s)name(s), \ dress(es)and pho a number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC) Limited Liab' Partnerships(LLP)with no employees other than the
members or partners,are not required to carry wor ers' comperes: 'on insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this davit be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Als be sur to sign and date the affidavit. -The affidavit should
be returned to the city or town that the application for the rmi or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regar a law or if you are required to obtain a workers'
compensation policy,please call the Department at the number i ted 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 legibl . The\affi
ent has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of In stigaas contact you regarding the applicant.
Please be sure to fill in the permit/license number which will a useefere a number. In addition,an applicant
that must submit multiple permit/license applications in any en yed only bmit one affidavit indicating current
policy information(if necessary) and under"Job Site Address'the ant should to"all locations in (city-or
town)."A copy of the affidavit that has been officially stamp or mby the city or wn maybe provided to the
applicant as proof that a valid affidavit is on file for future pe is oses. A new affi t must be filled out each
year.Where a home owner or citizen is obtaining a license or ermilated to,mybusines r commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is OT d to complete this affi t.The Office of Investigations would like to thank you in adv a for ooperation and should you h e any questions,
please do not hesitate to give us a call.
The Department's address,telephone•and fax number:.
The Commonweal of Massachusetts
Depmm ent of In trial Accidents
Office of In . st gations
600 Washin Street
Boston, 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax 4'617-72.7-7749
www.mass.gov/dia
�oF ,Er� Town-of Barnstable
hP �� Regulatory Services
"» sAaNmzm Thomas F.Geiler,Director
9 MASS.
039. a Buuildincr Division
'OWED MA"� b
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 509-862.4038 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,
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:#,yAld iCa P' /L a (-fp Estimated Cost
,Address of Work: /V at b llalL a/Y P R!UL" .
Owner's Name: ) C-A14 V
Date of Application:_d N
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
4. QBuilding not owneroccupied
Ovi�nez 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 ARKIMATION PROGRAM OR GUARANTY FUND UDDER MGL c.142A.
SIGNED UNDER PENALTIES.OF PERMRY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR JI
Date 1--- fltiyner's Name-----j
Qd'urns:hame�dav
THE Town of Barnstable
�OF Tp�
a Regulatory Services
BARNSTABLE, Thomas F.Geiler,Director
Huss.
1639• A,�� Building Division
tFD MA'I
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
T � Please Print
DATE: L U/14 `7, ,7,60 7
JOB LOCATION: y p 3 410t-t 46 A e PA I IV E CrAV7—,r f{V i L L E
UNnumber - street village
"HOMEOWNER":r/CR y V.�,6 ",roy—Y"?0 fyn
name 7� y home/phone# work phone#
0/
CURRENT MAILING ADDRESS: 7 5 A/()tV i41C. M J?A O`ilE
4f,VNt,cAVJ4,r M-a
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
require ents.
Signature of m ner
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 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 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
The Town of Barnstable
9 BARN SSBLE.O Department of Health Safety and Environmental Services
f639' �0
pfFOMPyp Building Division .
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230
Inspection Correction Notice
Type of Inspection �--
Location �`� N�"�'� G H 4" Permit Number
Owner Builder 0wN�2
One notice to remain on job site, one notice on file in Building Department.
The following items need correcting:
N p°T Q J !L--T" -T-0 it
Q ca 04 Puy N T
(� Na Fo D t N� P,
�� `3 � Td-� �'rRt—tl}`t- l�.�f D wl i L� S�'►4+1 Su PiPa�T' (12�9�1 P�
S P o(c-t- 4-I' O LJK cQ,S bs-y GN72!7-it ; s H t-L. c,FL-C
Please call: 5088-862-4038 for re-inspection.
Inspected by
W
Date 0-7
1
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