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HomeMy WebLinkAbout0394 OLD STAGE ROAD �� O, Dior U��. c...�� , ., .. .1 �, 0 t• - IKE. �S PERM Town of Barnstable *Permit#( O Ezpir ntles frome date Won , ; Regulatory Services Fee u�nurr�m,� r / 1 Thomas F. Geiler,Director. F BARN STABLE. Building Division . Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstabid.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 > residential Value of Work �, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name ��� Telephone Number ] -G 76 L Home Improvement Contractor License#(if applicable)_ Construction Supervisor's License#(if applicable)_ � O�4�/ ,4I ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ m the Homeowner 1 have Worker's Compensation Insurance Insurance Company Name //f x �/�,( Workman's Comp. Policy#- Iy A l 9-II & j 6 191 :�opy of Insurance Compliance Certificate must accompany each permit. 'ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors T 6 replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *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 required. GNATURE: . WPFILESIFORMMuilding permit formslEXPRESS.doC vised 070110 i Mass.ichusetts- Department of Public Safety MEL Board of Building Regulations and Standards Construction Supervisor License { license: CS 81843 E . I , Restricted to: ,00 STEPHEN T'DICKINSON t 12 BURNSIDE LANE . s„ M ERR IMAC, MA 01860 Expiration: 2/61201.2 y Tr#: 18033 — t ✓fie Panmzauuea/l o�✓�aaaar/uaelta License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME iMPRp4VEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Reg istratio4 J49840 10 Park Plaza-Suite 5170 Expiration �2/13/2012. Tr# 293041 Boston,MA 02116 Type; Ltd U 6ifity,Corpor PELLA WINDOWSFAND DOORS STEPHEN DICKINSONILI 4j ��r3 1325 AIRPORT ROAD - FALL RIVER,MA 02720.,a Undersecretary ANot va4idignature - .. f Ir! The Commonwealth of Massach usetts Department of Industrial Accidents �, . .. Office of Invesfigadon.s 1 zI r ti j .600 Washington Street . L i'iiU � Boston, MA 02111 r•I- www.mass gov1,dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /r� ;Ij-e)U)4 A)C Address: City/State/Zip: ! /�„� / �.� d �, Phone #: CS�" Are y an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-eontracfors 2, ElI am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, g. El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its I0.0 Electrical repairs or additions required.] officers have exercised their 3.El I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no _. 12.❑ of repairs . insurance required.] t employees.(No workers' 13. 0ther6fe; ���,_ comp. insurance required.] , t:Ct ,S *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. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site 1 information. Insurance Company Name: �aUit' � Policy#or Self-ins.Lic,#: Z/ j r.Vg Expiration Date: J Job Site Address: 6 <44Gr P 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, 1.52 can lead to the imposition of criminal penalties of a fine up to$1,S00.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fire 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 herek certify un er thepains andpenalties ofperjury that the information provided above istrue and correct Si mature Date: Phone#: Official use only. Do not write in this area;to be completed by city or town official City or Town: - Permit/Lit:ense# Issuing Authority(circle one): 1. Board of Health 2,Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Information and Instructions Massachusetts General Laws chapter.]52 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 employ is defined as"an individual,partnership,asso ' tion, corporation or other legal entity,or any two or more of the forego g engaged in a joint enterprise,and including a legal representatives of a deceased employer, or the receiver or tru\perit an individual,.partnership,association or ther legal entity, employing employees. However the owner of a dwouse having not more than three apartme is and who resides therein,or the occupant of the dwelling housether who employs persons to do mainten ce, construction or repair work on such dwelling house _ or on the grounilding.appurtenant thereto shall not becau a of such employment be deemed to be an employer." MGL chapter 1C( also states that"every state or local li easing agency shall withhold the issuance or renewal of a lir per it to'operate a business or,to constr ct buildings in the commonwealth for any applicant who t produ d acceptable evidence of complia,ce with the insurance coverage required." Additionally,Mpter 152, 2'5C(7)states"Neither the comm wealth nor any of its political subdivisions shall enter into any cfor the pe ance of public work until acc table evidence of compliance with the insurance requirements of pter have bee presented to the contracting a ority." Applicants Please fill out the workers'compensation\abcompletely,by ch cking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name( (es)and phone n ber(s)along with their certificate(s)of insurance. Limited Liability Companies( ' ted Liability P erships(LLP)with no employees other than the members or partners,are not required to crs' c pensatio insurance. If an LLC or LLP does have employees,a policy is Tequired. Be advise affida may be submitted to the Department of Industrial Accidents for confirmation of insurance colso be su to s gn and date the affidavit The affidavit should be returned to the city or town that the app the permit li ense is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the or if you are required to obtain a workers' compensation policy,please call the Department at the number listed 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 legibly. Th Departmen as provided a space at the bottom of the affidavit for you to fill out iii the event the Office of Investiga 'ons has to con ct you regarding the applicant. Please be sure to fill in the permit/license number which will be use as a reference n her, In addition, an applicant that must submit multiple permit/license applications in any given ar, need only submi ne affidavit indicating current policy information(if necessary)and under"Job Site Address"the pplicant should write" locations in (city or town).".A copy of the affidavit that has been officially stamped or arked by the city or town ay be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit ust be filled out each year. Where a home owner or citizen is obtaining a license or pe it not related to any business or ommercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NO required to complete this affida The Office of Investigations would like to thank you in advance/or your cooperation and should you ha a any questions, please do not hesitate to give us a call. . The Department's address,telephone and fax number- The Commonwealth/of Massachusetts ' ry Department of Industrial Accidents . Office of Investigations' 600 Washington Street Boston,-MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE D-4 a C 14_nc Fax# 617-727-7749 OP ID:31 DATE(MMIDDIYYYY) ACORO" CERTIFICATE OF LIABILITY INSURANCE 04/29/11 ��.. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to +- the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the i. certificate holder in lieu of such endorsements). E;ONT• PRODUCER 401-886-8000 NAME ACT The Preston A ency,Inc. 401-885-1700 PHONE FAX AIC No Ext: AIC No 1350 Division d Suite 303 E-MAIL PO BOX 810 ADDRESS: East Greenwich,RI 02818-0810 PRODUCER FELLA-1 Patrick Meacham,AAI,CIC CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED PFR Acquisition LLC INSURER A:Hanover Insurance Co. , dba:Pella Windows&Doors; INSURER B: Atlantic Millwork,LLC INSURERC: 1325 Airport Rd Fall River,MA 02720 INSURER D INSURER E: INSURER F! COVERAGES CERTIFICATE,NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP LIMITS ITR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY L MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY ZBE 8151344 05/01/11 05101/12 PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 PE RSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ 1,000,000 riPOLICY PROJEC LOC Emp Ben. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO AWE 8714919 05/01/11 05/01112 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULEDAUTOS PROPERTY DAMAGE $ (Per accident) X HIRED AUTOS X NON-OWNED AUTOS $ X UMBRELLALIAB TX �OCCU�REACH OCCURRENCE $ 10,000,000 EXCESSLIAB AGGREGATE $ 10,000,000 A S-MADE UHE 8714781 05/01/11 05/01/12 DEDUCTIBLE X RETENTION $ WC STATU- OTH- WORKERS COMPENSATION X TORY LIMITS 1 1 ER AND EMPLOYERS'LIABILITY 05101/11 05/01/12 E.L.EACH ACCIDENT $ 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ N/A WDE 8716568 1,000,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) 1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION PROOFRI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. Only AUTHORIZED REPRESENTATIVE At— ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD , r• of r , Town of Barn-stable Regulatory Services �usxsrasr.� Thomas F. Geiler,Director ` Building Division Tom Perry,Building Commissioner 200 Main Street,Hya=is,MA 02601 ' www.town.barnstable.ma.us. Office: 508-862-403 8 Fax: 508-790-6230 .Property Owner'Must Complete and Sip This Section , If Using A Builder ►,s > , as Owner of•the subject.property hereby authorize ; C to act on my behalf, in all matters relative to work authorized by this building permit application for- (Address o Job) 1 . SiL�of Owner Date 00,T�- , r-woq6 Print Name If Property Owner'is`applying for peimitpleas' complete. the. Homeowners License Exemption Form on :the reverse side: f THt: Town of Barnstable o Tp�o Regulatory Services Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Mam.Straa,_Hyannis, MA 02601 bra'table-ma-us Office: 508-862-403 8 Fax. 508-790-6230 HOMEOR/NE LIC}T'SE EXEMPTION Plisse riot DATE: JOB LOCAT1oN: number strcc village "HOMEOWNER": name bj phone# work phone# CURY,N'T MAILING ADDRESS: eityhown state up code The current excrnption for"homeowners"was extended o ' elude owner-occupied dwellings of six tmmts or less and to allow homeowners to engage an individual for hire o es not possess aLliccnse,provided that the owner acts as supervisor. DEFINlTTO OF EO O�i'itER Person(s)who owns a parcel of land on which he/she r ides or' tends tti residc,'on which.there is, or is intended to bc, a one or two-family dwelling, attached or detache structures a essory to such use and/or faffi structures. A person who constrgcts more than 6ne home in a two- car period s not be considered a homeowner. Such `homeowner'shall submit to the Budding OfEcial o a form accepta c to the Building Official, that he/she shall be r orisrble for all such work erforned'under the b din omit. (S tion 109.1.1) Th,c vndcrsigncd `homeowner"asstnncs responsib' ty for compliance with e State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner='certifies tbat.he/sh understands the Town of B ble Building Department mi„irnnm inspection procedures and rc:qufimm is d that he/she.will cornply wi said procedures and requ rcments. Signature of Hamemma Approval of Bunlding•Off'cial Note: Three-family dwellings co g 35,000 cubic feet or larger will be required to coarply with the State Building Code Section 127.0 Construe'oa Control. o3aov,, R,8 EXEMPTION -The Code states that Any hgmeownrr g work for which a building permit is required shall be ezmrp from the provisions of this Section.(Sccdon 109.1.1-Liccns hg of cansttvetion Supervisors);provided that if the homoowncr engages a per an(s) hire to do such work,that such Homcownar span act as supavisar:" Many homeowners who use this exenption arc unaware tbat they arc auuming the responsibilities of a supervisor Appendix Q, Rules&Regulations for Licensing Construction Supervisan,Scctioa 2.15) This lack of awarcss bftc n results in serious problcr=,particularly when the homeowner hires unlicensed persons. In this case,our Board an cannot proceed against the unlicensed person as it would with i licensed Supervisor. The hotneowoer acting as Supervisor is ultimately trsponsibla m To ezuurz that the hameawner is fully awarz of histba•responstbilidcs,many communities rcquu-e,as part of the pmnit appliea don, that the I omco"r-r certify that hdshe understands the rrspansnbtlitics 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 it form/cctti5c4on for use in your community. °FINE r Town of Barnstable *Permit# Fxpires 6 months.from issue date Regulatory Services Fee a: BARNSTABLE, * - e MASS. $ Thomas F. Geiler, Director _oA i639. TED MP A � —T IZZG 0 9 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.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 <1L/ Residential Value of Work. 4 JJ 0 _Mini um fee of$25.00 for work under$6000.00 Owner's Name R. Address F Contractor's Telephone Number'�j���^ (� I Ionic Improvement Contractor License#(if applicable) Construction Supervisor's License'#(if applicable) ❑Workman's Compensation Insurance Check one: -PRESS PERMIT ❑ I,am a sole proprietor am the Homeowner ��❑ ❑ I have Worker's Compensation Insurance APR Insurance Company Name TOWN OF BARNSTABLE Workman's Comp. Policy # Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box) - WRe-roof(strippiner old shingles) All construction debris will be taken to mj L� f ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .44) • *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Hom Improvement Contractors License is required. E SIGNATURE >.`N111-I]A-.S'\j:mMS\building permit forms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents rA Office of Investigations, 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): I J ram) • Address: udlam' R 1' City/State/Zip. Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or partftime). * have hired the sub-contractors 6. ❑New construction listed on the attached sheet 7. .Q Remodeling ..2:0 I am a sole proprietor or partner-' ship and have no employees These sub-contractors have g,•[]Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers',comp.-insurance comp. insurance.$ ��, re,4*ed.] 5. [� We are a corporation and its 10.❑Electrical repairs or additions 3.L1 am a homeowner doing all work officers have exercised their 11.0 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 fimi checks box#1 must also fill out the section below showing their workers'comprnsation 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. tContractors 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�loyees,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 finp 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 fy under the pains and p nalties of-perjury that the information provided above is true and correct Signature: Date: _ Phone#: Official use only. Do not 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#: Information and Insttuctions Massachusetts eneral Laws chapter 152 requires all employers to provide wdr rs' compensation for their employees. Pursuant to thisttatute,an employee is defined as"...every person in the service of another under any contract of hire, express or i li oral or written." P mP � An employer is de ed as"an individual,partnership,association,corporatio or other legal entity,or any two or more of the foregoing en ag m atom enferp in7u3ing the legal-repres fati�e§-uf- zlec�ase� receiver or tn►stee- an individual,partnership,association or other legal a tity,employing employees.'However the owner of a dwelling use having not more than three apartments and who esides therein,or the occupant of the dwelling house of ano er who employs persons'to do maintenance,cons ction or repair work on such dwelling house or ,on the grounds orb ding appurtenant thereto shall not because of su employment be deemed to bean employer." MGL chapter 152, §25C( also states that"every state or local keens' g'agency,shall withhold"the issuance or renewal of a license-or pe 't to operate a business or to construe buildings in the commonwealth for any applicant who has not pro ced acceptable evidence of compliari with the insurance coverage required." Additionally,MGL chapter 1 , §25C(7)states"Neither the commo wealth nor any of its political subdivisions shall enter into any contract for.the p ormance of public work until ae table evidence of compliance with the insurance requirements of this chapter have een presented to the contracting uthority." Applicants Please fill out the workers'compensati affidavit completely,b checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name ,address(es)andpho a number(s)along with their certificates)of insurance. Limited Liability Companies(L or Limited Liabi ty Partnerships(LLP)with no employees other than the members or partners,are not required to c workers'compe ation insurance. If an LLC or LLP does have employees,a policy is required Be advised tha this affidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance coverag Also be su a to sign and date the affidavit. The affidavit should be returned to the city or town that the application r the pe .t or license is being requested,not the Department of Industrial Accidents. Should you have any questions egard' the law or if you are required to obtain a workers' compensation policy,please call the Department at the r 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 le_ ly.. a Department has provided a space at the bottom r sue .r__ a_ Cll a' •L- a+U-r%4= F +. -eon,ha,t-rnn/a rt�,M reonrrlina the.pnn1ira t O the al dadyLl for 3wa w illl UUL iu LUU ir%ua un..VLuCe Vl i�eou t�� -p--a— rr Please be sure to fill in the permit/license number which be use as a reference number. In addition,an applicant that must submit multiple permit/license applications in an given ye need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Ad ess" the appl writ should write"all locations in (city or town)..".A copy of the affidavit that has been officially s ed or mark ' the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or license A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a licens or permit not relate to any business or commercial venture (i.e.a dog license of permit to burn leaves etc.)said perso is NOT required to c lete this affidavit. The Office of Investigations would like to Aiank you in a ance for your cooperation d should you have any questions, please do not hesitate to give us a call The Department's address, telephone-and fax number: The C6mmonw th of Massachusetts Npartment o dustrial Accidents Office of nvestigatons 600 Washington Street Boston,MA. 02111 TO. # 617-727-49-00 ext 406 or 1-$77-MASSAFE Fax# 617=727-7749 Revised 1 i-22-06 www.mass_gov/dia v rE Town of Barnstable N�P�o4 r�yT Regulatory Services - `• Thomas F. Geiler,Director • sARNSTA=t-e Building Division rfD A Tom Perry,Building Commissioner _._.. 200 Maiu:Street,—Hyannis;-MA 026-01 _...... ..... ... . _.._. _._..._..... w w vy.town.b arnstable-ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATR -09. /2 �( l JOB LOCATION:—_)' t/) ` ' a '�,j � s�Jtryc�ct) _ village "HOMEAWNER U7�.)JJ�!` name home phone# work phone# CURRENT MAILING ADDRESS: rityhowo 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- superyisor. DEFB TION 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*mdersign�d"homeowner"assumes responsibility for coamLance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned..'homeowner?'certifies that.he/she understands the Tpwn of Barnstable,Bui.lding Department minimum inspection procedures and requirements and that he/she will comply with said procedures and qements. 5igna ' 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 Constriction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing wont for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Uccrnsing of construction Supervisors);provided that if the homeowner engages a pason(s)for hire to do such work,that such Homeowner shall act as supevisor." Many homeowners who use this exemption are unaware that they are assuming the respmrsibilitics of a supervisor(see Appendix Q, Rules&Regulations for licensing Construction Supervison,Section 2.15) This lack of awareness often results in serious problems,particularly when the hnmcowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed priori as it Kvuld with a lice_nscd Supcfvisra. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully award of his/her responsibilities,many communities require,as part of the permit application, that the homeowner=Iffy that}nelshe 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 fomrlcertification.for use in your community. Q:forms:homccxcmpt cro�,ti Town of Barnstable . Regulatory Service UABS.LEA, Thomas F.Geiler,Direct 16;Fg. 16�m Building Divisi Tom Perry,Building Corn 'ssioner 200 Main Street,Hyannis, 02601 www.town.barnsta e.ma.us Office: 508-862-4038 Fax: 508-790-6230 \` \ Pro e�-(-�r erMust r. p `'J " ; r Complete and ign This Section If Usin A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work auth d by this building permit application for. .(Ad ss f Job) T • 4 Signature of Owner Date Print Name if Property Owner is applying for permit please. complete the Homeowners License Exemption Form on the reverse side. n.anu i rc.nnn.rcn nrv►rrocrn�a MAT Assessor's offioe (1st floor): li + > �' F THE T Assessor's map and lot number �6 / ...: q........ - I��STALL ED IN COflAPl.ld°:•:a'�, o Board of Health (3rd floor): IG.CL�C WITH TITLE 5 d '; Sewage Permit number ............. ..I`............................ .. • EhIV I -ONMENTAL CODE �AXL LL. . Engineering Department (3rd floor): 'oo 3 House number p .�� .... TO�� � '°�oYa APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTAB E BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....C..11.a.y'l'PS...... /"l 0 F"YLLe.... ...� U �.. . ... .... TYPE OF CONSTRUCTION ........k4:!C^[?d....67Aia.t.............P..`:yr. fly.�......................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...2.Q.11..........oM.......: �FAR.X'....... O..a1�............. .f h..l.f'! i/l.f'1 ........M.P:S,S....................:..................... ProposedUse ...... ............................................................................................................................................... ZoningDistrict ......... .. .�......� ................................................Fire District .............................................................................. Name of Owner ...C.A.a.k.4r.5.........i. ��.F'f''./ -..P...........Address ......3.9Y..y 00 �/2,9 & CP Te vv Name of Builder ..... 0tv.-k.7..........ex.A., i.....................Address ...... ........../.►.Ia/Vkcs............................ Nameof Architect .............. ......................................Address ..................N4. t' .................................................... Number of Rooms ..........&Q.......24�......":l1 ...Foundation ........::. 1s.Thl.............................................. Exterior ....... .Gf9: ..........................................................Roofing ..............:1L7 .1?. 1..1.............................................. Floors ...... __: ..... lP�f. $0 Il�y.....................................Interior .............,Sh.r.0 .i✓pe:!1...................................... Heating ..................k".?C ..........................................Plumbing ............. ....... .Rom. .......................................... A� ©0 Fireplace ................./.V•pn."C..................................................Approximate Cost ..........'...op;?........... ............................ . Definitive Plan Approved by Planning Board --------------------------------)9-------- Ar ...L /CQ. .. .. .�%� . Diagram of Lot and Building with Dimensions Fe �O° SUBJECT TO APPROVAL OF BOARD OF HEALTH New DorrMr�' rh51 �l N,Pw Q�� r Mew Ltia�i x s��af Sash Oed eoow, Deh sr�� , S�r�9r s �or-� 9r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. s Name ....."..4f.. ...................................... Construction Supervisor's License ...p2p.Y..?l........... MORRICE, CHARLES 31877 ADD DORMER No ................. Permit for .................................... Single Family Dwelling ......................................................................... Location .... ...Road ....................... Centerville Charles Morrice Owner ........................ .............. Type of Construction .........Frame.................... ............. ...........I....................................................... 0 P10't ........... .............. Lot ................................ May 9 , 88 Permit Gronled ............................... ........19 Date of,,Insp;ction ................................... 19 Date Completed ........................................19 t 10 %i M C)