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0050 PATRICIA STREET
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R.'f:''� �:x, , 1,C Sh..,,,•'. • •„ :, 1 :, t: x., -'}k {t roc a.Y i,' ;r'F( •,�•Y��,..ii ,, • r. .u' s,. ,r.'- ,i.� :,,{,r:`,... rf'F.,: ,. .. ]: " s+.. ,'{ , ?'t" .ry '7 t. 4- .:. .. rS .,. 'r , .. S y" ,,:. „,,,1., .R c ., a. .t', - c� R'}r. «# a Y :44 0. ,.y. p°e.. .b• 1,-, r`M�'•_ r<.^B+s n+s '� L _"'x ', .e '.� '+xr + F 4' t :.s, u :. 't: .,, 1 F .:c,: '.. �tt, ..r, D , _. r . a )S-e Town of Barnstable *Permit# (90L S s Expires 6 m the�In4u �e e Regulatory Services Fee EWWSTABIX 6 Richard V. Scali,Director '°tfp I. Building Division Tom Perry,CBO,Building Commissioner'.,, 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ®�� Not Valid without Red X-Press Imprint Map/parcel Number (p 4 Prope Address '. Residential Value of Work$- q00 , p O Minimum fee of$35.00 for work under$6000.00 t6wner.',s Name&Address u's Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Com nsation Insurance Check e: EIA a sole proprietor - am the Homeowner T❑ P 04 I have Worker's Compensation Insurance r 2D15 'Ba'�l �C Insurance Company Name v U t U OF �^ Workman's Comp.Policy# r��� Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ (check box) Re-roof(hurricane"nailed)(stripping old shingles) All construction debris will be taken'to OC A)i C-�S �G��P /`14 ' e-roo r omg over ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must si Owner Letter of Permission. A copy of th a Improveme Contractors License&Construction Supervisors License is re / SIGNATURE: ./ QAVvTFILES\FORMS\building permit fo XPRESS.doc Revised 040215 ' • .,r Ile Commorrivealth of Massachusetts 1I assachusetts Deparhuent cr,f Indu strial Accidents f3, ce of Imtigations 600 Washington,S teet ti Boston,MA 02111 tvFvm mass govIdici Workers' Compensation Insurance Affidavit:Builder s/Contracin sJEIectr cianslP'Iumbers Applicant Information Please.Print blv C� 1`1�e(BasimEesstDFganizationfFndisi�dnal}: �US},� f t� C.r� �c r S - - f t✓ S,� rcrty/stat-i e S'� l 1 C od no Are you an employer?Check the ippropziate bow: T of project r 4 I am a general contractor and I Y1� p ] { egnired}: 1.❑ I am a employer with ❑ g 6. ❑New constnxtion employees(full andfor part-time)-* have hired the sub-contractors 2.❑ I am a sole propzie#or orpastner- listed on the attached sheet. 7- ❑Remodeling ship and have no employees. These sub-contractors have g. ❑Demolition . wad-ing fix me in any capacity employees and hate wo&ers' 9. ❑Building addition IN 'cozrrP_u0surance comp_msurance-1 d 5. ❑ We are a corporation and its N ❑Electrical repairs or additions t3 I am a homeoumer doing all urork officers haveexercised their IL❑Plumbing repairs oradditions myself[No workers'camp- right of exemption per MGL 12. Roof repairs insurance required-]T c.152, §1{4X and we have no employees.(No workers' a❑Other comp_insurance required_] . •Any app€icsa fist checks box i"1 umst also fill out the section below shmaimg their wod era'compensation policy inforotadon. i HGMJeD neM who submit this dfidivt indicating they are doing all wa t and area hire outside contractors aanst submit anew affidavit indicating such_ FCanttactors tbat rhxt ibis boat must attached aar additiand sheet showing the name of the sub-contrac=and state whether at not tbose entities have employees.If thesubtontsactorshave employ-s,theymarstpmvide their workers'comp.policy number. I am Orr ernplo r Heat is prat zding ivurkers'conrpertstrticrrt i�rszira>rce for ar}*enrpiay�ees Below is Ylte policy and job site information. , Insurance Company Nam: < Policy;t or Self--ins.Lic-# Expiration Date: Job Site Address: CitylStateimp: r 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. 157 can lead to the imposition of criminal penalties of a fine up to$1,50D-00 and,-'or one-year imprisDummt,as vu as chit penalties.in the form of a STOP WORK ORDER and a fine of up to$250-00 a day,against the violator. Be advised that a copy of this statement may be f xvmded to the Office of Investigations of the DIA€or insurance covers verificatiom I do hereby certi,fj�ri a pains artd s o.fperFury that the infonnationptmitfedabove fs bus a? correct f$itaaiure: _� a 4 Date: 7 O Phone# �' f�+ D�aci ortl}. Do flat wrke in th s area,to be corinpletad by city or town official, C tf or awn: Permitffikense# ` Issuing 1•l uthor€ty(circle one): 1.Board of Health 2.Building Department 3.City1rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: - v;.. 6 liform ation and lastrnCfions . i Macear husctts Ge eralLEM chapter 152 requires all empl°yers'to provideworkem'compensation forfheir eraployr-es- pamraottD this stye,an.mpIvyme_is defined as."_every person in the service of another under any contract of hire, express or finpH --oral or " An emplyoyer is defin "an individual,parfnersh�p,association,corporation i other legal entity,or any two or more of the foregoing engaged a Joint enterprise,and mcluding the legal repres es of a deceased employer,or the receiver or trastee of an m partnersbip,association or other legal ty,employing employees. However the f owner of a dweIlmg house ha not more than three apartments and who des therein,or the occupant of the - " dwelling house of another who Ioys persons to do maintenance,co 'on or repair work on such dwelling house or oa the grounds or building app thereto shall not because of h employmeEt be deemed to be an employer-" MGL chapter 152,§25CP also states "every state or local Tic ' agency shall withhold the issuance or renewal of a license or permit to operate a ess or to co buildings in the commonwealth for any applicant who has not produced acceptable a ence of compIi ce with the 4ncnra_n ce.coverage required-" Additionally,MGL chapter 152, §25CM states"Neither the,co onwealth nor any of its political subdivisions shalt enter mtn any contract for the performance ofpublic until table evidence of compliance with the irmarancB:. requirements of this chapter have been presented to the co arrfhoz�y" A-pplicants Please Ell out the workers'compensation affidavit completely by Icing to boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and one n er(s) along with their certificates)of msu ce. Limited Liability Companies(LLC)or Limited ility-P erships(LLP)with no employees other than the members or partners,are not requied to cant'workers' comp anon" cc. If an L LC or LLP does have employees,a policy is required. Be advised that this affida maybe sub to tht Department of Industrial Accidents for confh'mation of iam aace coverage. Also be re to sign and to the aidavit. The of idavit should be rut=--d to the city or town that the application for the p or license is be requested,not the DeParhnent of Tnrh,ctriaT Accidents. Should you have any questions the law or ifyou required to obtain a workers' compensation policy,please call the Department of the er listed below. Self companies should enter their s elf-insurance license number on the appropriate line. City or Town Officials t _ Please be sure that the affidavit is complete andprjnt d 1 Iy. The Department has provided a ace at the bottom of the affidavit for you to fry out i a the event the Office Investigations has to contact you regar the applicant Please be sure to fill i a the pennitllicense number which be used as a reference number. In adat�. an applicant that must submit multiple perraWlicense applications in given year,need only submit one affidavit eating current policy in��rnation Cif necessaly)and under"Job Site A Tess"1$e applicant should write"aII locations n (city or town)-"A copy of the affidavit that has been officially ed or ma iced by the city or town may b e provid Ito the applicant as proof that a valid affidavit is on fide for permits or licenses. A new affidavit must be filled ovt each year.Where a home owner or citizen is obtaining alicer se or permit not related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said pen n is NOT reqaired to complete this affidavit The Office of Investigations would bke to thankk you is E dvaaco for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number Tht ia.of-Massachu�t s . D-pa�enfi C&1adusft A deRts Qffi=of jves#gatio= 600,washivan.st=t Ba tam MA 01 111 T(,-1.4 617 727-4 Qxt 4-06 or 1-9 MAS F. Fax 9 617` 27-7749 R wised 42407 vmassgavldia Town of Barnstable Regulatory Services i �oZVE ro Richard V.Scali,Director, Building Division * BARNSr'ABLF Tom Perry;Building Commissioner Mass. Y 1639• ��� 200 Main Street, Hyannis,MA 02601 . �p'ED MPS www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION �j Please Print DATE: I G S t JOB LOCATION: . f f�,�� S� l / .C� ' 1`t it/,✓�.S��/1 0� d number J_ +LCC street L t -village —� "HOMEOWNER": J v S�r�► ( 1,✓QJ'.. ) . Q �^ / / name home phone# work phone# . CURRENT MAILING ADDRESS: O /✓`Q ` 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_ ep rmit. (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 under-signed homeo certifies that he/she understands the Town of Barnstable Building Department minimum inspection p edures and requir ents and that he/she will com ''said procedures and requirements. Signature omeowner 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 for_m/certification for use in your community. Q:\WPFILES\FORMS\building permit fotms\EXPRESS.doc , Revised 040215 II * BARNSTABLF, ,�� Town of Barnstable QED MA't a . Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 1508-790-6230 Property Oovne ust Complete and Sign his Section If Using A wilder I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this uilding permit application for: (Address of ob) Signature of Owner Date Print Name If Property Owner is applying for per it,please complete the Homeowners License Exemption Form on the reverse side. - QAWPHILESTORMS\building permit forms\EXPRESS.doc Revised 040215 Assessor's map and lot number ....... .".............`.................... IRITM SYSTM MMT BIE INSTALLED IN COMPLIANCE VVI T H ARTlOLE7 II STATE Sewage Permit number . """""" SANITARY CODE AND TOWN ` REGULATIs yofTHE.r��1 TOWN OF BAR.NSTABLE i BARNSTSDLE, i 'NAAL 9 �UId® 8R`G INSPEECT T T .. . ............................................................. APPLICATION FOR PERMI O ..... .. TYPEOF CONSTRUCTION ...................�� .........................................................� ? .::...........:....................... fx l . l .............197 TO -THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Wryry /....�...+. ...���.F// 1 ! f/ .. Proposed Use / Zoning District ............/: ................................................Fire District ,: Name of Owner f...... !!�/ �F���.............Address .P2.7..�/9/ /.. .................................................... Nameof Builder ................. �....... .....................................Address .................................................................................... Nameof Architect ..................................................................Address ........................./.......................................................... Number of Rooms Foundation ... oC�J:................................................. ................................... ....... Exterior ..�Olez';...... !'.i/I/6��5...............................Roofing !'.......................................................... 4 .:. Floors .........--.— ............ Interior ...... Fieating ..... ................Plumbing .................................................................................. Fireplace ....................r �."".............................� ��o...........................Approximate Cost � ......-................................. .......... Definitive Plan Approved by Planning Board ________________________________19--------. Area .....Z(Z....s. ............. Diagram of Lot and Building with Dimensions r Fee .................... .. ..................... SUBJECT TO APPROVAL OF BOARD OF HEALTH --------------- 51 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .. /, Name ,Cy6agl��...................................................... Palmer, William .17 PERMIT kElUSED | , ...............— ........''`^-----^r'......................... .�� ~ ` . � .