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0271 PHINNEY'S LANE
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'.i3 , L, S d d fr, 4„Via: i .e. k ...; l o W — Y E4 „Y•:,# �,b.., rrr t to? .,.,,, .., :,. x , .,....A. , .. ,.: f ° ii s.i r:!; - ;�k.,y ' 'eOtt r ., :«.. d"- : , 11/17/2017 R. Anderson daily log 271Phinney's Lane Centerville— R230-003 Reported to site with David (Health) to investigate allegations of people living in 2 RVs. Found power to one RV but no sewer dine. No one responded to knock on RV entry. Found owner's wife at home in the dwelling. She called her husband, Headly Bowen who spoke to David. Owner stated that no one is living in camper; he is cleaning and working on it. His wife admitted us to the RV for a quick inspection. Found the bathroom to be winterized, there were no . personal effects noted, no creature comforts. The beds were not prepared for sleeping, no pillows. We did not ask to see inside the other unit as there was no power to it-at all. Dave advised Mr. Bowen on unreg MV ordinance. Said PD may follow up with them. He also advised owner to register or shrink wrap both RVs in order to avoid additional investigation. Owner will shrink wrap roof of RV (to avoid leaks) and maybe cover doors as well. That will be acceptable as no one will be able to enter units for living purposes without disrupting shrink wrap. 7 `4 0FTHE r Town of Barnstable p�`�,1� *Permit Expires 6 months from issue d t Regulatory Services Fee s�arrsr�sra, • MASS. sbgq' Thomas F. Geiler,Director rED MA'1 A. Building Division o - Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-623 0 . EXPRESS PERMIT APPLICATION - RESIDENTIA.L ONLY, Not.Valid without Red X-Press Imprint Map/parcel Number- 0z>!E� Property Address �C�� ���r124 S ��►� A ❑ Residential Value of Work P4000 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name 116 n rZ Telephone Number__-((3-- 6- 9 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ac ❑Workman's Compensation Insurance ' ` ' PE RANT Check one: ' ❑ I am a sole proprietor OCT. ® � Z �, I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF SARNSTABLE Insurance Company Name Workman's Comp. Policy# ' Copy of Insurance Compliance Certificate must accompany each permit. ~ Permit 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) Y ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value #of doors (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 Impr ement Contractors License& Construction Supervisors License is required. IGNATURE: IWPFILES\FORMSIbuilding permit formsT)TRESS.doc ..vised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigadons 600 Washington Street Boston, MA 02111 www.mass:gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: ('t,1 �,�V, ll� M� 0 a6-31 Phone#: FE e you an employer? Check the appropriate box: _I am a employer with 4. ❑ I am a general contractor and 1 Type of project(required): employees(full and/orpart-time).* have hired the sub-contractors 6 ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling shipand have no These sub-contractors employees b contractors have g, []Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp,insurance.# 9. []Building addition required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.gLI am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12 Roof repairs employees. [No workers' 13.[1 Other 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: Policy#or Self-ins,Lic.#: Expiration Date: Job Site Address: 1 �r,P I L,% City/State/Zip: e e,k-wfv; �\ *AA 0-a' a 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 coverage verification. I do hereby certify der the pains and penalties of perjury that the information provided above is true and correct c � i Signature: Date: Phone#: F ial use only. Do not write in this area,to be completed by city or town official 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#: �111E Town of Barnstable Regulatory Services L+Rtvsresra, Thomas F.Geller)Director 1639. �' Building Division ATFp�p Tom Perry,Building Comrnissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION —7 Please Print DATE: L JOB LOCATION: pC�- ( '► e y N i number en e�V► ��'� i 1 ` street ` village .HOMEOWNER":-O N�1<,V.P r"4/ cJ raw.-g �/'? name C/ home phone# work phone# CURRENT MAILING ADDRESS: S C.re eA 3 -e— city/town state zip code The current exemption for"homeowners"was extended to include owner-occulpied 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. DEFITIITION 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 requireiients. S a ure 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 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 oFT"E Town of Barnstable Regulatory Service t - iry s IIArwsxmt.a, +' A Thomas F. Geiler,Director i639. 1V3' ro+p►�` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4 8 Fax: 508-790-6230 Property Owner Must ornplete and Sign This Secti If Using A Builder as O er of the subject ptppetty hereby authorize t � o act on my behalf, in all'tnattets relative to work authorized by this b\' permit (Address of job)' Pool fences and alarms are the respo sibili of applicant.li tY cant. Pools are not to be filled before fence is install d and pools a e not to be utilized until all final inspections are Per. ormed and acc ted. Signature of Owner �"ignatare of Applicant Print Name Pont Name Date Q:FORM&O WNERPERMISSIONPOOLS �oFrruro�, Town of Barnstable /spires 6 molt/ jromr&sue(late Reg>!Ilatory Services Fee y #640. 1619- ��� Thomas F. Geiler, Director ) Building Division Tom`Perry, CBO, Building Cornrnissioner' 200 Main Street, Hyannis, MA 02601 www,town,barnstab le.ma.us Office: 508-862-4038 EXPRESS PERMIT APPLICATION Fax; 508-790-6230 - RESIDENTIAL ONLY Nol Valid Ivllhoul Red X-Press/mprinl Map/parcel Number Property Address t1 z� L v� ` �. �C" \A residential Value of Work Minimum fee ofS35,00 for work under S6000.00 Owner's Name & Address f j Contractor's Name Telephone Number Home Improvement Contractor License #(if applicable) . Construction Supervisor's License#(if.applicable)_ ' p) r -DER IT 7�" n ❑Workman's Compensation Insurance Check one: N0 V 2 O"i0 - - 4.7 L,. E ❑ I.am a sole proprietor am the Homeowner TOWN OF BARNS ABL, ❑ 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) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris.will be taken to Re-roof(hurricane nailed) (not.stripping.` Going over existing layers of roof) ❑ Re-side - #of doors Replacement Windows/doors/sliders, U-Value c� (maximum .35) # of windows *Where required: Issuance otthis 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 I required. ,SIGNATUI21;: 2:\WPFILES\F0RMSlbui1dingpermit forms\EXPRESS.doc 1 The Commonwealth of Massach usetts Department of Industrial Accidents I y j;,. , Office of Investigations el 600 Washington Street 1 Boston, MA 02111 ` www:mass.go.v/dia Workers' Compensation Insurance Affidavit: Builders/Contrac.fors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): 6 U[.,,.�-- f r Address: i City/State/Zip; I i.,� ✓; lic_ V' A 6,1 C,'-s a, Phone #:. 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 1, 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. # ❑ Remodeling ship and have no.dmployees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y p tY� 9. .❑ Building addition [No workers' comp.-insurance 5. Q We are a corporation and its 10.❑ Electrical repairs or additions quired.] officers have exercised their 3. am a homeowner doing all work right of exemption per MGL 1-1.❑ Plumbing repairs or additions myself. No workers' comp.,".., c. 152, §1(4), and wehave no 12.0 Roof repairs insurance required.] t employees. [No workers' comp, insurance required,] 13.0.Other. .*Any applicant that checks box#I,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. ' tContractors 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 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 fine up to$1,500.00 and/or one-year imprisonment,:as well as civil penalties in the form of 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 ify nder the pains and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone#: ��/ 3 hti ,r 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#: i Information and Instructions Massachusetts General Laws chapter 152 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 employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or truste of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwellin house having not more than three apartments and who resides therein, of the occupant of the dwelling house of an ther who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or b ilding appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C also states that"every state or!opal licensing agency shall withhold the issuance or renewal of a license or pe it to operate a business or to construct buildings in the commonwealth for any applicant who has not pro ced acceptable evidence of co�y pliance with the insurance coverage required." Additionally, MGL chapter I , §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the p formance of public work unttil acceptable evidence of compliance with the insurance requirements of this chapter have. een presented to the contra a ting authority." Applicants Please fill out the workers' compensate n affidavit completel by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)nam s), address(es)and p ione number(s) along with their certificate(s)of insurance. Limited Liability Companies (L C)or Limited Lia ility Partnerships (LLP) with no employees other than the members or partners, are not required to ca workers' compe sation insurance. If an LLC or LLP does have employees, a policy is required. Be advised th t this affidavit ay be submitted to the Department of Industrial Accidents for confirmation of insurance coverag . Also be s e to sign and date the affidavit. The affidavit should be returned to the city or town that the application r the pe it or license is being requested, not the Department of Industrial Accidents. Should you have any question egardin. the law or if you are required to obtain a workers' compensation policy,please call the Department at the umbe 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 legibly he Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of In tig ; ions has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will b used a reference number. In addition,an applicant that must submit multiple permit/license applications in any giv n year, n ed only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" e applican hould write"all locations in (city or town)."A copy of the affidavit that has been officially stamped marked by t city or town may be provided to the applicant as proof that a valid affidavit is on file for future permi or licenses, A n w affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or per it not related to an usiness or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NO required to complete is affidavit. The Office of Investigations would like to.thank you in advance fo our cooperation and shou ou have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: , The Commonwealth of Ma sachusetts Department of Industrial cidents Office of Investigatio 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or.1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia t I I fKWE Town. of Barnstable Regulatory Services IXER''iris.^BLX, Thomas F. Ceiler Director ..� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma:us t Office: 98-862-4038 Fax: 508-790-6230 --------------- HOMEOWNER LICENSE EXEMPTION Please Print DATE: 1 l 1 4 l number \\ street village "HOMEOWNER"��o.S �v� I'Vti. '.� YI"3 -j6V name C home phone N work phone# CURRENT MAILNG ADDRESS: s C.r % R_ 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 Per 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-yearperiod shall n'ot 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 agn aresand requirements and that he/she will coinply with said procedures and requirements. e of Homeow r 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.)27.0 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 a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness oPcn 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. J ' s . Q:IWPFILESIFORMSIbuilding permit formslEXPRESS.doc RevicPrl n721 10 pF THE Tp� ti t. • HARNFrAHLE, 6Ass. Town of Barnstable pIFD MP'I A Regulatory Services Thomas'F. Geiler, Director Building Divisiolh Thomas Perry, 0 Building Com lrssroner 200 Main Street, Hy nnis, MA 02601 wiYw.town.b rnstable.mn.us Office: 508-862-403 8 Fax: 508-790-623 0 Pr er ®weer Must Complet a d Sign This Section ff rig A Builder ..-- as wrier of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this uilding per t application for: (Address of Job Signature of Owner . Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exempt on Form on the reverse side. QAWPFILESIFORMSIbuilding permit formskEXPRESS.doc t i CA) (,Iq)cq Town of Barnstable .*Permit#_tW 1&oq Fapires 6 mondts from issue date Regulatory Services Fee BAMSTABM '""ES, Thomas F.Geiler,Director sbg9• �0 RFD MA'1 A „PRESS , uilding Division om�Per r"y,CBO, Building Commissioner .SUN° --,4 2003 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Officer 508-863MMN OF BARNST Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �Q Q(� Property Address Q , � &4 bCC LL,l k 2'\-4 CGRC` Q Q'Residential Value of WA 1n2o -I S00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 5w✓� Contractor's Name - (; y P lA e, _Telephone Number Home Improvement Contractor License#(if applicable) �l q Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor [`I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name 1_44 j 5 � _�� s �,- ,, U, ��,�,k;�� Assn , Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A "'of the Home Improvement Contractors License is required. SIGNATURE: C:\Users\decollik\AppData\Local\MicrosoMWindows\Temporary Internet Files\Content.Outlook\MY7NB41L\EIKPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t www.mass.gov/dia f` Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele tricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): r. r•-. Address: City/State/Zip: CQakc v,\k Phone M Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. �am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.$ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their, 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing 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: 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 coverage verification. I do hereby c r under the pains and penal ' of erjury that the information provided above is true and correct Signature: A Date: 6 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 Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...eve person in the service of another under an contract of hire, "...every P Y express or implied,oral or written." An employer is defin "an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged' joint enterprise,and including the legal-representatives of a deceased employer,or the receiver or trustee of an indi 'dual,partnership,association or oth r legal entity,employing employees. However the owner of a dwelling house ha ' g not more than three apartmen and who resides therein,or the occupant of the dwelling house of another who ploys persons'to do mainten ce,construction or repair work on such dwelling house or on the grounds or building app enant thereto shall not be use of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also stat s that"every state or 1 cal licensing agency shall withhold the issuance or renewal of a license or permit to op rate a business or t construct buildings in the commonwealth for any applicant who has not produced acce table evidence o compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7 states"Neither ' e commonwealth nor any of its political subdivisions shall enter into any contract for the performanc of public wor until acceptable evidence of compliance with the insurance requirements of this chapter have been pres ted to the ontracting authority." Applicants , Please fill out the workers' compensation affida it co pletely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),addr s es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or L' 'ted Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry work 'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that a davit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. so a sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application f r the rmit or license is being requested,not the Department of Industrial Accidents. Should you have any question regard g the law or if you are required to obtain a workers' compensation policy,please call the Department at ,listed below. Self-insured companies should enter their self-insurance license number on the appropriate li e. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the O ce of Investigation has to contact you regarding the applicant. Please be sure to fill in the permittlicense number r� ich will be used as a eference number. In addition, an applicant that must submit multiple permit/license applications in any given year,nee only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicants=ould write"all locations in (city or town)."A copy of the affidavit that has been officia stamped or marked by th city or town may be provided to the applicant as proof that a valid affidavit is on file for ture permits or licenses. A ew affidavit must be filled out each year.Where a home owner or citizen is obtaining a li ense or permit not related to business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said p on is NOT required to comple this affidavit. The Office of Investigations would like to thank you in dvance for your cooperation and ould you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth f Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia :�liassachusetts-Department of Public Safety. Board of Building Re-, lotions and Standards Construction Supervisor License License: CS 56765 Restricted to: 1 G JAMES P HEALY 15 ANNAWON RD MASHPEE, MA 02649 Expiration: 4/24/2011 Commissioner Tr##: 12978 - - Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration.; 115770 t Expiration 4l10/2010 Trig 268965 Type Individual F JAMES P.HEALY JR JAMES HEALY 15 ANNAWON.RD , MASHPEE,MA 02649 Administrator x The Continonwealth of Massachusetts Department of Industrial Accidents Office of Investi;ations ; 600 JEashin,on Street _ - Boston,-M.4 02111.• wivir.mass.;ov/dia r 3 'Workers' Compensation Insurance Affidavit: Builders/Contractors/`Electricians/Plumbers Please Print Legibiv A ticant Information ' - � - -�— r "Name(Business/Organizatior individual): Address l� !�✓ Gvo�✓ ��w, / '42 IY4 ©Zell Phone ;.:: � City,'State:`Zip: pTe an employer': Check the appropriate box: Type of project•(required) _ 4. I am a general contractor and I 6. New construction 1.yI uam a employer with � have hired the sub-contractors employees(full and/or pan-time).' V listed on the attached sheet 7 [E� emodelin g 2.❑ 1 am a sole proprietor or parmer These sub-contractors have ship and have no employees 8:'Q Demolition ; cmplovees and have workers' working for me in any capacity: 9. ❑Building addition , o workers' co insurance comp:insurance (N comp. 10.❑Electrical repairs or additions . required.) . 5• [] We'are a corporation and its x 3.❑ lam a homeowner doing all work officers have.exercised their 11.❑Plumbing repairs or additions m right of exemption per MGL yself [No workers' comp. ' , 12.0 Roof repairs insurance required.]t .�c.,152, §1(4),.and we have no employees.[No work erg' 13•❑Other comp.insurance required.] •Any appii=t 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 cona�ctors trust subtr>it a new affidavtt indicating such :Contractors t ust att his check this box n ' aehed an additinttal sheet showing the name of the sub•comactors and state whether or not theme entities have employees. If the subconvactors have apployems,they must provide that workers'comp.policy number., law an employer that is providing workers=compensation insurance for my employees Below is the policy and job site information. r . t Insurance Company Name: C7 y�� j V/�-i cIf CIL P -- • Q iration Date: !s 36 0 Policy#or Self-ins.Lic.#:' GiJ C /G. gP 1 / Join Sits Address: / �!s� Ciry/State/Z : 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 51.500.00 and/or one-year imprisonment as well as civil nalties in the form of a STOP WORK'ORDER and a fine- P. . of up to S250.00 a day against the violator. Be advised that a copy o this statement may be forwarded to the Office of' Investigations of the DLk for insurance coverage verification. I do herebj.•certify under the pains.an allies o erjury that the information provided above is true and correct Signature: - `. Date: Phone Ojficia/use only..Do not write in JJris area;to be completed bt'city or town official City or.Town: 1�„�� Permit/License# Issuing Authority(circle one): 1..Board of Health 2.Building Department 3.City/To«n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other y" Phone#• Contact Person: _- ------------------ 'PRODUCER THIS CERTIFICATE IS 1SSI IED AS A MATTER OF INFORMATION i ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PAYCHEX AGENCY INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1175 JOHN STREET' L R THE COVERAGE AFFORDED-BY. POLICIES BELOW. WEST HENRIETTA,NY 14586 COMPANIES AFFORDING COVERAGE • _ CO MANY .. .. ?triS•« =-- GUARD INSURANCE - i JANIES HEAL i s ! "r, ANNnWntil ROAD _ t - F f VU AR Jef - . T;IS 1S T .f'.�ER iFY-H—. (THIS POU'•Lia;S.OF INSURANCE 1 STED BE,vlw HAVE SEEN ISSUED TO THE 1N0.'nEv s11�'b ED i•esB..OVE t•�a-t-'s YL i v ia, i IPdI;lCAT`cEi,i'Iv^Te E rs?3 i3(A3�EDIIVta AnfY REO ieREieicivi, 3=R$t9 G}�'i COiVDiTev^N OF ANY CONTRACT OR OTHER DOf__UMENT'Vvi7-!RESPECT e Q Ve s1i.H 1 Iii3 j CFRTIFICA T E MAY BE iSSUED OR MAY PERTAIN.THE iNSUR INCE AFFORDED BY THE POL!CIEG DESrJ:iBED HEREIN IS SUBJECT TO ALL THE TERMS, � EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO'' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTfi DATE(MWOO/YY) DATE(MINDONY) 1 GENERAL LIABILITY GENERAL AGGREGATE $ — PRODUCTS-COMP/OP AGG S ED�LA1MS MADE CUR PERSONAL&ADV INJURY S OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE S FIRE DAMAGE(Any one tire) S MED EXP(Any one Person) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S ALL OWNED AUTOS SCHEDULED AUTOS BODILY-INJURY S (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY IMURY s -•-•_ (Per accident) PROPERTY DAMAGE S GARAGE LIABILITY ANY AUTO AUTO ONLY.-EA ACCIDENT S OTHER THAN AUTO ONLY: EACH ACCIDENT S AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM -- AGGREGATE' $ OTHER THAN UMBRELLA FORM S WORKER'S COMPENSATION AND X wC STATU on+ A EMPLOYERS'LIABILITY �QRr 11% ME PROPRIETOW EL EACH ACCIDENT $ 100,000.00 _ - _- PAIiTNERSE K rTIVE-- �INCL ..JAWC909296 O6/30/O8_:- 06/30/09'. ... EL DISEASE-POLICY LIMIT .S_ ,500,000.00 - OI-PICEM ARE EXCL EL DISEASE-EA EMPLOYEE S 100,000.00 OTHER DESCRIPTION OF OPERA'nONSr10CAnoNSNERICLESISPECIAL ITEMS , r I t - �i�ia7y..' �;c``=r�:�-`:�irz:=:::i:::;:7�::�:=:2`�:'�::::�:::::::;`.�:;s:::�':'.'1>::::;-:::`;::.:::.,o:::.�....:,•}Jf�[Mks - - - SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY W0.0 ENDEAVOR-TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO-THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTWRIZED REPRESENT A E .-..- ::. �SI: •.t.... .............. `/:: .nn�..f:.:...,....:..:....::.:.-•.�:.:_.:.. ,: ...,,.•.:.-: :. o f-,J.,: :. ,.:,�: r.•c,�2•-y., .,>.,..... a•R.---..-- ................. .....��:.:::::-:::::,--.h-:..-. ..........-..---•------.....:,:;rw•-.',•�--:._::::::�?.:r-.,f'E�%r:.:.. :v-�.. ..� '�jo-,:;t-.:=-:-,-ti,k:.rr+:?::„-::.,•.,-; - Town of Barnstable �pf IBE rg�y y�� o Regulatory Services • Thomas F. Geiler, Director s&Rrrsr&arr:, v MASS Building Division PJfD � Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us r Office: 508-862-4038 Fax: 508-790-6230 HO]%fEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: Pti, L number street v;llage ..HOMEOWNER": s-6 Qr t r—name home phone# work phone# CURRENT MAILING ADDRESS: r T �" n e S L✓` t�2n V" A Oo` 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 perm-it. (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 Xr,Cements.of Homco cr 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 1o9.1,1-Licensing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption aie unaware that they are assuming the fesponsibilities of a super visor(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 hcJshe understands the rrsponnbilitics of a Supervisor. On the last page of this issue is a form currcntly used by several towns. You may care t amend and adopt such a famvccrtifrcation for use in your community. �oFtHEr Town of Barnstable F Regulatory Services +BHA NSTAASLK Thomas F. Geiler, Director �p 019. lE10) Building Divi i0n Tom Perry, Building C mmissioner 200 Main Street, Hyan s, MA 02601 www.town.barns.able.ma.us Office: 508-862-403 8 Fax: 508-790-6230 a� �� . roperty O' ner Must ' Comp to and S'gn This Section , Z TJsing , Buff der 7 , as Owner of the subject property hereby authorize to act on my behalf, in altmatters relative to work authorized by this b; ' din ermit application for: (Address of Job) Signature of Owner Date ,.J Print Name If Property Owner is.applying for permit please complete the Homeowners License Exemption Form on tEc reverse side. TO ALL NEW BUSINESS OWNERS: �1 Fill in below: NAME OF NEW BUSINESS: TYPE OF BUSINESS ADDRESS OF BUSINESS "2-7/ ` MAP/PARCEL NUMBER C� ooa? If you are starting a new business there are quite a few things you need to do in order to be in compliance with all rules and retulations of the Town of Barnstable. Once you have been checked off on this sheet you may apply for a business certificate at the Town Clerk's office(Ist floor-Town Hall). 1. GO TO BUILDING INSPECTOR'S OFFICE(4TH FLOOR TOWN HALL) This individual is in compliance and has been explained the procedures needed to.start d a business Building Inspector's Signature 2. GO TO BOARD OF HEALTH(3RO FLOOR TOWN HALL) This individual has been informed of any permit requirements that pertain to this type of business. . V u ' Health Inspector's Signature 3. GO TO CONSUMER AFFAIRS(LICENSING AUTHORITY)-13RD FL SCHOOL DMINISTRATION BUILDING This individual has been informed of any licensing requirements that will pertain to this type of business Licensing Authority Signature After being checked off by all of the above-remember to return to the Town Clerk's office to actually obtain your business certificate. �W The Town of Barnstable Department of Health, Safety and Environmental Services . ; Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Home Occupation Registration Date: Name: Address: e- Village: Type of Business: D h S�/ �� Map/Lot: Z 3 4 0 D INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance, provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor, no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes:and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit, located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I, the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Dater 9 Applicant: � 2 C i