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Home My WebLink About0718 PHINNEY'S LANE .,t ..`L k_:< ° .. �'._er, 1 f'rr, ,. ,_.; ' �r '..: r -za.. -: '��` `,r. '� rm•a rr� aka air .�, f � ; Aa4� t 1 y4t i , 4 . s r 0 • 1 r Y' a Q a O f4 S r rq �4 f 9 J y m. APPLICANT INFORMATION (BUILDER OR IIOMEOWNE Name I Q Telephone Number L�ddress License # L� ;M4 _ Home Improvement Contractor# Worker's Compensation # p ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO h - Ve [A 9 Uh SIGNATURE DATE v f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 717,G Map Parcel Application # Health Division Date Issued 20 Conservation Division ` Application Fee Planning Dept. ., Permit Fee' Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation / Hyannis Project Street Address �� &Lv/v 0, a`5 4 N' Village Ili Owner i i i^ 2 Address Telephone 8 l Permit Request &vt Ot, 1 hl9U Ale. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio' Construction Type Vl1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting ciocu entation. Dwelling Type: Single Family Zr Two Family ❑ Multi-Family(# units) �= fD Age of Existing Structure Q-S Historic House: ❑Yes ❑ No On Old King's Highway: 0 Yesv❑ No Basement Type: -2 Full ❑ Crawl ❑Walkout ❑ Other -�- Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) r 9 S" Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: y , Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes -❑-No If yes, site plan review# Current Use , - Proposed Use _APPLICANT INFORMATION (BUILDER OR HOMEOWNER) t . Namegix, Telephone Number , a Address icense# lf/THIS H me Improvemen Contrac r# , Wo er's Compe ation # ALL CONSTR CTION EBRIS RESULTI G FRROJ T WILL TAKEN TO 1,04 0S rr SIGNATURE DATE ��® � FOR OFFICIAL USE ONLY APPLICATION# _ DATE ISSUED MAP/PARCEL NO. ADDRESS i VILLAGE s 4 { " OWNER r C l• t DATE OF INSPECTION: FOUNDATION!" FRAME it INSULATION . FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS:-- ROUGH FINAL t `FINAL BUILDING . -t .DATE"CLOS.ED-OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts ., Department of Industrial Accidents Office of Investigations « 600 Washington Street • _f t Boston, MA 02111 Z¢yy www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LejZibly Name (BusinessfOrganizationlIndividualj: ..Vit IV 4 Address: N L.. City/State/Zip: 6.-,J�4011e ' Phone #: �� 6 �� Are you an employer? Check the appropriate box: `type of project(required): 4. I am a geral'contractor and I .0 I am a employer with en 6. ❑New construction einployees'(full and/of paYt-tune).* have'hired the sub-contractors.` . _ _ 2.❑ I am a sole proprietor.or partner- listed on the attached sheet 7. ❑Remodeling ,ship and have no employees These sub-contractors have ,g• OrDemolition workingfor me in an capacity. employees and have workers' y P h 9. [] Building addition [No workers' comp. insurance comp. insurance.$ w required.] '5. [] We are a corporation and its 10,❑ Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 1I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per,MOL 12.❑Roof repairs insurance required.] t. c. 152, §1(4), and we have no 'employees. [No workers- 13..0 Other comp.insurance required:] ' *Any applicant that checks box 41 must also fill outthe section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and tbcdhire 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 employees,they must provide their workers'comp.policy number. C am an employer that is providing workers'compensation insurance for my employees. Below is the policy anti 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 rdeclaratiori„p age;(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL 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•statemeot may be forwarded to the �ffrce of th tigations.of the DIA for insurance coverage verification: erebycertify under the pains andpenalties ofperjury that the information provided above is true and correct. S nature: Phone# Official itse 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#: hformation and hStructzo-Us Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an emplo),ee 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 "an individual, partnership, association, corporatj�n or other legal entity, or any two or more of the foregoing engaged a joint enterprise, and including the legal representatives of a deceased employer, or Lhe receiver or trustee of an in Mdual, partnership, associalion or other legal entity,employing employees. However the owner of s dwelling house aving not more [ban three apartments and who resides therein, or the occupant of the dwelling house of another w o employs persons to do maintenance, co�stniction or repair work on such dwelling house or on the grounds or building ppurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also fates that "every state or local tic 'sing agency shall withhold the issuance or renewal of a license or permit to erate a business or to const uct buildings in the commonwealth for any applicant who has not produced ac eptable evidence of compliance with the insurance coverage required." Additionally,MGL chapler 152, §25C ) stales "Neither the conunonwealth nor any ofils political subdivisions shall enter into any contract for theperforman e ofpubhC work until acc'eplable evidence ofcompliance with the insr�rance requirements of this chapter have been pr ented to the contra ting authority." Applicants Please fill out.the workers' compensation affi avit comple ely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), ad ress(es) d phone numbers)along with their cerlificate(s) of insurance, Limi led Liability Companies (LLC)o Limit Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry wor ers'jccompensatjon insurance. If an LLC or LLP does have employees, a policy is required. Be advised that th) af,idavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, lso be sure to sign and date the affidavit, The affidavit should 'tense n be returned to the city or town Ihat�the application for e permit or 1i is being requested,not the Department of Industrial Accidents. Should you have any question re aiding the law or if you.are required to obtain a.workers' compensation policy,please call the Department at e n mber 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 inted legibly, The Department has provided a space.at the bottom of the affidavit for you to fill out in the event the Office of lnves igations has to contact you regarding the appli cant. Please be sure to fill in the,permitllicense numb which will be u ed as a.reference number. Ln ddition,an applicant that must submit multiple permitflicense applica ions in any given ear, need only submit one affidavit indices Ling current policy information (if necessary)and under"Jo Site Address" the a'plicant should write"all] ]Ocaiions in (city or town),"'A copy of the affidavit that has been of icially stamped or m ed by the city or town may be provid e d Lo the applicant as proof that a valid affidavit is on fil for future permits or li nses. A.new affidavifmust be filled nut each year. Where a home owner or citizen is obtaini g a license or permit not laled to any busines slor commerci a l v en lure (i,e. a dog license or permit to burn leaves etc.) said person is NOT require o complete tbis afLavit. :y. The Office of lnvestigatjons wo--u1 I e 101h n -in-ad-a-ne a-�0+� d should a�have any questions, please do not hesitate to give us a call. f The Deparlment's'add-css telephone and fax n mber: The Co onwealth of Massachusetts, Depa ent of Industrial Accidents 0 ice of InYestigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised q-24-07 www.mass.gov/dies rr _ Town of Barnstable Y y�� o Regulatory Services BARNS-,uLF- ; Thomas F. Geiler,Director Building Division PIED { Tom Perry,Building Commissioner 200 Main Street Hyannis, MA.02601. vr'ww.town.b arnstable.ma.us Office: 509-862-4038 Fax: 508-790-6230 I301\'IEOWNER LICENSE EXEMPTION Q (J Please Print LDATE: lJ/( y CAT]ON: �LIJ / R/ N�I L.�/. WVVr/number street o villageOWNER": Irk / I S 46 c'3 d 77S v � name D home phone# work phone# Nr MAILING ADDRESS: f »Vd �✓� • �Q.IV'rUW/ /I'� -/'/i�'T �-'OTC+<��..` ' city/town states 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 siructures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be consideredr ,a'bomeowner, Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsib)e 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. �'fr The undersigned "homeowner certifies that.he/she understands the Town of Barnstable Building Department m;m;muM inspection procedures andwquircments and that he/she will comply with said procedures and re ements. . r F ' Signatur f 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 Consiniction Control. HOMEOWNER'S EXEMPTION' The Code states that "Any homcowncr performing work for which a building permit is required shall be exempt from the provisions of this scction.(Scetian 109.1.1 -Licensing-of construction Supervisors);provided that if the homeowner engages a pa-son(s)for hire to do such work, that such Homeowner shall act as.supervisor." ;; Many homeowners who use this exemption arc unaware that they art:assuming the responnHities 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 homcowncr hires unliccnscd persons. In this case;bur Board cannot proceed against the unlicensed personas.it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. t; To cns-urc that the homeowner is fully aware of his/hcr responnbilitics,many communities require,as part of the permit application, ' that the homeowner certify that helshe understands the responnbilitics 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:fotms:homccxcmpt ' zrrokti Town of Barnstable . Regulatory Services � t lARN6CABLL, $ Thomas F. Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 r a 'Property Owner Must ' ` t'►rk w ,,,,Complete and Sign This 'Section If Using A Builder 1 as Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to ork authorized by'this building permit application for- (Ad ss of Job) Signature of Owner Date -.� ;. Print Name If Property Owner is applying for permit please comple the . Homeowne rs License Exemption Form on the reverse sl Q:F0RMS:0 WNERPERMISSIDN