HomeMy WebLinkAbout0915 SHOOTFLYING HILL RD a .
a
...........
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 19 1 60q 2 4
/ Parcel ! Application.# Z'®I
Health Division Date Issued l
Conservation Division :Application Fee
Planning Dept. Permit Fee
Date Definitive,Plan Approved by Planning Board ` l-7111
Historic - OKH _ Preservation/Hyannis
Project Street Address /S� 'SH0a% n— //V6 Z-I/U-
Village
Owner L AL&L t Cull-be-, Address 5!--( 71=
Telephone S295 r7`7S' �
Permit Request PL�"/C ' 1 /aenAt i ol�C eJ//V� J5 �+It�/� �°iv
yL 3_` /,9s
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: U Yes ❑ No- If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No . On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: 4;existing 4new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
NO
Current Use Proposed Use .,
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Lebl4,144b 4z- Telephone Number
Address ��d?c�QI,J � w�%`,[ �,� License # J "
Q
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE `S `— DATE ��
FOR OFFICIAL USE ONLY
t , APPLICATION#
3
r DATE ISSUED ?= '
MAP/PARCEL N0. •
ADDRESS VILLAGE "
OWNER -t
DATE OF INSPECTION:
FRAME
INSULATION ,
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL ✓
GAS: ,"#" ROUGH fiG ' FINAL
,:FINAL BUILDING i _ 'l: J > '
s
;. : DATE CLOSED OUT
r .
' `' ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 f _ ; . Office of Investigations
600 Washington Street
Boston, MA 02111
c=�. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Bus iness/0rganization/Individual):
Address: X/14A.AQS/
City/State/Zip: Phone #: c®� � 54�
r.�
Areyou an employer? Check the appropriate box: Type of project(required):
I.❑ I 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-contractors
2.[Z[am a sole proprietor or partner- listed on the attached sheet. t �• Remodeling
ship and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their ]0.❑ Electrical repairs or additions
required.] of
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
Myself.[No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.}t employees. [No workers'
comp, insurance required.] ]3.� Other/�f��Q,i„)
*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,
tCon tractors 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 andjob site
,information.
Insurance Company Name:
Policy#.or Self-ins. Lie. #: 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 s.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 s250.00 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 hereb certify under the pai an pe es of perjury that the information provided above is true and correct.
V6t/ Date:
St nature: �
Phone#: /
Official use only. Do not write in this area, to be completed by city or town offlcial
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
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 trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner.of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to'do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto-shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely;by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
-Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,'please call the Department at the number 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. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance 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:
The Commonwealth of Massachusetts ,
Department of Industrial Accidents `
Office of Investigations
600 Washington Street
Boston, IOTA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MAS.SAFE
Fax # 617-727-7749
r,
Town of Barnstable
� a .
Regulatory Services
stxxsrAs[.� � '
IF Mlaa g Thomas F. Geiler,Director
ibsg. �a
�Eo Building Division
Tom perry, Building Commissioner
200 Main Street, Hyannis MA 02601
www.town.barnstable.ma.us
office: 508-862-403 8 Fax: 508-790-623
Property OwrierMust
Complete and Sign This, Section
If Using ABuilder
as Owner of the subject.pmperty
hereby authorize � 0 2}. LZZ 0 to act on my be
m all matters relative to work authorized by this building pemut application for..
CC
(Address"of job)
signature of Owner Date
Pent Naxne
If Property Owneris applying forpermitplease complete the
Homeowners License Exemption. Form on the reverse side.
Town of Barnstable '
Df THE Tp�o
Regulatoty Services
Thomas F. Geiler,Director
Building Division
f° Tom Perry, Building Commissioner
200 Mairi.Street,_Hyannis, MA 02601
wwFv.town.barnstable_ma.us '
Office: 508-862-4038 Fax. 508-790-6230
HMSOWNER LICENSE EXEMPTION.
Please Print
DATE:
JOB LOCATION:
number s tract village,
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
7bc current exemption for"homeowners"was extended to include owner-occupied&CI ings 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
SuDeryisoL
DEFT7UTON OF HOMEOWNER
Persons)who owns aparcel of.land'ou which he/slie resides of 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 constrgcts more than one home in a two-year period shall not be considered a bomeovmcr, 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/sbe understands the Town of Barnstable Building Department
rr;n;rnum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. '
t
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or large will:be iequired'to comply with the
State Building Code Section 127.0 Constriction Control.
HOMZOWNER'S ExEma—nONr
The Code states that "Any homcowna performing work for which a building permit is required shall be exempt from the provisions
of this sec6gn,(Section 109.1.1 -Licensing of co.mtruetion Supenrisors);provided that if the homeowner aigages a p=on(s)for hire to do such
wofk, that such Homeowner shall act as supervisor."
Many homeowners who use this cxcinption are unaware:that they arc assumingsupervisor the responsibilities of a (see Appendix Q,
R.u)cs&Rcgu.lations for Licensing Construction Superv;sors,Section 2.15) This lack of awarcncss often results in serious problems,particularly
when the homeowner hires unliearsed persons. In this case,our Board cannot proceed against the unlicetrsed parson as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware ofhis/h4responnbilitics,many communitics raquirc,as part of the permit application,
that the homeowner certify that hrlshe understands the respmnbilitics 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 fom>Iccrtification for use in your community.
Masslichusetts- Department of Public Safety
Board of Building Regulations and&andards': _
Construction Supervisor License
License,: CS. 70862 w
Restricted to: 00 1,
LEONARD D DELOREY
PO BOX 46 -
MASHPEE, MA 02649
Expiration: 6/22/2011
('ununisiuucr. .-Tr#: 20182
I
Office 0 co mer mik ifsiness egu'ion License7or registration valid-for individti use onl
< HOME IMPROVEMENT CONTRACTOR before the;expiration date: If found return to - y ;r
Registration136739 Typei Office of Consumer Affairs and Business Regulat on
f Expiration 8/21f2012 Individual 16Park Plazaite 5170
I Boston,MA`02116
L ARD D.DELQREY
-
LEO.NARD DELOREY �,
3 r
27 STURGIS LN y
} CSC
MASHPEE,.'MA 02649 _
r _ Undersecretary — iVot valid Without signature —
s
,j
i
l� ad l 6S
'p
�oFr►ur Town of Barnstable, *Permit#
ti
r - - .Expires 6 rnonl/rs from issue dale I'M
Regulatory ,services > ee� ��, V
13A.Rvsrtist.s. :
y AAss, ;#
1619. �� Thomas F. Geiler, Director
�prE'1 Mp`f a _
Building Division , -PRESS PERMIT
Torn Perry, CBO, Building Cornmissioner
200 Main Street, Hyannis, MA 02601 0 r T ,a 4 201L.
www.town.barnstable.ma.us l AWN ®F BARNSTABLE
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid rpilhout Red X-Press.Irry)rinl
Map/parcel Nurnberg=
Address / / `� /v'o /�
Property Add _ S�7 �y�//liar 0P,!j7 /'////�,O �l(�
❑ Residential Value of Work 5560 Minimum fee of$35,00 for.work underS60001.00
Owner's Name 3c Address a7,�11,Ve- �� g _ / / /
s /� oSo��T
Contractor's Narne- dNo/r%, . ���dr� Telephone Number - 7�.j
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#t(if applicable)
❑Workman's Compensation Insurance
C eck one:
I am a sole proprietor
I am the Homeowner.
❑ 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 , ' � _ (maximum .35)# 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
re uired.
i
IGNATUIZE:
:�WPFILESIFORMSWuilding permit forins�EXPRESS.doc
evised 072110
OF THE TOE
• BARNSTABLE, -
Ass.
i679• Town of Barnstable
��
prFD MP't A
Regulatory Services
Thomas F. Geiler, Director
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.m,
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sigh This Section .
If Using A Builder
�r✓/- ` /� : , as Owner of the sub ect Property
1 P p t1'
hereby authorize /-IA4�r 7 o�p/—� �/ to act on my behalf,
in.all matters relative to.work authorized by this building permit application for:
AAF
(Address of Job)
`� D— _
�1117e
Signature of Owner Date,
Print Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
QAWPFILESTORMSIbLidding permit formslEXPRESS.doc
.Revised 072110
1 "
.y
P�01HKE ,o Town of Barnstable
' Regulatory Services
iBA]YSrABLE, " Thomas F. Geiler, Director
IA SS. $ ,
' 9.N Building Division
Tom Perry, Building Commissioner/
200 Main Street, Hyannis, MA 026 'l°
www.town,b a rnsta ble.m a.
Office: 98-862-4038 Fax: 508-796-6230
HOMEOWNER LICENSE E EMPTION
Please Print
DATE:
10B LOCATION:
number 1 treet village
,,HOMEOWNER„
name home one# work phone#
CURRENT MAILNG ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include own -occu ied dwellin s of six units or less and to allow
homeowners to engage an individual for hire who does n t possess a licen e, provided that the owner acts as supervisor,
DE NITION Or HOME WNER
Person(s) who owns a parcel of land on which he/she r sides or intends to res' e, on which there is, or is intended to be, a one or.two-
family dwelling,attached or detached structures acce sory to such use and/or fa m structures. A person who constructs more than one
home in a two-year period shall not be considered omeowner. Such "homeow er"shall submit.to the Building Official on a form
acceptable to the Building Official, that he/she sh be responsible for all such wor Performed under the buildingpermit. (Section
109.1.1)
The undersigned"homeowner"assu//shewill
ility for compliance with the State Bu ding Code and other applicable codes,
bylaws, rules and regulations.
The undersigned"homeowner"certi understands the Town of Barnstable Buil ing Department minimum inspection
procedures and requirements and thamply with said procedures and requiremen
Signature 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.]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 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:\WPFILES\FORMSIbuilding permit formslEXPRESS.doc
Revised 072110 s ,
: The Commonwealth of Massachusetts "
.:Department of Industrial Accidents
Office of Investigations:r
+ d 600 Washington Street
y`
Boston,-MA 02111-
wN =� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual):
Address:
City/State/Zip: 6 Phone.#: �
Are you an employer?Check the appropriate box: Type of project(required):
1.El I am a employer with :` 4. I am a general contractor'and I
6. New construction
employees(full an m d/or part-tie).* ' have hired the sub-contractors ❑
2. ' I am a sole proprietor or partner- listed on the attached sheet. 7...Q Remodeling
ship and have no employees These sub-contractors have g, 'Q Demolition
workingfor me in an capacity. employees and have workers'
Y P h' - 9. �Building addition
. comp.insurance.$
[No workers. comp: insurance P
required.] `f 5 We are a corporation and its 0 P
q ] 10. .Electrical repairs or additions �
3.0 I am a homeowner doing all work officers have exercised their I LE]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 `,,;; C
employees. [No workers' 13_ Other l/�%/ dtA JfJj/I q
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 assequired under Section.25A ofMGL 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 here certify under the pains a d enalties ofperjury that the information provided above is true and correct.
Signature'. 4
u 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#:
- T
t
Infoi matron-and-Instrac-tions---
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 aecea§ed emp oyez;or e
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house.of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." . .
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number 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. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license.applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and.under"Job Site Address" the applicant should write"all locations in__(city or
town)."..A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
permit to bum leaves etc. said person is NOT required to complete this affidavit.
i e ado license or mP
(• g . P ) P q
The Office of Investigations would like to thank.you in advance 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
e _ ,
Massccbusetts- Department of Public Safety,
x
'Board of Building Regulaaions andSlt�ap �
<�q®`�ict •Supervisor.�Lia�ense
r4kense: CS 7Q862 � I
Restricted rF 6# M
IlEONA
p0 BOX «
£M�kSH �
.. , -.0
Expiration: ¢/??l17.11
(omiui�siuner ' Tr# 2018$ lI
0fficeTok, ADOn'm'e'�& Bess ° License or registration valid for individul use only }
' HOME IMPROVEMENT CONTRACTOR t =x before the expiration date. If found return to:
Regis':ration: 36739 Type: Office of Consumer Affairs and Business Regulation
Expiration 012 Individual =- 10 Park Plaza-Suite 5170 -
E E — Boston,MA 02116
L RD D.DELOF 2v
{ ,
LEONARD DELO # = 1
�E F .
27 STURGIS LN E
MASHPEE,MA 02649
-��,: Undersecretary Not valid without signature
e
Town of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services F .�
* BARN,
163 Thomas F.Geiler,Director
Building Division co �13�110
T _ Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038, Fax: 508-790-62,30
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 17L �37
Property Address
Residential Value of Work d�r e>r}. Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
its
Contractor's Name TelephoneNumberi� %Gry 'Z
Home Improvement Contractor License#(if applicable) C '��'
Construction Supervisor's License#(if applicable) (1, �,
❑Workman's Compensation Insurance
Check one:
W I am a sole proprietor
0 I am the Homeowner
❑ 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)
10 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to1-3c) tP,; %c—' 4g,Q c�
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
ElReplacement Windows/doors/sliders.U-Value (maximum.35)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property"Owtier must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet,F'es\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 072110
'= MILSSItchusetts-Depitrtment of Public S t#tty
Bttitt-d of Bu tiling Re
i;uljittuns.rtttt�t;tttgl art
nslr t€o S.upervisor Li e
.License: CS 70862
Restnctedto 00
? 4
fiEONARD D DELOREY
PO BOX 46 a� .
IMSHPEE; MA 02649 x" z�
Expiration: 6/22/2?71
C'uni�j�issiwic ' Trit: 20182
Office�t o amer'e t a ors&�9iness egu a-6o."
HOME IMPROVEMENT CONTRACTOR
' Registration: A36739 Type:
Expiration 8121%2012 Individual
.....�
�
LEONARD DELOR'Ee—,'
27 STURGIS LN
MASHPEE,MA 02649 ."r
\._: Undersecretary
oF�
i r
i iARNBTASI,E,
3 9. Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director ,
Building Division
Thomas Perry,,CBO
Building Commissioner
200 Main Street,. Hyannis,,MA 02601
www.town.barnstable.ma.us=
Office:..50&862-4038. .Fax:. 508r79M230.
Property Owner Must
Complete and Sign This Section
If Using A Builder
6 n N . !'//. d L S ,.as Owner of the subject property
hereby authorize�A // P /Q P'� to act on my behalf,.
in all matters relative to work authorized by this building.permit application for:
(Addres of Job).
ak Z' ' /-�O/D
Signature of Owner Date
_Print-Name.
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
_reverse_side.-
C:\Users\decollik\AppDataU,ocal\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 07-21:10.
y
i
77se Commonwealth of Massadiusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street.
Boston,MA 02111
tvwn.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbeis
Applicant Information_--_ Please Print Leably
Name(Business/organisation/Individual): �,KAP
Address: PC --
City/State/Zip: � N dRe Phone#: j,50,8 L e. (O 3
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
s have hired the sub-contractors 6_ ❑New construction
employees(full and/or part-time).
2.1P I 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.
I 9. Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3_❑ I am a homeowner doing all work officers have exercised their i LE]Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]i . c. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required]
*Any applicant that checks boa#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 wort and then hue outside contractors mast submir a new affidavit indicating such.
Contractors that check this bat must attached an additional sheet shotcing 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 S1,500.00 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 cerfnJy under the pains and penalties of perjury that the information provided above is true and correct
1
Si tore: Date: — O /
Phone#: .--- -
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Iown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB. LOCATIO
um er Street address beCtion of town
"HOMEOWNER"
ame
om e
P one or pone
PRESENT MAILING ADDRES � �j� 3Z
ity town Z
ip code
The current exemption for ."homeowners" was extended to include owner-occupied
dwellings. of six units or ess.'ana to allow such homeowners to engage. an in-
dividual for hire who.does not possess a license, provided that the owner
acts as supervisor. (State Building Code Section
DEFINITION OF HOMEOWNER:
'Person(s) who owns a parcel of land on which he resides or. intends to re-
side, on- which there is, or is intended to be, a one to six 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
The 'undersigned ."homeowner" assumes responsibility for compliance with the State
Building Code and other applicable codes; by=laws, 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 compl ith said procedures and requirements
HOMEOWNER'S SIGNATURE ^
APPROVAL OF BUILDING OFFICIAL f
Note: Three family .dwellings 35,000 cubic feet;' or larger, will be required
to comply with State Building Code Section 127.0, Construction Control .
r
f y
8
e'
HOME OWNER'S EXEMPTION
The Code state. that : Any Home Owner
permit Is required shall be exempteCfroomingheork for which a building
(Section 109.1 . 1 — Licensing of Construction Supervisors) ;Provis
provided this section
If a
Home Owner engages a person(s) for hire to do such work, thatsuchHometOwner
shall act as supervisor .
Many Home Owners who use this exemption are unaware that they are a
the responsibilities of a supervisorssuming
for Li (see Appendix Q, Rules and Regulations
censing Construction Supervisors, Section' 2.15) . This lack of awareness
Often results In' serlous problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot
unlicensed proceed against the
Person as It wnulc! with licensed Supervisor . The Home Owner acting
i, as, supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities,communities require, as part of the ities, many
certify that he/she understands the responsibilitiesiof�a_. suaerVhe Home Owner
last page of this issue Is a form currenti p or ' Oh'nt he
care to amend and adopt such a form/certificateonbforeuseaIntYour You may
Your community.
AshpssQr's Wfice Ost floor):
Assessor's ma and lot number R 1..��..:....ate ��" o�TNcty
Assessor's p ..... ..........7..... SEPTIC SY MUSTS `o
Board:of Health (3rd floor):
�.K..Dom.����°s:•r. . r. INSTALLED IN COI�PR.'A�
Sewage Permit number ........
T VATIC TITLE 5 i INAUSTODLE, i
Engineering Department (3rd floor): WAS
House number _............. E ,fit 09NIXENTAL CODE A. ,a3q. ' 0�
................................................... "�o ,•
Definitive Plan Approved by Planning Board _______________________________19 : .1't�WN REGULATIO�'� �aY
APPLICATIONS' PROCESSED -8:30 9:30 A.M. and 1:00-'2:00 P.M. only
TOWN OF . BARNSTABLE.
BUILDING INSPECTOR
APPLICATION-FOR PERMIT.TO ...: ...D i J.. ,i�� dV...&Iky.�am/
...
TYPE OF CONSTRUCTION ..... ...0.0..n/".... ...............................
••........... .....
TO THE INSPECTOR OF. BUILDINGS: i
The undersigned
hereby appliesfor a permiit/according to the following,in formation:
Location ....C,61 ..CI(,tz :... /�yl!!..�r—:..,/ /..� ... �s.( .lfr'ti...!l,1 �`./�j ff ...........................
ProposedUse ...A-s '� .....................................................................
Zoning District .................Fire District ..... :....... ................ ...... ........... '��.�....C�.S./...,........
Name.of Owner . .. L�®®V...P�.g. l./� 4101'e.. .. e.........Address !O. .�/...........y/.� .�CT!.�//►. i""� ...
Name of Builder ... .. . . l�y ..........Address
Nameof Architect ..................................................................Address .........:..... . ....................................................:
Number of Rooms .............!........ ................... .....Foundation ..: ....���.���....S.r..6GC�C.
Exterior .......V .. ....0..�.. / T .................. Roofing ......... �1G'`/7`�..........................................
Floors .........41,V,...... ...................................................Interior ......
� . ... .7...
1`(!V .`............ ...............................
Heating ................................................................... Plumbing ... L , .................
.
I
Fireplace .......:......................:..................................:................Approximate Cost ......... .............
•�s f•• ...........
•
�..} ) _
Area .. .. ./. f . .. .......
Diagram of Lot and Building with Dimensions Fee �v
�ARc rr !
OCCUPANCY PERMITS REQUIRED FOR NEW.DWELLINGS
I hereby agree to conform to all the Rules and Regulations oft Town of Barnstable regarding the above
construction: ,
Nam .. ... ........................
Construction Supervisor's License .............
CHILDS, ROBERT L.- & PAULINE M.
No (n31;9.58? permit for ....Addition _.
- 1 ..............
= Single :,Family. Dwelling
14 y
901 Shoot Fl in Hill Road .�' - � ✓�r Location ...................... ...... ....Y......q... . ..................
Centerville............. ........ ....
.G. .... ... ,.
Owner Robert L. & Pauline M. Childs
`✓,,. I '
t +.....................'..... ..................... « 7
Type of.Construction' Frame..
.............. ................ ..... ... ..... -A ......... . I ,,` '„ i ce'. . • .w - ' ,
Plot ......... ' Lot``......:. .........
... f-`� O i • F
June 3 `
Permit Granted ........ ............! 8
nt ......�......19
.M
: Date of:Inspection .:.....................................+9 .
D e 'Completed ...........?............... ...�... 9 r ` . , •;
� aar a Gv �.e �. �A � � �� �.•^�.. ..
d � .4k� T + r�. � f k�v/�� "�' ',.,,Y �r `., •. « -� ram,',,.-..� -
^ ff4,,_V.. n •�,. .li ✓ �r .`I • •.J'. "d•' f .� F'�f al` ,/' f' ,1 .
,� �g "� � `� n III � .� ,� -- (t,r _ ' .•i` � �,f� •
/Mrs I '7,. .r .� • 7-,
r
y i
� � _{, ..- .mod:.a`:'►•...Asa ^�F 3T'a$� ?S', y'.5, Zvl`fia' �`evr;k's:�+r>,�e.c:6. �4 iK,:.z h.*y�:;,1� i:..,r;�£iF»�•r: ..scK.a: -,r -�.•„.. 4i;
Assessor's office Ost floor): Q
Assessor's map and lot number !! > cF THE to
.......�. 4, r......�F
Board of Health (3rd floor):
Sewage Permit number ........ ...� . 0 BAS39TODtE, :
Engineering Department (3rd floor): 'moo NAM-
House number `e
Definitive Plan Approved by Planning Board ________________________________19-------- .
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
.... ......
TYPE OF CONSTRUCTION ....... e.4. `,d ��
TO THE INSPECTOR OF BUILDINGS:,., !
The undersigned hereby applies for
—~a permit according to the following information:
Location ...C�..AZ,.,,�. ..r�./0167 ...rC..../� /? ...,!�e/ ..jV�le—, �� j�............................
Proposed Us
e .Y. .;..t<'��....... ;!..:J.,.:...................................1...................................................................................................
Zonin Dist #.g District ................................................r........................Fire District ....C !s ...........................
Name of Owner PA2�ie. ..,. ... r..........Address ,...........
Name of Builder ... )44,.,,�tt'..!...�dj',� ..........Address ....................................................................................
Nameof Architect ..................................................................Address ...............
Number of Rooms ............./..................................................Foundation ... ..... +�. ��.............. 4........ ..........
Exleiior ....... ......................Roofing ......... .j.....T .........................................
Floors ......... .,�./l...!. _..........................................Interior ...... !<.1`: J. .................... �:
....................
Heating .........-..-..'............:.... ....................................Rlumbing
AQWZ-AWZ12,
Fireplace ..................................................................................Approximate Cost ........,
Areo ? ..
Diagram of Lot and Building with Dimensions
F
ee ............ ...�............
PO qC
f
I !J
I
Ao
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. /
Name .�. . .
Construction Supervisor's License .% 1 �....o,.....,..,
CHILDS, ROBERT L. & PAULINE M. A=191-037
No ...U95.$.. Permit for ...Additi-on............
......k5iiagle...F.am ily..Dwe-1 ling.........
Location AtS..Shoot..Fly Ing...H-il-1...Road
.................C.e rite-r.vi.1.1e.................................
Owner ......Robert...L-...&...P-a-uline—M.... Childs
Type of Construction ...Frame.........................
...............................................................................
Plot ............................ Lot ................................
Permit Granted .....qWMe...3...................19 88
Date of Inspection ....................................19
Date Completed ......................................19
44
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