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Geiler,Director I rF0 MA'1 A Building Division I Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY lNot Valid without Red X-Press Imprint vlap/°parcel Number 'roperty Address / Sty ►'l A li ' �PiYt ter 1//l4 /' ' d 2 � Residential Value of Work -✓�� Minimum fee of$35.00 for work under$6000.00 •I )wner's Name&Address 12 'ontractor's Name d 6 4'r Mile,-6e`/ Telephone Number `570f tome Improvement Contractor License.#(if applicable) 1111966 9 'onstruction Supervisor's License#(if applicable). -50 © .5/ I' ]Workman's Compensation Insurance � � lam; l Check one: . a Si'. , � RI'I1 x I: i am a sole proprietor ❑ I am the Homeowner U L C :9 .2 011 ❑ I have Worker's Compensation Insurance �� is vI'..t Sl ( S 'A ! i isurance Company Name lorkman's Comp.Policy# opy of Insurance Compliance Certificate must accompany each permit. :rmit Request(check box) Re-roof(stripping old shingles) All construction debris wil] be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I . ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Impr ment Contractors License&Construction Supervisors License is re Lured. 1� GN.ATURE: WPFILES\FORMS\building permit fbrms=RESS.doc =;-d 070110 — I he Com t orri ealtlr of assachusetts Department of Industrial Accidents DPIce of Investigations w 660 Washington Street Boston,MA #2111 nmv.jna&Lgov1di4ff Workrrs' Compensabim Insurance Affidavit Bmlden/CGimtractors/EIectncunslPh mbers Applicant Information Please Pint UnAlv Name Address: City/statelzsp: (fe4 r V d 4 e Phone 4- Are you an employer?Check the appropriate box.: Type of project(required): 4 I am a contractor and i >"❑ I am.a employer with ❑ i 6_ New camstsasction . �,f logem(ho arrdlaspart-ftime).s havehired the sub-=trachm 2-i f I am a sole prngrietw orpartner- listed an the attached sheet 7. ❑Remodeling These sub-contractions have �P and have no employees, $. ❑Demolition working forme in any calmily- employees and have was' tr [No workers' comp.insurance comp.tncnrare 4- ❑Building addition regaared] 5. ❑ We:are a corpan tiou.and its 10.❑Electrical repairs or additions th 3.❑ I am a hometrivner doing all work �.cers have emercised ew 11.❑Plumbing repairs or additions mywlf[No workers'comp. right of exemption per NfGL 12. of repairs insurance required.]r c.152,§1(4),and we have uo employees-[No worl=s' 13_❑Other comp in==ce;=piredl] 'Any appg'=that checks box#1:mast also fill out the section bekw showing dieir woekess'compensnion ply infumwaiL t Homeowners who submit this affidavit in&cxtWg they are doing allwad sod thmhum outside coa7z mrs nnLq submit anew affidavit indicating such- rs that check this box must 3tmcbed an additi— sbeet showing the name of the and state whether ar not those en¢iees hwe employees. If the sub-cenb=os have empla3es,fey—ssi F-ide t4eir markers',camp.policy number. I am an emplcysr thatis praaiiffirg morkers'comperlswian ia.mnurce for my 9Vq2kjw& Mow is thepviicy and jab site Wit,formrritarL;.: Is3Surat=Company Name: Policy 9 or Sett"ins-Lic}.# fi Fxpiratian Date: Job Site Address: Cityfstate,00: Attach a cuff of the wo km'compensation policy duration page(showing the policy number.and ezpirabon date). Failure W secure coverage as required under Sectitm 25A of IMr1:GL c. 152 can lead to the.imposition of criminal penalties of a tine up to WOO.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORS and a Eve of up to$250_00 a day against the vioWzr- Be advised that a copy of this statmnent may be forwarded to the Office of Investigations of the D1A for insar ce covaage verlfkatiaa 3 do hem4t cer##i lydar the and ofpedury Herat the infor+tda fan proWded iis bw and correct Date- Phone#: ©BWal use only. Dv not vyite in this area,to be carupieted by racy ar born o i'ciat' City or Towne PermitUcense# Issuing Authority(rude one): 1.Board:of Health I Building Department 3.CitylFown Clerk 4 Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: r of THE rqy� Town .of Barnstable Regulatory'Services BARNSMZL$ 9 NAM. g Thomas F.Geiler,Director 1639• Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to.wn.barnstable.ma.us Office: 508-862-4038 f Fax: 508-790-6230 Property Owner Miist Complete and Sign This Section If Using A Builder letof the subject property hereby authorize .o�4 r % 1 f 1Pil to act on my behalf, in all matters relative to work authorized by this building permit'application for (Address of Job) ell S.igna e ofOOwner Date Print N If Property,Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side.. Town of Barnstable o„ Regulatory Services BAMSPABLE, : Thomas F.Geiler,Director 9 MASS, ib39. p,0 Building Division lFD MA'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAIIANG ADDRESS: 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 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 requirements. 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 127.0 Construction Control.. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perfomvng 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&Regulatidns 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 ` Massachusetts- Departmci t 6f Public Safeh . :Board of Buildin, Regulations and St:u>(l.ut15 Construction Supervisor License License:'CS 50051 - S Restricted to: 00 #T ROBERT E'•.MITCHELL F 452 STRAWBERRY.HILL RD " sz f CENTERVILLE, MA 02632 - i Expiration:..318/2012 (5inunissiune� Tr#: 18673 Office of Consumer Affairs&BJsiness Regulation j HOME IMPROVEMENT CONTRACTOR Registration: 110069 Type: 1 Expiration: 10/6/2012 Individual RbB RT MITCHELLF =,J- a j _ ROBERT MITCHELL 4 a 5.2 Strwberry Hill Centerwlle,.MA 02632% Urideisecretary z I - t i 3 License.or,registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and.Business Regulation 10 Park Plaza-Suite 5170 I Boston,MA 0111-6 ` 4k, Not valid without signature of Town of Barnstable *Permit# b o,3 5/ Fxplres 6 mond a from issue date : . : Regulatory Services Fee s �0� Thomas F.Geiler;Director CFO"'�`� Building Division . g Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601PER—-:,; ` Office: 508-862-4038 c Fax: 508-790-6230 OCT 2 9 2004 EXPRESS PERK APPLICATION - RESED ENTIAL OMLY Not Valid without Red X-Press Imprint TOWN O STAE3 LE Zap/parcel Number roperty Address l g�=- J /yd,GN 67— afresidential Value of Work j (9e Minimum fee of-$25.00 for work under$6000.00 )wner's Name&Address ,ontractor'sName Telephone Number 5279--771 come Improvement Contractor License#(if applicable) ;onstruction Supervisor's License#(if applicable) Workman's Compensation Insurance `T Ch ne: . I=a sole proprietor JEkI am the Homeowner I have Worker's Compensation Insurance asurance Company Name Vorkman's Comp.Policy# ,opy of Insurance Compliance Certaficate'must be on file. 'ermit Request k box) Re-roof(stripping old shingles) All construction debris will be taken to_ /�/��dP�I�D`� <-,�¢iyn ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. 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. Home Improvement Contractors License is required. ►ignature ` 2:Forms:expmtrg tevise063004 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. OATEN, •i��ye.. � .... .. • . . .JOB..LOCATION , um e r /p tre t a Tess ection o town "HOMEOWNER" fr3 ame ome p one or Gam- asii ?��ia PRESENT`MAILING ADDRESS Pone 1 ty own The; cu'r,,rent exemption. for ."homeowners" was extended to 1P. co e dwellings. of six: ess an o allow i.ncIude`pwne'-occupied i ivi ua for hire. who. does not possess a license; provided such homeowners, to engage. an..i n-acts as supervisor. (State Building that'the owner g Code Section ' - DEFINITION OF HOMEOWNER: {P,erson(s') who owns a parcel of land on .which 'side, on which there is, or is intended he/she resides or intends to r %attached or: detached structures.accessory to such use and e to be, a one to six family dwelling, A person who constructs more than one hometo a two-year /or farm. structures. ;considered a homeowner. Such "homeowner" shall. submit period shall not be `on a. form• acceptable to the Building Official, thatmhe to the shall be responsible 1, ,for all such work performed under the bui'I_din er ' he/she shall be 'responsible :The undersigned "homeowner" ass g P mi ection Building Code and other a assumes responsibility for compliance with the State pplicable codes, by-laws, .rules. and regulations. ;The undersigned "homeowner" certifies -that Barnstable Building DepartmentAinimum inspecteoshe understands the Town of +and that he/she will comply with said procedure n procedures and requirements s and requirements::; HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFLCIAL Note: Three family dwellings 35,000 cubic ' .to comply with State Building Code Section feet,``orlarger • 127•0, ConstructionlCobtrolQuired ' VY 8 op i �9 ,,!�•:,rat+!r ..�R.— . HOME_-,OWNER,'S .EXEMPTION The Code state that :. permit q "Xny Home Owner performing work for whlch a bullding Is re ulr'ed shall be exempt from the Provisions(Section 109.1 .1 — Licensing Of this section 'Home Owner engages a g °f Construction Supervisors) ; •provided—t�hat. `If :a III persons) for hire to do such work, shall act as supervisor. ° that such H• . . omo Owner III Many Home Owners who use IIIresponsibilities this exemption are unaware that the the respons l b l l i t l es• of a supery isor (se aor. Llcepsln Y are assuming. 9 Construction Supervisors a Appendix 0, Rules and Regulations• :; often results in serious Section 2.15) . .,This lack of awareness Unlicensed pr;obl:,ems, particularly when the Home Owner hires • Unl'lcensed persons: In this case our Board Per-son as it would with licensed Supervlsernnolhe Home Owner ervlsor Is Ultimate) proceed against the rw,.__..P...ti._... y responsible. acting. To ensure that the communities re Home Owner is fully aware of his/her responslbllltle quire, as part of the s, man/ certify that he/she Understands the responsibilities of a s Permit application, that the.•Flome Owner last page Of this Issue is a form current ) care to amend and ado t . .up©rvisor , . On the p such .a form/certlflcatlonbforeUSealntowns. You may • your community. Assessor#office(1st Floor): /��j r " 7"� SVSTEM r�- F Assessor's map and lot number 1:711:�11���� Pp Q�of TH E To`` Board of Health(3rd floor): 2 WITH TITLE 5 Sewage Permit number / ' 3 lT _ 0a� ETAL ®DIEAIND DAUST LE o VassEngineering Department(3rd floor): TO REGULATIONS o '°soHouse number Definitive Plan Approved by Planning Board 19 �o Nil d } 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 ale," � � 9` TYPE OF CONSTRUCTION 17 19 �fC5 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ,✓ Location Proposed Use sy/V /C ao Imo! Zoning District Fire District 1�' "701f 6//Ile Name of Owner el. let <° Lt i44oseai Address /o) ! S. Al;lz) 1/41 Name of Builder 69W,*VC-1,C Address Name of Architect 1C�'P.Nl��/ "�r('�tii�y Address /:339 l'ovc y .Q.,/. eI*4 j�� &,e&— Number of Rooms / Foundation OoO^KI C'oN a-IeP fe Exterior &//L"-fir, �'ea,l Roofing A,5I M*114 Floors l[/o0 Interior --Vee7- Aiee/C Heating Plumbing _ s Fireplace J�D Approximate Cost /�. r?-y Area �� o0 Diagram of Lot and Building with Dimensions Fee >�1c • �;7j ►�Gw 131 � 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. Ale,& C Name Construction Supervisor's License �� RICHARDSON, ROYD.EN C. s e No 33460 Permit For Add Sun Room & Deck 4 Single Family Dwelling f Location 129 S. Main Street Centerville ; ° Ro den C. Richardson Owner Roy den of Construction Frame Plot Lot t Permit Granted January 17, i9 90 f Date of Inspection 19 Date Completed � 19 f U `' ` +"�'�..:o-„�w`�'�3�r ,'.'SC?�L„A3".:���T ,'+.��.'iC`77.'if/`{'r7F. 'WIY!%'FT'.+Ynus :'�..�i.r.,y;.:,ni,•+;S`a+,s.Y.�fsEyg ,F. �,.�/ v4,:;a-""_c^..�.�,.to..ry,n.....-�.,�.yR:, r.��.^.; 1'�k�tt3lGiy -^ '°�Ay��i°t:.-`i:�,`•t' .eft''" 7s•� "`i .. ; !; .T'.`�a.t^' Assessor's office(1st Floor): Assessor's map and lot number f T"t. o� . Board of Health(3rd floor)* � '� Sewage Permit number T Z Dssa9rsnit Engineering Department(3rd floor): y� V rnss House number ;l-1" �Y1 °o 1630- 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 C&6,t TYPE OF CONSTRUCTION 7 19 TO THE INSPECTOR OF BUILDINGS: �� •i . The undersigned hereby applies for a permit according to the foll ing information: Location Proposed Use Zoning District ✓� !U'r Fire District �t Name of Owner / !c//, ii+x•[� Address Name of Builder OWIOI=J,C - Address Name of Architect Address { ; ,. Number of Rooms Foundation Po un G7 �'�F/e°ai-7r Exterior Gf��, + `� C'��'aa'Z . =' Roofing Floors Interior Heating Plumbing Fireplace o Approximate Cost /,01, r Area Z� g Diagram of Lot and Building with Dimensions ' „ Fee r t I� t l �.. 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 Je J(:;Z_ � J . Construction Supervisor's License ti 4j v I RICllARDaON, ROYDEIir,C. A=208•-1 38 ` a i 38' No 33460 Permit For Add Su.i Ro,::irn &,,eDeck Sinale Farai. .y Dwell- ii-Ig 9 S .. an Street Location 1 Centervi;..].e Owner_ Royden C. Richardson Type of Construction Frarie Plot Lot 17 anuary , 0 Permit Granted J 19 Date of Inspection 19 Date Completed 19 PERMIT COMPLETED 1 f 1/21- /, ' IN �^%��� /����� �'/ / � 1 r 1 �• , .' - L--.T__--y__,_.._. _--.., -_ - --- ___ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION F. Map Parcel - -` Permit# 3� j Health Division Date Issued Conservation Division Feed Tax Collector Treasurer Planning Dept Date Definitive Plan Approved by Planning Board t X Historic-OKH Preservation/Hyannis i Project Street Address M12 Sig GSA Villages Owner kio olrfiv Cl MAI A&IML) -Address /c�-* Telephone Permit Request 6,��.v�/i•�6 � �,y��L=Cy Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost ®DD Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size o Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family('#units) Age of Existing Structure C'` 5� c� Historic House: ayes '❑No On Old King's Highway: ❑Yes Basement Type: mull El Crawl ' ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) G� Number of Baths: Full: existing new Half:existing ' new Number of Bedrooms: existing_ new Total Room Count(not including baths):existing Z 6 new First Floor Room Count Heat Type and Fuel: Z6s ❑Oil ❑ Electric ❑Other Y Central Air: ❑Yes Flo ' Fireplaces: Existing _Z_'New Existing wood/coal stove: es ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:U existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑. Appeal# Recorded❑ Commercial ❑Yes a, o If yes,site plan review# Current Use Avlz� Proposed Use BUILDER INFORMATION Name � r�LQ Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE • __ ri DATE FOR OFFICIAL USE ONLY ' PERMIT NO. DATE ISSUED I MAP/PARCEL NO. •' t - ,± `,, - ADDRESS - VILLAGE OWNER. . r ` DATE OF INSPECTION: ' r FOUNDATION FRAME INSULATION r ` FIREPLACE a ELECTRICAL: ROUGH FINAL, PLUMBING: ROUGH FINAL` • - GAS: ROUGH FINAL _ r FINAL BUILDING DATE CLOSED OUT { - ASSOCIATION PLAN NO. 9BUM � Department of Health Safety and Environmental Services �Fo r Building Division ` 367 Main Street,Hyannis MA 02601 ` M Office: 508-862-4038 Ralph Crossen Fax: 508-790-6"0 Building'Commissioner Permit no. J Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building.be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Ga, - _ Estimated Cost_ O� Address of Work: 1 o4 sO crI L/ ��' , r ��744-5/e ULG le Owner's Name: zg� Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 rw ding not owner-occupied :er pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. f OR DAe Owner's Name q:fomis:Affidav Department of Industrial Accidents .7 _ Olfrcr aflatvestfgatlans r 600 Washington Street Boston,Mass 02111 Workers' Com ensation Insurance davit �//%%%%%�/r/%�/�%%%% ����� ii �i�///////// //�/////////////�/////%�%�/�%//r. a .. name:location- �� �Zs�iry � �✓�— r'/ city r 26 �� hone am a homeowner performing all work myself. ❑ I am an employer providing workers compensation for my employees working on this job. comnanv name: address: :::.:;: :•.:::,: . ::.. .:,.::;.,:;.:::::;:;.. city phone#: insurance co. Unlicy# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the foIloiiing workers' compensation polices: comnanv name: address: :';:; { ' dtv: phone#- insurance cn. oitcvfl.. :...,.<•:,<:. ... Yr�::; /.!%l�! l// comnanv name- address- citti- phone :.. ..: All insurance co. . :.. ,.,.>.. ,•m�.:y , ..... ., ......... Failure to secure coverage as required under Section 2SA of MGL 152 can lead to the impositloa of erhninai penalties of a fine up to s1300.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement maybe forwarded to the OlUce of Investigations of the DIA for coverage vetificatiotr. I do"hereby certify under the panes anti penalties of perjury that the information provided above is tru.and correct Signature Date Print name 1\ yn� �/l t. �b�L�t�J Phone otIlcial use only do not write in this area to he completed by city or town otllcial dty or town: .:pernWwcense 0 ❑Building Department (:)Licensing Board ❑check if hMediate response is required QSelectrnen's Otilce ❑Health Department contact person: phone#*- ❑Other�� . (msmuo 9,95 PJAI Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for theM, employees. As quoted from the "law", an employee is defined as every person in the service of another under any 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 o: the foregoing engaged in a joist enterprise, and including the legal representatives of a deceased employer, or the rec=ve: 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 c: building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew 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,neitl=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 coatracria¢ authority. , Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits maybe submitted to the Department of Industrial Accidents for confirmation of i m arce 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 'r are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns 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 is the pemutllicense number which will be used as a reference number. The affidavits may be rcwrii6d in- the Departmeat by mail or FAX unless other arrangements have bees made. The Office of Investigations would like to thank you in advance for you cooperatim and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax munber. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of imres unions 600 Washington Street Boston;Ma. 02111 fax#: (617) 727--7749 phone #: (617) 7274900 ext. 406, 409 or 375 Imaoing tnvision MAS& ' 367 Main Street,Hyannis MA 02601 awes. .1659. .0� Office: 508-862-4038 Ralph Crassen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 1c;L 7 6e.. m5i,_111. street village "HOMEOWNER": name home phone# work phone CURRENT MAILING ADDRESS: Pe/ �dX 13/ 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„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 req ' ents. r Signature otHomeowner 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 to amend and adopt such a form/certification for use in your community. Q:FORMSMaIM Map 2-0 Y Parcel \�Y Permit#. House# Date Issued "2- rd of Healthr oor - - . Fee' A;a O t� Conservat1 ice(4th floor) -9:30/1:00-.2:00) Planning Dept. oor c min. Bldg.) a IMF rp; Defin• a Plan rove PlanningBoard 19 r BARNSTABLE. 9. TOWN OF"BARNSTABLE 'F° 'y'� f lam" Building Permit Application # Project St dress Village Owner o - -- dress iZ� �. Mkt ` QaALV ti Telephone Permit Request oc r ' First Floor square feet Second Floor - square feet Construction Type V-Lj C> Estimated Project Cost $ �_' (' U Q , (-Q Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family �wo Family ❑ :�esC] ily(#units) Age of Existing Structure \0(3 Historic House No On Old King's Highway p Yes Basement Type: ull X Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing_� New ('� Half: Existing 0 New 0 No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New 0 First Floor Room Count Heat Type and Fuel: [:��replaces: Oil ❑Electric ❑Other Central Air ❑Yes Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attac (size) ❑Barn(size) 01 one ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# 1 Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE - - � BUILDING PERMIT DE FOR THE FOLLO ING REASON(S) v" FOR OFFICIAL USE ONLY is - PtRMIT NO. DATE ISSUED NiAP/PARCEL NO. 1 v ADDRESS VILLAGE, OWNER DATE OF:,INSPECTION: FOUNDATION FRAME - -' INSULATION FIREPLACE 1 , ELECTRICAL: ROUGH f ` FINAL 1 r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f • • 1 1 a FINAL BUILDING 1 " DATE CLOSED OUT ► ; ASSOCIATION PLAN NO. # } ! ! { OF THE l� �-- : . � The' Town of Barnstable • BARNSTABL-MASI • 9� 11619.. ,0� Department of Health Safety and Environmental Services ArEDA Building Division y 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with e certain exceptions,along with other requirements. r Type of Work: Est. Cost Address of Work: Owner's Name —7-0 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied wner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's i ame I The Commonwealth of Massachusetts Department of Industrial Accidents Office ef/nyesm oli fens 600 Washington Street ,r Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location: .. city phone# I am a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in any ca achy ❑ I am an employer providing workers' compensation for my employees working on this job company name. address...: city. phone#. insurance co. olicv# . ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: co. Many:name.. : address:<' cififi » Mhnne#. is inadranee ca oiiev# I//,% camoanv'name. ......:. address:.: ;: city , phone# insurance co.: olio # Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi under the \pains and penalties of perjury that the information provided above is true and correct Signature Date ' Print name SI-11 Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# - ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/95 PJA) Information and Instructions ,l Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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,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 r Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be retu reed to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 Olflce of Intlesugauens 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION ---------------- . ----- Please print. ; DATE JOB. LOCATION t Number Street address Section of town "HOMEOWNER" D Name 0Home phone Work phone -711V PRESENT MAILING ADDRESS 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, 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 Officia: 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 Stat 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 comply with said procedures and requirements. HOMEOWNER'S SIGNATURE \ APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 < Home Owner engages a person(s) for hire to do such work, that such Home Owne: shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awarene; often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home "Owner actir. as supervisor is ultimately responsible. ,. To ensure that the Home Owner is fully aware of his/bier responsibilities, r. P , ma communities require, as art of the permit r P p t application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. 0 I ---- �C�R-MEb I � LjILL.J c�uc - I _ 4' L[EX 1. "ArCA-i ISTIN t n 0�5 i ' _;,s1 j 2c•s ,, I ' L J t�ll2oc�r% --b I T v I Ll I 1-il I I— --- - L I `� G_CG�_-�ta1� T� /y�v`✓e 2 1 1 75:7_— _— 4ol- , �jpuL�L01,IrJ� t�C71 1O1 -- -L UN� WMI TE� r s \ 2 Z'- C.It_AZ�d ../t�'►} h41G�H -- L�v E oNJE l7 G�`�S• cs -a1' I — 2 ALL NEw SKYLIC,F-iTS 51-4ALL PJE JE L..E'K°. _�'�, _ ,'-�' 21�.1"1P CAN ?. /,t-L_ I-IE'n! DUOFZS jHL�L_ 2�,E SNL+.I•-•` �� Tv.lO 1-1-3`�� Rw2Eo (�� � �-1�.•_•-� r� I 1--�--� -- ---- TOGr.r7-"I Z WIT+-i A P11�tE`T" T�►�C1A�. — - -- -- — -- - �, 4-j-O'' -CAI _4' -d' ` tr t k I j t T"f'SZ I I TGSZ I I TPS2 TPS2 I �...a I I I _ — I r�21 T21r•i v-i/ r IZz� _ ------ ------ - --- '--_... .---- ._ _ cs:- ll ,.,� .,9. H i I 1 }} 1. I LAI - t- TITLE SCALE y --•- ---- -- - I ~ DATE _ SEAL DRAWING NO. KEENAN + KENNY, ARCHITECTS, LTD. 1337 COUNTY ROAD r-;ATAUMET, fvIASSACHUSETTS, 02534 P.O. BOX 128 (5061 564 - 5901 REVISION L>iK