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' ,. Town of Barnstable Biillding
a Post This Card So That it'is Visible From the Street-Approved''Plans Must be Retained on Job and this Card Must be Kept
t659 SAPIMA
Posted Until'Final Inspection Has'Been Made. ' ey. lt
Where',a Certificate of Occupancy'is Required,such Building shall=Not be Occupied until a Final Inspection has been made 11 Yil
Permit No. B-19-4236 Applicant Name: William Callahan Approvals
Date Issued: 03/30/2020 Current Use: Structure
Permit Type: Building-Alteration INTERIOR Work Only Expiration Date: 09/30/2020 Foundation:
Residential Map/Lot: 250-015-002 Zoning District: RD-1 Sheathing:
Location: 141 WEQUAQUET LANE,CENTERVILLE
Contractor Name:``-,,EFFICIENT BUILDINGS LLC Framing: 1
Owner on Record: LAMBERT, EDWARD&SAUNDRA Contractor License: 169944 2
Address: 14 SHIRLEY POINT RD -
"' Est Project Cost: $4,000.00 Chimney:
CENTERVILLE, MA 02632e4 Permit Fee: $85.00
Description: Attic Insulation (, Insulation:
Fee Paid:_ 585.00
Project Review Req: "_. � Date ¢ 3/30/2020
Final:
G 'J Plumbing/Gas
Roug
h Plumbi
ng:
g g:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced-within,six months after issuance. Final Plumbing:
All work authorized by this permit shall conform to the approved application and the.approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by'-laws and codes. Rough Gas:
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
Final Gas:
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire-Officials are"provided on this permit. Electrical
Minimum of Five Call Inspections Required for All Construction Work:i
Service:
1.Foundation or Footing
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest fluelining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
'Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Health
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
Oiv�yrJ�
T Town of BarnstableBuilding
ass u �t
Post This Card So That rtis�Visible;From the Street ApprovedPlans Must be Retained on Job andthis Card Must be Kept
v BARNStASM
MA . Posfed UntilFnal Inspection Has:Been MadeF
ruwt° Where a Cert�fcate•of Oceupancyis Required,such Building shall Not be Occupied until a Final In.spectwn has been made e�' 1�
Permit NO. B-20-187 Applicant Name: HOMEOWNER IS APPLICANT Approvals
Date Issued: 01/23/2020 Current Use: Structure
Permit Type: Building-Stove Expiration Date: 07/23/2020 Foundation:
Location: 141 WEQUAQUET LANE,CENTERVILLE Map/Lot: 250-015-002 Zoning District: RD-1 Sheathing:
Owner on Record: LAMBERT, EDWARD&SAUNDRA F Contractor Name: HOMEOWNER IS APPLICANT Framing: 1
Address: 14 SHIRLEY POINT RD .Contractor Licenser EXEMPT 2
CENTERVILLE, MA 02632 Est Project Cost: $0.00 Chimney:
Description: Wood Stove Permit= ee: $35.00
Insulation:
Project Review Req: Atlantic Stove Model#224 Fee Paid. 35.00
Date. .. 1/23/2020Final:
z4 f r -
� k z
Plumbing/Gas
f� Rough.Plumbing:
r s Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within sizlmonths after'issuance.
All work authorized by this permit shall conform to the approved application,and the=approved construction documentsforwhich this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structaresshall be in compliance with the local zoning by laws and codes.
This permit shall be displayed in a location clearly visible from access street or<roadand shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same.
g Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by th6i86ilding and Fire Officials are provided on th'is,permit.
Minimum of Five Call Inspections Required for All Construction Work: 3` Service:
1.Foundation or Footing
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until-the Inspector has'approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A).
- Fire Department
Building plans are to be available on site
Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
C�•1
71,
4
Application numbe. ..............................................
td
OF
JARNaDL Fee.. ............... :�
.).........
KA ft 29_ `JAN z f S ,. Building Inspectors Initials.....A!�A..........
DateIssued............................... ..... .................
VISI
0 Map/Parcel.. �� ..... .. .
....... .. ��.......
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS7D ORS/TENTS/STOVES/WEATHERIZATION
PROPER INFORMATION .
Address of Project: IZ171 i4cl
NUMBER STREET VILLAGE Owner's Name: �v 't'c -I 'N��" Phone Number .92—;�4 2_ XI50;
Email Address: `� lAh� �1Q . Ur4 Cell Phone Number-�d,& . 36 7 _S'L 7
Project cost$ N Check one Residential ' Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize.
to make application for a building permit in accordance with 780 CMR ,
Owner Signature: Date:
TYPE OF WORK
❑ Siding ❑ Windows(no header change)# ❑ Insulation/Weatherization
❑ Doors(no header change)# Commercial Doors require an inspector's review
❑ Roof(not applying more than 1 layer of shingles)
Construction Debris will be going to
CONTRACTOR'S INFORMATION
Contractor's name -
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY-IS IN
A n1PV'"10 r vn1/ Aw1/rr AnTA 1A1 LIIC'r^DU"A DDD/11/A1 DCCADC A DCDAAIT/'AA1 RC ICCI ICn "
fi
r-
: . APPLICATION.NUMBER............................................................
*For Tents Only* '
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each-Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with-the location(s) of each tent
Fuel source being used LP tank 20 lbs. or> Yes No ,if yes, a'gas.permit is required.
Natural Gas Yes No ,if yes,a gas permit is required.
If food is being served at your event please obtain.a health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. CommereW even Fire Department approval.
LW2OD/COAL/PELLET STOVES
Manufacturer# ��-
Fuel Type &= Testing Lab
Offsets from combustibles: front 3 q- back tt'l left side i::,�0 right side 2-3
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name: l!/ r}
Telephone Number Cell or Work number —<2K Z 7,5 2- d
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,speck inspections and documentation required by 780
CMR and the Town of a stable.
Signature Date �✓ r r
APPLICANT'S SIGNATURE '
Signature Xate ' Z
All permit applications are subject to a building official's approval prior to issuance.
` The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): d'/i(/ � G
Address:
City/State/Zip: GU= Phone#: 7 —,5 2,76
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
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
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, {Demolition
working for me in an capacity., employees and have workers'
g Y P h' 3 9..❑Building addition
[No workers'comp.insurance - comp.insurance. -
required.] 5. We are a corporation and its 10.El Electrical repairs or additions
3 I am a homeowner doing.aU work officers have exercised their I I.❑Plumbing repairs or additions
"' ri` t of exemption per MGL
myself. [No workers comp. P P 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13,❑Other WM(2
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.
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. '
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: N/14 9
Policy#or Self-ins.Lic.#: Expiration Date:-
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as"required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the Vlhs and penalties of perjury that the information provided above is true and correct.
Si ature: Date: — I'20
Phone#:
Official use only. Do not write in this area,to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions �-
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...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,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07
www.mass.gov/dia
0
-� Town of Barnstable o if# ' `'(
t►mo ,
Expires 6 mont ro 's, ate
Regulatory Services Fee
• snatvseABLK
MASS. Richard V.Scali,Director
1639.
Building Division . c
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number ,rj Q� 1 SIL" c u
Property Address —'t 1VE-ov�.
Residential Value of Work$ 60 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name �Tele hone Number
p 5(!' 3(y
Home Improvement Contractor License#(if applicable) ' e�0 -1 4l Email: 0 Om WL-Go�
Construction Supervisor's License#(if applicable) ,
❑Workman's Compensation Insurance
Check one: NOV Z 2014
I am a sole proprietor,
El am the Homeowner TOWN OF BARNSTABLE
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to`,*-11AkM0 Q} -k
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*.Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required. p "
SIGNATURE: ZUQ �� Pe
QAWPFILESTORMS\building permit forms\EXPRESS.doe
Revised 061313
k The Comnzanf of Missuchusef
Depmtinmt afhulustrid Accidents
600 WgY1r&zgtbn,reef
ffastan,MA 02111
W-orkers' Compensati€onInsarauceAffidavit:$uildeislF`ant.—Etors/F ectricianMumbers
tlicaut Information Please hint Iepibly
A&e—ss: R o X ► o
City/S tat�Z�p 7 L Phoneme
Are you an,employer?Check the appropriatehOx: T , of o'est
�' J :�r Vim,.,-Pd)=
l_❑ I am a player wiEh • 4-- ❑ I am-1 gem�ral confractor affd I 6- ❑New consauctoa
employees(full and/or part-time).* have hired the sib_raairacfoEs
I nTn a Sole propaefof or partner-
listed on the attached sheet_ 7- ❑1adeliag
sb3p arri have no employees These sob-contractors have g_ ❑Demnlitioa
worlcing fir me in any capacity employ- and have workers' 9_ ❑Building addition
F"Mo,worltsrs' comp:im%i a=e comp-ii=ance_I
5_❑ We are a corparationand its 1t3_❑laectncal repairs or additions
�
3-El I am a hrfine�-�-*ne-r doing all word officers cers have exercised(heir IL.❑ >?�Plumbing airs or additions
. ,
xxryseIf. [No worlatrs'comp- right of e�pfiats per Iv£GL R 12.❑ of repai g
ircimin£erequired_]I c_152, §1(4} and.we have,nor
ernplayeeS_[No urDA=S' 13_0 Other
comp_msnraxr reg6xed-1
'Any zppricmit taut checks boa rl n: t also fill old the section below dLawing on policy inR)MaEon-
T Hnmeorwnc--s who MIIu Tt ibis Q,fa dzvit i—fir eMg they azz thing Ell tME?,End tlim YM Mta&e contxacmrs mnst subnlA a new ayd.Trrt mdirotkV MrIL
lGtninccars i{�i ct�k this boa mazsst rhuT au a 5ditinnsI sheet shooing thA name as @ie scb- is=d stsh!: dries fizq;�
tloyscs_ Ii` scb cont�cfrits l�Ce empIo}pes,the}•mist ptmaae ih—=r S s'romp-pohcg number
at;t arts s:rt� 's that is prodding tt�orke-rs'corr>pgrurliizn ans-ttrattce for rah enrlvZ�:ecs. �etvtr is Sty paT�c}and job azl� .
u2jotmof<os�
Insurance GompamyName:
Policy w or Self-Lap-Lim Expiration Date:
Job Site?address_ Ciao StatelZrp_
Attaclt a copy of the-workers'compensatwn policy decTatrstion page(showing the policy-number and expiration date).
Failure to secure coverage as mj6redunder Section 25A o€MGL c. 152 can lead to the imposition ofcrimiaal penalties of a
fine up to$1,50Q-00 and/or as well as civil peaalfies in the.fosm of a STOP WORK ORDER and a fine
of up.txx$250.0{l a.day against the violator_ Be advised that a copy of this statement maybe forwarded to the Office-of
Ltsvestigattons of the DIA for in�ee coverage-mriEtation_
Ida hereby ceriifp nnd-r tks Jxu attctpenaLftas of ptdwy that the iaformati¢n prmzd/sd above is bus and correct
€}ffecfai rise ant}. Da trot writs in tHs area,to be completed by city:or town ofj=iciaL
City or Towa: _pm mitlLicetue ff
Lssuirig u-thaiity(cirde one}:
1.Board of$exltl Boil is g Department 1 Cityffax u(Imk 4_Electrical Inspector S.Plumbing LL pector
6,Other
Contact Persan: Phone#:
6
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto this statute, an emplayee 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,partaership,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
cr 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 sees that"every state or Iocal Licensing agency shall withhold the issuance or
renewal of a liee)ase or permit to operate a business or to construct buildings in the commouwea_ttfa for:a».y
applicant who has not produced acceptable evidence of complia.n.ce with the insurance.coverag--required."
Additionally, MGL chapter 152, §25C(7)sites"Neithex the comnoawtalth nor any of its political aibdivisiorus shall
enter into any contract for the per Loimpnce of public work until accep;abl_e evidence of compliance a i h the i_nsuranc.e
r.q uiremeats of this chapter have been presented to the contracting authority."
Applicants — —
Please fill out the workers' compensa-tion aidavit completely,by checks-v.g the boxes that apply- y ror situation and,a
necessary,supply sub-contractors)naJne(s), addresses) and phone rs,be,-(s)along v) hen G:-R'D:,EIc`c-(s) of
insurance. Limited.Liability Compares(LLC) or Limited Liability Pal tnersh-ips(J--.LP)veithno e nployets other than the
members or partn(--rs,are not requ ed to carry workers' compensation; slr once_ if an LLC or LLP Foes have
employees, a policy is required. Be advised that this affidavit nay be s-bi iftad to the Depa.i Tent of indu la-,aI
Accidents for conf=ation of in_sqn•ance coverage. Also be sure to sign z-nd date the aifdavA. '11,e aflEdavrit should
be returned to the city or town that the application for the permit or license is being requested,not the Depaftrient of
Industrial Accidents_ Should you have any questions regarding the law or if you are required to ob��n a workers'
compensation policy,please call the Department at the numrber lis'w--d beiov. iletl inner-ed companies s:nould enter thtir
self-iTCt C,e license number ontbe appropriate line,
City or Towa Officials
Please be sure that the affidavit is complete and printed legibly The Department has provided a seat-at the bottom
of the affidavit for you to BE out in t e event the Office of Investigations has to contact you regarding the applicant_
Please be sure to fill in the permit/licease number which v,,BJ be used as a refe-once number. Ia add-ition,an applcant
that must subunit multiple per=Ylicease applications in any given year,need only submit one afECavit Md:icaar g current
policy information (if necessary) and under"Tub Site Address'the appl;Cant should v.rite"all locators iz_ _—(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 Lceuses. A new aff davit mu?st be tilled out each
year_Where a home owner or citizen i c obtaining a license or permit not related to any business or co;ssercial venture
(i_e.a dog license or permit to burn Ieaves 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,
pease do not hesitate to give us a tail.
The Department's address,telephone and fax number:
T �Commomvca1&of Mamadausefts-
D42paztcatnt of Industial Acci:dcnfs
QTzee oziesfit%any
600 washmgtan te,t
Boston_IAA 02111
Ttl 617- 7-4! 4W w 406 or 1-c��?�i�SSAFE
�Ir9
Revised 4-2�07 Fax# 617-727- -
�. rLLil�gV Flf 1 i� -
f
Town of Barnstable
Regulatory Services
�an h iE� Richard V.Scali,Director
ED39.
y a�� 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
Property Owner Must
Complete and Sign This Section
If Using_A Builder
I. SMIId9A,- L' ,A1J�J P��� , as Owner of the subject property
5
herebyauthorize Fn: rk()C- c 1-�pW r_ ( fin() � to act on mybehalf,
in all matters relative to work authorized by this building permit application for.
(A dress of Job)
'Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q TO RM S:O W NERP ERM IS S IONP OO IS
Town of Barnstable
Regulatory Services
�4oF�te Totyk Richard V.ScaIi,Director
° Building Division
2ARNSTABM ` Tom Perry,Building Commissioner
MASS.
�b i6s9- ��� 200 Main Street, Hyannis,MA 02601
ATFO �s www.town.barnstablema.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION ,
Please Print
DATE:
JOB LOCATION:
number street village
.•"HOMEOWNER": l
name home phone# work phone#
CURRENT MAILING ADDRESS:
cit3/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
i
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.
i `1, , 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 &ReguIations 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 formJcertification for use in
your community.
Q:\WPFILES\FORMS\building permit fomu\EXPRESS.doc
Revised 061313
&xeoa�r �aoarcoec�l/1 o��/la�aac/ccoeG/�t __— r
�A1 Af t rrixsur,�r afwe�aA u �res5 tegulitiff•; ;a License or registration vah'd for individul use only
` i `r2O\irl 'G'o G� u3fxCTOi2 before the expiration date. If found return to: i
ls9ra+roA r 3�i967 Tyi r; Office of Consumer Affairs and Business Regulation
Escpirah�on 7/3/2G1'6 Individual 10 Park Plaza-Suite 5170OR i
ON,; Boston,MA 02116
BLED'A. PADDOG`K
BF;ADL.EY PADDOCK,F i-'
a�
.]��nv .r
�4 MBIES LANE w
P14Ls MA 02648' _
at�ecretarji I Not valid ithout signature
`i
Massachusetts -Department of Public•Safety
Board of Building Regulations and Sta:3dard's
Constructidn Supervisor
f'h
Lidense: CS-048086
BRADLEY PADDQIC
r 2 Bay Terrace �.
Plymouth MA 0260
..Expiration
Commissioner 03L28/2016
1
.. a ♦_ � b•I�yR',.'�r" ���a "�T `►
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e,
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FIL-6 k
Town of Barnstable Permit: m
Regulatory Services Date:
�pFSHETpyy Thomas F. Geiler, Director
Building Division ee.
II BARNSTABLE, Tom Perry, Building CommissionerMASS
16.39.. ��� 200 Main Street, Hyannis,MA 02601
Alfo �a www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
TOWN OF BARNSTABLE
SOLID FUEL STOVE PERMIT
Owner: t .� L Phone: (-69'' 36 / 3
Install at: ��// F L( T &, Village: &U&411_&
Map/Parcel: �r(� (jI L� c/C/� Date: �r ZY—d q
Stove
A. New sed _
C. Maut . ''`' ��- � Lab. No.
D. Mod
*. �' 7 l j
Chimney
A. New/Existing (If existing, please note date of last cleaning) 9f�
Zt
B. Flue Size
C. Are other appliances attached to Flue? /)O _ ar `�
D. Pre-fab�pe and Manufacturer
E. asonry. Line nline
•� ^.i r
Hearth / `
A. Materials:
B. Sub Floor Construction:
Installer
Name: ��� � Address:
Phone:
Location of Installation:
H.I.0 Registration #
Construction Supervisor#
OR check i,4omeowner Installing, no license required
APPLICANTS SIGNATURE
APPROVED BY:
CAV
Please make checks a able to the Town of Barnstable
*This constitutes an of stove permit after inspection, photographed, and approved by the
Building Inspector
Q:forms:stove
Rev 103107
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
+ e 600 Washington Street
Boston,MA 02111'
www.mass.gov/dia '
Workers'Compensation Insurance Affidavit: Builders/Contractors/Eleetridans/Plumbers
Applicant Information .Please Print Le0bly
Name.(Busin ess/Organization/Indiv ual):
• •Address:•). ��// ��ll�t7u�T ��
City/State/Zip:, C Iy/I�� Phone.#:
Are.you an employer? Check the appropriate box: .Type of project(required):.
4:.- -•-I.am_a general contractor and I
1.❑ I am a employer with 0�,-� �- -r�� 6. ❑New construction .
employees(full and/or part-time).* • have biredthe�stib-contracto_rt , 1
2.0 I am a'sole proprietor or partner-
hsted-onthe'attached-sheet 7. ❑Remodeling
These sublconiraciois-have g, []Demolition
ship and have no employees ,,� ,
employees-^and haveworkers
working for me in any capacity. 9. ❑Building addition
1i[No workers' comp.insurance comp, insurance:$`
5. We are a corporation and its ME]Electrical repairs or additions
requ�ed.] -- _._..� _ officers have exercised their 11.[]Plumbing repairs or additions '
. I am a homeowner doing all-work .
--�-- _ right of exemption per MGL
`'-`_.myselfw[No workers comp. 12.❑Roof repairs
insurance:requzred]"t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners,wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
XContractors that check this box must attached an additional sheet showing the name of the$ub-contractors and state whether ornot those entities have
employees. If the sub-contractors have employees,they must providt:their workers'comp.policy number.
I am an employer that is proyiding workers'compensation insurance for my employees. Below is.the policy and job site'
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
lob Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date).
Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a_STOP WORK,ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unde he ins-and pen Ities of perjury that the information provided above is true and correct.
Si ature:-1 • Dater
Phone#:
Official use only. Do not write in this area, tb be completed by.city or town officiaL
City or Town: ' Permit/License#
Issuing Authority(circle one):
• s Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 hue,
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 produce&acceptable evidence of compliance with the insurance coverage required."
AdditionaIly,MGL ehapter.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:t1ie 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-contiactor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability-Companies LLC or Limited Liabili Partnerships(LLP with no employees other than the
ty mp . ( ) h' P )
' insurance. an LLC or LLP does have
members'or artners are not req
uired to c workers compensation insuran . If
P � q
�Y P
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 pemut.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 fo any business or commercial venture
(i.e.a dog license or permit to bum leaves-etc.)said persona 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:.
he Commonwealth of Mamachuwtts
Dep utnwt of l.dusWa1 Accidents "
Office of Investigattons
600 Washington Stma
&oston,.11tiA 02111
TO. #617-727-4900 ext 406 or 1477-MAS.SAFE
Fax#617-727-7749
Revised 11-22-06
www.ma;ss.gov/dia
I
Town of Barnstable
Regulatory Services
Z BARNM"LF- : Thomas F.Geiler,Director
nsnss.
�bs� .•� Building Division
Tom Perry,Building Commissioner
_^ry 200 Main-Street, Hyannis,MA 02601 _
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
/l Please Print
DATE: /
JOB LOCATION: �`7 G�'�G���GP � y//�C��•
number !'street village
"HOMEOWNER':
name { home phone# work phone#
CURRENT MAILING ADDRESS: / /Or
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.
DEFINMON 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 buildinepermit. (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 thathe/she understands the Town of Barnstable Building Department .
minimum mspecti n procedures and requirements and that he/she will comply with said procedures and
requireme• H Signa omeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
.The Code states that: "Any homeowner Performing work for which a building permit is required shall be exempt from the provisions
of this.section.(Section 109.1.1-Licensing of construction Supervisors),provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assumiri g 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 A Duld 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:homeexcrn t
sTati Town of Barnstable
Regulatory Services
RARLYMASM
nuas• Thomas F.Geiler,Director
Eo39.
16 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
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete.the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O WNERPERMISSION