HomeMy WebLinkAbout0971 WEST MAIN STREET _ _
- - - '�
1
i
j 2)1lry
Town Barnstable .,of Btable . *Permit
o�TMe '
Expires 6 months from issue date
Regulatory Services Fee s
+
+ fAENSPABLE.
M" $ Thomas F.Geiler,Director
1 39.
Building Division ®PREW
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 DEC 0 8 2014
www.town.barnstable.ma us
Office: 508-862-4038 T(� WABLE
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
�� Not Valid without Red X--Press Imprint
Map/parcel Number
Property.Address Dt
esidential Value of Work ."Minimum fee of$35.00 for work nder$6000.00
—a2fe4. -�7
Owner's Name&Address
74ffle�
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
J .
❑Workman's Compensation Insurance
Check
I am atsole proprietor
❑ I am the Homeowner s z
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit RWe-roof
eck box)
(hurricane nailed)(stripping old shingles) All construction debris will be taken to-eZ�l
❑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
,
❑ 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 c y of the Home Improvement Contractors License&Construction Supervisors License is
r ired.
SIGNATURE:.
QAWPFI1M\FORMS\building permit forms\EYFRESS.doe
L {.
,
is
The Commonwealth th of Massadlirseffs
Deparhnent of irndus&ial Accidents
Ogee of Investigations
%j MO Washington Street
Boston,M4 a2111
. rvrvry rrrnsmgvv1di,rr
Workers' Compensation Insurance davit Builders/ContractorslElectric anslPl�mbers
Apighcant Inferr matzon Please Pri mt L . kb
Name(Besine lorg�ttiondn iv daai):
A darts: i
Are you an employer? Check the appropriatt-box: Type of project(required):
1.❑ I am a employer with 4. ❑ I wn a general c=ractcr ant!I 6- ❑New c ction
mecca{fall andlar part-hme).* have an t the attached
shoe trsrs
7_L!�711 anz a sale g�oprrie�baz orparhaer- listed an##ae attached sheet, y- ❑ ��11
ship and hate no employees These sub-eontrar#ors ha"ve $_ ❑Demolition
wor1cing for me in any capacity. employees and.have workers' 4-- ❑Budding addition
[No.workers'comp.iMi sur nee comp_tasuranml
required-] 5. ❑ We are a corporation.and its 10.O.Electrical repairs or additions
3_❑ I am a homeowner doing all walk officers have exercised their 1 l_❑Plumbing repairs or additions
myself [No workers'camp. right of exemption per MGL 1� of repairs
insurance required.]T c. 152,§1(4),and we have no
employees_[No workers' 13.❑tither
comp.insurance required.]
•Any applicant that checks box#1 avast also fill oat the secuan below showing then wuAers'campansamn policy informatiaa
1 Bomeoviners who submit this amdsvit indicating they axe doing an wad mad then bum outside canttsctors must submit a new affidavit indicating such.
lConaaors that check this bmi must attached an addidmisl sheet showing the name of the sub-cmuractm 2ad mie whether of not tbose entities heye
employees. Ifthe sib-contmciars have eaplcyees,theymarstPmvide tleeir *"kern'camp.policy number.
I ain an employer that is providbig vorirers'conq misa6#n it=raum for lays employees. B atp is the pv rice+mod,job sits
information. ,
Insurance Company Name:
Policy 9 or Self-ins-Lie. Expiration Date:
Job Site Address: CityfStatxlZip: i
Mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). i
Failure to secure coverage as required under Section 25JA of MGL a 1522 can lead to the imposition of criminal penalties of a
fine up to$1,500-00 and.`or one-year imprisonment;as weil as civil penalties in the fonn of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violatcr. Be advised that a.copy of this stet may be forwarded to the Office of
Investigations of the DIA for insurance coverage vedfirafim
I dip hem by certify izqogr thepains aMdpm m wary the the information prm ided ahove is hate an correct
5 . Date: 6
Phone
Of chrl use only. Dar not tptita in this area,to be coarpletod by do or tm m afficia!
.0tp or Town: PermitfUcense#
Esu ng Authority(circle one):
1.Board of Health 2.Building DepaErt>ment 3.C ityll'own Clerk d.Electrical Inspector, 5.Plumbing Ins}rec#or
6.Othes
phone 9.
of 1t+E ram,
BARNSrABLE �
1 MASS. ,�� Town of Barnstable
pTf�µp'l a
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: 508-862-4038 Fax: 508-790-6230
Property Owner' Must
Complete and Sign This Section `w.
If Using A Builder
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:
Iva
(Address of Job) j
ignature of Owner Date
Print Name
J .
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on;the
reverse side.
QAWPHLESTORMSIbuilding permit formslEXPRESS.doc
�oFt t Town of Barns#able
P �°^ Regulatory Services
M
" aARNSTABLE. ` Thomas F. Geiler, Director
y Mass. �
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
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellints 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
r
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State.Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner perforrning work for which a building permit is required shall be exempt from the provisions of this section(Section
109.i.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as
supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for
Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons.
In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately
responsible. � '
To ensure.that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner
certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and
adopt such a form/certification for use in your community.
Unrestricted-.Buildings of any use group which
contain less than 35,000 cubic feet(9911j,) of
enclosed space.
Failure to possess a current edition of the Massachusetts.
state Building code is cause for revocation of this license.
For DIPS Licensing.information visit: www.Mass.Gov/DPS
Massachusetts Department of Public Safety
4 Massa ulat
Re ions and Standards
Board of Building 9
Construction SIIP ?yvisor
License CS-078000;.
s .
SCOTT:O QUILTO
PO BOX,727 02672 <
West Flyannispor€1VIA .
>r,+�•' Expiration
02iO3I2016
..Commigsivner
or
ui6e 6 License or registration valid£founds return to
onty
C� �c�/�luloucl.. L irat►on date. I Regulation
iuea�th a ulahon Business
Reg
._ ��ie Tcaxr Business Reg before the exp
Office of Cortsurne;Affairs&., ,. . CTaQ Office
.of Consumer Affairs and,B
F{�T CON-fR Type; Suite 5170
SOME IMPR�VEM 10 Park Plaza 021 6
egistratian: 132691 . IndiVidUal ,
1
Boston'
xpiration 312312015� '
�GQTT.
QUILTER
QUILTER
ur
SCOTT � f.- � o
NIBERRY HILL FI.Q Not valid without out-signature
-
247 STRA 1JndersecretarY
Mp.02632
CENTERVILLE, ,
s ,
m
i
Fit r Town of Barnstable *Permit�60bw7bl
� Expires 6 months from issue date
Regulatory Services Fee
aARxsrnst E; Thomas F. Geiler, Director -�
" Building Division
Ep MA
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 225/0 5-b
Property Address q1l Wesr MA1r,) WUt. C NTOMVIIIE M4 UL63Z-
[Q'Residential Value of Work '�yOOU Minimum fee of$25.00 for work under $6000.00
Owner's Name& Address •SIISAIJ SWUL
MA I�u S fyrj f
Contractor's Name Sut Qud AweY Telephone Number_(�ZJS _1_�_—
Home Improvement Contractor License# (if applicable) I32bq
❑Workmari's Compensation Insurance
Check one:
[l��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 be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will betaken to
❑ Re-roof(not stripping. Going over existing layers of roof))
R side j �LC r 'Iee ti A G
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required:'fssuance 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 is.required.
SIGNATURE: _-,�ZLIA
r� +
alflt o Massachusetts
. � The Commonwealth f
Department of Ittdustrial Accidents
UfOffice of Investigations
600 Washington Street
Bostort, M-4 02111
wWwanas's.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i
A ficant Information Please Print LeffzblY
Nainc (Busincsslork niz t;on/Indmdual): stiff tit U(L Its-
• Address: ?�f� � -
City/Statdzip: L-N its-Ayi I If. .'KA 04632 Phone.#: C5y 0 ?71 04YI
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4- [] I am a general contractor and 1 6 ❑New constcmtion
employees(full and/or part-fimc).* have lured the sbb-c-ontractors
2_[ I am a's.ole proprietor or pxdner-
listed on the attached sheet 7. Remodeling
These sub-contractors have g, Demolition
ship and have no employees
working far tine in any capacity. emp loyees and have workers' 9. ElBuildingtaddition
[No workers' c mp.•msuranre mmp.ins ra_LtGe.
-_ 5. 10.❑Electrical repairs or additior
ztgvlred] We arc a corporation and its
3.El I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or addition
myself; [No workers' comp. right of exemption per MGL 12 ❑Roof repairs
insuranm z t c. 152, §1(4);and we have no
r�j employee workers'
s. [No 13.[] Other
comp,insurancc required.]
Any appli=t that check box#1 must also fill out the section below showing their vmr 'cornsaysalion Policy information
t Horncownc-c who cubmit this affidavit indicating fficy arc doing all work and ffim hire outside cantractors must submit a nrw affidavit indicating wrl,
tContractors at cbmk this box umst attached an additional sheet showing the name of the sub-canftactun and sialn wheiha or not thosd entities have
that
anployecs. if the sub-contractrnx have cinplayccs,they must pruvidt;their workers'comp-policy number
I am art employer that is providing workers'compensatzort insurance for my employees Below is the policy and job site
information.
Insurance Company Nunn-
Policy#or Sc1f-ins.Lie.#:_ : Expiration Date:
fob Site Address: City/St,.Wzip.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date,
Failu rr to secure covcragc as requimd un. r Section 25A of MGL c. 152 can lead to the imposition of criminal pcnaltics of.
fine lip to$1,500.00 and/or tme-year imprisonrnnnt, as well as civil penalties in the form of a STOP WORK ORDER and a f
of up to$250.00 a day against the violator. Bc advised that a copy of this statrmcrit may be forwarded to the Office of
Investigations of theMlA.for�'urance covcra c verification.
nder the ins• nalti,- of perjury that the information provided above'is true and correct
I do hereby cer�4 u
Si c: Datc: 6 0& -
Phone 7-1 04-V)
O fucW use only. Do not write in this area, to be completed by city or town officiaL
City or Towa: Permit/License#
Isor ng Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
°FTH�r � Town of Barnstable
Regulatory Services
'ARNMIB
MAIM ; Thomas.F. Geiler,Director Y
$ArEo;9.,ya`� - 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
ff Using A Builder
r SVSA,\) ,(- , as Owner of the subject property
hereby authorize Suit QUt L.�� to act on my behalf, .
in altmatters relative to work authorized by this building permit application for:
q?I (LEST Mk N S� &,)Ta tyy kf. AAc O L63 Z
(Address of Job)
Signature of Owner to
SU SA�J SuJ�L�
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on the reverse side.
Tow_ n. of Barnstable
of YHE rp�y
w o Regulatory Services
aaxxsTAs>i Thomas F.Geiler,Director
M` BuildingDivision
Tom ferry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.to A,n.berrnstable.ma:us
Office: S08-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
i
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT 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 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,iegulations:
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 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 persons)for hire to do such
work,that such Homeowner shall act as supervisor.,.
Many homeowners who use this exemption aie unaware that they are assuming the rosponsibilitics 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.
�1ie yr o�rrr�y�? �pc�ieWe� I ;
Board'of Buddjng Regulations and;,5tandards
<.,
HOME IMPROVEMENT CONTRACTORi
Registration g132691 IyY4�
Ezp""iratton=31�312009 , Tr# 127243
De:
Ind n'dual �
SCOTT QUIL`TER �' hf '
T .QUILTER(
SCOT
247 STRAWBERRYHIL�RD
Admm�stra'to
CENTERVILLE.MA 02632
�
y
r �i
LiOrise oc registrati'on valid for individul use only. i
I, pp before the.expiratron date .If found return to:
4 .Board of Building Retulations.and>St dards
11' One Ashburton Place i2m 1301 ! {\
Boston;Ma.02108 °
11 7.{��"��• {
I
Not,valid wl ou#signature
a
R��,
-- -
�/����..
r
Town of Barnstable *Permit#
Ike Expires 6 months from issue date
A-PRES's pER Services Fee 0 y
APRr920W I*egulatory
omas F.Geiler,Director
06 Building Division 4iIA,
ro"OF SARNST Tom Perry,CBO, Building Commissioner
ABL600 Main Street,Hyannis,MA 02601 �'
www.town.barnstable.ma.us
Office: 508462-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
Residential Value of Work (A AZ � imum fee of$25.00 for work under$6000.00
Owner's Name&Address rqw.T.441
Contractor's Name �� �B/r� �. er Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
eck one:
ErTiam 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 be on file.
Permit Request(check box) j
Re-roof(stripping old shingles) All construction debris will be taken to ar h ��b�e Lcn 111
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
eplacement Windows. U-Value (max;m .44)
Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
3
***Note: JZ40IMI.,'21,4(,0�
perty Owner must sign Property Owner Letter of Permission.
me I rovement Co is License is required.
SIGNATURE:
Q:Forms:expmtrg
Rrvise071405
Town of Barnstable *Permit# 9 S 2-
Expires.6 months from issue date
r
PERIWVi egulatory Services Fee 0
APR omas F.Geiler,Director
T®�N 1 9 20�6 Building Division �j _
OF Building
Tom Perry,CBO, Building Commissioner NST �7� ' �°D� �
ASL 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us '31
Office: 5084624038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
a �
EQ Residential Value of Work timum fee of$25.00 for work under$6000.00
Owner's Name&Address r?Wj,4N/%; ,
Co*actor'sName , �� �� B � E'� Telephone Number �j® ���
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
(;heck one:
Erra—m 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 be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to l
❑Re-roof(not stripping. Going over existing layers of roof):
*A;adQws. U-Value J (maximum.44)
Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.'
***Note: P perty Owner must sign Pro erty Owner Letter of Permission.
me I rovement Co rs License is required.
SIGNATURE:
Q:Forms:expmtrg
a
Revise071405
{
Department of Industrial Accidents
,f, Office.of Investigations
600 Washington Street
y� Boston,MA 02111
www.maugov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Autplicant Information Please Print LeLd bly
Name (Business/organizationafflvidual):
. Address: a Si'uw� (
City/State/Zip: SJaW,6 : AA O ZIo.3,�- ' Phone#:
Are you an employer? Check the-appropriate box:. Type of project(required):
1.❑ I am a-employer with 4. ❑ I am a general contractor and I
employees (fall'and/or part-time).* have hired the sub-contractors 6• New construction
2.R? am a sole proprietor or partner- listed on the attached sheet. $ °delmg
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp.insurance. g, ❑ Building addition
[No workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical r airs or.additions
required.] ,officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Phuming repairs or additions
myself. [No workers' comp. C. 152,§1(4),and we have no 12,[Moof repairs
insurance required.]t employees.[No workers
comp.insurance required.] 13.❑ Other .
*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.
tContractbrs that check this box.must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and•job site
information.
Insurance.Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,.00 and/or one-year imprisonment, as well as.civil penalties in the form of 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 certi under the pains es of perjury that the information provided above is true and correct.
Signature: and p • Date:*. 0 —04'
Phone#: (A8) 721 -0.2_:4i
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
r
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 aR."_an?nd 4at.:partnMtip,.:association,Forporation 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:tlie
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 woikvu 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 fin 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
ed to carry workers' compensation insurance. If an I.LC or LLP does have
members orpartiaers; are not requir
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. Shouid you have any questions regarding the law or if you are required to obtain a workers'
ent at the number listed below.. Self-insured companies should enter their
compensation policy,please call the Departm
number on the
nate line.
self-insurance license numb approP .
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.fiataare 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would life 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 qff Investigations
,. 600 Washington Street- .
Boston,MA 02111..
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
T
Town of Barnstable
Services
Regulatory
t s LL _' Thomas F.Geiler,Director
,��� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Ommer Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize&2-�� /'
to act on mp behalf;
in all maf{ers relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Da e
P
Print Name
Q:F ORW:OW NERPERMIM SION
:�-
fze"V�omuectll�i o�✓l�aaoac�waa __
71
13„erd ci Suiidin� � ,Rc ul►lro�ti and a c., 1 ^.v 1w or registratiomvL id t61,lnciiy+.i i1 Fir"E r
HC r t.� -70OVE- NT CONTRACTOR, r ., a tU expiration d ite._,`ljounc l ra&tos aRegis,3 �n sr � ;wlding Reg l; und-� aruerri*cr cdes 1-12691
F;As;rburtori Place R i 1301
'2-3/2007
62.108 i
i �' R' ��y16iduat _
`NEERRY
/i LLE,AAA 026v'
r�unnni,Usr+ `c1; 1,u!R it�t t s+an�tutc ��
554
of Tat, Town of Barnstable Permit# �.
Expires 6 months from issue e
(9
Regulatory Services Fee
A AL 6 1
1639. Thomas F.Geiler,Director x.P C��
Building Division �E M
Tom Perry, Building Commissioner SEP
200 Main Street, Hyannis,MA 02601 1.0VV
92003
Office: 508-862-4038 N OF SARNS-LAE
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number a-2 9 OS 6
Property Address '� ,/v V I'
ffResidential slue of Work
Owner's Name&Address -/ A) SWtg,t -
°f7/ G��ef rti(fi-r� S�t'ftf CA-_-tjf1AVjj1EF Mk 02-632-
Contractor's Name �C't)Ti Qom— _Telephone Number�5�fl�
Home Improvement Contractor License#(if applicable) 13 Z-b"i
Construction Supervisor's License#(if applicable) S 0-7$OW
1�
❑workman's Compensation Insurance
Chec one:
[TI am a sole proprietor 1
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance .
Insurance Company Name
Workman's Comp.Policy#
Permit Request(check box) t
[�Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. 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 Owne ust si roperty O er Letter of Permission.
Home Impro a ent Co actors Lic se is required.
Signature
Q:Forms:expmtrg
Revise053003
y
Town of Barnstable
Regulatory Services
� s
sa MASS.
� Thomas F.Geiler,Director
ass.
9`6prFp;prp�e Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
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 S tU� to act on my behalf,
in all matters relative to work authorized by this building permit application for:
gli WEs'4- MAw S�M�f
(Address of Job)
/x Ll
Signature of Owner ate
�.I
Print Name
Q:FO RM&O W NERPERM IS S ION
i
` C
f,.
1 t
3 W.sea: 74 .
71.
•i . y.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Re.*W n` 2fi91 I
123 2005
dividual
1A I
i SQOTT QUILT€f�
SCOTT QUILT �
20 ST12A1WB�FtRY a
CENTRRML-6E,MA 02-632
r Adniiaistrator
TOWN OF BARNSTABLE BUILDING PERMIT•APPLICATION,.
Map Parcel ®S PPLICRNT MUST OBTAIN ASEvR Permit# ��� 9
p,
Health Division -1 ,ENC E TiIOti DIVISION
THE Date Issued
ENGINI3»RID..I DIVISION PRIOR TO
C�JNg'I UCiION.
Conservation Division Fee d? ao
Tax Collector..
VQ
Treasurer 9/Qq
Planning Dept.
t.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hlannis
c
Project Street Address /
Village
Owner Address
Telephone /eJ
Permit Request
Square feet: 1st'floor:exis'ng proposed 2nd floor:existing proposed Total new,
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family 0/11*,Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes �]No On Old Kin 's Highway: ❑Yes QiHo
9 9 9
Basement Type: ❑Full yawl Rq �kout ❑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 includi baths):existing new First Floor Room Count
Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan yeview#
.Current Use Proposed Use
BUILDER INFORMATION
Name Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE !ti0 DATE , , .5s C?
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED t
MAR/PARCEL NO.
314
u
ADDRESS . { 'VILLAGE
OWNER
DATE OF.INSPECTION:
FOUNDATION
FRAME' p. - �� a •� '. [.
INSULATION
FIREPLACE
• rk �
ELECTRICAL: ROUGH FINAL !'
PLUMBING: ROUGH !«=FINAL
GAS: ROUGH FINAL
FINAL BUILDING t 4
DATE CLOSED OUT
ASSOCIATION PLAN NO.
i
e 11own o Barnstante
• �' Department of Health Safety and Environmental Services >.
Building Division
367 Main Street,Hyannis MA 02601
r
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
J
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 certain exceptions,along with other
requirements. 1 t
Cod
Type of Work: Estim ted Cost �®
C i�,e[ /1/0 P
AdLZ of Work•
Owner's Name:
Date of Application: C71V 2z
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job Under S1,000
Building not owner-occupied
Owner 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.
A�Z 04-
X,�d
Date Owner's Name
gAmis:Affidav
•
J
1 1 11 11 � 1 1 1 1 1 1 1
1
■ 11 . . / / 1 1 I 1 • 11 11 1 1 Y I 1 . 1 1 �. It • 1 • • �.
1 .
MEW 04
Of
I '.
1 �
1
1. 1 11 :.#. .y .� •1.�1 •
w.: ...
n 1 .
■ rT31
■
':,....a<Y'.;:�.\w.w.�s<-. .•�:.:. :,.cover�»,,,err:;qr�c< '+.c??oo°;':"x'�,ca'°;.�•••,•.;<.•.•••......•:�<.�<oa�.�:ccc9.i�a.: :.: .. �»>aourcr.<0.CS"»o'?o:o-�:na::.vocmi�ox�:yc--•>nccc>�:.;nn..
tKe r
Depar�ine t° -1th Safety and Environmental ��•� �_g��:
. ;, Building Division
►ar'srrnsr M ' 367 Main Street,Hyannis MA 02601
KAS&
Office:. 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please Print � � !' •
DATE:
JOB LOCATION:
number t village
"HOMEOWNER":
e home phone# work phone#
CURRENT 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 homeowners to engage an individual for hire who does not possess a license,=vided
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 resroonsible for all such work performed under the building permit,
(Section 109.1.1)
x
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 I
Department minimum inspection procedures and requirements and that he/she will comply with said
procedures and requirements.
Q
e
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 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:FORMS:EXEMPTN