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HomeMy WebLinkAbout0052 WESTMINSTER ROAD vr2 lies „ ..r. } �� .,i, :'• '. ` M,1„!6' .-. •i t _ -. ,'.:,,. :w. -.�. ... �l �A'�h t �y�tfi�� ���",�'�y" �(-r i F-�", ��Ji;'.1 '��1 r 4+A Ale +tf 7 tp jixfi t jA G �- I � - _ ��:.,c�. t '� '�e� 3 �ttt �xx 9 s➢��r �*r,F r r �� >f>�S '' ;:i+. f W t., o , a , � 3 r r Parcel Detail Page 1 of 4 (Pit/ 4i""?.-W it y' S 9A Jhk q 'Tv aiie�.... �C7gy�+..�—.ra,,l•�'�c, ;� ttttBN' VI`'�i:'SgyS«'� Logged In As: Parcel C�etail T"` September . Parcel Lookup 1w Parcel Info S f «i�1 - (,�S iS-.._"� U .. .._._. -.--- Pa rce I �168-0 7 _ Developer °LOT 6 ...m.__-.. �. ... _ ID Lot� Pri j 1 oo___. Location 152 WESTMINSTER ROAD Frontage ' Sec . .. __._ _. Sec ......... : Road j ROUTE 28 Frontage 1100 Village !CENTERVIL E , Fire C-O-MM District' Sewer __ �� __, .... _.: �� Road i�81s. .r_�. Acct Index' Asbuilt Septic Scan: ` P Interactive z 168067_1 Map Owner Info __ _ _.. -- - _........ _._.__... - .. Co_ .._.__._ Owner!DESOUZA, TALIS Owner %HOMESALES, INC Streetl C%O JP MORGAN CAHSE BANK- I Street2 110 POLARIS PARKWAYY z City#coLUMBus �.. .� State off._ Zip a324o...._ . Country Land Info Acres 35 Use iSingle Fam MDL-01 1 Zoning F�- Nghbd O1o6 Topography Level RoadPaved Utilities Septic,Gas,Public Water Location ' Construction Info http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10978 9/3/2009 Parcel Detail Page 2 of 4 ,l Building 1 of 1 Year Roof _ ___..._ Ext Gable/Hip Clapboard I Built Struct Wall Effect 1727 ROOF Asph/F GIs/Cmp AC None I 0. 3 Area Cover Type Style Ranch Int J Bedrooms Bed Wall Drywall Rooms3 Int _.._ ... Bath 2 _ j ry �� Model [Residential I Floor Carpet Rooms Full _.... .. ... _ Heat Total ._.mm._...._� ._. Grade Average Type Hot Water Rooms 7 Rooms Stories 1 story I Heat[Gas I Found- Typical I Fuel ation Permit History Issue Purpose Permit Amount Insp omments Date # Date Visit History Sales History Line Sale Owner Book/Page S` Date Pr 1 10/11/2007 DESOUZA, TALKS 22397/182 2 03/14/2003 SOUZA, MARIA 16576/286 $26% 3 07/15/1996 MAXCY, ADAM R 10296/018 $8%1 4 04/15/1991 RISCHMANN, JANET 7498/086 5 10/25/1977 RISCHMANN, JANET & 2604/123 LISS, HELEN 6 05/22/2009 HOMESALES, INC 23726/137 $24%c Assessment History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10978 9/3/2009 Parcel Detail Page 3 of 4 Save Building Land Tot # Year Value XF Value OB Value Value Part Vale 1 2009 $1297600 $2,600 $0 $140700 $27Ad 2 2008 $156,300 $21600 $0 $150,600 $30(, 4 2007 $1551400 $27600 $0 $1507600 $30E 5 2006 $1427100 $21600 $0 $1531200 $291 6 2005 $131 ,600 $27500 $0 $1227200 $25E 7 2004 $1067900 $21500 $0 $91 ,600 $201 8 2003 $102 7600 $2,500 $0 $40,700 $14; 9 2002 $102 7600 $23 500 $0 $40,700 $14% 10 2001 $1027600 $2,500 $0 $401700 $14% 11 2000 $76)500 $2,300 $0 $307600 $10c, 12 1999 $76,500 $2,300 $0 $307600 $10c, 13 1998 $76,500 $2,300 $0 $30,600 $10(, 14 1997 $81 ,800 $0 $0 $271 500 $10c, 15 1996 $817800 $0 $0 $271500 $10c, 16 1995 $817 800 $0 $0 $277 500 $10c, 17 1994 $77,300 $0 $0 $19)300 $9E 18 1993 $77,300 $0 $0 $19,300 $9E 19 1992 $87,900 $0 $0 $217400 $10c, 20 1991 $937400 $0 $0 $54,300 $14i 21 1990 $93,400 $0 $0 $54,300 $141 22 1989 $937400 $0 $0 $54,300 $141 23 1988 $651100 $0 $0 $237700 $8E 24 1987 $657100 $0 $0 $237700 $8E 25 119861 $657100 $0 $0 $237700 $8E http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10978 9/3/2009 Parcel Detail Page 4 of 4 Photos WWI -AC " a 6 p http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10978 9/3/2009 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_ Parcel 667 . . 7 . Application Health Division 95'" 2�9 Date Issued - Conservation Division Application F-�� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address tV e S—�-'Y►n + ►� S �,� )ZO a4 Village .( 0 1 I '� ` Owner la-cwhny Now,# �6 wS gp f #i4,t ht Address �® I LI O eO< Ue c K (J, Telephone Q �h�`5, M 026 6 Permit Request cti ;�ti f~"'2 D cJ f fY � t'�R I . y y1, I �.v✓L �� n f� Square feet: 1 st floor: existing proposed 2nd floor: existing !�° proposed Total new Zoning District R Flood Plain r1 Groundwater Overlay Project Valuation 57,�� Construction Type Lot Size 3 Grandfathered: AULYes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure i 4 7 1_ Historic House: ❑Yes JPJo On Old King's Highway: ❑Yes 1lo Basement Type: Wull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Q' PLC/ Basement Unfinished Area (sq.ft) 5 f'[_A,* 1 Number of Baths: Full: existing new Half: existing new Number of Bedrooms: 3 existing ff new Total Room Count (not including baths): existing new First Floor Room Count (o Heat Type and Fuel: j Was ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes Flo Fireplaces: Existing I+ New ® Existing wood/coal stove: ❑Yes 4 No � Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: $.existing ❑ new size Shed: ❑ existing ❑ new size _ Other: 0 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ x71 C) Commercial ❑Yes Flo If yes, site plan review# W 01 Current Use Ae5(-A f 0-- Proposed Use lG (A e.. t Q( ? APPLICANT INFORMATION o. rn (BUILDER OR HOMEOWNER) Name �Vl Q e�S T� t ►� Telephone Number L% "���r� O's Address 1� ot Aeck 2 License # 0 Home Improvement Contractor# ply/� Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO o c) v\a. h S o 3 rn ( C SIGNATURE �46DATE 1 FOR OFFICIAL USE ONLY -APPLICATION# DATE ISSUED MAP/PARCEL N0: ADDRESS VILLAGE t OWNER DATE OF INSPECTION: FOUNDATION FRAME 'F INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL •��i` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. . The Commonwealth of Massachusetts Department of Industrial Accidents P� Office of Investigations 600 Washington Street C Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L.e2ibl Name (Business/Organization/Individual): Address: O 0Aiz_ IJJ�zK ILb City/State/Zip: v IS VIA A- au Phone #: Sa C-T7,5'`f I, -2 - Are you an employer? Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.�K I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp.insurance" comp. insurance. required.] ¢5. We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: a 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 pains and penalties of perjury that the information provided above is true and correct Signature: Date:LI'Ell Phone#• 3 L L`U �� ? l J� Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: -Phone#: 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-contractors)name(s), address(es)and phone`number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit.. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. 'Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (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 Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia Town of Barnstable �pf TtiE ray o Regufatory Services BARNSTARM Thomas F. Geiler,Director '`` . Building Division Tom Perry,Building Commissioner 200 Maid-Street, Hyannis,MA 026.01 K NmAo wn.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEO"ER LICENSE EXEMPTION f q Please Print DATE: I ! L( — l -�- JOB LDCATIDN: -a- N ST-evr 12J- ( --&, 11, �.V-(f number strcct village - --HOMsowNER���qryos j9. HT--g Btvv, j-09' 7 7S= 1-/15�- 4W-cR?d - a(. name p home phone# nc work_pbo # CURRENT MAILING ADDRESS: I g ©a'� N e ck ya—& Q-- 4t y rt v. S JLl A— 6 Z&0 1 ritylto6m state ;rip code The current exemption for"homeowners"was extended to include owner-occupied dwel inWs 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 Slrperyisc) DEFINITION OF HOY EOWNER 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 Btulding 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..Wshe understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and e mquirem tsVIM— Si tin;of Horneowner 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. HOMMOwNER'S EXEnfPTION .The Code statrs that "Any horneovmcr perfonning work for which a building permit is required shall be exempt from the provisions of this scction.(Section I D9.1.1 -.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 awarrncss bfien 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 homcownrs acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of hiArr responsibilities,many communities require,m part of the permit application, that the homeowner certify that he/she understands the respoTmbilitirs 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/certifiration for use in your community. Q:forrns:homccxcmpt z r i Town of Barnstable Regulatory Services Thomas F_Geiler,Director v ' �Da Building Division Toni Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 )VWW.town.barnstabl e.ma.us Office: 508-862-4038 Fax: 508-790-623( Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the suSt ct.property . hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of rob) Signature of Owner Date Print Name If Property Owner is applying for permit please p e e e Homeowners License Exemption Form on reverse �OFTHE r � Town of ]Barnstable eiZt# O Expires 6 months from iss a date Regulatory Services Fee r * BABNSTABLE, MASS. $ Thomas F.Geiler,Director �A i63g. 16 I nlZ3l01 ,¢A4 TFD MA't (� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 J Q� Property Address SZ_ W GS-r n1l 'Residential ValueofWorklqQ00, 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ` �� A-6 9 14 (6 0 AA1 5_2 WES1:1M IAJST�7 0_ &Ab Contractor's Name N)6�_i a N 6�NA u Telephone Number < - 6 ' _Oil Lt fo Home Improvement Contractor License#(if applicable) FERMI . Construction Supervisor's License#(if applicable) s g O 7 Q�� ❑Workman'sCompensationInsurance �� Check one: �o\ ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name GG&N ( E S ) rL t NS CJ A A0CJ Workman's Comp.Policy# WC 00 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) J�Re-roof(stripping old shingles) All construction debris will 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. ***Note: Property caner must sign Property Owner Letter of Permission. c py of t e e Improvement Contractors License&Construction Supervisors License is r gnir,d. SIGNATURE: Q:\WPFILES\FORMS\building pe t forms XPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents � Office of Investigations 600 Washington Street 'f Boston, MA 02111 FBI fvwiv.niass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information {� ES Please Print Le0bly Name (Business/Organizationnndividual): DI Cco� CN�TEP Q,1� Address: S�o 1 (L( A jS City/State/Zip: &W_td��(4Zt_E Phone #: c�� Are ou an employer? Check the appropriate box': Type of project(required): 1. I am a employer with 3 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 any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12�Roof repairs insurance required.) t c. 152, §1(4),and we have no employees. [No workers', 13.❑ Other comp, insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. �p Insurance Company Name: rV't (J�� C � 1 S�� C� L-©�( 1 IT l _ Policy#or Self-ins.Lic.#: k)C- 00,7—LA Z— Expiration Date: 0_s- 1 Job Site Address: S2 WEST 1'VI 1 49\ L City/State/Zip: �'re�9 r (U(,f ✓LI A 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$ 0.00 anAa one prisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 50.00 a�dayns t e viol tor. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of th�Do iin ranee coverage verification. I do he by certify un,e h at a d penalties ofperjury that Ihe'information provided above is true and correct. Si ature: Date: (0/9W90,-,q Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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,constriction 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 " affidavit that has been officially stamped or marked b the city or town may be provided to the town)."A copy of the o f y p y Y Y A new affidavit must be filled out each affidavit is on file for future permits or licenses. applicant as proof that a valid aff v 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 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: P P 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 Town of Barnstable Regulatory Services v $ Thomas F. Geiler,Director Fp;q;� 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, 7T /l%1�/45 (6 jQ GL'� , as Owner of the subject property herebyauthorize act on mybehalf, in all matters relative to work authorized by this building permit application for. (Address of Job) �d -7-,o 6 Si ature of Owner Date Print Name If Pfopedy Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERP E RM IS S I ON • c Town of Barnstable o Regulatory Services _ • Thomas F.Geller, erector sataysrasr.E, Mass. 9�P 039, 1&6 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#1 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 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 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 hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexemptDOC i II i GRAN IT S TE INSURANCE COMPANY 0076138-oo WC 007-42-2856 13102 ------------------0�3-66-0509-00 ... DICENS ERPRISES INC 56 JENKINS LANE W BARNSTABLE, .MA 02668-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 LD# MA U#• .. . ,.. SABATINO. INSURANCE WORKERS COMPENSATION AND EMPLOYERS 564 BROADWAY LIABILITY POLICY INFORMATION PAGE EVERETT, MA •02149-3717 INSURED IS PREVIOUS POLICY NUMBER CORPORATION NEW OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's - mailing address FROM 05/16/09 TO 05/16/10 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC2003o6A D. This policy includes these. SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM4 The premium for this policy will be determined by our Manuals,of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Remuneration Premium Classifications Code Number luera on a Annual1:1 mn t 3 Year M Annual 3 Year Please revi w you licy SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 p for a curac . If TAXES/ASSESSMENTS/SURCHARGES, Yclu Wish to Inake tiny $32 cliangesplease ca to EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $2 0 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $762 If indicated below, interim adjustments of premium shall be made: • Semi-Annually El Quarterly El Monthly DEPOSIT PREMIUM o6/23/09 ASSIGNED RISK 66 Issue Date Issuing Office Authorized Representative WC 00 00 01 39967(Rev'd 04/08) . r �/ze -C�arr�rnmuuea�/ °���vaaclu�orlla 1 1 Board of Building Regulations and Standards i '! Construction Supervisor License Lice s0: CS 88015 :I E Ezpiratton�4f4/2010 Tr# 25434 r I" � c ANGELO G DICENSOttr ' 56 JENKINS LANE`� '%j --�- W BARNSTABLE,MA 02668 Commissioner Bo ril o m mg egu at�o° a�an ar s License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards I Registration: 156258 One Ashburton Place Rm 130 Boston,Ma.02108 Expiration6L15/2011 Tr# 285810 I ylug DBAn ADC BUILDERS ANGELO DICENS1O 56 JENKINSvalid without signature I W.BARNST Administrator ABLE,MA 026G8"�' - i (L I C � Q r �.��1 [ 1J G p�►�1 2 _ I I � _ .. I i I i : 2 : U� T4 f i i v�90 Tfl { ' PPE 1 rl 77 i 1 r 1�9.f I-A c 4- V'ftAj: r'fj '�q- j. V') 1 '54�44 C-- RFC L ..Il► r►..r u✓1►-�Dd�V w rr`►- .� Ky 92- WF$'C` P ^1 5 = ---- o.�P_t r �� N' A R4 � ;ia�sra��.�-- ►J�dU KiT�; covti�r�2.To�g '' �� �3�[,..t t7u> +� c:-� ' t i�� ►.� r�r� a1 . .co sa 8--775- /�"Z.- di o_ ......... w__. 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