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Home My WebLink About0095 GROVE STREETrqs d�,-- ,�-�a � / f Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 7/28/15 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St.Hyannis,MA 02601 c RE: Building Permit#201504063 , TO: Building Inspector(s), This affidavit is to certify that all work completed for 95 Grove Street, Cotuit has been inspected by a third party Certified Building Performance Institute(BPI) Inspector. a All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey j TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel a 6 7PT&I OF FARNSTMOlication #220, Health Division ! Date Issued Conservation Division Application Fee ,_S7(D Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board �J"f °1SION Historic - OKH _ Preservation / Hyannis Project Street Address 25 r o rt S-t-r'ee+ Village Co tw,14— Owner Gai Do,11%S Address cSame Telephone 508 L1 a B �, p 31 Permit Request a nJc ec k A l :4 - 13 s e rIsiJ ►nja 141 en +0 tke— a -I�, A R-►9 6Prr145-f +,2 " b 4.seme Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes KNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name vll�ovk c I w3 Y,,e /Ctot SVC 7n c , Telephone Number So 9 3 IF Q 3 Q Address i- D -H-tAn+,1q+o A f 1 4.va= License # T C MA- �a�,� 6 �( Home Improvement Contractor# Email Worker's Compensation # W e 31 3 6 all II"I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE a 6 s FOR OFFICIAL USE ONLY _ z APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING C DATE CLOSED OUT ASSOCIATION PLAN NO. - The Commonwealth of Massachusetts DepaitmentoflndustrialAccidents � f d I Congress Street,Suite 100 Boston,MA 0211.4-2017 www mass gov/dia ' NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letibly Name.(Business/Organization/Individual):Cape.Save Inc .Address:7-D Huntington Avenue City/State/Zip:South Yarmouth; MA 02664p phone#:508-398-0398 Are you an employer?Check the appropriate box: Type Of Project(required)C 1;[D I am a employer with 0 employees.(fuli and/orpart-time):" 7. ,❑New.construction 2. m a sole proprietor or partnership and have no employees working for me in. ❑I a 8: ❑Remodeling. any capacity.[No workers'comp.insurance.required:] 3.D I am a homeowner doing all work:myself.[No workers'comp..insurance required.].t 9. Demolition 4;❑I am:a homeowner an []d'will be hiring contractors to.conduct all work on my property: I will 10 Building addition ensure that all e contractors either.havworkers'compensation insuranmor are sole 11.[]Electrical repairs or additions proprietors with no employees: 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOf.rep3irs These sub-contractors have employees and`have workers'comp.insurance. 6.❑We are a cotporation and its officers have exercised their right of exemption.per MGL.c; 14.DOther Insulation 152,§1(4),and we have no 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 who submit this affidavitindicating:they are doing all work and then hire outside.contractors must submit a new-affidavit,indicating such.' 'Contractors that check this box.musrattached an:additional sheet showing the name of the sub=contractors and state whether ornot those entifies have employees. If the sub-contractors have.employees,they must:provide their workers!comp.policy number: Jam an employer that.is providing workers'compensation insurance for my employees. Below is the policy and fob.site information. Insurance Company Name:Wesco Insurance Company Policy#or Self-ins.tic,;r WWC3136274 Expiration Date 04/09/2016 Job Site Address:. 95 Grove Street City/State/zip: Cotuit Attach a copy of the.workers'compensation policy declaration page(showing the policy number and.expiration:date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500:00 and/or one-year imprisonment:as well as.civil penalties in the.1orm of.a STOP'WORK ORDER and a fine of up to$250.00:a day against the violator.A copy of this statementmay be forwardedto the Office of Investigations:of.the DIA;for insurance coverage verification: I do hereby certify 0. h an pains d penalties of perjury chat the information provided above is true and correct Si ature Date: /25/2015 Phone#:508-398-0398 Official use only. Do not write in this area,to be completed by city or town ofciaL City or Torun; Permit/License:# Issuing,Authority(circle:one), .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical,;Inspector 5.Plumbiing.Inspector ' 6.Other Contact Person;_ Phone : AC cp an F /(1 DATE(MMIDDfYYYY). TE QF LIABILITY INSURANCE Sr24�2g15 TH S CERTIFICATE IS ISSUED AS ►.WlATTER OF INFORMATION ONLY AND CONFERS-NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES..NOT AEFIRMA7illELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE;AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES: NOT CONSTITUTE A 'CONTRACT BETWEEN THE ISSUING INSURER(S) AUTHORIZED' REPRESENTATIVE OR PRODUCER,:ANO THE:CERTIFICATE HOLDER. IMPORTANT. If the sgrttl3cate halder.Is an Ai3 MONAL INSURED,the poltcy(tes)must tee�r)dorsed. Ffi 3UBROOA f10Pd tS WAIVED;subject to the terns and conditions of the policy,certaln;policies may requlre an endorsement.. A statement on this rertlficate does not confer rights to the certificate holder in.lieu of such endorsement(s). PRODUCER, NAME: Colleen Crowley RiSk Strategies Caanpaay PHoI� (781)986-4400 FA E ►C o c tT81)963-4920 15 pacella Park IIxive ccrowley@risk-s:t:rateges.com Suite 240 INSU S)AFFORDING COVERAGE NAIC a3dlph t32.368 INSURERA:►Selective 'Ins.;. 4E' 23a1IIP.�]C.a INsu>zFo INsuRERsAllmr-ica Fiaaacial-Alliance 0212 Cape Save, .. INSURERC-PesCO XVISUraYiC@, an 7 D Huntington Ave . . INSURE-RD.: INSURERE OUth YlMetsth : 62694 INSORERF: .. COVERAGES CERTIFICATE NUMBER:CI,1532491501 REVISION NUMBER: TICS is?O G€RTifY TI AT T#if Pf3L1CIES'(F i�►S13f2ANCE 4STED$ELOW HAVE BEEfV ISSUED TO THEINSU#iED NltlyrEr7;A6`OVE' i}i OR E"POLICY-PERIOD INDICATED. iUOTWITHSTANO G ANY REQUIREMENT,TERM-OR CONDITION OF ANY CONTRACT OR OTHER 01OCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN; THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED:HEREIN`rIS SUBJECT To ALL THE TERMS, IX��LUSIONS.AND CONDITIONS OF SUCH:POLICIES.LIMITS,SHOWN MAY HAVE BEEN.REDUCED BY PAID CLAIMS, INSR TR TYPE OF INSURANCEIlal POLICY'NUMBER AP90L WMIDONYYY)ICYtEFF PO ICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE` g 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGET � PREMISES Ea occuEence $ 100,000 A CLAIMS-MAOE l=J OCCUR 9,199449 0/16/2014 0/15/2015 MED E)tP( +Y one person) $ 10,000 PEItSOtdAL;$AaV IN Jt1?Y s 1 r Q:Ob,Ci0t3 GENERAL AGGREGATE $ 2 l,0Q0,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ Z y:000,000 POLICY X PRO X LOC. $ AUTOMOBILE—LIABILITY_ - Ea acaaent I 11000,000 B. ANY AUTO BODILY INJURY(Per person) $ :: ALL OVvNED SCHEDULED BODILY INJURY(Per acddent) $ :. AUTOS , vaTp3: 67966t10 1/6/2014.. 1/6/2015 h10hJ OVSA!EII X 'HIRED AUTOS X- AUTOS Xs . X UMBRELLA uA8 X OCCUR EXCESStlAB CLAIMS-MADE, EACH OCCURRENCE $ 1,000,000 A � AGGREGATE $ i,000,000 DED RETENTION 01 199.4480 GI36(2o14 4/3e/20i5 woRKI:RS CoMF9NSAllQN AND EMPLOYERS'LIAITY, gfiC°AYS IlSClUtlecl for X `vtCSATU TH ANY PROPRIETORJPARTNcR/EXEtXJItVE�vrN average. r OFRCERfMEMBER EXCLUDED? t-' I N IA ,�n,v, E L.EACl1 ACCIDENT $ 5'OO OOQ ,(Mandatory In NH). 93G[34 /9/�(Pt'5 f9j cva 6, ' if.yas,describeunder EL.DISEASE-EA.EmpLo $ 500 t}0E! DESCRIPTION OF OPERATIONS below _ EL DISEASE-POLICY LIMIT $ $QQ QQQ DESCR)PnON OF OPERATIONSI LOCATIONS I VEHICLES(Afte6 ACORD W,AddlHenel tpm"a.Schedule,If more space is roquirerq Issued as evidence o£ insurance.., Thielsch Engineering, Tnc. is listed as additional insured:.as =espeets ts'el3Cral'I+3d)313it:y d$'--re tquired.by �zritt roaatraa~t., , _. CERTIFICATE HOLDER CANCELLATION aP� get aCt,.org S HOULD ANY OF THE ABOVE DESCRIBED POLfCII=S THEREO i�E CANCELLED BEFORE THE EXPIRATION DRYS F, NOTICE WILL SE DELIVERED IN Cape bight Conpact ACCORDANCE:MTH THE POLICY:PROVISIONS. Attar Margaret song:. . AUTHORIZED REPRE3ENTATI VE BO box 427/sGti - 3195 Main Street Barnstable,.MA 0268t); chael Chrstian/CLC = AGORD 26(2010105). 0J 1988Z£I'IO Acom coRp I�A'�!C}Pf J�lf r guts reser d.iNSU25(zotooe).ot The ACORD mine and'logo are registered marks of ACORD HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I �� .L _ ►`� hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: �- �V SY The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic&basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give permission to Housing Assistance Corporation the property with such.equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions.of this agreement and give my consent. Home Owner(signature) r Home Owner email: ' � �-� ` At Date: �O f Agent:(signature) Date: Weatherization Contractors: Adam T Inc Cape Save All Cape Energy r nergy Solutions Alternative Weatherization Lohr Home Improvement Building Science Construction Resolution Energy Cape Cod Insulation Tupper Construction Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation j Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. ' WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE , SOUTH YARMOUTH, MA 02664 4 _, rN Update Address and return card.Mark reason for change. sCA 1 0 20M-05/11 Q Address E] Renewal Ej Employment Q Lost Card -. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only #40ME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: egistration: 771380 Type: Office of Consumer Affairs and Business Regulation 4/2016. Corporation 10 Park Plaza-Suite 5170 k'Vdxpiration:z0j6 x � Boston MA02116 11 ��' CAPE SAVE INC. pZ WILLIAM McCLUSKEY _ 7-D HUNTINGTON AVENUE?'- SOUTH YARMOUTH, MA 02664 Undersecretary Not vali tthout signature Massachusetts -Department of Public Safety Board of Building:Regulations and Standards t` c. .. uii!iii3Ciiirn o�Si-iEivSioT Jiifiiiaii4_' License- IML-102776 WI 14JMC U 37 NAUSET 1k0Z West Yarmouth ILIA Expiration Commissioner 0812812017` UelG. A. Assessor's map and lot. number +.................. uF t N Sewage Permit number114.-. .../fk1SEPTICSYSTEM TM M iSgga STAR LE,€N TALLEDryaNHouse number ............. 7..................................................... �MPy MA86 'WITH i639. ♦� ° TITLE w ». 'Ea MPY a, JOWN�„ OF BARNSTAKEE BVIL.DING :INSPECTOR y 4 APPLICATION FOR PERMIT TO .............�`a...... � ......... r TYPE OF,CONSTRUCTION X. I� 1� J.....lf... ........< �.. ........ ............................... :....19........' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby 'applies for a permit according,to the following information: Location ......�� ..... .U ........... .7`....... ,. ... ...................... ProposedUse ........ � ........ ..................... .............................. ...... d Zoning District.............................. ......... ........Fire District .................................. ................................. Name of Owner .... .. ..... ..... ....Address. ...... .... ........ .... Name of -Builder' .. ...4Ll�.�U... .... ....... ..................Address.:...: ... " -........ ... Name of Architect ��Ae ....:.:.......:..............Address ...........��! ............................................................ Number of Rooms /........... .. ............. .................Foundation � ............................. Exierior ......�� ...5/7//� —"�f. .. ...........Roofng .:.G°.�!!.!,.?.��.... ....... ............ Floors f Interior . ................................................ Heating .. Heating .. .....Plumbing '........ Fireplace, .......`.....4!9n,e.,................................................Approximate Cost.......... . ........3 .......,......... .:....... ... Definitive,Plan Approved by Planning Board _____________________________19________. Area ..Q.. . .... ..... ....... Diagram of Lot and Building with Dimensions Fe / l e ...... ........................... ............. SUBJECT TO APPROVAL OF BOARD OF HEALTH' ` NO • , OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ` b hereby agree to conform to all the Rules and:, Regulations of the Town Bar 'table regarding th ''above` ` construction. c Name . .. .................... DAVIS, RUSSELL E. No 23710. . . Permit for ADDITION .................................... ...............01...Garage.......................................... Locatiori 95 Grove Street co.t.ui.t............ ....................... ............ ... .. .... .. I sse E.Owner ll Davis ................................. g Y . 4P/ Type of Construction .......Fr.ame............I........... I .... ....... lee................................................................................. j Plot ............................. Lot ................................. f 1V December 21, .0 81 Permit'Grante'd ......................................!f 19 a' D te of In spection .................................. f9 4f Date, Completed ....... ...... ... 19 or /ell CIO, VA* A-i 71� IV ... • •� R 1 �. -oil— �/ Assessors map and lot number �� .. ..``� ........ ............ r Q��f TH E t0� Sewage Permit number ::..... ea. :.:„ .....A Z 33AH39TOIILE, i House number ............9. 7.............................................. ro MA & O i639• 0 MOR ' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....�:Q......�.............................................................. ...................... TYPE OF CONSTRUCTION ....... X %?.¢ �.�-r/r f'�..... .. ........��..��r / �i ... .t_ . ................ S : ................................................19........ TO THE INSPECTOR OF BUVLDINGS: The undersigned hereby applies for a permit according to the following information: Location "G� ll. ...........�5z 5zt.....................`--L;7'.w. .................................................................. ProposedUse ........:5-. . ga.............................................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner ... /�"„U�� ...1�,. Ul.L>....Address ...../ . .........U ..... ......... ............................ Name of Builder' ..........................Address Name of Architect . ............. Address ....... - ........................................................... .. . 15 Number of Rooms /................................................Foundation .. 4/U�........ G� �'_ ' . ............................... ........... Exterior �'�b' . /..... � t"..a�:......................Roofing ... /�.... ��.....��`;/ram: ✓✓`�� ....................................................... ..... Floors - .... //d.d'!.........................Interior ......... 1�U ................................................... . . .•�� rAl Heating //' ;'�? .:..............................................Plumbing .......... . ; -............................................... Fireplace .........../ !1 .............................................Approximate Cost ..............Z.d........`.�............ Definitive Plan Approved by Planning Board -------------------------- u .. ------19--------: Area ..:..... .................. .............. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH rT ! r r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of B ra nstable regarding the above construction. Name ....�r .....: .............. i DAVIS, RUSSELL E. j A=19- 26 No ..2.3710 Permit for „ADDITION ................. ............ o.. ix'.ache............................................. Location ....95 Grove. ....Street. . . ......................... .... .... .. .... .. . Cotuit ............................................................................... Owner ......Russell. . ...E......Davis. ......................... ....... .. .. . .. .......... Type of Construction .,Frame ............................................................................... Plot ............................ L ................................ Permit Granted D ember , ........ .................21.........19 81 Date of Inspection ... ... ...........................19 Date Completed ............ .........................19 Engineering Dept.-(31d floor) Map p/ o5 Parcel Permit# 3 b b House# _ 'S hoc ,Date Issued ,;2-Board of Heal 3rd floor 8:15 -9:30/1:00-4:30). � �� Fee 3�• 4. Conservation Office.(4th floor)(8:30-9:30/1:00-2:00) - L Planning Dept. (1st floor/SchoolAdmin. Bldg.) - , efiniti a Plan Approved.by Planning Board A 19 } : BARNSTABLE.p` - �, TOWN OF BARNSTABLE r Building Permit Application oject Street Address 6 O "+LI-e- S Village Owner . 2,V5S-e 1S Address dLre Telephone Permit Request / /V— u G P C /I PE,4 C1 O&C-., First Floor ' 7!Q square feet Second Floor square feet Construction Type �/Zfl'ri1 Estimated Project Cost. $ Zoning;District �" Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ®-� Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name ��S'e ( � 14 ! Telephone Number Address U e License# �O/-,Vl Home Improvement Contractor#, Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CO� / TRUCTION DEBRIS RE LTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ! DATE /Z BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) v � 4 1 FOR OFFICIAL USE ONLY ` PERMIT NO. DATE ISSUED _ r; MAP/PARCEL NO. ADDRESS VILLAGE - OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION i FIREPLACE ELECTRICAL: ROUGH, r FINAL'" PLUMBING: ROUGH FINAL GAS: ROUGH FINAL # FINAL:BUILDING « it , y � i ' - Y � ! � � • ,. i DATE CLOSED OUT 1 ASSOCIATION PLAN NO. ' TOWN OF BARNSTABLE f . .BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE :.. JOB. LOCATION V / o U fi co Number Street address Section of town "HOMEOWNER" P U `e f ( Name Home phone Work phone -fir• .. PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does. not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(s)' who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Officia. on a form acceptable to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes ..responsibility for compliance with the Sta. Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply wit s id procedures and requirements. HOMEOWNER'S SIGNATURE / r APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. V, HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of-this section (Section 109.1.1 - Licensing of Construction Supervisors) ;' provided that if Home Owner engages a person(s) for hire to do such work, that such Home Owner shall acts as• supervisor. " J . Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awarenes often results in serious, problems, particularly when the Home Owner hires unlicensed persons. In this case our. Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home "Owner actin as supervisor is ultimately responsible._ To ensure that the Home Owner is fully aware of his/her.responsibilities, man communities require, as part of the permit application,�that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. d,n+e he Town of Barnstable Department of Health Safety and Environmental Services BuiIding Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph CrossenBuilding Comr. Fax: 508-790-6230 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION 1 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 requ' ements. Type of Work: Est.Cost Address of Work: 2Ta-�� ZOwner's Name Date of Permit Application: — — I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,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 MOROVEMENT 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. s Z Registration No. ate Contractor Name �� fi'IG'• �w NCR 4 IA T/ie Cr,nu11(mi-calth of.Massachusetts Drparinurrt of ludustrial.4ccldents pfflc8o/ltt 8Sf19at1,Uns �;, __�'• b!!U !f a hiugtotr Street Bustotr.Alas.T. (12111 Compensation Insurance Aftidws Workers' Comp i li�tn inf rm inn• I am a homeowner performing all work myself. M I am a sole proprietor and have no one working, in any capacity �_..__.....__,•---.,«,�..-.ns�.ems--w.w�e+►�ee'��.+.a-•---- •--- .. ._ .. �.�...---- M I am an employer providing workers' compensation for my employees working on this job. not tam• name •tddresc• tv- hnnc lt' insur-iner co. I am a sole proprietor.ro rietor, general contractor, or homeowner(circle one) and have hired the contractors listed beio« wit, the following workers' compensation polices: enm sm• nnme• adtirccc• nne e• cin•- nm nnv nni addresc- hnnc i1• rift•- IVORY+� insurnnee co, Attach additional sheet if necesia_rv� :::' s+';"""� _� •.. ,_.. - - — =are-•- ...~ in--cure-averse--.required under�ectton 2A of p1GL 152 can lead to the imposition of cnmtnai penalties o1 a line up to SI.50U.UU Failure une.cars'imprisonment:is well as civil p-naiti-s in the form of a STOP"'ORK ORDER and a fine of S100.00 a day against me. 1 understand cop}:of this statement may be forwarded to the OlTce of Investigations of the DIA for coverage verification. I do herchr cerrify t rrh r a pains and pcna11' of penury that the information prorided above is true at rrect. Date S � Z Si_nature Phone# Print name 21 .r..�,.. 'otliciai use unly do not write in this area to be completed by city or town ofIr P-rtttiUlicens-0 r1Building Department city or town: C 2uccnsine Board C 0Scicetm-n•s olTiec tri check:if immediate response is required 011c2lth Department Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their mployees. As quoted from the an empl({rcc is defined as every person in til service of another under an%• ontract of Itire`cxpress or implied. oral or written. - un enzpli!rer is, cfincd as an_individual, partnership, association. corporation or other legal entity, or any two or more u forc_.:oim_ cnaaacd in a Joint enterprise. and"includinL the legal representatives of a drec:asctl employer, or the :cciver or trustee of an individual , partnership. association or other legal entity, employing employees. However the wilcr of a dwelling house having not more than three apartments and who resides4herein. or the occupant of the house of another who employs persons to do maintenance , construction or repair work: on such dwcllin�_ hour oft th: :_rcunds or building appurtenant thereto shall not because of such employment be deemed to be an employer. 1GL cha*ptcr 152 section 25 also states that even-state or local licensing agency sliall withliold the issuance or •u01111 of a license or permit to operate a business or to construct buildings in the commonwealth for am• 1plicant tii•ho has not produced acceptable evidence of compliance with the insurance coverage required Jd1tionaliv. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the rformance of public %vork until acceptable evidence of compliance with the insurance requirements of this chapter iia _n presented to the contracting authority. •hiicants ase fill in the workers' compensation affidavit completely, by checking the box that applies to your situ. uon and plying company names. address and phone numbers as all affidavits may be submitted to the Department of lstrial Accidents for- confirmation of insurance coverage. Also be sure to sign and date the affidavit. The jovit should be returned to the city or town that the application for the permit or license is being requested. the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required btain a workers' compensatior, policy. please call the Department at the number listed below. or Towns se be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of : idavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas ire to fill in the permit/iicense number which will be used as a reference number. The affidavits may be returned to )epartment by mail or FAX unless other arrangements have been made. Dffrce of Jnvestigations would like to thank you in advance for you cooperation and should you have any questions. ,e do not hesitate to Live us a call. . • .. —.. �.. .. .. .. .. .. _�.. .. ....•ti_. �,. • .. — —.ate... .. .��. .�:R• Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents r i Office of Investigations 600 Washington Street Boston,Ma 02111 fax #: (617) 727-7749 phone #: (6I7) 727-4900 cxt. 406, 409 or 375