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Home My WebLink About0124 GROVE STREET °vtr+t r°y TO`6 on .of Ba]C nst�ble' ' *Permit#t y Expires 6 montl from issue date Re°gtllatory Services Fee a?6 1 y y - v htA $ r Thomas F. Ceiler,Director PRE PERMIT lfo�y r4 - Building Division Tom Perry; CBO, Building Commissioner" . MAY W 5 2010 r200 Main Street, Hyannis,MA 0266i � TOWN OF BARN-STABLE www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-623.0. EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without"?ed X-Press Imprint' k r Map/parcel Number:( / J Property Address i Residential Value of Work � ��r Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �1-1��,�'f" Contractor's Name - Telephone Number Home Improvement.Contractor License#3(if'applicable) ' Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor j am the Homeowner ❑ I have Worker's Compensation Insurance .. Insurance Company Name' Workman's Comp.Policy## " Copy of Insurance Compliance Certificate must accompany each permit , Permit Request(check box) _ ❑ Re-roof(stripping:old shingles) All construction debris will be taken,to ❑Re-roof(not.stripping. Goirig over existing layers of roof) " ❑ Re-side ; #of doors `pLlReplacement Windows/doors/sliders.U-Value (maximum .44.)#of windows *Where required Issuance.of this permit does not exempt compliance with other town department regulations,i.e.:Historic,Conservation,etc. 'Note:„ d Property'Owner must sign Property Owner Letter of Permission. y A copy of the Horne Improvement Contractors License.&.Construction Supervisors License is re ui ed. SIGNATURE:. : " � , s 1 The Commonwealth of Massach usetts — Department of Industrial Accidents 6. Office of Investigations J 600 Washington Street 1 r Boston, MA 02111 rvivw.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibhy Name (Business/0rganization/Indivi dual): f � /� 1'///ll 7—) Address: City/State/Zip: a ;k6 _�3_,;— Phone Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hued the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity, employees and have workers' 9 '❑ Building addition [No workers' comp. insurance comp. insurance.$ 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 11.❑Plumbing repairs or additions Worke�s'_cozxrp,. right of exemption per MGL _ ❑ p... 12. .__.Roof.re airs. insurance required.] t C. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks bc•x#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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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 may be forwarded to the Office of Investigations of the DI_A for insurance coverage verification. , I do hereby cerinder the pains nd p nalties ofperjury that the information provided above is True and correct. Si nature: Date: 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/Torun Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other r « io Phnne#, i 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 full out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if names address es and hone numbers along with their certificate(s) of necessary,supply sub-contractor(s) O, ( ) p O g insurance, Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not requ ' to carry workers compensation insurance.- If an LLC or LT P does have employees, a policy is required. Be advised that this affidavit maybe 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 your 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 your to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to full in the permit./license number which will be used as a reference munber. 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 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 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: The Commonwealth of Massachusetts Department of Industrial Accidents i 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 wwtiv.mass.gov/dia Town of Barnstable o� regulatory Services • Thom as F. Geiler,Director BARNSTABI.E, '� 1639. ,�� Building Division ATfD MP'1 a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barristable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: �Zold. JOB LOCATION: IOC !� number street village ,.HOMEOWNER":�yv � 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 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 requir n Si atu of Homeowne 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 t amend and adopt such a form certification for use in your community. Q:\WPFLLES\FORM S\homeexempt.DOC o�iKEr Town of Barnstable Regulatory Services saxNs BLF Mass Thomas F. Geiler,Director v �. F16 g.,a`� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ' Property Owner Must } .Complete and Sign This Section If Using A BUilde'r as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) _ F Signature of Owner Date Print Name . If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FOF NIS:OWNERPERM IS SION Town of Barnstable *Permit# 12130' 1 Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner PER PRESS-XMIT 200 Main Street,Hyannis,MA 02601 B� 1— R www.townbamstable.ma.us oQ 2((�� FF Office: 508-862-4038 FaxT 508 79b�b'230 EXPRESS PERMIT APPLICATION - RESIDE NTIA� 1 NL�F BARNSTABLE Not Valid without Red X Press Imprint Vlap/parcel Number Property Address 007-- Residential Value of Wor �FD©.�a Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �fj/,?� /is ergo-1 /— Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) A ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor -I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance.Company Name i 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 ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc- ***Note: Property Owner must sign Property Owner Letter of Permission. Home vement Contractors License is required. SIGNATURE: Q:Fomns:expmtrg Revise071405 Town of Barnstable *Permit# SSo°► ► Expires 6 months from issue date Regulatory Services Fee,z sy-- Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner®RESS PERMIT 200 Main Street,Hyannis,MA 02601 1� www.town.barnstable.ma.us (� Office: 508-862-4038 Q Fax A8 7 b-'6'230 EXPRESS PERMIT APPLICATION - RESIDENTIAEIQF BARNSTABLE Not Valid without Red X-Press Imprint \lap/parcel Number Q 9 t'!2�20) Property Address sr, C D� a Residential Value of Work" c9 O �' Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address V AME /IS e —b VIE-- Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) y. Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor --I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance.Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) �Re-side ❑\Replacement Windows. U-Value (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc: ***Note: Property Owner must sign Property Owner Letter of Permission. Homebjlvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 T'he Commonwealth of Massachusetts Department of bidaz tr Accidents Office of lnvesdgations•VIM • 600 Washington Street ' Boston,MA 02I11' . Uwww.mass.gov/dia ensation Insurance Affidavit; Binders/Contractors/Electiidaiisirlu abers NVorkers Comp , • Please Print Lee! licant Information . 'qame(Bu§=s10rtionlIndividnai): Address: v2 g P�ione#: � g�h� ty1 tote/Zip' r ' ire you a employer? Checkthe;appropriate hoe.. ;Type of project(required). n am a employer ysrith �4. ❑ I am a general contractor and I .6, ❑New con=ction employees(fall and/or part tim}e .* • have hired the snb-contractors : 7 ❑ Remodeling rietor orpariner- listed:onthe attached sheet.$ .[] I am•a soleprop These sub-contractors have ys►orking for a. •[] Demolition ship and have a in nay capacity.employees.. workers' comp.insurance. 9• [] Binding addition [No workers° comp. • . insurance 5• ❑ We are a corporation and its ` 10.[3 Electricalrepairs or.additions required.] officers have ekera ed their 3 � right of exemption per MGL 1'1,❑ Plumbmg iepairs or additions a homeowner dot aIl.work . " . •m o workers, camp. c. 15Z,§1(4);and we have no.. • 12.[] Roaf repairs elf.• • employees.INo workerst 13;❑ Other ' insurance required.]t camp.insurance required.] Any appticantthatchacks box#1 must also fill Out section-below showing their workers'compensation policy infonnadoa: '`• - • -a - 'who snbatitt is affidavit indicating they an doing alwork andthenhire outside caattactvres must submit a w ffidavit milt s M• Coatracbars that check this box must attached ea additional sheet shcw3n9 the name of the sub-amtractors snd their wcrktirs xc Otsey [am an employer that is providing workers'compensation.insurance for my employees.'Below is the policy and job site Information. [nstrranee•Company Name' . policy#or self-ins.Lic.#: Expiration Date:' Q • • t11Css: • • CZ•�y/l7tatelL.�JIj rp• ��• Job Site A{1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and•expiration date). galure to.secure coverage as requiredunder Section 25A of MGL c. 152 cirrileadto the f aS Op WC5ctiminalp E and aSine fine up to$1,500,00 and/or one-year bVrisozzment, as well as civil penaTtses m die form o of up to$250.00 a day against the violator• $e advised that a copy of this statement may die forwazded to,the Office of Investigatidns of the DI.A for insurance coverage verification. I doh hereby certify un t e pains and pp atire of perjury that the information provided above is true and correct. Si attire: �` Date: /0 Phone#: S D g �� FFLBoardolf only. Do not write in this area,to be completed by city, town off 1ciaL wn: PermitUcense# ; thority(circle ones Health 2.Building Department 3.Ck/TownClerk 4.ElectricalInspector 5.Plumbing Inspector erson: Phone#: �1S$r11C$1011S• Information and ter 15Z t Hires all employers to Provide workers' camPensatiaa for their employees. Mass achusetta General La e? chap is defined as"...every person is the service of another under any contract of hire, Purs�t to this statute, Written. rit�' mess invli Drat or legaltity,or anY two or more Ioy '':2•'4,1AP,'MS1b'''asso:the legal R ses oidry other f to•er or the An�p er is defae in a joint enterprise;and including ep of a dec 'HoW0V.Cr:*e- of the foregoing engag association or other legal entity,employing en3P receiver Or trustee of as individng of mO rshrp, ant of the er of a dwelling hoes a having not more�flee apartrneats and who resides herein,Or-the,oecag own, io persons to do mainteriaacc,construction or rep air wo=k'on such dweIlimg hous e dwelling house of another who employs p e7nplaymemthe deemed to be an employer.".. e grounds or bu-ndiug apputenaat thereto,shall not because of suchonth chapter 152,§25C(�`also states thatmeveo state�ar localUiensing agency shall withhold the issuance or MGL aP to operate a business or to construct buildings in•the Omnnonwl. for arty renewal of a license or permit applicant who'has not produced acceptable e�dence of compliance with the insurance coverageohtrsbdgm�sions shall aFii MGL chapter 152,§25C(7)states"Neither 1he commonwealth nor any of its-political Ls'p eo w the insurance Additiamally, erformanc0 of public work•unt l acceptable evidence of co . en. into any contract for the p , tractia aufority." =egoements of this chapter have been presented toApplicants the con g le ,b checking the boxes that apply to your situation and,if Please fm out tilework�' compensation affidavit'coarp telY Y their cerlificate(s)of•. - �b_contractor(s)name(s),addresses)and phone numbers) along to ees other than•the necessary,supply or Limited Liability Partaeribts'(LLP)with no erV .y insurance. Limited Liability Companies(LLC) Or LLP does bave members or p minas; axe not required to carry workers' aoazpensatib the DepCartment of Industrial employees,a.policy is required. He advised that this affidavit may . The affidavit should on of insurance coverage, also be sere to sign and date the afflda not the Department of - Accidents for confirmati the application for the permit.or license is being req teA b e retsrned to the city Sboui n the law or if you are required to_ .h•�'` ndustrial Accidents. Should xon have any questions regarding antes should water their compensatioupolicy,pleasecalltheDep�nematthenumberlistedbelow, Self-iasuredcomp . self-insurance license number on the appropriate line. City or Town 001dals artmmthas provided a space at the bottom please be sure that the affidavit is complete and printed legi'61y. The Dep applicant of the affidavit for you to fM out in the event the Office of Investigations has to contactyou regarding the a a applicant' Please be same t4 fill m thepeaaigeense number which wMbe used as a reference number. In addition,an app le ennit/lieense applications in any given Yam,need only submit one affidavit indicating currentor that=st submitmnif p oli information(if necessary)and under"Job Site Address--the applicant should cit�t��locationsb in to the F cY H A of the'affidavit that has been offiaa]ly stamped it mark, se knew town) SPY or'1ic•,enses. Anew affidavitmastbe filled out-each applicant as proof that a valid affidavit is an•file for;fatare permits ear,Where a home owner or citizen is obtaining a license or p ermit noted to complete thiseaff'idavit�ercial venture Y ermit to bran leaves etc.)said person is NO eq • (i.e.a dog license or p . . ce of Investigations vtauld be to thuk you in advance for you?cooperation mad should you have any questions, The Offs a us a call. o pleased nothesitato to give TheDep�ent's address,telephone andfaxmimber: The Commonwealth of Massachusetts . . I>epaziment of la&gtrialAccidmts . office of Tuvestigaoons 400'W+'ashi�n///�gjfm-$�treet . 11, .-.,"Tel.#617-727-4900 ext 4% or•1-877 MMSATE ' Fax#617-727,-7749 „____� t ��115 �rurw.maSS.SOV/din Town of Barnstable *Permit# 3LY �pFtHE TC 'Y Expires 6 Months from issue date - • Regulatory Services Fee-:�, .� nines - - ;_,Thomas-7.'Geller,Director T_ Buildiiag Division- _ Perry, Building Commissioners= t 200 Main•Street,• Hyannis,MA 02 862-4038 �AsjR 2005 Office- 508 __ - - Fax;'508-790-6230' -• -EXP S : ]ERTGII'T: I�]GYCATI: N - RESIDENTIA 1 a �� Not Valid without Red X-Press imprint Map/parcel Number Property Address)< Residential Value of Work �a� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Telephone Number Contractor's Name Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) []Workmen's Compensation Insurance Check one: I am a sole proprietor _ `.i amthe Homeowner C] I have Worker's Compensation Insurance Insurance Company Name Worlunan's Comp.Policy" _ Copy of Insurance Compliance.Certificate must be on file. permit Request(check box) All construction debris will be taken to Re-roof(stripping old shingles) . Re-roof(not stripping: Going over existing layers of roof) [� Re-side [] Replacement Windows. U-Value (maximum.44) e.Historic,Conservation,etc. *When required: Issuance of this permit does not exempt compliance with other town deparhnent regulations,i. ***Note,. Property Own �Owner must sign Property Owner Letter.of Permission. Home'Improvement ontractors License is required. Signature ' Q:Forrns:expmtrg • Revise063004 F Town of Barnstable of•rt+E tok, '• " Reguiatory Services- ,�. Thomas F.Geller,Director •• ' Building Division TomYerry, Building Commissioner 200 Main Street, $yannis,MA 02601 Tnm.town.barustable;ma.us Fax; 508-790-6230 ' Office: 508-862-4038 Property Owner Must Complete aad Sign This Section If Using ABuilder as Owner of the subject.property M hereby authorize to-act oa rnybehalf'3 all matters relati-re to work authorized bythis building pernu tio t applica In for; ° (Address of Job) Date Si nature of Owner --" __ The Commonwealth of Massachusetts _- --_ Department of Industrial Accidents - Office oflnuesUgat/ons 600 Washington Street, 71h Floor --- , Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors �c name' ALFR D AE /4A•jCT1/0 address: � Ra VL 97- City state:. /`/,,/�4 zip: phone# work site location(full address): '�haut a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ' ❑ I am a sole ro rietor and have no one working in an ca acity. Building Addition [ 'n on this ob> • ❑ I am an em Toyer providm w�or•rkers compensation for my employees worla � ,� 5 - > .r, .+.. ,r. .Kan it,;,• .a.a. ;x .y, 'R. ,retry o:+•. ��ro.x fir" a �eoffi an 3tau►�� _ ��-: �- Ksn.. >:,cw .�:aa`5'q�A..- -.>. = F_: .,<:':•::. , }r s sf .,E¢ .K,a, ,•�..[ ',, # �Y.>' 3'aux' s : rG , ••. �Yw�'s �n f ��{,l�k� c'�';:. .�:£` a..�1 �'h„', .r �X.�Y.�a?Fp -':�ti {� n�-�Y`!1. ,Y.: ';e: /;i'',`.1," s��. °' •'i.':'<: i+ y:Vr..n, � x'i y ,lka>.s�+":;ka�a. d�'�iXia� 3 fr`o- �'S cY:>,�n+ �.t4g n v::,�,•r.G,:�,,a,.�{ :"'^�t4 +. y .e 'S tr at�d�'e$� J a }' ..f .f!tr 1•! ,NJ# . e r a r } a r..:,.. :::.< r " ��'y4 .y,�?9 yl+d4'•S "� �x re ew 1 V. ) ,r S c"' !+ J f 1. �. 'r,`i••:r:r..':-ri:, r `,6 ,d ay�.•5^ �" r. a' s' �; � •i,di;i i k � s s'., ty'w'. tf �'� � ..�;. >fi".t�R r z� r� +.''r w k�Yc!i'd.� tr*t, ��t� � j5✓a x r r'�i<n 4�'r'�'r�,e>,�Fa•�s+� y F 3', �.1,.tt n r` �` r :y r ' LCIIX� ti,l..�`C v u��'`�Y"�•"^�`iY�Yr AS"�4- ,�.wu fST'� kL3'y""fit' �'n.`t:t��'��K t..:�Il�ee 'L�w � .r...h r � . .�: ,•:Cy:,µ' 'es'9's�?r. Y�t$..'E-0'.tT. Ng��a��,k,�T� as c w.,ri�sr4 rr,yF„sJ''4L x rnoV i;s..�'.,",i,:d : �r{ 3 } -..�4 s u° r �r..�' y�t,A�t:"x �,,:{ if� ,� r' � �i At .1 i F •7 �" iL 4 .q -..r-�� Y(4� ,,y�dS�y,� fyj'�y :r� f yA .� '• G' 4.tiis f ,•Y''d '''ff��..''1InA� .�t+K•P„ �?; sy, 'Z4'+..^7 t 'C +f' 7 iiranee?Cb�,. {)`. .r'.�:","J,�k +-"�y.s��.fA�!a.tt17;�,.�W�e'.�w?Yu �t�:;N��''�oa 1Cw, y�:�a,:•. �.�' ��c^[ �` - - - ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following.workers' compensation polices: _ ..y[:„ :#+ 't[y3•;'n �,L.: 7i.s ri:'- !%4i`.: ::i'.`.,J?'r.:: `:.f'.n S?jTF.•'•.�'- „'jY'. .v:� %'t .d se?. :.j..:. .,t;� A�. i. .f+.r , ,•� .,..i... v ...a..,. .r>,.: ,,f, ,. .....:, _ _ .......,.v..._:.: - ,x:,.:....>.....:,...,.:....:.....,:..,,.._.__Lv.,...,....A._tom..,..n.. ......:;}•� . ,,.yi � � < :.z.,5;-,-?::,E•. .:'.•, 7.A ,,:,::��sS' �.�Ir �� 1}':¢1..t.{i ,;:�y.3s. a JfS;'�.�,t F.[:ca ';<•�;L9 d' 1' -'1 :d',.:' ..,wk yf. .y:.:;- - ,..:c,,::.,n.: •• ».>r:..,.,,. .., .. `moo. ;i•t :r. ry• i 4 Y gg ]nSlrrall`CL t:bc. ...'v,,:.'..1 •?, ..e?I-..r.. _,.3., 'o " .a._,.`.".�.� ._��,t,1,a,t`:.;.y r...�t•..t. b�C N'' '' �M1 t _ :1 °1 •ra.• - biWi:` `'i 5•¢:a ��4�� - �i 1.:,:r,.::i'ti�...iik >r;.v r• �.. ' sl ):6..r�.� 4+ ..:,..'1.-.,..fn'Y..:>•?.::_l..i.h ,.F"1'.J r <�,': h !Crlty S r .<., r- �. ; ?• D110ne°#• ) - 'litSIIF811C&�C'.e: - �:c•.:,.F ,t :'*• - .:`Q11C`..:#°. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a . copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. V I do hereby certify r the pains and penal' of perjury that the information provided above is true and correct " Signature GLL Date a� Print naine4 9- Phone# official use only do not write in this area to be completed by city or town official city or town: x permit/license#� []Building Department' ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ; [-)Health Department contact person: phone#; ❑Other (r ..s Sept 2aa3) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their w" an employee is defined as eve employees. As quoted from the laevery person in the service of another under any p P contract of hire,express or implied,oral or written. other legal entity,or an two or more of as an individual partnership,association,corporation or o g ty, y An employer is defined ,p p, rP 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 w employs persons who em to s erso to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or operate a business or to construct buildings renewal of a license or permit to op ,_ s in the commonwealth for any g applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance-coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license numbe r which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation'and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number:. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 Assessor's map, and lot number ............................................. �TNE SeNWage Permit number ..................................................) !Ywc fts House number ............... ................................ STABLE, ......................... WIN T1'k Co 13 -r- 51 4L TOWN OF,, .BARNSTA- BURDING.." INSPECTOR APPLICATION FOR PERMIT TO .......7. ..,.1...te....... ...... TYPEOF CONSTRUCTION ............... .................................................................. .................... TO THE INSPECTOR OF BUILDINGS: .......................... 19@0 The undersigned hereby applies for a permit according to the following information: ...Location ............... ...... ...ORO..V6............�27. .............C-OZZ-117--—-----...................................... ProposedUse ....................... ......................................................................................................................... Zoning District ........................................................................Fire District .............C!2TZ/ ......................:...... Name of Owner O,4R.134VU........Y��. PTIII.`Acldress ....................C07.21 ................................ ... -. Name of Builder 1V-,p-`...7.-1A1...............Address ................ C.o 1../........................................ Nameof Architect ...................................................................Address ...........::7...................................................................... Numberof Rooms ................... ..............................................Foundation ................................................................................ Exierior ................. .. ................... .................Roofing .................. ......................... Floors ........................CC.&C ........................Interior ................ Heating ........................ .....................................Plumbing ................... Nl ........................................ 00 Fireplace ..................................................................................Approximate'Cost ............. ............. Definitive Plan Approved by Planning Board ------------------------------19--------- Area ......C�. .............. Diagram of Lot and Building with Dimensions 0-2- Fee ............ . .. •....................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ............... 77)yl ��U� Sl I hereby agree. to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... I ..... .... .. ....... . ..... .. .... ............ ........... MARTIN, BARBARA No ... Permit for ...ADDITION............ Single Family.. ..................................... ..... ............... Location .12.4...Qr.Q.Ve..5tr.eat.................... .................C.Q.t1at............................................... Owner ....Barbztr.a...Maxtija......................... Type of Construction ...Frame............. ........... ............................................................ .................... 'Plot ............................ Lot ................................ .-'-Permit Granted.........August 22 .19 80 Date of Inspection ...........19 .'Date Completed .................................... .19 PERMIT REFUSED ................................................................ 19 's................. ................ ............................... ....................................... ............ ............................................ ............. ......................................... Approved "3 ......................................... 19 5Y ..........•............................................. ..................... ............... ............................................................... Assessor's map and lot number .............................. .... ' .�,.,,i tiic.--l° T X-v `Ll�,.li,4, It s!!�• �� Q�OF ETp�1 N Sewage Permit number ................................................f 1; BABBSTABLE, i House number ............. ro M"M p 039. e00 p No TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .,,....,� .........� CQ , -� ��i'I L r` '�� _ .......................... ..... TYPE OF CONSTRUCTION ................. 4? 5tt( �' ,............................................................. ...................... ...........................:.., . .19..�. j TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...............� '.`? �......... �'..1��}.O..�.z ... ....�..�. ...............OZZ// .... ProposedUse ................. ... ....................................................................................................................... Zoning District .................................................. �- T/,/ 1 .....................Fire District ............. n......................`...................................... Name of Owner 4-121-S%4 2.r.,: ........A/X0 ddress .................. +.....1 J...................................................... Name of Builder :!`!.::z�... /�� 3�7 f.<' J........... ...Address .................. ................................... Name of Architect `......................................Address "" ' Numberof Rooms ..................................................................Foundation .............................................................................. Exterior .......................... ..'..........................................................Roofing ,!� l - .............:...........................Interior ................................. �+ - -D Heating ...............................:. .........................................Plumbing .......................f ............................................ Fireplace ..................................................................................ApproximateCost............� :C1� ..^....... .. c Definitive Plan Approved by Planning Board -------------------_-----------19--------. Area ..... r...... Al .�-�.%....:........ Diagram of Lot and Building with Dimensions Fee � 6a ........... �........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH V 1. I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . '/::' x'!L ...............s //� ?Y�.. .......... � ' M\BTI]8' -----'r--' No ..22..4.4.6.. Permit for ..A.}DZ.T1{I0.---- ...........S ..Famlly...Dwelling.......... ` � Location .1.2.4..i3rove'.�Stremt.------- COtoit � ----^'-----~---------------' Owner _. ��za .Ba�� _8�aztin________ . . FrAme Type of Conm,ucti ~ ..... ........................ ' ' . rm/ � Permit Granted^ ^ ....... lgu�t...2.2.........19 80 --- — In.ection ... � Date Completed 19 . ' "=RM=" REID ' . � ____ 19 ' -----��'.�--'' ------ / .......................................... .................................... ` '---'—'--~---^' '—^'^'--^^~^--^—` ' ----^^---^~--' .......................................... Approved ................................................ lA � - ............. --------..--...--..~..—.-- � . ^ .'.� . � -----------'^---'---^---^^^'—'^ ' U u ' THE INSTALLED IN CO TOWN OF BARNSTAIEPMEGULATIONS � ^ ' BUILDING � NN NN �� 0 �� INSPECTOR , ^ ' �� 00N0-0� N �� - � �� - -- -_ � APPLICATION FOR PERMIT TO .........-A0.412... [t�.......... ...................................................... ' TYPE OF CONSTRUCTION ----_. _ _____.__,_._._..................................... � � ' ............................ —..—lgJ�L�. TO THE INSPECTOR OF BUILDINGS: - � The undersigned havu6v applies for o permit according to the following information: ��/ -�|/ ' Location --^—'.^--'��Q��—..~°.,..�--..��^(-------------------.___---------- Proposed Use --.. ..... ------------------.-----,------__. Zoning District -----.^(.}.��...---.—.--.-----.FiveDi��icf —.----��/.�/�'/---~_..-------. � Name of Owner I.Jl-vFlI5qg... - ---A66,00u W —. r- '-- Nome of Builder ----------------------'A66rex -------------..—.—....—,....—.---, Nomeof Architect ..................... .........................................—Addren ..................................... , Numberof Rooms ................................................... ...............Foundation ..................... ........................................................ Ex/erio, -----' i?...................... ...........Roofing ---' t ............................ � Floors --------............----------------..|ntehcv ........... ............................................. Heating ..........................=...................................... ......Plumbing ........................ . �w Fireplace ---------------------------.Approx|mo^eCoo ----'ZgM/— ................ Definitive Plan Approved by Planning Board --------------------------------lg--------. Area Diagram of Lot and Building with Dimensions Fee _.. .................. SUBJECT TO APPROVAL OF BOARD Of HEALTH ' � ( � . � .. � OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS � ~ � | hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above � construction. ` � Nome .. ----`."------.~ Construction Supervisor's License —./°}�� MARTIN, ALFRED E. t , No ..•28332.•• Permit for ...ADD DORMER ................ "`Single FamilY. Dwellin ...................................._ ........................................ 'f 124 Grove Street- Location ................................................................ Cotuit - i '^ Alfred. E. Martin Owner .....................................................:............ Type of Construction Frame ................................................ r Plot ............................ Lot ................................ Permit Granted ....Auguat...LS,...............19 85 Date of Inspection ....................................19 = - Date Completed y. ...............19 I R ..s S + Q - . ---X M C) i S Q, r a:, . I `. 'Vw1 .1 [ w �, Permit number— -----------------r' , House number -----------------`-----..` . . �� ' �� ]� |"� �-�� » �� . P� �� ]� ^��-� ��u ' | � BUILDING � NN N N �� N �� INSPECTOR — �� N0N0-NNN �� ~ ~= � �� ~ �� APPLICATION FOR PERMIT TO ..... .. .�'. [�.--...—.--.—...—..----.—..^--.. � , TYPEOF ---- ........................................................................ 1 [� �~ i —,....----,JL�� ........lg/�Ll | TO THE INSPECTOR OF BUILDINGS, . The undersigned hona6v applies for o permit according to the following information: � �� . LLocation '_.�/��--.\��p��f�—..�l/.� ....... --------,.--..---.—.—..—,—....------- ` ProposedUse ........... —. ms..................................................................................................... ]Zoning District ................. .............................................Fire District ................. ,____________ . Z� /,�� «77— 7-- Name ofOwner —��—.-�}�I�Tl.��—..—Add�ss ��x^— ...L.,��/�!�.^--,—.. /' )' 1[ > � Nome of Builder ....................................................................Address —.---------.—,.—...,.—.—.--.-----. � ` � Name of Architect ..................................................................Address ---_--------_---,----.--_---' Number of Rooms ............................................ ,...................Foundation -----.---------..._..-------. � Ex/erio, ------��a� --..'-------Roofing ----/��7��,�/-----__--------- Floors ---_----..��----------------..|nh�icv ---. --.-----_.^--_—~. ' � Heating ............................. ...' --------------Plum6inQ —_--......._.X -~_ _` Fireplace -----''�--------_-------_----ApproximoheCos _---.��6��,.—.,,,,,'_,__~_,, � Definitive Plan Approved by P|onning800nd l9--------, Area . .�� Diagram of Loton6 Building with Dimensions Foe .....�(��.�-�— -----. SUBJECT TO APPROVAL OF BOARD OF HEALTH ' ' ' ' ' ' � ` � . . | ^ ` OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ` ! hereby og,ao to conform to all the Rules and Regulations cf the Town mfBarnstable regarding the above construction. � Nome .. ----------_., Construction 3upervioor� License '409. ....... ` ` j MARTIN, ALFRED E. A=19-30 No ....28332. Add. Permit for ..... Dormer ......................... Single Family Dwelling Location 1.24. ...Grove. ...Street. . . ........ .. . ........ . .... . . .... ............. Cotuit ............................................................................... Owner Alfred E. Martin ................................................................ Type of Construction ....Frame ................................................................................. " Plot ............................ lot ..........::.................... Permit Granted .....Auguat..15...............19 85 Date of Inspection,....................................19 Date Completed ......................................19 C( Del r -� -4- ,��.,-� TOWN OF BARNSTABLE BUILDING PERMIT'APPLICATION Map Parcel D3 ID Permit# S Z5 c2V o Health Division Date Issue —71- Conservatio,RDM ion Fee Tax Collec - - Treasur k ' Planning Dept. Date Definitive Plan Approved by Planning Board • Historic-OKH Preservation/Hyannis Project Street Address a el y / ; Village ' Owner LT Address /q :''t- Telephone 6�®�g ey Z Permit Request I pzlyn V"e- �� /� ��o y S�As-0/V 006M Square feet: 1st floor: exists proposed �2nd floor: existing proposed Total new g ; 1 Flood Plain Estimated Project Cost ©•� Zoning District Groundwater Overlay 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 ' *o On Old King's Highway: ❑Yes U6, 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:O existing ❑new size Barn:0 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 review# Current Use Proposed Use �1 BUILDER INFORMATION Name [ J/, AI e l? Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �e-�l Y FOR OFFICIAL USE ONLY r -- PERMIT NO. DATE ISSUED MAP/PARCEL NO. . it r. •, � `.. � _'� - ._ • ADDRESS , VILLAGE r. _ t OWNER DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 1 V. PL'UMBING: ROUGH FINAL r GAS: A ROUGH FINAL FINAL BUILDING V�/ `' 'r 1 i l DATE CLOSED OUT , 3 • `� ASSOCIATION PLAN NO.' f EAigineering Dept. (3rd floor) Map / Parcel :O,'3Q Permit# CO U 2 House#• I Date Issued 2� v Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee 2S. C D Conservation Office(4th floor)(8:30-9:30/1:00=2:00) Planning Dept.(1st floor/School Admin. Bldg.) oF1HE Definitive n A roved by Planning Board 19 • BARNSTABLE. 039, 5 TOWN OF BARNSTABLE, . B ilding Permit Application Project Street Address Q Village Owner A��t�t E(� �i� r� Address 1�2,4f 6f OVE- Telephone ,Permit Request .First Floor square feet Second Floor square feet Construction Type ; Estimated Project Cost $ (a, Zoning District Flood Plain Water Protection Lot Size Grardfathered ❑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 i °a 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 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITION REQUIRE S REQU E A SITE PLAN AS BUILT SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR qE FOLLOWING REASON(S) t i/29'� FOR OFFICIAL USE ONLY PERMIT NO. - 3 .60 DATE ISSUED - MAP/PARCEL NO. c- ADDRESS VILLAGE ; OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS:,., ROUGH FINAL { FINAL BUILDING 1 ✓ ' c� CJ�/ 1lit�(� ; DATE CLOSED OUT ASSOCIATION PLAN NO. , The Town of Barnstable - usxsrnBM - 9� Department of Health Safety and Environmental Services ArEDMO'f� Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph•Crossen Fax: 508-790-6230 Building Commissioner 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. Type of Work: C2(Y�I FM[9VA L, Estimated Cost Address of Work: Zed e9 1?0 yk- `r Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 .f 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. 2, Date Owneirsgzr q:forms:Affidav The Commonwealth of Massachusetts !� Department of Industrial Accidents " ONCe ollnsestionfaffs �: It?�M 600 Washington Street � Boston Mass. 02111 Workers' Com ensation Insurance Affidavit name: 4.4 F ,,5-17 L" Md GM I A) location //�of 4 0 e1 D yE city 0,6-ru I-T phone# am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers* compensation for my employees working on this job. comynnv name: address: citV. phone 0- insurance co. pniicv# ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the follonzng workers' compensation polices: company name• :::. ......... address• dtv phone#- Jmurnnce cn. Rolkv# comnanv name' address. cih^ ... phone#' insurnnce co. .: oiicv# ::: :.;::..:.,...:.?..::::: / / Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a Me up to$1.500.00 and/or one yeah'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tlne of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the 011ice of Investigations of the DIA for coverage vefocation. 1 do hereby certify under the pains and enalties of perjury that the information provided above is true and correct Signature �2 Date Print name 41-Fa E v z �t4 aT i it) Phone# 60 8' 02 8' PLO 44- rCoi3 ial use only do not write in this area to be completed by city or town ofIIcial or town: petittif/ltcense# ❑Building Department❑Licensing Boardheckitimmediate response is required ❑Selectmen's 018ce ❑Health Department contact person: phone#; ❑Other (revisee 9,95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under anv coat—-- 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 receive: c: trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: 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,neitherthe . 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the`law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/licease number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been,made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. O%EN/011 %///�y70/ The Department's address,telephone and fax number. ` y The Commonwealth Of Massachusetts- Department of Industrial Accidents Office of Invest1gadons 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 TH S PIS USE '. r I ONLY I MA F S 9N 4�` _�.... �_ \ 7 ANY WAY. S NOT NDUCEDIA TOWN OF BARNSTAB IS 24.3 • h 2 5; / i /��y I. / 24 :.1 ._. ..� .� G ��/ . Syr ,........ , Y � f 3. ............ 23,2 365 35. f , rr . .\......`.... fit- - i �•--` . n. Y .... 55 -4 c:/barn/conrad/base019.dgn May. 02, 1995 12:28:.19 T ZFIE The Town of Barnstable 4 F �'tio� Department of Health Safety and Environmental Services Building Division BARNSTABIZ 367 Main Street,Hyannis MA 02601 i6gq. �0 �ArEO INA'I A Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER"/JZ62 ZAWj /, V 5��g�� g(6o? A103V name l7,/�,, Ec home phone# work phone# CURRENT MAILING ADDRESS: �T7, oy _- 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 requir a ts. o Signatur of Homeov4ler 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:FORM&EXEMPT The Commonwealth of Massachusetts ),"s I=- Department of Industrial Accidents . 600 Washington Street Boston,Mass. 02111 Workers' Co m ensation Insurance davit • ��iiiaiii sill/��%��/��J � // ��/r//�%%,�» name T �.ER L O L � I/-V location: V E- R TT - - city 0671)1 T— - d - (7) oZ 3 phone am a homeowner performing all work myself. ❑ I am a sole rietor and have no one workin in anv ca acity DG%///%"//%%O/%�/O�/%///%/%% /%/ %%%l%%%%%///%//////////%%/O/%/%/%/%%%%/////%/%O//%/%%%/%/%///////O�"� �///%%/ %%//„': ❑ lam an.employer providing workers' compensation for my employees working on this job. comaanv name: address: city phone#: insurance co. olicv# WON ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the.contractors listed below who have the following workers' compensation polices: comoanv name- address: dhr phone* insurance cn .>:.;::.;.:.::.:,.::::, .:.:..,:.:. oltev#.. :. ;::>.....camn :>;:;:;: »:::;::><;< anv name* ....;.:>; :::::.:::::;:::•:;;; :::<>:::.>:::;:>.:.::.::.::::....:::::;:,.:;:::;:.;:.;;:.:<:•;:.;::;•;>:::.>: . :.. ::.:....:::..:::.:. ..:. ..:... address: :<';:;:`::< phone .:.... ;::... _. .;::. ::.;:.:._: :.:... insurance co:. .. ... Failure to seentz coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certi r the pains and pen ies of perjury that the information provided above it&w and correct Signature Date !2 Print name - Ph0e# offlcial use only do not write in this area to be completed by city or town official city or town: penn"cense# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Oince ❑Health Department contact person• phone#; ❑Other. orand 9/95 P)A) The Town of Barnstable 9 ' AM �m Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building•Commissioner 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. Type of Work: Estimated Cost Address of Work: Owner's Name: Date of Application: , I hereby certify that: Registration is not required for the following reason(s): Work excluded by law 01ob Under$1,000 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. OR Date Owner's Name q:forms:Affidav A - TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. JOB LOCATION © U��- Number Street address Section of town "HOMEOWNER"A f F.-0 2d('7- Name Home phone Work phone . PRESENT MAILING ADDRESS �x /0 700' l r4 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 Offic: on a form acceptable to the Building Official, that he/she shall be resuonsi-Z for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes . responsibility for compliance with the S.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 minis-m inspection procedures and requirements and that he/she will comp3pdurft-,* and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. t J HOME OWNER'S EXEMPTION -� The code state that: "An Home Owner �u Y performing work for which a building permit is required shall be exempt from the p 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 Owr, shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for •licensing Construction Supervisors, Section 2.15) . . This lack of awarenE often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home "Owner act as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware -of his/Aer responsibilities, ma communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of. a supervisor. On t.: 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. Engineering Dept. (3rd floor) Map Parcel 3 Permit# L House# �`11 w D to Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Conservation Office(4th floor)(8:30-9:30/1:00-2:00) sat W. 48TEM MUST of! Pl4vePIan floor/School Admin. Bldg.) INSTALLED ce Droved by Planning Board 19 `� AB•4a3LT®TOWN OF. BARNSTABLE Building PeennitApplication Pss fay cy�bV II: al . Village` ,, Owner A�Ea,a EMi9 j�j�%m / Address Z211 91t?0VF 8- , Telephone �7 Permit Request First Floor square feet Second Floor square feet Construction Type 00 Estimated Project Cost $ Zoning District / Flood Plain Water Protection Lot Size Grardfathered ❑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 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO FA — SIGNATURE - DATE BUILDING PERMIT DENIED F THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. � ' DATE ISSUED MAP/PARCEL NO. ADDRESS t' VILLAGE OWNER } DATE OF INSPECTION: FOUNDATION , FRAME i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBINC4j ROUGH FINAL GAS: a ROUGH ' FINAL , FINAL BUI ID-5G; _ , r .. , -, I .. ? wt DATE CLON ^ ASSOCIATJ;.�� LAN NO. Tina Cu"J"YOUNT171111 of ntassacliusetts Department of Industrial Accidents IfficeafloceW-atleas 60l1 ilT +I i�,ton Street 4�•` Burton.A1am 02111 �-' Workers' Compensation Insurance Affidavit .� e„pnlic•�n nformation ~ Ple-:tse�'R►NT'le�ibly�,a,,�, - name �� ,� /i locition ett� Ir nhone f �� ? am a homeowner performing all work myself am a sole proprietor and have no one working in any capacity I am an entplover providing wort-ens' compensation for my employees working on this job. o v Irirc • city phone N. incur-ince en ^^incv .e...... I am a sole proprietor. general contractor, or homeowner(circle one)and have hired the contractor listed below who na the following workers' compensation polices: m am•name, idre n nhone 0: nnlicv tt incur-ince co -�,•, .,. �.. �..---�•--Y� -�- om am•name: •tddre c• its nhone 0, ' curtnce co policy a_ ------ — Attach addi_tionai shcetif neeessa�w�-�--:�...''d!'rsfiesf.-.:. :�r+d.�� .....,r..v...°•a� -y"�rn - 1�. ,��..-�ru•;r. raiiurc to sceurc cnvcrage as required under Section 35A of A1GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 andiur one wears'imprisonment as well as civil penalties in the forth of a STOP N+'ORK ORDER and a fine of 5100.00 a day against me. I understand that a cap)*•of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. 1 do hereby ce, y a der the pals d penalties of peilut t•that the information Prot ided above is true and correct. Si_nature -Date /�� / Pont name3 �,4f rT-1 ` Phone# otTicial use onty do not write in this area to be completed by city or ttm-o official city or town• permit/license rt rIIuilding Department • C3Ucensing Board �. �Scicctmen'x Olticc Li cheek if immediate response is required011calth Department phone ft; M01her . contact person: ,F Information and Instructions ' Massachusetts General Laws chapter I S_' section 25 requires all employers to provide workers- compensation for the emplrn ccsti i;As quoted from the "law", an employee is defined as every person in the service of another under an%, contract of hire, express or implied. oral or written. An emplm•er is defined as an individual. partnership, association. corporation or other legal entity, or any two or mor the fore-oina enLagcd in a joint enterprise, and including the le-al representatives o`a deceased empoovrsr. or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However th owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the dwcllina, house of another who employs persons to do maintenance , construction or repair work on such dwcllin�= Ile or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to bc.an employe MGL chapter 152 section 25 also states that every state or local Iicensing tlgenci•shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contraurt for the performance of public work.until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of industrial Accidents for confirmation of insurance covera=e. Also be sure to sign and date the affidavit. The aftidavit 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 ydtt have any questions regarding the "law" or if you are requireo to obtain a workers' compensation policy, please call the Department at the number listed below. Cin• or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie: be sure to fill in the permit/license number which will be used as a reference number. The affidavits maybe returned the Department by mail or FAX unless other arrangements have been made. The Office of Investi=ations would like to thank you in advance for you cooperation and should you have any question, Please do not hesitate to give us a call. . .. n• .z ��-ii.• — - .;tin,. 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 fax #: (617) 727-7749 f .. nhnne,g: (61 7) 727-4900 ext. 406. 409 or 375 . The Town of Barnstable mum Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 ' Ralph Crossen Office: 508-790-6227 Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME DWROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to_ structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work W/4�9 S1,!E1dAZZ-S Est.Cost ©� Address of Work: Owner's NameLF1�PL� ` '�� T112) 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 HUROVEIVIENT• WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR. :-_ .. TOWN OF BARNSTABLE BUILDING DEPARTMENT ' HOMEOWNER LICENSE EXEMPTION Please print. DATE L JOB. LOCATION � -Number Street address Section of town "HOMEOWNER" �1j� Name Home phone Work phone-. -- PRESENT MAILING ADDRESS �0� 1 © Q 'IT�'-:'- C-ty town State Zip codE The current exemption for "homeowners" was extended to include owner-occupy' dwellings of six units or less and to allow such homeowners to engage an ir.' dividual for hire who does not possess a license, provided that the owner acts as supervisor.. DEFINITION OF HOMEOWNER: Person(sJ who owns a parcel of land on which he/she resides or intends to r side, on which there is, or is intended to be, a one to six family dwellinc attached or detached structures accessory to such use and/or farm structure - A person who constructs more than one home in a two-year period shall not I considered a homeowner. Such "homeowner". shall submit to the Building Offi on a form acceptable to the Building Official, that he/she shall be respons for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes ..responsibility for compliance with the Building Code -aad 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 requiremen and that he/she will comply said p c dures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be requirec to comply with State Building Code Section 127. 01 Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a.- bu±ldi: permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 — Licensing of Construction Supervisors) ; provided that Home Owner. engages a persons) for hire to do such work, that such Home shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assumii the responsibilities of a supervisor (see Appendix Q, Rules and Regulati( for .licensing Construction' Supervisors, Section 2.15) . This lack of awa: often results in serious problems, particularly when the Home Owner hire: unlicensed persons. In this case our Board cannot proceed against the inlicensed personas it would with licensed Supervisor. The Rome"6wner* ; as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, communities require, as part of the permit application, that the Home 'Owr certify that he/she understands the responsibilities of a supervisor. Or last page of this issue is a Iorm currently used by several towns. You it care to amend and adopt such a form/certification for use in your communi