Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0135 GROVE STREET
L � n �--- ,� - ,� �. ., BIKE Town of Barnstable *Permit tres 6 months from issue date vi Regulatory Serces �ee_ , — BARNSPABLE. MASS, g Richard V.Scali,Director 059. Building Division � a Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 NOV 0 2 2016 www.town.barnstable.ma.us Office: 508-862-4038 TOWN OF BAR M&0 0[6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Q/ Property Address C yh' l esidential Value of Work$ q000' Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name �.�f.� i�'L Telephone Number_-7744 '3�, _7&Z(' Home Improvement Contractor License#(if applicable) 1T`e (O 7 — Email: 6JP I5,+(L+A\ l L"toy K M&R tit? Construction Supervisor's License#(if applicable) r , ❑Workman's Co ensation Insurance Ch ne: 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 accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Rv. ide glf�eplacement Windows/doors/sliders.U-Value . (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. . ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improve nt Contractors License&Construction Supervisors License is re uired. SIGNATURE: Q:\WPFILES\FORMS\bu' ng permit forms\EXPRESS.doC 06/20/16 171e Cozamornvealth ajfMassadrrrset s Department afladustrialAcddents . 600 Washington street Boston,MA O2HI tvrvtt_ma=gov1dia Workers' Ctampensatien Insurmce Aflidzvit BBmlder-dCuntraciurs/Elecfncians(Pbmibers AppHcan#Tmfarmaiian Please FFin Env Dame Address: � �I,t �'� .• City-/Sta t=1 1!✓ Phone Are YOU an employ+er?:Qteckthe appropriate bar: Type of project{required}: I.El am a 1 m ith 4 ❑I am a get erdl contmctor and I . ❑ oyees( o�pant-timed* have lured.the suFr�onbMctors fi. lkie�v cousi cEzosx 2. I am a sale proprietor orpartner- listed on the attached sheet. ?- ❑RemodelFug sbx p and have,no employees . These sub-contractors have S_ E]Demolition wodaag forme in any rapacity. employees and have wod=- 9..Q Building addition [No lam'Comp.fim=nce Comip.amrance I retailed-] $. ❑ We are a coaporatim and its 10-❑Electrical repairs nor a,ddi ions 3.❑ I am a homeowner doing all work, officers have exercised their 1L0 Plumbingrepairs or additians mysel€[No worker'comp- right of exemption per MGM 13.❑lioofrepaim . incurranceretuired.]l C.Lit,§I(4) and we have no employees.(No workers' 13_❑Other comp-insurance Vie-) •Amy gVHc=&atchedsbcmRrwstRIsufMoottiLesectionbgowshuvdagde¢wMke3S cmmpensatiauperuginffi=2dm3- #Ekweoamerswbosubmittthise$idzmmtffr tm_gtLeyma&iingzUoral=1thenhima ti&conurem submita new affidazit'huhcoingsmb_ ICa I -ffi t chedkthi b=nMast sttache�aa9aa;r;,,.g�si�e2 shotcffigthenam of the and stafe�rhe�h�arnotfhnse a fiesha� aployees.7fthesabtoabactashave emplayw%theynwrpmvide t&warkms'comp.poIk3r n=3hes I am are etlipL*w Mat is prmiding warkes'compertsaftan utsviraumfor my empkyves. Mow is Ae pa cy aad job she in�Ot7nflffDn, ' Insurance Company Name: "Policy 4k or Self-im Lio ;k ExpinfionDafe:- Job Site Address: City/Stdel2�p- Attach aropy of the workers'compensationpolicy dedaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MM m 15 can lead to the imposition of criminal penalties of a fine up to$L OD.00 indror orie=yeairim p isousmeut,as well ascivil pr 161--sia She faaa of a STOP WORK ORDERand s fine of up to$250_00 a day 26 the violator. Se adidsed that a copy of this statement may,be fxvmded to the Office of Inestigataons ofthe DIA for insmance coverage verifrca3ion- e I do ifercmby thepal#sandpan - a the iqfbrat3a Twsprmtided abmw is bug and car red; Sitntature. Tate G►; iat usg rxrt£ Do ttat ante in this area to be txrreipfeted by tarp srtuirtt aQt City or Tav= Perm tlLieense;ff Issuing Authority(tazrle true): L Board of Health I BWTArM3g Department 3.fitpTowt Qerk 4.Electrical Inspector 5.Plumbing Fn pector 6,Other CbRtMct Person: Monet: 6 Information and Instructions ` M&S.M. 7•rtrceff s CIM-3elaI Laws amptm M reqp=all may=tD FQav2de woks'campMSa1on for then'=.ployees. p -toi this stdctm,as=FIayee'is defm ed M, .may person in the smcvice of another under any camfr ct_of hoer express or implied,oxal or 71itte:m" An=,player is dafned as"an bdrnidnal,partnership,associEdion;corpM&M or ofhPa legal=±[ty,or any two or more of the foregoing=gagedis ajoin± ,andinck(fmg the legal*eprmseE[fatiyas of a deceased employer,or the receiver or trustee of an individual,per,association or offer legal eattty,employing=PmyCCS- However fhe owner of a.dwelling house havnag-notmore than tbrw apartmeats and-who resides therein,or the occupant ofthM- dw Mag house of another who emph U s persons to do mamtenanw,cent uLt on or repair work.an such dwelling house or on the grouni3s or bculdmg appmtma -&=tn ffiO not because of sash emplapmez3t be deemed t,be an employer." MGL chapter 152,§25C(6)also states that"every sfaf a or local licensing agency shall withhold the h trance or renewal of a Itcense or permit to operate a.business or to construct buUdings in the commonwealth for any applicant Who has not produced acceptable evidence of edmpU mm with ffre insurance coverage requirmdL sr, Additionally,MCZ.chapter 152, §25C(7)statrs,fileither the rn rx rrwealth nor a'dy ofif3PDT ical Snbdivisions shall enter into any contract for the perEaanae 0fpubhc work until acceptable evidence of compliance TM the inSMMc6. regc�rrmrnea3ts of this chapter have Been presented to the contra g aofhoaty_" Applies Please fill o:Ct the workers'compensation affidavit completely,by g the bones that apply to yom r situation and,if necessary,supply sub-confrador(s)name(s), addresses)andphone— arcs) alongwiatheir cent ficatecs) of insaran.ce_ Limited Liability Companies(LLC)or Limited Liability,Partnessbips(LIP)withno employees other f-um the members or partners,axe not mquard to carry warke&compensation inscnance• If an LLC or LT P does have. employees,a policy isregn- Be advised that thisaffidayltmaybesabmifedtothm Department oflndustrial Accidents for conffimation of fimz mce coverage: Also be sure to sign and date the affidavit The affidavit should be resumed to fie city or Town that the appficafion for the pe>mrt or license is being xequeste(L not the D Ppartmeatof n a �_=d� Should you have any quest ons regarding the Iaw or ifyon arm regnaed to obtain a wn�ers' S msared a cries should ear their ease call the D of the number Iisi>rd below.. elf � compeusatxonpolxey,PI Department s elf i ocean cc license number cm the apgropdiaf m line. City or Town Of Please be sore that the affidavit is cemplets and prirxted legxibly. The Department has provided a space at the bottom of fie affidavit for you to fM out in the event the Of oflnvestiD ons has to con act you iegarding the applicant. Pleas e-b u m=to fill in the pen�aid'/liccn=Tn--n ea which viill be used as a rsference number. In-atidition,an applicant that must submit m-ultipIe pexmllicense applibations m any given year,need only submit one affidavit indicating current policy or ial oration(if necessary)and under`Job Site A-ddress"the applicant should wrhe"all locations in (may town)"A copy of the-affidavit that has been.officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for b3tai permits or licenses_ Anew affidavitnmst be tilled out each year.Where a home owner or citizen is obtaining a license or permit not related s�to any bn or commercial 4entirm (i-e- a dog license or penDit to bran leaves etr--_)said person is NOT regahed to complets this affidavit: The Office of Inds would like to thank you m advance for your coopexatian and should you have any questions, please do not hesitate to give us a call. The Dep�rtnenfs address,telephone and fax iaumbeax Tha Comn(MVMn of MasmchuSCM Daparfmmt of�A00kenta Office of l gati=.� Ta 41' 617-727-49W=ft 406 car I-a77 MA SSAFF' Fagg 617 727'749 Revised 4-24-07 �-g „ � - - . •{ Y;X .• L/16G ,Y 077UJ776�21UPiQ'LUL�����LCL10�C�Cl6EG/.1 Office of Consumer Affairs&Business Regulation HOME IMPROVEM ENT CONTRACTOR t a Registration:;;:5),84667`' Type: � Ex ira'p tioa-� 20.1ig • Individual �! ;_ KYLE A.MARTIN -- . , _. i KYLE MARTIN :E _� 0 .466 BOXBERRY HILL`I EP E. FALMOUTH,, MA 02536 ' ! Undersecretary License or registration valid for individul use only before.the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 i Boston,MA 02116 _ I Not valiJ without signature I " Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-094654 - � _` Construction Supervisor or Suervis Construction P Which contain KYLE A MARTIN s of any use group 466 BOXBERRY HILL IV;qrM ResCnct- to: Building g91 cubic meters) of Unrestncted- EAST FALMOUTH MA 02536 000 cubic feet( U less than 35, ya enclosed space. • (�,.�n Expiration: Commissioner 11111/2017 possess a current edition of the Massachusetts Failure top MASS•GOIIIDPS Building Code is cause for revocation of this license; State Licensing information visit:YVWW pPS Licensing." - i �IME]ty Town of Barnstable Regulatory Services x�TaaLe' " Richard V.Scali,Director Es639, � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 , www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section . If Using A Builder I, f��l t p ,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) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Si ature of Applicant hqLe-., A W6-t-v-%, Print Name Print kame Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,Map Parcel U Application Health Division Date Issued Conservation Division Application F C)o Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board eYn Historic - OKH _ Preservation/ Hyannis Project Street Address Village co-T-0 t_ _Owner ( '� Address l` S�' G- Telephone __Permit Request siau aA AeW l`Z- k wp= �'s,e— . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 i i 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: BUILDING DEPT• Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# JUL 26 2016 Current Use Proposed Use TOO AiN OE RARNSTABLE APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam -z�1- � E, V vl_C�tk°mil Telephone Number -7-7244 73�0 s�Zcf Address q(o& 70 �Ve �-1 t ec c� License# ©c(L4 ca V+ Home Improvement Contractor Email C;0-46t(UCtt0v1 ICE TV14i Ckvorker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOJ2� SIGNATURE � -;DATE, Pr FOR OFFICIAL USE ONLY APPLICATION # u- j DATE ISSUED i MAP/PARCEL NO. i ADDRESS VILLAGE Is , ',. .t OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL P GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. TIM Coazm-or weah*qfMksNa =ets e�ca'tn€e t a ' zed skid Acddentr # 600 W=hhwton JS re et , Boston,MA.02HI _ App$c.mit InfornuafiioIl Pl.e2se Prfi Fit i�p -Na= ko- An�-I J Ad&e= CSio �� Oy� Y� ° `�7�—f CO SSA Are you an emplger?Checktbe apprapriate box: Type of project(regmired)_. I.❑ I am a employer with 4. ❑I am a general coafmctor and I 6. ❑ldeiu construction e _ Owl andioc part- e * have]sired.the sub"CoatmCtors 2. am asale p mpa iebx or gamer- listed oa the a-tta6ed sheeL 7. ❑Ram &Iiug ship and have no emplayees These soil-conhactars.hate g- F]Demolition wcddIIg facme,in any capars4g_ ea�glayees a�have x�or]�s' 9. ❑BIIi1dmg adtiifioa [NO q'�-kWM= 0 comp_i murarnrp# . d 1 5- ❑ We are a caporatim and its 16-0 Ekcidad repairs or adcS ons- 3.❑ I am a.homeownw doing all work offioers hmm•ermrcised their 1 L❑Finmbiag repairs as ad&ian!� myseLt[No workers' of a fiflu per M(M repairs o in cee�ired j i � c.I52.§I(4k aadwe have n 12_❑Roof ewlayem U90 wad=' 13-0 o fier klj . ` cow msoaanre require&] 'day spgff��at c5ed�bas�l mast e]sa ffio�tfit��ttioabdmv�n�:g @�eirivodcexs'ca®,gw�.e,n�.pay�y��� t sah�ic6is g they sedahigsg+w sadBenhamoaMideceatss sacIL -'f:h� tz[6-1,thin bmc Est fie$ adt ti�al sitie�t sfioscing then of the sf�e�rheths�aot thII52 ha , - des.7€thgcs hgce emgiop�rs,�ep�srgiavide Sur trark-e�'�mg paw as�tsez lam im emiplayw float is pravirMW ivarkets'caaWensafian inmrazzs far any eazpkQ 3etvw!s the pv&7 anal jab site iu,farnxatFDa I-aso m e Cmapanp Name r PdRey 44 or Self-ins.Iic.� FxpimfiaaDate: Job Site A&hv Cingl5tatef p= Attach a copy of the workers'compeusationpolrcg declaration page(showing the policy,number an4 expiration date). Faslmre to secure coverage as requiredund r Section 25A of MM-CL 15:1 can lead to the imposition of climiaai pena]ties of a fine up to SUOO OU amVar one-y-earimpriso as we11 as civil penalties m ihe form of a STOP WORK ORDERand a fine of up to$250- (1 a day against the violator. Be mhrised door a copy of tb is f-Wercient maybe forwarded to the Office of 1mvesttadow of the DIA for insumoce cage,vedfica3ioa F rfa ftereby 'Buder.dta pains d gff flan tha info d a i g has and carrer.t Ste_ 4 Date:,, C'e 2 Phone fib a w aunty: Da scat write to figs ahem€a be carvTfiW by cep rarfawn a,Trcrrat Coy or'Tawn: PermlLicen se# LegAalhartfy(rude omt): L Bw"d of Hzd& M BmTiring Department 3.ff1yfTo n Clerk 4..Uectrical Inspector S.Plumbing Inspector b.other coact Per�mn � Pho�#: i 6 L_ u: n■w�•w ■�_ ■.n tr .■m:.._ _1 ann ••�w "n rI •- ■- -••n��s. .nna:+■ .Ia•n rn i• a .+nu • •■■ ■Y■■1 ■• t. /. "mail •.)■t■�■ - - •�i •■ it it - • ..■/•• ■1■■� .n r•I■It r • •■■ • %/I/ r •I ■ - It!i/ : -■1 ■■■[ Il•Y •Y■ r1�w■[.r •I.•wrla•1■ r•1 •• _■■na •1 •r■� -_ fatal ' .1 -r■• ••• • 7■•I " • ■•- nl - ■■/' �• _w:■ rf■1:- .It• t■ n■■1/ ■■- - _ •1 �?•1Y.••w • : ■ �/ ii1.a• •• •1 I■- �. �7 +- • ■ • ate- • :11 n• • n■. •d ■■rw■■1. .I-w•wY[■•■ •1 •t.►: -1: Ufa■t • ilnlr in• NMI • •• i•` • t■- •••■ ■ _ ■ - 1 n• ■•■ - •. O• ■• u•f - ■■_n Or v .rr a ■n r■1■. :u. ••■• :.Y•' O u ifU a t•- • rn•.ut • lr" • -1 n• .■a • .n■•1 o- •t• gnu •• ■�w sn n .• u.un■�■.n r m r ■r■m n ■.rl •••■. n■ • ■ ■- Im: a•r/. • u. n •u■• u 1 u ■n• 'a I 811M a .■a-nu 0 161,502 WEIAll■ ■-emu�/ u • n gnu • I Ci ■:u■1 • • rna.. a:. - - ram■- • .■r_ .w.• - a t. l u .• • i• �. . . - a r - ■ • -7 - . ■ ■■ 1 ■1 /•- ■ ■ ■•/ •I 011"Iffwellknow.Im as big 0• is • II 7■ rt t1/.I/ • - ■. r ■ •y ■ ■ • ■ - r■ • •. 1 riI -r -r r ■ - - ■�1 r" ■ Masi■n ago .18 •- -•■ a >• ■■ t■••. 1 I ■.n Fi.f •• .t■• la. r 1 1••.: 1•■ Y na t_1 rnr u • .n r•■ ■.r nl u" •�, P n•.n r • ••■ •n. Inn .rr.�■r_• - - /:I. - • •lu• .0 - In r■- 1. n .n �•■a■ rn i/Ita. • ■■ r as 1� a. - •icta •/ �•.ii/Or. L I■- rn■n r■Ia .laln•• v_ - 71 •n n- -•aa.�:+w aun.+a .a•■ _In.. I .•nu �r • r■� .ten- n- •r► a.l .n■ • •■n ym_■•■ .n• ■�r�. .t ■./r ■r r••u .r■a a_m► .e n r. .n■ ■■n■ ■tan■•� •1• •• 1■ n 1 � tlr rn� • ■■ ■t :■• - n2-vqzim Y•• I •Irn•:■•■w •1 Ir.t 1-. / I• •.. a■Mw•■■ • 11 •• �n1r ■•- �. •la�i t•.n I■ n '•■■=• • •_■ o� .. - r• �•m�• a �n •••■.�w rnuu:�■w.■m n n :n r- .n u ' ■■�- a. - r�■u • •-- _ a• �•■ 1 �• .• -/ ■■_ n _ i■■.•t u. •- ■naa n■-• n n- �:••. m -.■ • ■u1 r •�,■ll u •a ■nn.n m • n u as r- ra•- _- ■ ■ - .t u ■ _u sire ■- ■■- - n•- ■ : is■. ■• .- -nna�.. .a u- t n n . n./ u- _n•■ru•II n i■- •�•n 1 ■ as - ■- n• �•r:�1}■ ■• i1- �-•.■ ■n�n • u u_ rwa.�:uw y1a/ . •■ ■: .u• ■•..an1 - .Inn• n- • ■ •. .1- �■m�■ n •/rm ••.■.��+ ■Ina�a r_■•■ ■■ 1 • r r.1 ea /.I ne.et ■■ nna■r ■�• ■ •• u 1�• tuna_n ■■a a a a a n ■ t• It d■ ill - Inln■i. a]■ t■- .n rl//1■.n- IN �1 ■ •'•■ It ■r Y. ' .c - •- n - u_I u- .Iia■.•1 nnn r _n• •pu1�a -�r r•- �1■a m r■ ■. u • •�. _ •. _I u ■•uou • n _aGa.. I as •■ u 7I • 1 n u ar n Y Gt r • ■•a ■•:n n■ •: u ►unr r •r •.■ • n_ ■• n■ r.■ r - . ■ - u i7 n n ■Win■ 1 :+• - n m•r ■ ■ 1 a rl.►a - a� �i1 - nna•.+ ■ ■•n■•■ a1 _■.• r:n f■_■ n■ a■n Ia nU - /�•u Ir if■ :O• r:n a). 1. :11 9 �!• �a •��■ •■ ■nn ql" �■•. 1 ■■• r:n■_ ■1■ �a ■• n •t■n. a•■ ■ter.. _■ :n r n■•. a• n- ■a ry a :n■ rnt ■• ■ ■lr 1 •r.■ ■ n wl u••■ •• • O" �t I. 1 n. ■. •�!■ •1■w.1 .rn■U�a •1 n.n.fr. . n- t n ■•••I u. r- • • •-• la i.- .n• r_n. ■ •• n.t . it•_•1 •I 0 w ■nut - ■:+tm ► ■ .�+■ - ■- • n..• 1 nu •- 71�■ • I - -■ ":• *�a w - ••■■ � •`•■�! •t Mla /�I ••r•r■II■ ►�1/� n ■.+a.■1 ■• - a:a n .Ir• .•Y■■�.r. • r•./n�i w •i!nn1 " ■• rrl■ ■ n■1 1• •along wI ■ ■:Iw nl �■■al i■ ■• rn11n - ■- n ■t■. ■" � ■a • ■ •w■•.ta•1■ •'•. . .�- [r n.[■. ••■ n .1•_n r� ■1 •n r•••� .1■■p :t■. ■•■ 1 •■1 1. •- .n ■•w•n■ �■' 1�'•a .n as G a at :..`. I- G■a■ta_ m a ri ■Ina•ti .1 i ��.w�11■■• I•_r Its.,. •-■ • nr •jam • • SL , -. - t. , wd �TMETa„yti Town of-Barnstable .� Regulatory Services MASS J71L Richard V.Scali,Director '��► Building Division ' Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 ; www.town barnstable m&us Office: 508-862-4038 - b r . , Fax: 508-790-6230 Property Owner Must Complete-and Sign This Section If Using A Builder I, It C-3 tK /��Jas Owner of te su •ec , ." _ _ hbl t property L hereby authorize ` V�.wL> to act on my behalf; in all matters relative to work authorized bythis building permit application for. r (Address of Job) **Pool fences and alarms are the responsibility,of the applicant. Pools; are not to be filled or utf7ized before fence is installed and all final inspections are performed and accepted. - Signature of Owner . , Applicant, f S• tore of . R y 4-a 4.O�� V�� •i , $ •_4 ..VJ ( `+- ` ��OI��I.WV �i .+ Print Name x. ? t.h Print Name ,2Z, j ' ... " to + wR �.r - , s, . •. a 69 _ Daze - • a �. . � - Q:FORMS:OwNERPERMISSIONPOOLS Town of Barnstable Regulatory Services T�raxy� Richard V.Scali,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 ww ,town.barnstable.maus Office: 568-862-4038 Fax. 508-790-6230 HOMEOWNM LICENSE EXEMPTION • 'Please Print DATE: JOB LOCATIOI�L number shut village "HOMFAWNER": name home phone work phone# 4 CURRENT MAILING ADDRFSS• city/6own state up Code The current exemption for"homeowners"was extended to include owner-occupied dwellings,of sire units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINMON OR 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 MMonsible'for all such workperformed 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,roles and regulations_ The undersigned"homeowner"rcerlif=that he/she understands the Town of Barnstable Building Department Ininimu rn inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Bm1d'uig Official Note: Three-family dwellings containing 35,000 cubic feet,or larger will be required to comply with the State Budding Code Section 127.0 Construction Control.• ` HOMEOWNER'S EXEMPTION l 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 109.11-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,Seei3on 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 lastpage of this issue is a form currently used by several towns. You may care t amend and adopt such a formfeertification for use in your community. Q\WPFILESIFORIAMuiIdmg pmmit fD=\EXPRE.SS,doo ltevi.sed-661313 Massachusetts D eFartment of Public Safety F Board of BuildingR ' egulations:and,Standards License: CS-094654' ° Construction Supervisor KYLE A MARTIN f 466 BOXBERRY HILL RDA EAST FALMOUTH MA 62536 4 } � f CO Rnestrstriucti017 p} S Unrest cted to: Upervisor /essri enc/thec/a space p cluings Of a o a� Cgrn r Expiratio: pace bic feet(9 ,se cub c metehich Conte, m�ssioner 11/11/2017 rs)Of ain, Failure to State 84ild- ssess ; a urre n o c t fps Cic 8 C d n • ensin9. a is cans edition L -� fo a Torre of the m►ation visit vocation oithachusetts . �V A1gss G his license. V/pps ° 4 I ♦ „ . (;5�s W111 rooao e`1�a yi g ac�i�aeltt —'_- tl, �*Office of Con u Affairs Bu'smess Re ulaHon I License or,registration v � HOME IMPROVEMENT CONTRACTOR I before the expiration alid for individul use only t' Registration 184667 Type: date. If found return Office of Consumer 10 Park Affairs a t0 Expirat�on� /232Ekh$ Individual Plaza- and Business Regulation F }Boston Suite 5170 �f MA 02116 KYLE A.MARTIN KYLE MARTIN F,, ,' °',466 BOXBERRY HILL`:RDE.FALMOUTH MA 02536 + Undersecretary Not.vaii with out'signature a u. 03 x CO D rn co ni 4 1�---7 • , i I! A i � P Y. 03 Cr t�s - Z c m rn D � rn i Cot o t�� y , 19 • j i i m la 4S i a 'C-0 O W77 CO c r- t� U) oi ; f Assessor's map and lot number ' r. ........... ..........:....... . .. ....... 0� .fc=duly/L - /tom v o l GG�ci� 0A, . Sewage Permit number ... ......y .a .3.'.7L1 TOWN OF BARNSTABLE i BARNSTABLE, i "6 BUILDING INSPECTOR am ................. ........7...................................t).. APPLICATION FOR PERMIT TO ........... TYPEOF CONSTRUCTION ....... V.°.'. .......4. ..... ........ ............................................................................. 19..7 Y TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according � to the following information: a Location ....... ./ �1.." ........... ......................................................................................................................... ProposedUse .....�,1�. ................................................ .................................. ........................................... ZoningDistrict ................. ....:.�........................................Fire District ....... .. .. .... .....r................................................. Name of Owner ... .C....... .. ... ...�. ........Address ....1.. .. � 4—^...... ......................... Name of Builder ��netlA �� I w/��" O �`..........................................................`.......Address .......... .7-. . ............................................................... Nameof Architect .................................................................Address .................................................................................... Numberof Rooms ....(.�.........................................................Foundation .............................................................................. ..../ ,,,,,,, ..Roofin ...:.... Exterior �N �.................................................................. g ....�:'�.`�.`.��................................................... Floors ........................................Interior ....................................... .............................................. ............................................. Heating ......:....7:....................................................................Plumbing ......................�.......................................................... Fireplace ..................................................................................Approximate.Cost ..... 5...0....0.......................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. I SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. // �/G/� � Name .. /.............� .�....!.... . � .......... Bird, Barry R. No .J?RR?... Permit for add 2nd floor to portion of dwelling .. Location l35 Grove Street ...............................�otuit.................................. Owner ............Barry..R.....Bird.................................................. i Type of Construction ..........frame ................................ `R............................................................................. Plot ............................ Lot ................................ Permit Granted April- 23 74 ...19 Date of lnspection,'�.I� 19 Date Completed ..�.�(... 1 PERMIT REFUSED ................................................................ 19 - ............................................ ............................................................................... ............................................................................... ! Approved _ ............................................................................... ..................... ......................................................... FEE TOWN OF BARNSTABLE, MASS. f p d 19 0 w q Do c (u THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO vA > 0 O � (PROPERTY OWNER) (ADDRESS) O Ap t~a TO ............................................................................................................................___._.._.............. ._»_.. p .............................._ ..._....................................................................................... ...._.»». FI�.q'd (BUILD) (ALTER) (REPAIR) ...................._............................................................................................................................_»___»............................ .................................................................................._...._.......... (TYPE OF BUILDING) (APPROXIMATE SIZE) O ac eeoo�O (�a o c LOCATION ..............»._......................._....................................._.............._...» ............................................................................_............._................ . .» _ (y"J (STREET AND NUMBER) (VILLAGE) ibe NAME OF BUILDER OR CONTRACTOR ................................................_................................................._._........._........._..........._ � � APPROXIMATE COST ... ... ... .....»................................................_...._......... y w eoaa I HEREBY AGREE TO CONFORM TO ALL THE RULES AND REGULATIONS OF THE TOWN (u OF BARNSTABLE, REGARDING THE ABOVE CONSTRUCTION, OM >4 4: aC)= ._.......__......_._.._......_..._........_.._..._.................................................................. _................_................. ............................_.............................................................................. h N ce y (OWNER) (CONTRACTOR) 6 ce 6 O () ti N BUILDING INSPECTOR Subject to Approval of Board of Health. r .Its .r.i i�'. n4';� E`�. "+' �` ,e ""q� �C+ ^.YS �.{» �'�CI"�;ra .., •,�s�t:;.'� a .e p �. ® � y .•I.G } +fit ti'.yla k`i _ ! - t a; LA f k =� j' 3 SENIOR MITER TOURS AND TRIPS FLOWER SHOW -- Thursday, March 18. Cost: $10.50 (includes bus and admission _. Bus leaves West End Municipal Parking Lot, corner of North Street and Bassett Lane, promptly at 9:00 A.M. Standby reser- vations only. WASHINGTON D. C. CHERRY BLOSSOM SPECIAL -- April 1 - 4. Cost $189.00. double occupancy, includes 6 meals and sightseeing. Standby reserva- tions only. BOSTON BUS TRIP -- Tuesday, April 20, 1982. Cost: $7.25. Bus leaves West End Municipal Parking Lot promptly at :00 A.M. Leaves Boston at 4:00 P.M. (Please note change in time due to Bridge repair) . Call Center for reservations. Tickets must be paid one week in advance. z °0 q IIJAI'd 3d yT MAP U -Y IP JAFFREY NEW HAMPSHIRE -- Thli r NL �H Cos" C1 x n u es bus, guided tour o historic � ���e 04�t*T visit t2 P$n� Rhnson�s Sugar House and luncheon at �'jmg sII3NnO0 Woodbound Inn -- choice of Yankee Pot Roast or Bak 4 'RgHi(adW&1 ) All taxes and gratuities included. Call Center for reservations. TEN-DAY CRUISE -- S .S .ROTTERDAM -- May 4, 1982 to Charlotte Amalie, St. Thomas, Philipsburg, St. Maarten and Bermuda. Cost: $1425 .00 per person. Brochure available at the Center. STURBRIDGE VILLAGE -- Thursday, May. 20.. . Cost: $24.50 (includes full course buffet, admission and 'bus)'. Call Center for reservations. WORLD'S FAIR KNOXVILLE, TENNESSEE -- June ,7. Cost $499.00 double occupancy; 449.00 triple; and 29.00 single. _,-. At this time, standby reservations only. NEWPORT, RHODE ISLAND -- Tuesday, June 22. Details next bulletin. NOVA SCOTIA AAD PRINCE EDWARD ISLAND : -- June 27.. Six days.. Cost: 349.00 double occupancy; 319.00 triple; $449.00 single. Deposit of $25 .00 per person due March 12. Standby reservations only. Due to the tremendous. response, , there is•the possibility of a second bus .UTURE TRIPS are being planned to the ISLAND OF HAWAII and to . ,IRELAND provided enough interest is shown. r v 1 1 Engineering Dept. (3rd floor) Map Parcel Permit# 330 House# 13��:, I'JJ - Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) - Fee Z o7S—. (� Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) d THE Definitive Plan Approved by Planning Board 19 BARNSTABLE. _ MASS. ��FD MA'S•` TOWN OF BARNSTABLE' _ Building Permit Application Project Street Address Z s!2 sT t Village- el-,o rvt Owner Address +' Telephone Permit Request �T`'L/P �� ,/t'0V U>9� GTIo� Sip v � First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ a 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 • r 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 t Builder Information Nam Telephone Number Address License# Home Improvement Contractor# Worker's Compensation Q_�z 1�2,1 aAL 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 SIGNA DATE B ILDIN 3 PERMIT DENIED F E FOLLOWING REASONS) • /J FOR OFFICIAL USE ONLY -PERMIT NO. _ DATE ISSUED MAP%PARCEL NO. F. ADDRESS:; VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME r a y INSULATION FIREPLACE ; s ELECTRICAL: ROUGH FINAL ; PLUMBING: ROUGH • ` FINAL GAS: ROUGH FINAL FINAL BUILDING y s F r y -DATE CLOSED OUT ASSOCIATION PLAN NO. : ' I � , ACORD .. 111 cA- OF t,� ,0.0 NStJRAill to► R DR; DATEiMM/DWYY) S Asz� 2 08/12/98 oouR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION cake,Swan 6 Crocker Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE {} Jency,, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR F = Lot's Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _•leans MA 02653-0429 COMPANIES AFFORDIIVG COVERAGE r avid D Rust COMPANY F°r,oneNo. 508-255-3212 Fax No. A Assurance Co. of _Unerica It ;URED ' COMPANY B Credit General Ins urance Co. Paul J. Cazeault etal DBA Paul COMPANY J. Cazeault 6 Sons Roofing C P O Box 2781 Orleans MA 02653 COMPANY c wBRaGGS i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEIIT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE POLICY NUMBER { POLICY EFFECTIVE POLICY EXPIRATION L DATE(MMIDDIYY) DATE(MMIDDIYY) LIMITS GENERAL LIABILITXo GENERAL AGGREGATE $ 1000000 I X COMMERCIAL GENERAL LIABILITY CFP25552812 05/01/98 05/01/99 PRODUCTS-COMPIOPAGG $ 1000000 CLAIMS MADE,•r X]OCCUR PERSONAL RADVINJURY $ SOOCiOO OWNER'S 8 CONTRACTOR'S PROT FF CH OCCURRENCE $ 5O O U OO k — ! E DAMAGE(Anyone fire) ''$ 3QQ(}QQ ( D EXP(Anyone person) $ 10 Q O Q I AUTOMOBILE LIABILITY ANY AUTO �_ �C%OMBINED,SINGLE LIMIT. $ ALL OWNED AUTOS j SCHEDULED AUTOS t BO OILY INJURRY(Per person) $ HIRED AUTOS — BODILY INJURY NON-OWNED AUTOS (Pe accident) $ I i PROPERTY DAMAGE $ GARAGE LIABILITY - -•. AUTO ONLY-EA ACCIDENT $ ANY AUTO # OTI iER THAN AUTO ONLY EACH ACCIDENT $ —I ' L 1 AGGREGATE $ EXCESS LIABILITY -�{ EACH OCCURRENCE $ j UMBRELLA FORM I AGGREGATE $ OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND WC STA'rU- OTH -:: EMPLOYERS'LIABILITY TORY LIMITS ER :> EL F ACH ACCIDENT $ 100000 THE PROPRIETOR/ INCL SWC17005902 08 PARTNERS/EXECUTIVE /09/98 i OS/09/99 EL DISEASE-POLICY LIMIT $ 50000L DISEASE-EA EMPLOYEE $ 10 00 000 M1I OFFICERS ARE: EXCL E r OTHER -� :RIPTION OF OPERATIONS/LOCATIONSIVEHICLESISPECIAL ITEMS f I -ofing .E JIFICATE HOLDERXX CANC..: ... ..ELLATIUN i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'tHE EXPIRATION DATE THEREOF,THE ISSUINIG COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SW LL IMPOSE NO OBLIGATION OR LIAE1ITY OF ANY KIND ON T E COMPANY,ITS AGENTS OR PRESENTATIVES. AUTHORIZE EP ATIVE a • aGO,RD 25-5(1J95) a O CORD CORPORATION 1*:. i Zil k a .r. r M1 s 35 ./ih. C:4 :HOME CON RACT , -REG, TRACT I ON M oa -a of ul�dVng, R � 61at`i s�a`'d ,ta darids, One Aftl5u ,tonPice — ortm: k , MassaG UsBt 0na> I}. a x, Y`.r i� nfiR F" �... WTI Iy M HOME IMPRO�IEME e&T�2ACT � :,'M ,�x � i � ` - =��, x- ---- --- - � --- Regis�ata on 10371`4 Exp�4�rata 00 i „, Type iPARTNERSIfiIP` ��:. '0ME IMPROVEMENT CONTRACTOR. Registration ,103714kt PAL7L:h `. CAZEAU$L7 �&eSO�lS ROOFjg.G ' .I lype PARTNERSHIPPI t T' _} t k t`,1 ; EXPITation22* Gi�ddia <:Rd: FP 0 ;8Qx 27 .,, i 3 :, _ , �;. '- A Or leans MA, 02653 � I S �PAUL J.•CAZEAULT & SONS ROOM Ax •' {"aF3 PdUIJ..Cazeault.., !Giddalt Rd: P, 0 Boz`*278 a' ADMINISTRATOR ;leans MA 02653 _ � '; w tt 31 (KoARTMENT .,OF f-)U6L1C '::AFE TY ;z ; ONL:.:ASHBURTON PLACE_ I M 13(9? 0ST91. A 02108 -1618 $: CONSTRUCT.'i'M SUPERVI';30R LICENSE r 325 10/n/1999 _ 997 PAUL .:i CAZEAUL.�. i , t V.-385 'i,(AIN ST Keep top .riI, rec:ipt a;id chanr-j k: bf,addi k, rIotJ.f cat;. i:i. r' ti Fk�' k•../X�� .� i�� irk � t � q y �.... _ 'a S w bgtj t 1 - 1 y. .ji o 'a aFn+e rq The Town. of Barnstable MASMs�vsrnar,� ; 9� �0� Department of Health Safety and Environmental Services '- & ►,9.. Building Division 367 Main Street,Hyannis MA 02601 Officc: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commis For office use only 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: _ Est. Cost �a(J Address of Work: 13,E l 1P1,)U, JS7'- (a Owner's Name y Date of Permit Application: b' I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I h e y apply for a permit he agent of the owner: Date V Contractor Name Registration No. OR Date Owner's Name . The Commonwealth of.4fassachusetts a,i! ---= t r" - ;_-_. � Dc partnrcnt of Irrtlustrial Acciflurts ` Ofliceolln ew �estigat/ores 1 1 f - •\ 600 Washington Street BtlN1011. Afars. 02111 Workers' Compensation Insurance Affidavit Llpplisant information: --- PleasePR1�1Tle�Lb1Y •_. ._...e_,_..._.,.,.,_. name: locstion: 6 t�ti0�91/E �1 city phone I am a homeowner performing all wort: myself. I am a sole proprietor and have no one working in any capacity • ""+- .-..+��-.7 «O_.,,.,_,......_.-*-.._.gleevs.s.s+ersT'�T.�.'J.1�:!r'..:.ATr'^_..•w^ .�.w� �...�.T..+ a ._.ww-. ►.w!.^-'...-......... .CZI am an emplover providing workers'compensation for my employees working on this job. corn army name: address ® llf� - city: hone#• insurance 1 am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: ' cominn,%' mine: address- phone#• insurance co. nolic� # •i.. ..r.• _ _ ._`T•:Y'^ � - -- 2r^.K: 1�iT"S!�w•i.:S.e•r. ..-��.r._.__ _ ...a.�u.,..i...-._.- conman%' nnmc: address: cin: nhnne#: insurance co. policy# Attach additional sheet if necesiaty =F� ^--`� •�i' :re ��' ���'_.T'".ir..i.•'�' `.:a.• �..y.w: r.•.=�--c -' -- -----.. ._._---- .__._ ..,•-•" .�_....�..:.- -=i:Ii• ----��,r.°- -•—inv.a.�='-- - -:a"iie•,a:�aa•.w.r�:+r. railure to secure covernac as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties ot'a tine up to 51.500.00 andior one y cars'imprisonment as well as civil penalties in the form 0172 STOP NVORK ORDER and a fine of SI00.00 a day against me. I understand that a cope of this statement mni be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerrift•under the pains and penalties of perjure•that the information provided above is true au co rect. Si_naturr� Date Print name �PrUL ( !a 2tt�r�� Phone# (officini use on1v do not write in this area to be compacted by city or town olrtcial - cin•or town: permit/license# r iBuilding Department C31,iccnsinn Board (7 check if immediate response is required 0Scicetmen's Office C311calth Department . contact person: phone#: + r,Other : r. z. r - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers* compensation for thei employees. As quoted from the an emplaree is defined as every person in the service of another under any contract of hire, express or implied. oral or written. An enzplurer is defined as an individual, partnership, association, corporation or other legal entity. or any two or more tltc foregoing cnI- in a joint enterprise, and including the le�,al 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 dw ellin�1, house having not more than three apartments and who resides therein. or the occupant of the dwcllin�_ house of another who employs persons to do maintenance , construction or repair work on such dwelling hou or on the ;;rounds 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 agenc,•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 contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter h 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 affidavit should be returned to tite 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 police. 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. Plea be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t, the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any question, please do not hesitate to f-T ive us a call. The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents ... Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 f RE-ROOFING If located in OKH or Hyannis Historic District-Certificate of Appropriateness required unless same color/same materials specified on application Map/parcel number Sign-offfrom: Ell' Tax Collector Treasurer 0#'Of squares of shingles or square footage of roof to be shingled [Dsfecify stripping old shingles or going over old roof. If going over Ohow many roof layers existing now what size are rafters? What is span? Complete dwelling information for the Assessor's Dept. - if known Workman's Comp. form (� Home Improvement Contractor Affidavit(RESIDENTIAL ONLY) Home Improvement Contractor's License OR Homeowner's License Exemption(RESIDENTIAL ONLY Check expiration date on license COMMERCIAL WORK-No License is required. 0/ Fee q-forms-PERMITS 1 Rev 6/2/98 RE-ROOFING ❑ If located in OKH or Hyannis Historic District-Certificate of Appropriateness' required unless same color/same materials specified on application Map/parcel number Sign-offs from: [� Tax Collector Treasurer E]16f squares of shingles or square footage of roof to be shingled [Dsl5ecify stripping old shingles or going over old roof. If going over []how many roof layers existing now ❑what size are rafters? What is span? ❑ Complete dwelling information for the Assessor's Dept. - if known Workman's Comp. form [� Home Improvement Contractor Affidavit(RESIDENTIAL ONLY) Home Improvement Contractor's License OR ❑ Homeowner's License Exemption(RESIDENTIAL ONLY) ❑ Check expiration date on license COMMERCIAL WORK-No License is required. 0/ Fee r q-forms-PERMITS 1 Rev 6/2/98