HomeMy WebLinkAbout0031 HIGH STREET � ��
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Town of Barnstable Buildin
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Post This Card So That it is Visible fromaMe Street Approved'-Plans Must be Retained on Job and,this Card Must be Kept
s Posted Unti1;Final Inspection Has Been Made Permit
oll
Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspectionhas been made Permit
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Permit No. B-20-908 Applicant Name: Gerald R Patriquin,Jr Approvals
Date Issued: 03/30/2020 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors- Expiration Date: 09/30/2020 Foundation:
Location: 31 HIGH STREET,COTUIT Map/Lot 035-097 Zoning District: RF Sheathing:
Owner on Record: BIDDLE, KATRINE T Contractor Name'. ;LONG ROOFING OF Framing: _1
MASSACHUSETTS LLC
Address:. PO BOX 1989 r, 2
COTUIT, MA 02635 - Contractors, License' 187510
Chimney:
Description: Strip,check for rot and re-roof 11 squares.fees paid with,tb-20-872 Est Protect Cost: $9,985.00
:Permit Fee: Insulation:
Project Review Req: s
Fee-Paid: $0.00 Final:
3/30/2020
. Plumbing/Gas
Rough Plumbing:
" Final Plumbing:
,. Building Official
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas:
All work authorized by this permit shall conform to the approved application and the approvedconstruction documents-for which this permit has been granted.
Final Gas:
All construction,alterations and changes of use of any building and structures shall in compliance with the local zoning by-laws and codes.
be
This permit shall be displayed in a location clearly visible from access street or=road-and shall be maintained open fo"r public inspection for the entire duration of the
work until the completion of the same. Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire officials are provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work: Rough:
1.Foundation or Footing — - -- � `-"
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy `
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site L Final: _
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
c-n�� sir
17
Town of Barnstable *Pe l i # S
p� Expires 6 months from issue date
Regulatory Services . Fee
• s�xivsr,�si,E, «
� Thomas F.Geiler,Director
�prfp MA't� -
Building Division X-PRESS PERMIT(O
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 S E P 112012
www.town.barnstable.ma us
Office: 508462-403 8 Fax:.508-..790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIALTM OF BARNSTABLE
Not Valid without Red X,--Press Imprint
Map/parcel Number
Property Address 1 1 S
residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �°�'' � CL h.L-1
Contractor's Name -�w►t,�r I ® Telephone Number 2—
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) S l J .
�orkman's Compensation Insurance
C�h,�e ne:
L'f l am a sole proprietor
❑ I the Homeowner
have Worker's Compensation Insurance
Insurance Company Name / ;'of V r" J�
Workman's Comp.Policy# k L)/.J °—Q0 7. 7d ' 4F-- l 2__
.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) `� "t'-4— �J
❑ Re-side / y
#of doors
❑ Replacement Windows/doors/sliders.U-Value_ (maximum.35)#of windows
Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.,
***Note: Property Owner must sign Property Owner Letter of Permission. ,
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE: �.•�
Q:\WPFILES\FOR 4S\bui in ermit forms\EXPRESS.doC
Revised 053012
The C'ommonriu+ealth o,f Massachusetts
Depaphnent of Industrial Accid
Off we o,f Inm igations
600 Washington Street
Boston,_CIA 02111
4WM masx�govldid.
workers' Compensation Insurance Affidavit:t:BuiMerslContractursMectricians/Plumbiers
Applicant Information Pleases Print Legibly
Naive(Basins mtlniiidduau: .r��
Address::
Cliyl ta _ aC/v✓L d J" `� �b✓ `� U C /j ��T
Are u an employer?Check the appropriate boa: Type of project(required):
1_ I am a employer with�_ 4. ❑ I am a general contractor and
employees(full andlor part-time)-* have hired the sub-contractors 6_ ❑New construction
2..El I am a sale proprietor or partner-
listed on the attached sheet. I ❑Rertmodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
working fe mein any dY employees and have workers'
9 ❑Building addition
[No wodms'.comp.insurance comp,.insuranm
required] ❑'We are a.corporation and its 10.❑Electrical repairs or additions
3.❑ I am a hamebiener doing..ail:worir ., officers have exercised their 1 I.❑nofairs
g repairs or additions
myself[No worlm s,comp. right of ese®ptiou per MGL 12.
inu re r ]t c.152, §1(4� and we have no
employees.[No wwketss' 13.❑Other
camp.msurzam required.]
A�uy spplica that checks too#1 nmst also lilt out the section below showing:their watexe rompensatiaa.policy iafnrm dui
Hoaoeosva�s who submit this affidmra m&catmg they are doing all wv*and then hire oat &contractors mast submit a new aff davit indicating sad_
TCbn=ctars that check this box must attached as additional sheet showing the name of the sub-coo>=Aws and state whether orna t those entities ham
employees.. i1te 6IIt iaAtDiCtnI511aSR employees,fey must pxnvide their wurlcer5%comlt.policy ntanber.
I am an employer that is prong workers'compnnsation,insurmce for my employees. Below is the policy and job site.
inforeerrtioti. l
Insurance Company Name:
Policy#or Self-ins.Isc:#: y l7 '' ® 7 1�7 Z
irati�+n Date: a/X0 X-3
Job Site Address:: /� �. S 4— CO 4 Cityis': C' e
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 ODDER and a fine
of up to$250.00 a day against the-violator. Be.advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA ibr insurance coverage verification_.
I dv hereby ntltparrs and lgesof rh petjuty that the information:ptvni&d a gs and correct
Si cure: �f_ o0oi /4. Date: 1 f � l
73
Phone
Official use only. Do not write in this area,to be completed by city or town o�ic4aL
Q*iy or Town PermitUc' e#
Issuing Authority(circle.o'ae):
1.Board of Health y.lauding Depart 3.CitytTotQn Clerk d.Electrical Inspector S.Plumbing.Inspector
6.Other;
Contact Person: Phone 9:
j
6
}
,�� Town of Barnstable
prED MA't
Regulatory Services
Thomas F. Geiler,Director
Building:Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
.Pro ertY Owner Must
' Complete and Sign This Section
g
If Using A Builder.
I, �� CQ `� , as Owner of the subject property
hereby authorize �d vrl cultjo to act on my behalf,
in all matters relative to work authorized by this building permit application for:
r C- 6 �.,-
(Address of Job)
Signature of Own r Dat "
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
Q:\WPHLESTORMS\building permit forms\EXPRESS.doc x
Revised 051811 -
�t > Town of Barnstable
Regulatory Services
RntuvMBM ' Thomas F. Geiler,Director
9� ib ,��
ArEo 5,,,A Building.Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA.02601
www.town.barnstable.nia.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied 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 wbo constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building-Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION -
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as"supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc
`'-vised 051811
THIS IS A QUOTE, NOT A POLICY
AW
l'
' AY ELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
QUOTE PROFILE VERSION 01
POLICY NUMBER: (6KUB-0072N72-8-12)
RENEWAL OF •(6KUB-0072N72-8-11 )
INSURED'S NAME AND ADDRESS
WORKERS COMPENSATION
MILANO, JAMES A INSURANCE PLAN
38 WINTER STREET A/R (WCIP) # MA
YARMOUTHPORT MA 02675
POLICY PERIOD FROM: 02-20-1.2 TO 02-20-13
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 341
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 159
TOTAL ESTIMATED PREMIUM 500
TAXES AND SURCHARGES 4
DEPOSIT AMOUNT DUE 504MP
y .Y
Employer's Liability Bl Limit: $ 100000 Each Accident
500000 Policy Limit
100000 Each Employee
INSURER: . THE TRAVELERS INDEMNITY COMPANY
Adjustments of Premiums shall be made ANNUALLY
******************************* Deposit Amount Due: $ - 504 **** *************************
POLICY NUMBER: (6KUB-0072N72-8-12)
DATE OF ISSUE:12-23-11 WC - ST ASSIGN: MA
Uttice or consumer A11Quz,
10 Park Plaza- Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Registration: 158718
Type: Individual
t ; Expiration: 2/26/2014 Tt# 221312
JAMES A. MILANO
JAMES MILANO
38 WINTER ST
YARMOUTHPORT, MA 02675
Update Address and return card.Mark reason for change.
Address Renewal J1 Employment Lost Card
DPS-0A1 50M-W04G101216 - -
_w ✓ � ue ° d "`Qe License or registration,valid for individul use only
office of Consumer Affairs&B smess Regulation before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation
Registration: - 158718 Type:
. 10 Park Plaza-Suite 5170
Expiration: 2/26/2014 Individual Boston,MA 02116
JA S A.MILANO--
JAMES MILANO
38 WINTER ST
YARMOUTHPORT MA 02675 Undersecretary Not valid without signature
�N'lassachusetts- Dcpurtntcnt of Public S itch
Board of Building Re�aulations Mid Stand a tls
Construction Supervisor License
License: CS 15W
JAMES A MILANO
38 WINTER ST
YARMOUTH,MA 02675
c
Expiration: 11/5/2013
(ununisniucr Tr#: 7809
°FtKE r�
Town of Barnstable e tte I �
P� �( Expires 6 non fromjs�trtdate
Regulatory Services , Fee
Y ..
Y BARNSTABLE, ► - -
r MASS' Thomas F. Geiler,Director' .
1639.
Building Division 0
Tom Perry,CBO, Building Commissioner;
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us ;
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address - `
[Residential Value of Work W �. Minimum fee of$25.00 for work under,$6000 00
Owner'•s Name&Address 0-1itj
Contractor's Name / '� l lU� Telephone Number. ?Z G 36 3 �
-.._.._._ -.... . -- ----
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) '
Workman's Compensation Insurance.
Check one: MAR �010
❑ I am a sole proprietor
❑ I am the Homeowner TOWN OF BARNSTABLE
I have Worker's Compensation Insurance -
� d,,,�.��t�,; Isis � � • ;�,
Insurance Company NameU
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. Going over existing layers of roof)
Re-side r
#of doors
❑ Replacement Windows/doors/sliders.-U-Value (maximum .44)# of windows
*.Where required:,Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,Conservation,etc.
*"°`Note: Property Owner must sign Property Owner Letter-of Permission.'
A copy of t}ie a Improvement Contractors License& Construction Supervisors License is
required. ;
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC
Revised°090809,
_ The Commonwealth of Massach usetts
Department of Industrial Accidents
11 Office of Investigations
' M. 600 Washington Street
�1r Boston, MA 021.11
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr.'icians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �Y� C .
110 � 51
'Address:
City/State/Zip: 05�e l It 0 Phone #: 4,?_7 � 30 q 6 Q y'
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4..0 I am a general contractor and'I
employees(full and/or part-time)
have hired the sub-contractors 6. New construction.
2.0 1 am a sole proprietor or partner-
These on the attached sheet, 7. [�Remodeling
ship and have no employees ' These sub,contractors have g, 0 Demolition
workingfor me in an ca acit employees and have workers'
Y P Y , 9: E] Building addition S,
[No workers' comp. insurance comp. insurance. '
required.] 5. 0 We are a corporation and its . 10.❑ Electrical repairs or additions .
officers have exercised their 11'.0 Plumbing repairs'or additions
3.0.1 am a homeowner doing all°work
right of exemption per MGL
m... ___.myself._[Ng-=w._orkers _comp ;..,, _ -•-- „ ._. r,._. -.1.2. ..Roof.,repairs _ _ y_
insurance required.] t ' c 152;§1(4),.and we have no
employees. [No workers' 13:0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ,
t indicatingsuch.
th r oin all work and then hire outside contractors must submit a new affidavit
Homeowners who submit this affidavit indicating they are doing
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have.
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for fny.employees. Below isahe policy and job site
information.
Insurance Company Name:
VvvV 6 .316,0 �Q Ex i :+ 2 �lQ
Policy#or Self-ins. Lic #. p ation Date:
Job Site Address: r� �' City/State/Zip: � 1
Attach a co of the work4 . e j f copy ers' 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$1,560.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER-and,a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ldo hereby cerfify'und r e pains andpenalties ofperjury that the information provided above is true and correct.
3 1z,41 0
Signature: - Date:
�y0 w
4
Phone# I
Official use only. Do not►vrite in this Area, to be completed by city or town official.
City:"or Town: Permit/License.# '
Issuing Authority(circle one):
1.•Board of Health, 2. Building Department 3. City/Town Clerk A..Electrical Inspector 5:Plumbing Inspector
6. Other
Contact Person: Phone#:
r.
_
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this'chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
_ -- --- -- - _._.
members or partners;are not required to carry workers'compensation insurance. If an LLC'or LLP`does have'
employees,.a policy is required. Be advised,that this affidavit 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 you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write`,'all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax # 617-727-7749
www.mass.gov/dia
i
o'OKET , Tovvn of Barnstable
ti
a
r
Regulatory Services
rMA Thomas F. Geiler,Director
1639., Building DivisionF,
Tom Perry,Building.Commissioner ,
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
508 79 0 623
_ _ .
Office: 508 862 4038 Fax:, .
N
Property Owner Must
Complete.and, Sign 'his Section
If UsingA Builder }
I
Owner.of the subjectproperty as )
hereby authorizes- �� to.act.on my behalf,
in all matters relative to work authorized by this building permit_application'for:
GIV ,
(Ad ress of Job)
Signature of Owner Date
Print Name s
If iropea Owner is;applying for permit please complete4the
Homeowners License Exemption Form on.the reverse side:
QTOPMS:OWNERPERMISSION
StiE Town of Barnstable
Tp ,
o� Regulatory Services
" Thomas F. Geiler,Director
swxxsraBLE,
truss.
9�A 039. ,�� Building Division
T6n �a Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor." .
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor.The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that 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:\WPFILES\FORMS\homeexempt.DOC
CERW ICATE OF LIABILITY INSURANCE DATG{s1M,ODrYWY)
12./07/2000
Sylvia Insurance Agency (508)426-0440 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
A Main Street
'ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
OStervillD MA 02655
- INSl.1RER9 AFFORDING COVERAGE
NAIC#
West Bay Property MDnagornont Trust --U -R_A—M_.o._n.._t p_elier US Ins C
rrustooAdam HoalDttar, D `---
j
INSURER 0 Waaco Innuranco Co
770A Main Sirecl ----------
C)gfervilla, MA 02655 NSURER c_=- - --- -- - -
.. ..---- L'--
/.
INnURER D
'ERAGFS - -- Ii'9L'RER E
m POLICIES OF INISLIRANCE I.ISTED DFILMV HAVC,B_EN ISSUED TO THE INSUREO NArnC0 AUOVf FOR THE POLICY PERIOD INDICATED.NOTVATHS.AND!NG
Y REERTAIN,THE I TFR,11 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RFSP&CT TO WHICH THIS CGR'rfFiCATE MAY BE ISSUED OR
Y F'rRTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO PE THE TWR IC THIS CCA S AND CONDITIONS OF SUCH
LILIES AGGRCGATE LIMITS SHOWN MAY HAVE BEEN'REDUCWI)BY PAID CLAIr,!S
----
NG ICV I_FPLC'rIVL P LI Y XPIRATION '----
CiCNCr.AL LIABILITY "�r 1'11DC/Y -�"' LIMITS
:Cohfr.titRCIA1.GI7iIi:N.AI.LIAUILII'Y MP0008001002077 GnutoccuRReNc s 1,000,000
12/4/2000 12/4/2010
D Ir�Z�^ris'ar.Nre� _ _
CIJ ",13 AA,I.
I I hCtdIGC&.(fln a&ENI9(cn) _ U 100 000
] OCCUR
... •. PP_i�30NAL&AADV INJURY_- .... 1 Du01000_
UEN'L AOOREGATE LIMIT A?PLIf96 PER.
of NCRAt AGOREOATE, °' 2,000,000
PRODUCTS COMPIO'AGO B 2,000,000
POLICY�._._) P 0 I I.00 ---_...
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DIN(:D SINGLE'LIMIT ` —a
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^7I goarriho iin�lnr * C L nlEEnsh IfA I'MPLOYCC s - 500,G00
"iI.IAL PROVISIONS hnlow - _ -_-.. .. _ . „----
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AUTHOR 12E D RCPA 1 91:NTA'I'I'/r)
®ACORD CORPORATION 1988
Massachusetts Depstrtrnent of Public c Safet%
A Board of Building Relyulations an(] Standards
Construction Supervisor License
License: CS. 94302
Restricted to:,,00
ADAM HOSTETTER
f 770 SUITE A MAIN St
r
OSTERVILLE, MA 02655
Expiration: 12/22/2011
(''ununtasfuncr Tr#: 13857
,
152124
' EXpttuttc� 8020+p 7r7''JT 4"
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;k TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map b S' Parcel D! iYI Application#,207CO LaD
Health Division
Conservation Division Permit#
Tax Collector Date Issued -
Treasurer Application
Planning Dept. Permit Fee l 3� •��
Date Definitive Plan Approved by Planning Board �(,L
Historic-OKH Preservation/Hyannis
Project Street Address flQiA� .
Village
Owner Erun k�kp/ ,/ 4r4_& ,6_f_4&ss sNta
Telephone
Permit Request ADD 3'Z e— A u l TL wn
Square feet: 1 st floor:existing roposed 2nd floor:existing ) proposed Total new0`10
Zoning District rood Plain Groundwater Overlay
Project Valuation Construction Type CiD
Lot Size ��� �� Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 2r/ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes alb On Old King's Highway: ❑Yes U O
Basement Type: ❑Full ❑Crawl Ll 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: as ❑Oil ❑Electric ❑Other E
Central Air: ❑Yes polo Fireplaces: Existing New Existing wood/coalstove: Ctfj�es
M
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑e9ling ❑new siz§
Attached garage:Z cisting ❑new size Shed:❑existing ❑new size Other:
cn
Zoning Board of Appeals Authho ' ation ❑ Appeal# Recorded❑ Lo
Commercial ❑Yes U o If p
,es site Ian review#
Y
_,
` Cuhent Use- Proposed Use=
BUILDER INFORMATION
Name al Telephone Number " 776,773
Address License#
In igdot Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
z -
PERMIT NO.
BATE ISSUED re -
MAP/PARCEL NO.
ADDRESS VILLAGE -
OWNER:
DATE OF INSPECTION: _
FOUNDATION
FRAME p
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL -
FINAL BUILDING ti ----
DATE CLOSED OUT '~
ASSOCIATION PLAN NO..
/ 11
Town of Barnstable
Regulatory ServicesSAMSTABM
.
HAS& Thomas F.Geiler,Director y
�Eo :► Building Division
Thomas Perry, CBO,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnsta ble.ma:us
Office: 508-862-4038 Fa-: 508-790-6230
PLAN REVIEW 00 -7 b e( 2-
Owner: /31,b,� 'g Map/Parcel: 6 3 57- - 0 ? 7
Project Address 3/./4 A Jf C r Builder:
The following items were noted on reviewing:
N7r Qiy GL " VI, s
flti� ALL oz�, AtJg-A-) U-F= -C-rC-C Q AA,,S 6-p_
Reviewed by:
Date: / L 1- o. d' -
Q:Forms:Plnrvw
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I
Generated by REScheck-Web Software
Compliance Certificate
Project Title: Frank Mann and Katrine Biddle
Report Date: 12/19/07
Energy Code: Massachusetts Energy Code
Location: Cotuit,Massachusetts
Construction Type: 1 or 2 Family,Detached
Heating Type: Other(Non-Electric Resistance) -
Glazing Area Percentage: 12%
Heating Degree Days: 6137
Construction Site: Owner/Agent: Designer/Contractor:
31 High Street A.Roy Brown Massachusetts
Cotuit,Massachusetts 02655 Home Repair Company
34 Horatio Lane
Centerville,Massachusetts 02632
508 776 7384 '
roybrown@homerepairco.com
Compliance: Passes
Compliance:0.0%Better Than Code Maximum UA:97 Your UA:97
Gross Cavity Cont. Glazing UA
Assembly Area or R-Value R-Value or D..
Perimeter U-Factor
Ceiling 1:Cathedral 465 30.0 0.0 16
Wall 1:Wood Frame,16in.o.c. 692 13.0 0.0 48
Window 1:Vinyl Frame,2 Pane w/Low-E 82 0.330 27
Door 1:Solid 21 0.300 6
Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other
calculations submitted with the permit application.The proposed building has been designed to meet the Massachusetts Energy Code
requirements in REScheck-Web and to comply with the mandatory requirements listed in the REScheck Inspection Checklist.The heating load
for this building,and the cooling load if appropriate,has been determined using the applicable Standard Design Conditions found in the Code.
The HVAC equipment selected to heat or cool the building shall be no greater than 125%of the design load as specified in Sections 780CMR
1310 and J4.4.
'Name-Title Signature Date
Project Title:Frank Mann and Katrine Biddle Report date: 12/19/07
Data filename: Page 1 of 4
' The Commonwealth of Massachusetts
Department oflndustrial Accidents
W Office of Investigations
' d 600 Washington Street
Boston,M4 02111'
w)*.mass.gov/dig '
• 'ply y4.
"Korkers}.Compensation Insurance.--Midavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual): .
Address: (2 d'°I�
city/state/zip: Phone.#: 77 4 75eil,
Are you an employer?Check the appropriate box: :Type of pioject(required):,
1.❑ I am a employer with 4. [] I am a general contractor and I
e ees (full and/or part time). ha• ve hired the sib-contractors 6. ❑New construction .
2. am a sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. El De lion
'ivorking fox me in any capacity. employees and have workers'.
$� 9. wilding addition
[No workers' comp,insurance comp,insurance. re Electrical airs or additions
required.] 5• ❑ We are a corporation and its 10.❑ P
officers have exercised their
3.❑ I am a homeowner doing ill-work . 11.7 Plumbing repairs or additions '
myself, o workers' right of exemption per MGL
Y � conP. 12.❑Roof repairs
insurance,required.]t c. 152, §1(4), and we have no
employees. [Trio workers' 13.7 Other
comp,insurance required.]
*Any applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy information.
f 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 ornotthose entities have
employees, If the sub-contractors have employees,they must provi de their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Corp any Naive: Qj1C
Policy#or Self ins.Lic.#: 1 y�' NI �y; 1 -6 Expiration Date:
LATabite�ddress: ate/Zip:
S a
Attach a copy of the workers' compensation policy.declaration page'(showing the policy number and expiration date).
Failure to secure coverage as requred under Section 25A of MGL c. 152 can lead to the imposition of criminal penaires 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 aad a fine
of up to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the.O Ece of
Investigations of the DLk for instrance coverage verification,
I do hereby cerd un r the pay d evaI of perjury that the information provided above it/true and correct.
Sivnature: Date: e '0-7
P=one
!i Of�zcial use only. Do vat write in this area; io.be completed by.city or town official. i
City or Town: ' kermt(License rr
Issuing Authority(circle one),
:1.Board of Health 2,Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing T spector
6:Other
Contact Person: Phone r:
l
Massachuset`�s General Laws chapter
152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute, an employee i,defined as"...every person in the service of another under any contract of biro,
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 incIud;ng 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
owmtr of a dwellln'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 iicense'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 covera;e required."
AdditionaIly,MGL chapter-152, §25C(7)states"Neither the commonweal`rh nor any of its political subdivisions shall
enter into any contract for.the performance of public-work until acceptable evidence-af-coz~•ipllm'c'e with the insurance
requirements of this chapter have been presentedto the contracting authority."
Applicants
Please fill out the workers' compensation affi.dati-it completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-conta:actor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability'Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'°compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to'stgn and date,the affidavit. The affidavit should
be returned to the city or town that the application for the permit.or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers
compensation policy,please call the Department at the number listed below, Self-insured companies should enter their
self-insurance license number on the appropriateline.
City or Towli Officials
Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write"all-locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant.as proof that a valid affidavit is on file for future permits or licenses. •A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to born leaves-etc.)said person is NOT required to complete this affidavit
a questions,
would like to thank you in advance for. our cooperation and should you have any q .
The Office of Investigations wo
g Y Y P
please'do not hesitate to give us a call.
The Department's address,telephone-and fax number;.
Dtpaxkzanit of Industdal A.eexdemts
Qfee of IIAVesgattos
6.00 Washino-tari Street
BWOn-I IA 02111
TO.# 617.727 4900 ext 406 or 1•-877 MASSAFE
Faye#6.17--727-7 4.4
Revised 11-22.06 W.mampv/dia
°FTME Tp� Town of Barnstable
ti
Regulatory Services
sa MASS.
� .A Thomas F.Geiler,Director
9 M $
16.59. 0 Bui ldinu Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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: 6D D 1 f ( Ov� Estimated Cost_
Address of Work:_ ( S I �� t V C-
Owner's Name: go-T-tUv �tddXQ 4-
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
" OBuilding 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 WORD DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby a ly for permit agent of the owner:
Date Contractor Name Registration No.
OR
Date Owner's Name
. t s
e�d
KZLILL
Idd
._
Town of Barnstable,
Regulatory Services
a6SOR Buildiug DivWon
?omParry, V%ldtagConunLniener
200 Main 5ttee4 21yam iI6 MA 02601
ionrrn.to�a.barnrtablep+a.ua ••
office: 508-862-4030 Fax: SOSma.6230
Property C YWner Must
Complete and Sign This.Section
rf Using A Buudtr
. � � �, -.-.. »Owner of the aub'ect :o e •
• �—r � o. , . J P P rtJ�
herabpai tho&e2a'7T�ru'l TN - to act onmybehalf,
in aR zm=rs rckdve to wrk'authotiud bythi Building permit appustion for
s o Job
$,gpature of Ow er -- Data
AT
C�•FORMS:O'WA�P>�'19�1ON
C '� 9E8T-SLL-®09 umoje ROM Wes ti1 1'0 Sa ADM
T 'd ZTEE 4Jo2S Sdn a41 WdOT : T LOOZ 90 OaQ .
BOARD OF BUILDING RE ULq Ip Sl nor ��"� �� �
Of'Uiidin
License CONSTRUCTION SUPERVISOR S Re�nlations and
, '►SOME IMPROVEMENT Standards
Number CS 065525 EMENT CON
lop
TRACTOR
1265G0
_ Expiration 008
:
jExpires 02L12/2068 Tr.no: 16902 6/2
/2
TYpe DBA
Restricted 00: ALBERT ROY pR0 _
ALBERT R BROWN; _
ALBERT WN MOME REPAIR
34 HORATIO LN _ BROWN
CENTERVILLE, M"2`0 Q'32'°' y. /� ``}HORATIO LN P
CENT .,-
t�..iILLE,
Commissioner MA 02632
ntY Administrator
•
N67 o r, Q I V
0
0�=1U __
r lilt R '► 4�'CS
I h ' o LOT.. f.
o
ff •f
3' Of l)U - O
14 7±
- T5 1 01
LOT A
b i \� „ ,
o r N4�3'0L',45 E 15.86'
47 1.9"!� 3. 79'
�~ " 15. 89' w
LOT D Dl'-C' 1 __-=--, CJ518'<35 {
f90*00')0" , 107 86' .
NQ7 `
pRE-1'A77 TING
NONCOIVFDIilIITNC
f
RES ZONE ':Rf",
rh,� MORTGAGE INISPEC'110N PlanBan is For- F'1.00D ZONE „C"
!: DISTAIi.•S AND MEASU ,.L ") ON THIS N HHOULD IFI) BY rtJl�NT
--- ------ --- REGISTRY" OWNER ,JOff-IY7H A, R�_5G--- --------- - -----
DEED PEF; _845%1;%�Z---- ' ---- BtfYER: --
h'F:_311/6�',.---- ----:;CALIJ:1 �---F 1.
DATE. _9.Z4_1_Q-L--- ------ -- pj1gT� N� .
11IFREHY CERTIFY T0. A7 f _TACl1; _ _ "' ' ' ---- �tk OF YANKEE SURVEY
THE BUILT)ItiG �:� '` "` y• C:U N t7T,T 4N'I'S
5110�'N ON 'i'Hh PLAN IS T...00KEL;D ON T111:' GKc.>tIND l� -o �
SHOWN AND THAT ITS PQSi'llON
nQr� _ c:ovr0xti P� 40B (Surrr i)
TO THE ZONING I,AW.SE'1'NACK REQ1j.1Rr�tENTS Qt' THE �� NIA.mm9mal INDUSTRY ROAD
'TOWN OF 1L9NS`T�1HL __-- ____ 'AND THAT
ARSTONS MILLS. MA. U2Ei44
LAREA
O�;�_-?oT— LIE WITHIN THE SPECIAL FLOOD HAZARD TFL 428-0055
AS SHOWN ON THE H.U.D. ,41A�' HATED_ / ��__ f�TVr'qX 420-569m t --Fan I Z50001 0018 D
L
TM '1) N N S 4 R i'ENL'ES BUIT.AING PERMITS. ETC, 31���5 CD
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Y
Map � � Parcel' Application #
Health-.Division 3 Date Issued A a d 8
Conservation Division Application FeR
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic- OKH _Preservation/Hyannis
Pro��ject_S�treet,Addr-ess 31 'r7.4 �TtevT v
(._V_illage— C tV T-
Owner A L�C— Address,._
.Telephones
Permit Request
crj
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
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 0 new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �� .� 025. Telephone Number
Address Vol �*M up nl P�> License
A V`-t' 0'�' o L Home Improvement Contractor
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO!: hj� OF iceT=,
SIGNATURE DATE A71"v �r
r
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED.
MAP/PARCEL N0.
ADDRESS VILLAGE
OWNER '
DATE OF INSPECTION:
L
FOUNDATION '
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL ;
GAS: ROUGH FINAL
FINAL BUILDING
I
DATE CLOSED OUT
ASSOCIATION PLAN NO.
x
I .
k
r Find a Licensee Page 1 of 1
The Official Website of the Executive Office of Public Safety and,Security(EOPS) ,
Public Safety '
Mass.Gov Home
DPS Home EOPSS Home Mass.Gov Home State Agencies State Online Services
Department of Public Safety Licensee Lookup
The list is current as of Wednesday,May 07,2008.
You can search/filter the licensee list by any of the criteria below.
License Businesses Individuals
Select a License Type Home Improvement Contractor ❑,;'
Search by License Number 1136386
Search i
Select a License Type Home Improvement Contractor Q�
Search by Business Name
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Search Results
LICENSE TYPE BUSINESS NAME CONTACT NAME LICENSE RESTRICTION ADDRESS STATUS
Home Improvement Contractor Brian T.Powers Powers,Brian 136386 . 32 Hemeon Way Hyannis,MA 02601 Current
http://db.state.ma.us/dps/licenseelist.asp 5/9/2008
Town of Barnstable
Regulatory Services
• r
r BARNSTABLE. .*"
y MASS. 8 Thomas F.Geiler,Director
i639
iOrFn�rA Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
NOTICE TO THE BUILDING DIVISION OF
CHANGE OF LICENSED CONSTRUCTION SUPERVISOR
owner of_property located at .
,31 hereby certify that
r., is no longer
Construction Supervisor listed on the application for the project under construction as
authorized by building permit#' 7. 9-0 , issued on 3 20
I understand that the project under construction must cease until a successor-licensed
Construction Supervisor, is submitted on the,records of the Building Division.
PROPERTY_OWNER DATE
2
q/forms/newcontrowner
reference R-5 780 CMR
rev:011608
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Le 'bl
Name(Business/Organizationgndividual): lej=LL,*- 0am
Address:C1 A Arr, S 05 yttyLl,(_., A4 23-14 SS
v
City/State/Zip: Phone.#: Q y :9 3' ��
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction f
employees(full and/or part time).* 6 have hired the sub-contractors
2.El am a"sole proprietor or partner- on the attached sheet 7. ❑Remodeling
ship and have no employees - These sub-contractors have g, ❑D lition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers'comp."insurance tnsurance. .
required.] 5. We area corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work ' officers have exercised their 11.❑Plumbing repairs or additions
myselL[No workers' comp. right of exemption per MGL 12 ❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'con?msation p6Hcy information.
t Homeowners who submit this affidavit indicating they arm:doing all work and then hire outside contractors must submit a new affidavit indicating such.
t--Mtractors 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 pravidc their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the Office of
Investigations of the DIA for insurance covermze verification.
I do hereby certi cn -and penalties of perjury that the information prov! dahDve true and correct
Si tare: Date: O
Phone#- <O-(�c ^7+34--- A l '
Official use only..Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees:
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hue,
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 RZth the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insu mane license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit'license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
.The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone-and fax number.
The Com:monwWth of Massachusetts
Department of Industrial Accidents a
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 4-06 or 1-977-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
IKE►° Town of Barnstable
Regulatory Services
BARNSTABI'E Thomas F.Geiler,Director
s659. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
NOTICE TO THE BUILDING DIVISION OF
LICENSED CONSTRUCTION SUPERVISOR
ASSUMPTION OF RESPONSIBILITY
O—
I, W ,Construction Supervisor License
# q ,hereby certify that I have assumed responsibility for the project under
construction, as authorized by building permit# ���}del o� , issued to
(property address) I I�k.Lbl� 5-1 Po;�T-
on , 200-1
The following documents are attached:
copy of rriy Massachusetts State Construction Supervisor's license
or Homeowner's License Exemption form(if applicable)
copy of my Home Improvement Contractor registration(if applicable)
Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit.
Road Bond (if applicable)
ICENSE HOLDER DAT
'',� ` ; ✓�ie omvrzonureall/'a�✓�aaaac�isiaeG`la
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number 079418
Ex{fires '08/01/2008` Tr.no: 870`.0
p t
`.onctrurtinn rC Rest ICtef�=�00 3
BRIAN T. POWERS fr
32 HEMEON RDA
HYANNIS, MA 02601 Com io�f; i
200
°FTHEr Town of Barnstable
ti
r
Regulatory Services.
RAMST"IE�, - Thomas F. Geiler, Director
�p .z639 �0
TF1619 & Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
, 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)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on the reverse side.
Town of Barnstable
�oF 1HE Tpk�
y� o� Regulatory Services
♦ •y
Thomas F.Geiler,Director
+ BARNSTABLE,
Y MASS.
16_19.A�� Building Division
rFn I�� Tom Perry,Building Commissioner .
200 Main Street, Hyannis,MA 02601
armv.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230.
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
I
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a'license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on'which he/she resides or intends to reside, on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1).
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption aie unaware that they are assuming the 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 Huth 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.
04/19/2008 18:01 5084197708 HP PAGE 01
o0 p ° `d P d
Town ol` Barnstable
Regulatory Services
Thomas F. Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.ba rnsts ble.ma.as
Office: 508-862-4038 s Fax: 508-790-6230
Lki
Property Owner MustCn �
Complete. and Sign This Section
-- If Using A Builder
c- f
cam+ � •
,
T, +►�-t�-+�:�... ,as Owner of the subject property
hereby authorize ,r` •.,ram Q®uu is f~ S to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
/1-23
�.
Signature,of Owner Date
Print Name
If Property Owner is applying for permit please complete the Howeowners License
Exemption Form on the reverse aide.
Town of lii� ie
_ Regulat&3y Services
d
b p BiuRdlDk DivWmm
Tom Perry,Dti IRM Com wonea .
200 Main Sft8t,ITYAnGb,mA 02601
.Office- 508-862-e€038 r Fax 508•790-6230
NOTICE TO TIN,BUMDINC DMSION OF )DRA►wAL OF.:",
LICENSED CONSTRUCTION SUPERVISOR FROM PROJECT
ca Construction Supe IAcense .
hereby certify that I ana no longer the Construction Supervisor liatod
on the application for the project under construction as authorized by building pex�dt y
C�1 0 a iss�edAt® r d4iriss
� •Y a i,Y - . T r
I also certify that do M� 200 noti�iea the property®weer,that the
project under construction must cease until a successor licensed Consuubtion Supervisor,
•
is submitted on*e records of the Building Division. r
5.
LI DATB
oe
__ _-- _.
Z
°'
r �.��=
,
� � _
` Nov 28 2007 4: 36PM The UPS Store - 3312 603-356-4873 p. 1
Town of Barnstable.
:�;egulatory Services. _ -
sM ThOmu r.aeiUr,Mrecfor '
Divwon
''fi 't�? ?om�'arry, BuildingGonxduioner
_ t,(v i
200 Mik Sheet, Eywais,MA 02601
vrww.toxn.beit�tabie;ma.ue
pffice; 508-862-4038 F,vc: 508-790.6230
Property hex Must
complete and Sign This Section
if Using A BuUder
i •.. ,as Owner of the subject property
hereby authorize �C. t�r1 ,. 3b Act on=7 behalf,
is an=aars relative to•work authorized bytU b�permit applicaaan for
ss of rob
,gr iwe of Owner Date
i�rrame
QFOF�i�g:0 41+h�.�p8RM:8 Slow
T 'd SEAT-SLL-809 umoag pau , WCQ i T T 40 "e X A01
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�INETpy� TOWN OF BARNSTABLE Building
Application Ref: 200708120
BARNSTASLE, Issue Date: 01/23/08
Permit
9 MASS.
Qpp 039• �� Applicant: ALBERT ROY BROWN
rFG MAC s Permit Number: B 20080157 I
Proposed Use: SINGLE FAMILY HOME Expiration Date: 07/22/08
Location 31 HIGH STREET Zoning District RF Permit Type: RESIDENTIAL ADDITION/ALTERATIO
Map Parcel 035097 Permit Fee$ 137.76 Contractor ALBERT ROY BROWN
Village COTUIT App Fee$ 50.00 License Num 065525
Est Construction Cost$ 33,600
Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND
ADD A STICK FRAME 15 X 14 ADDITION TO HOUSE FOR USE A+ H 'METHS CARD MUST BE KEPT POSTED UNTIL FINAL
OFFICE '44 4PTECTIONGASEEN:MADE. WHERE A
CERTIFICATy, OCCUPANCY IS REQUIRED,SUCH
Owner on Record: MANN, FRANK&BIDDLE, KATRINE T $UILDING-ShI�Z L NOT BE OCCUPIED UNTIL A FINAL
Address: P O BOX 1989 I11 SPEC rION HAS BEEN MADE.
COTUIT, MA 02635
Application Entered by: RM NBI i lding Permit Issued Byj
THIS PERMIT CONVEYS NO RIGHT TO OCCUP%AIIXD�
�S� �E�T A`LOR SIDE F O', �I PART THEREOF,,,EITHER TEMPORARILY OR PERMANENTLY.
ENCROACHEMENTS ON PUBLIC•PROPE ,'N FICALLY�PER�MITTED DTHE BUILDING CODE,MUST•BE APPROVED BY THE JURISDICTION.
STREET OR ALLY GRADES AS WELL.ASTCATION OF.PUBLIC SE 1 MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS...:
THE ISSUANCE OF THIS,PERMIT DOES NOt + SE THE'•APPLWAN JR0 CONDITIONS OF ANY APPLI CAB LE,SUBDIVISION RESTRICTIONS
I: . .
MINIMUM OF FOUR, ALL SP IONS LQUIRED FOR ALL CO 'TSTR CTION WORK:
1.FOUNDATION OR F `OUTINGS.
2.ALL FIREPLACES M-U OINSPECT D AT THE THROAT La VEL' BE ORE FIRST FLUE LINING IS INSTALLED.
3.WIRING&PLUMBING S�PECTIONS TO BE COI�VkPLETED P I " FRAME INSPECTION.
4.PRIOR TO "VERING STRiJC-TURAL MEMBERS(READY TOO LATH).
5.INSULAT�I
6.FINAL PEC., : BEFORE O PANCY.
WHERE AP P ICABLE,SEPARA PERMITS ARE REQUIRED FOR"ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS.
WORK SHA OT PROCEED TIL THE INSPECTOR HAS E\PPROVED THE VARIOUS STAGES OF CONSTRUCTION.
PERMIT WI)L 1 BECOM NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF
DATE THE PE T . - ISSUED AS NOTED ABOVE. "
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A).
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
1 1 1
2 2 2
3 1 Heating Inspection Approvals Engineering Dept
Fire Dept 2 Board of Health
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �)35 Parcel App lication#
Health Division
Conservation Division Permit#
Tax Collector Date Issued � �1 161
Treasurer Application Fee
Planning Dept. Permit Fee
Date Definitive Plan
�1AI prod Planning Board
Historic-OKH n Preservation/Hyannis �1N
Project Street dress J
Village61 /1 �
Owner lG� �f 1-4gA R"Address
Telephone
Permit Request oIL !�^
Lira—
Square felt. 1 st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 69 Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family 8_ o Family ❑ Multi-Family(#units)
)
Age of Existing Structure Historic House: des fQo`' On Old Ki 's High ay. ❑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 s 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:❑exist i'g ❑nMv size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
'Q t
Commercial ❑Yes ❑No If yes,site plan review#
a..n
Current,Use Proposed Use "=
UJ
BUILDER INFORMATION
Name (2 Telephone Number
L=�a ,
Address � License#�,4" . �
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE /
.~ FOR OFFICIAL USE ONLY
PERMIT,NO.
DATE ISSUED t
MAP/PARCEL NO.
• i -
r
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME b�/ Of ift 41t107
INSULATION4e PI�6 7 �o
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
' The Commonwealth of Massachusetts
UTDepartment of Industrial Accidents
f Office of Investigations
600 Washington StreetBoston,MA 02111 www.mass.gov/dia '
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Piumbers ' .
A-pplicant Information .Please Print]Le ' 1 i
Name(Business/Orgmization/Individual)—: .�
Address: taw
City/State/Zip:
Phone.#:
:27 6o
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 .
ees (full and/or part-time),* • have hired the sub contractors
2, am a'sole proprietor or partner-
listed on the sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. Demolition
i�vorkin for me in an capacity. employees and have workers'
g Y p ty. $. 9. ❑Building addition
[No workers' comp,msuTance, comp, insurance.
5. C1 We are a corporation and its 10.❑Electrical repairs or additions
required.]
3.❑ I am a homeowner doing ill-work . officers have exercised their 11.❑Plumbing repairs or additions '
myself.[No workers'comp. right bf exemption per MGL 12,❑Roof repairs
insurance.required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other___- .
comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors mutt submit anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether arnot those entities have .
employees, If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site'
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
tAJJob Site Address:. ?2 _ City/State/Zip: e
Attach a copy of the workers' compensation policy declaration paae'(showing the policy number and expiration date).
Failure,to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the.Office of
_ Investigations of the DIA fox insurance coverage verification
I do her e u . ains and penalties of perjury that the in provided above,is true and correct
Si tune: Date:, _
Phone-4: -
' Official use only. Do not write in this area, fo,be completed by,city or town official.
City or Town: ' Permit/License#
Issuing Authority(circle one):
'1,Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and i nstructi ns l
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 ofhiie,
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 adeceased 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
'entei into any contract for.the performance of public-work until acceptable evidenee•of•co41{?iee vwithtlie insurance-
requirements of this chapter have been presentedto the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(S)of
insurance. Limited Liability'Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the .
members'or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that ibis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pemut.or license is being requested,not the Departrnent of
Industrial Accidents. Should you have any questions regarding the law-or if you are required to obtain a workers.'
compensation policy,please call the Department at the number listed below, Self-insured companies should enter their
self-insurance license-number on the appropriate-line.
City or Towp Officials
Please be sure that the affidavit is complete-and printed legibly. The Department has provided a space at the bottom
of the-affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"an.locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe 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 pemut not related fo any business or commercial venture
(i.e.a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Depaziment's address,telephone-and fax number:.
The Commonwwi&Of mmarlhuseds
Dopartmwt of JhdustdW A ccid pits
Q£ ice of Invesdigat ons
' . • ����as1>in St�e� •
Bostm,NIA 02111
TO.#617-727-400 ext 406 0r 1- MASSAFE
Fax#C17-'27-7749
Revised 11-22.06 www.m=.gov/dia
.r
i
°pTME 1p Town of Barnstable
ti
Regulatory Services
" BABNSrABLE, ' Thomas F.Geiler,Director
MASS $ '1 7� .
1 39•'�°�� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 509-862-4038 Fax; 508-790-6230
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. f �`
Type of Work: � Estimated ost �—\J`' o ""�
Address of'Work: ,
Owner's Name: �f
Date of Application: .
I hereby certify that: '
Registration is not required for the following reason(s):
QWork excluded by law
❑Job Under$1,000
OBuilding 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 WORD DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I h ply for S' s the agent of the owner:
SDate Contractor Name Registration No.
OR
Date - '— r s ame
Q:foims:homeaffidav
1-.
f ,
4a
Jlie eol"W-aiea z �� TIONS
BOARD OF BUILDING REGULA i
' NSTRUCTION SUPERVISOR
License: CO {
NUmber -S 065525 II
n
16902 I
'Expires 02(1212008 Tr.no:
— Restnct'd
t 4
I + ALBERT
34 HORATIO LN --c' i commissioner
CENTERVILLE, MA'026.32`'
77
,per ✓die '�omvrrw.uuea�.o�✓GG'aaaczelaccaelta
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration 126560
wo
u iration`
p 6/21/2008
T e:r DBA
yP.
ALBERT ROY BROWN4.10MEP REPAIR
ALBERT BROWN,
34 HORATIO LN
CENTERVILLE,MA 02632 Deputy Administrator
Town of Barnstable *Permit#.c2&7tla6 3c/
Expires 6 months from issue date
Regulatory Services Fee C)
-PRESS PERMIT Thomas F.Geiler,Director
Building Division
MAY 1 2007 Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,ARIA 02601
TOWN OF BARlVSTABLE
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
J�, Not Valid without Red X-Press Imprint
(J`.J
ap/parcel Number S
operty Address /
]Residential Value of Work Minimum fee of$25.00 for work under $6000.00
Pner's Name&Address G /Y t
mtractor's Name Telephone Number_
ome Improvement Contractor License#(if applicable)
�3t i nt Upe, r's-Licenses {{ app ieablej � �,� �
]Workman' C ensation Insurance.
Cheanle proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
surance Company Name
orkman's Comp.Policy#
opy of Insurance Compliance Certificate must be on file.
:m it Request(check box)
e-roof(stripping old shingles) All construction debris will be taken to �_
❑Re-roof(not stripping. Going over existing'layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission,
A copy of the Ho provement Contractors License is required.
GNATURE:
Forms:expmtrg
;vise06 i 306
f
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ise 'lal
Name(Business/Organization/Individual): .
Address:
City/State/Zip: Phone:#:_ _ e7
Are you an employer? Check the appropriate box: Type of project(required):,
1.El am a employer with 4. ❑ I am a general contractor and I
e ye—es(full and/or.part-time).
* have hired the sub-contractors 6. ❑New construction .
2.MTam a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
shipand have no employees These sub-contractors have
8,'❑Demolition
working for me in any capacity. employees and have workers'
coin insurance.$ ' 9. ❑Building addition
[No workers' comp.insurance P•
required.] 5. ❑ We are a corporation and its 10.0 Electricalxepairs or additions
'3.❑ I am a homeowner doing all work officers have exercised their 11•❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no 13.❑Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check.this box must attached an additional sheet sbowing 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.
lam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name:
Policy#:or Self-ins.Lie.#: Expiration Date:
Job Site Address: ? City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c i u r the pains penalties of perjury that the information provided bo a is true a cor`r`ecctt.
Si afore: { l./ /
Date:
Phone#: >Z2
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): �(
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r..
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hiie,
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
reaeivPr nr 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 producedtacceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for;the performance of public work until-acceptable evidence of compliance with the insurance
requirements.of this chapter have been presented'to the contracting authority."'
Applicants
Please fill out the workers' compensation affidavit completely,by.checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that ibis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town-that the application for the permit or.license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law of if you are required to obtain a workers'
compensation policy;please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete"and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related io 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 tquestions,__-
please do not hesitate to give us a call.
The Department's address,telephone-and fax number:
The eommwvvealth of Massachusetts
Df, zut of Industrial Accidemts
office of Investigations
600 Washington Street
Boston,MA 02111
TO.#617-727-490:0 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
r'-
�OFZHE Town of Barnstable.
.
Regulatory Services
'+ BARNsrAUm, +
buss. $ Thom-as F.Geiler,Director
�AlFO MA'S A` Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town,barnstable.ma.us
Office: 508-862-4038
Fax: 50.8-790-62.30
1
Property Owner Must
Complete and Sign This Section
If Using A Builder
Y"
as Owner of the subject property
hereby autho ' to act on my behalf,
in all matters relative to work authorized by this wilding permit application for; .
(Address of Job)
oar
Signature of Owner Date
Print Name
QTOFUM S:0 WNERP ERMIS S ION
oNlR�G.tpR
`MPRp�IEM 6560 0a
HpM a��or\'•.. �120
2.
`° fc`t•'� .hype . ,. P PAR ,�,.---- .
0\O\N MP o263.
34 NOR
G�N•(E
.. �aac��elta
Bu D'IG R C,U4ATIp RS
OF PERVISO
x n BOARD g-vp TION SU
�icen$e: GON.
065525
Number GS
• _�. 16902
0211212008
„ b
Restncf. 0
ERT R BRO
GENTER 10 LN MA 32' COmmissioner
Al b
34 HOR `b26
V1��E,
aa �K
BOISE- Double 1-3/4" x 16" VERSA-LAM® 20 3100 SP Roof Beam1R1301
BC CALC®9.3 Design Report-US 1 span No cantilevers 0/12 slope Monday, May 07,2007 08:29
Build 057
File Name: Brown Biddle.BCC
Job Name: Biddle Description: Roof Beam
Address: High St Specifier: Bill Campbell
City, State,Zip: Cotuit, Ma Designer:
Customer: Roy Brown Company: Shepley Wood Products
Code reports: ESR-1040 Misc:
�o
12
1
20-00-00
BO,3-1/2" /B1,3-1/2"
DL 1657 Ibs DL 1657 Ibs
SL 3000 Ibs ESL 3000 Ibs
Total Horizontal Product Length=20-00-00
Load Summary Live Dead Snow Wind Roof Live
Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% Trib.
1 -Standard Load Unf.Area-(psf) Left 00-00-00 20-00-00 15 30 10-00-00
Controls Summary Value %Allowable Duration Load Case Span Location Disclosure
Pos. Moment 22232 ft-Ibs 51.7% 115% 3 1 -Internal Completeness and accuracy of input must
End Shear 3901 Ibs 31.9% 115% 3 1 -Left be verified by anyone who would rely on
Total Load Defl. U367 (U.64") 49.1% 3 1 output as evidence of suitability for
Live Load Defl. U569 (0.412") 42.2% 3 1 particular application.Output here based
Max Defl. 0.64" 64.0% 3 1 on building code-accepted design
Span/Depth 14.7 n/a 1 properties and analysis methods.
P P Installation of BOISE engineered wood
/,jproducts must be in accordance with
%Allow. %Allow current Installation Guide and applicable
Bearing Supports Dim.(L x W) Value Support Member. Material ! building codes.To obtain Installation Guide
BO Post 3-1/2"x 3-1/2" 4658 Ibs 52.4% 50.7% Spruce-Pine-Fir or ask questions,please call
B1 Post 3-1/2"x 3-1/2" 4658 Ibs 52.4% 50.7% Spruce-Pine-Fir (800)232-0788 before installation.
BC CALC®, BC FRAMER®,AJST1
t ALLJOIST®,BC RIM BOARDT"" BCI®,
Cautions ` BOISE GLULAMT"' SIMPLE FRAMING
Column at Bearing BO analyzed for bearing only, column analysis has not been performed. SYSTEM®,VERSA-LAM®,VERSA-RIM
Column at Bearing 61 analyzed for bearing only, column analysis has not been performed. ` PLUS®,VERSA-RIM®,
E VERSA-STRAND®,VERSA-STUD®are
Notes trademarks of Boise Wood Products,
Design meets Code minimum(U180)Total load deflection criteria. L.L.C.
Design meets Code minimum(U240) Live load deflection criteria.
Design meets arbitrary(1") Maximum load deflection criteria.
Member Slope=0, consider drainage.
Connection Diagram
b d
a
c
a minimum=2" c= 12"
b minimum=3" d= 12"
Member has no side loads.
Connectors are: 16d Common Nails
Page 1 of 1 t
Engineering t. 03-� 7Parcel 6 7' Permit#
e g g Dept.(3rd floor) Map
' House# 3/ - Date Issue ^�
�U Board of Health(3r oor)-(8:15 -9:30/1:00-4:30 Fee •
C ice - or - - � �✓.
�Ymurirrg�ep . st oor/School Admin. Bldg.) THE rp
Defi 19 '
BARNSTABLE. `
MASS.
f TOWN OF BARNSTABLE .Eo,�.a,.
Building Permit Application
Project Street Address /
Village -' �fd-tu /.-T
Owner GI Address <
Telephone ('/ 7 �`- G 57 Z
Permit Request '14c) &,r29 LA—_ .*Ffr r,,X 2-7 _Sq(���> it �jZ i S
e2d:E Cif dq,Ir Z POOrW S
eKl r F d
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ 4 G n 0
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 WNo On Old King's Highway ❑Yes No
Basement Type: ❑Full JKCrawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) ILIA 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: Q Pool(size)
❑Attached(size) ❑Barn(size)
❑None Q 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
S'GNATURE DATE
BUILDING R I FOLLOWING REASON(S)
a
t- - FOR OFFICIAL USE ONLY '
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS ` 1 VILLAGE _ «
OWNER , r
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION =
- - s
,FIREPLACE
ELECTRICAL: ROUGH FINAL- r,
PLUMBING: ROUGH FINAL
GAS: ROUGH `FINAL ' >
FINAL BUILDING I r
DATE CLOSED OUT
• r
ASSOCIATION PLAN NO.
erne r� _ r
: . The Town of Barnstable
• a,►Eursr�,E, .
Department of Health Safety and Environmental Services
prFOt � 4, Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only t
Permit no. '
Date
AFFIDAVIT
' HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION { t
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-70C)o -Go
Address of Work: fil-.G `� �l-rV l Al
'04—
Owner's Name &(),
Date of Permit Application:
I hereby certify that:
r
Registration is not required for the following reason(s):
Work excluded by law
Job 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: ! 20 12-00d
Date Contractor Name Registration No.
OR _
&L5f
_Date Owner's Name s
The Conutroml•calth of atascachusctts
Department of Industrial.4ccidettts
• , .. .e : liwi -
. OJ�ceollttyestlya11otts
" i 600 f f'ashiu,ton Street
Busttllt. MasS. (12111
`• Workers' Compensation Insurance Affida-s•it
•1lmlic.int information: Please PRINT lei�U!'"'"�
Vo Se
17� ,qqq- �S- 71
cati
ki am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
[II am an employer providin= workers' compensation for m% employees working on this job.
emmu:tns• name:
atldress•
city. lthnne#•
insurance cn. nolier#
I am a sole proprietor. general contracto or homeowner ircle otte) and have hired the contractors listed below who have
the Following workers' compensation polices:
`
comminv natne: b
sin nhnne 0-
in-mr.incr rn. tr y e- )�o ge nnliev H
•••e„ -.. ti••r•.---' - �••:Y.... . .__.,___._.�_��r—'z tT••r-+ems• _�._.__ _� ...,,...b.�._... �.
mninam name:
�ddresc�
rin•� nlirc�e r'
insurance co nniicv
Attach additional sheet if neeesiarv� li'e:•Sys.' :�____'':�==-�'�7-77•� _���+_�6..y..1y: _�1+..•=��_'_�•.._�•�"_
F:Iiiurc to secure coverarc:is require) nu der se+ c— ttioon 3A of 111GL 152 can lead to the imposition of criminal penalties ol'a lineup t S1SDU.UU ndiur
unc rears• imprisonment as crcll as civil penalties in the form of a STOP lt•ORK ORDER and a fine of 5100.00 a day against me. 1 understand that a
cop} of this statement mai be forwarded to the Oltce of lavestigations of the D1A for coverage verification.
!t10 hercht•cerrif rr r er rlte pai is and acnalfte nerj ,•that the information prorided above is true and correct.
•Siznaturc Date 7
Print name Phone#
official use unit' do not write in this area to be completed by cin or town ofliciai
kfr•
citi or town: permittlicense# rtlluilding Department
C31rcensing Huard
check if immediate response is require) Oseleetmen's Once I
C3111callh Department
contact person: phone#: rjOther�� g.
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers* compensation for th
employees. As quoted from the "lay+•". an esrplgree is defined as every person in the service of another under any
contract orhire. express or implied. oral or xvrinen.
An enrplt rcr is defined as an individual. partnership, association. corporation or other legal entity. or any two or Inc
the foregoing enuaged 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 t!
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwellin, house of another who employs persons to do maintenance , construction or repair work on such dwellingh,c
or out the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employ,
MGL chapter 152 section 25 also states that even state or local licensing agency shall withhold the issuanee or
renewal, of: its�:aa� s r per."ut to operate a business or to construct buildings in the common %•calttr for any
applicant who has not produced acceptable evidence of complianec with the insurance cowerag.c tequip°ed.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
perforniance 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 ail affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coyera`e. 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 require
to obtain a workers* compensation polio', please call the Department at the number listed below.
Cin• or ,towns
Please be sure that the affidavit is complete:and printed leas-bly. 'flag .Department has provided a space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pl:
be sure to fill in the per•mittlicense number which will be used as a reference number. The affidavits may be returned
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 questic
please do not hesitate to __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) 72 7-4900 cxt. 406, 409 or 375
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE — /0
JOB. LOCATION 3 ij-It C-G C
Number Street address ` Section of town
"HOMEOWNER" 617 l qqq- (?5,71
Name Home phone . Work phone
PRESENT MAILING ADDRESS .� a7rey-rn9ln Ave- /v '.t'w 4 op1
0:
City town State Zip cod:
The current exemption for "homeowners" was extended to include owner-occup.
dwellings of six units or less and to allow such homeowners to engage an is
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Persons) who owns a parcel of land on which he/she resides or intends to
side, on which there is , or is intended to be, a one or two 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 t.
considered a homeowner. Such "homeowner" shall submit to the Building Off--:
on a form acceptable to the Building Official, that he/she shall be respon;.
for all such work performed under the building permit. (Section 109. 1. 1)
The undersigned "homeowner" assumes . responsibilty for compliance . with ,.the
Building. Code. --and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requiremen
and that he/she will compl with said r res and requirements.
HOMEOWNER'S SIGNATURE '
APPROVAL OF BUILDING 0 FI IAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be require:
to comply with State Building Code Section 127. 0, Construction Control.
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