HomeMy WebLinkAbout0077 MAIN STREET (COTUIT) �� Isla� � S-l-
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Town of Barnstable .. .Building }
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Post°This Card So That�t is VisibleFrom the StreetA,, roved:Plans%Must beRetained ort aob and this'Ca;rd Mustbe Ke t
tnnxttCABLe. 'a,« k" a:agy
M 'Poste 61 Until4Final:lns action Has=:Been.Made ;: � �,"„ Perm' it
Where a,•Cert�ficate;ofbOecu ancV;wis:Re u red=i: uchBuildm shall Notbe Occu red unt�I aF�nallns ect�onhas been.Emade
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Permit No. B-18-1204 Applicant Name: RetroFit Insulation Approvals
Date Issued: 05/15/2018 Current Use: Structure
Permit Type: Building-Insulation-Residential Expiration Date: 11/15/2018 Foundation:
Location: 77 MAIN STREET(COTUIT),COTUIT Map/Lot 009-013 Zoning District: RF Sheathing:
ter:
� .RETROFIT INSULATION INC. Framing: 1.
Owner on Record: JENSEN,ROBERT JR&FIONA M TRSk ContractorName w ,
xE � �
Address: 77 MAIN STREET ^� Cotractor 1icense` 160461 2
SANTUIT, MA 02635 ��
f Est Protect Cost: $9,899.00 Chimney:
Description: Install 14" layer cellulose open attic, Install 9' layer cellulose open Permit Fee: $ 100.48
attic, Install 5" layer cellulose slope area, Insulate,Attc€Hatch,Propa Insulation:
Vents,Air sealing, Door Kits&sweeps, Install bI.6W ih' cellulose r Fee Paid $ 100.48
exterior walls, Install 10ml poly over open gr and crawlspace, Date 5/15/2018 mat.
Install closed cell spray foam insulation to craw space perimeter
F
wall. Plumbing/Gas
Rough Plumbing:
Project Review Req: �
r _� �� Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authonzed by this permit is commenced within six months after issuance. Rough Gas:
All work authorized by this permit shall conform to the approved 49
appI''ton and the approved construction documenu for which l is permit has been granted.
�q r Final Gas:
All construction,alterations and changes of use of any building and str resll be incompliance with the local zoning by la and codes.
This permit shall be displayed in a location clearly visible from access street�or road and shall be maintained open for public�spection for the entire duration of the
work until the completion of the same. a Electrical
zy Service:
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided onthis permit.
Minimum of Five Call Inspections Required for All Construction Work r Rough:
1.Foundation or Footing ,• .. ., "�.' R. �.._: .,
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-TNF Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
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so that we can return the card to you. -Addressee
■ Attach this card to the back of the mailpiece, (Printed Name) C. Date�f Der e
or on the front if space permits.
1. Article Addressed to: D. Is delivery address different from item ? Yesr
`'7te'e6e�-t.• J r If YES,enter delivery address below: ❑No
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I!I IIIIIIIIII III I I I I I II I III I II I II II III I I I II III 3. Service Type ❑Priority Mail Express®
❑Adult Signature ❑Registered Mail*^'
i ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted
9590'9403 0521 5173 2831 63 Certified Mail® D�livery
0 Certified Mail Restricted Delivery C4Return Receipt for
t,) ❑Collect on Delivery Merchandise
2 Artipte Number(Transfer from service 1a6e11 ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationT
❑Insured Mail ❑Signature Confirmation
f 7 0 15` O 6 4 0 0 5 i!8 4 8 9 8 4 9 ❑Insured Mail Restricted Delivery Restricted Delivery
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PS Form 3811,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt
UNITED STATES MMODVIOI°"E. First-Class Mail'.
Postage&Fees,'Paid f
USPS
-; --fiJN y 16 Permit No.G-1
• Sender: Please print your name, address, and ZIP+40 in this box*
Of BARNSTABLE
Y,JILUING DIVISION i
200 MAIN ST.
NNIS, MA 02601
USPS TRACKING# T
Illllilil_IIII_�1.111�111�1_I_Illllllllll_Il�ll_III _
Postal Service"
CERTIFIED o RECEIPT
p Domestic Mail Only
c0 For delivery information,visit our website at www.usps.com".
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cc Certified Mail Fee
co $
Extra Services&Fees(check bar,add lee as appropdate)
Lr) ❑Return Receipt(hardcopy) $ -
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p ❑Return Receipt(electronic) $ - Q
p ❑Certified Mail Restricted Delivery $ \ Here
p ❑Adult Signature Required $ �� 0
❑Adult Signature Restricted Delivery$ = j
Postage jo 13 2016
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p Total Postage and Fees '
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PS Form 3800,April 2015r, rrr•,
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. I NSPSO-postmarked Certified Mail receipt to the
■A record of delivery(including the recipient's retail associate.
signature)that is retained by the Postal Service' Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent.
Important Reminders: Adult signature service,which requires the
■You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Class Package Service®, available at retail).or Priority Mail®service. -Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age
cifi
International mail. and provides delivery to the addressee speed
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
insurance"coverage automatipaliy included with accepted as legal proof of mailing,it should bear a
certain Priority Mail'items'l% USPS postmark.If you would like a postmark on
■For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail Item at a Post Gffice-for +
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion '
of delivery(including the recipient's signature). of this label,affx it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.-
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Retum
Receipt;attach PS Form 3811 to your mailpiece; IMPORTMM.Save this receipt for your records.
PS Form 3800,April 2o75(Reverse)PSN 7530-02-000-9047
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FOR DATE TIME
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OF
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MESSAGE ire ' �� ) J l TELEPHONED
;i ht h 0 paRETURNED YOUR CALL
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PLEASE CALL
WILL CALLAGAIN
CAME TO SEE YOU
SIGNED WANTS TO SEE YOU
�.=i°own of isarnstaDie
b Regulatory Services
°F1HE tti Richard V.Scali,Director
Building Division
BAIMSTABLE,
* Tom Perry,Building Commissioner ;r
Ar 1639• a`�� •200'Main Street,Hyannis,MA 02601
FD MA'S y,' #• „� _� - - I
Office: 508-862-4038 ''` '�P ' r Fax: 508-790-6230
Notice of Zoning Ordinances'Violation(s) and Order to Cease, Desist and
Abate:
Robert Jensen, Jr, Fiona'Jensen& Cotuit Mooring & Marine "
and all persons having notice of this order..As owner/occupantof the,,'.
premises/structure located at 77'Main Street, Cotuit,MA 02635
Map 290 Parcel 028,you are hereby notified that you are in violation of the Town of Barnstable'Zoning }P
Ordinances and are ORDERED this date,June 10,2016 to: . .
1. CEASE AND DESIST IMMEDIATELY,all f auctions connected with this violation on or.at the above y '
mentioned premises. •a �#
SUMMARY OF VIOLATION-
Violation of Town of Barnstable Zoning Ordinances:
{ Chapter 240 Section 14 4 `
RF Residential Single Family Zone T `
e, _
2: COMMENCE immediately;action toi abate"this violation` w.
SUMMARY OF ACTION TO ABATE:, q'u
Operation of any and"all uses and activities associated with the operation of Cotuit i
Mooring&Marine including but not-limited 64he sales, rental, or brokerage uses
storage, repair or.-transportation of marine vehicles' Employees and clients of
Cotuit Mooring&Marine prohibited from residential site. x
Remedy:
Immediately relocate office«and all associated uses and related activities Y�
to a zoning PP P a ro riate commercial location.
w*_ a .' •'x -: •.. a^ . _'. . ,. ;-; �Y:°' .� _ '- ! i
And,if aggrieved by this notice and order,to show cause as to why you should not be required to do so,by
filing an appeal with the Town Clerk of Barnstable,a Notice of Appeal(specifying the ground thereof)
within thirty(30)days of the'receipt of this order(in accordance with Chapter 40A°Section 15 of,the
'Massachusetts General'Laws): _ p
If,at the expiration of the time allowed,action to abate,this violation has not commenced,f i tlier action as
the law requires will be
Anderson `
t is z
Zoning Enforcement Officer
Ro x
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Cotuit Mooring & Marine (Massachusetts) Page 1,of 2
COTU|T MOORING& MARINE
The Telephone Number cf the Company: 5OO42OOOO9.(5OO)42U-6OO9
Tel: 4enuen[a]oope.com
Phone Number: 5OD42UOO8S. (5Og)42O-6OD8 .
Fax Number: null . ,
VVebsbeMO0RNGSRUG.00M
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Tel:4en»an[a]capeuom
Company Name:Cutjh Mooring&Marine
A Brief Description of the Company:Cotuh Mooring&Marine isaU.O. �companyioCOTUrr Massachusetts,Uelon.ga
to Boat Dealers Sales&Service industry.
Country:United States of America(]SA)
State: Massachusetts(MA) -
City:COTU|T
` Company Address:T7 Main SB
Postcode:2635
A Brief Description nf the Company:Cotuit Mooring&Marine isaU.S.company mCOTU[rMassachusetts,belongs
to Boat Dealers Sales&Service induooY,Phone:5U0420OOD9.(50O)42V-6809E+na|: rjens*n[a]cape.com '
Loavo�a uomme�mmv�wahoo Cotu�MoohnB&Marine(Massachusetts):
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Cape Cod Moodna Systems
btto .5Uumio1o/72475 btol� ' 6/9/2016
Official Website of The Town'of Barnstable - Property Lookup Page 1 of 4
y
I
Select Language E
Assessing Division Property Lookup Results - 2016
367 Main Street,Hyannis,MA.02601
<<BACK TO SEARCH«` _ Priht Friendly
Owner Information-Map/Block/Lot:009/013/-Use Code:1010
Owner
Owner Name as of JENSEN,ROBERT JR&FIONA Map/Block/Lot GIS MAPS
1/1/15 M TRS.. 009/013/
77 MAIN STREET Property Address"
f 77 MAIN STREET(COTUIT)
SANTUIT,MA.02635
Co-Owner Name ROBERT JENSEN JR TRUST = .
Village:Cotuit
Town Sewer At Address:No
F GIS Zoning Value:RF:
Assessed Values 2016-.Map/Block/Lot 009/013/-Use Code:1010
2016 Appraised Valtae2016 Assessed Value Past Comparisons
Building $113,200 V$113,200 Year Total Assessed-
Value: s Value
Extra $9,700 $9,700 2015-$329,800
Features: 2014 $330,100
2013-$341,300
Outbuildings-$19,400 $19,400 2012-$338,200
Land Value: $171,400". $171,400 2011;$361;900
2010-$365,300
2009-$426,000 {
2008-^$426,400 ,
2016 Totals $313,700 $313,700
2007-$426,400
Residential Exemption Received=$90,000.
Tax Information 2016-Map/Block/Lot:009/013/-Use Code:1010
Taxes ,
Cotuit FD Tax $690.14
(Residential) _ Fiscal Year 2016 TAX RATES HERE
Community Preservation $62.48
Act Tax
Town Tax(Residential)
=2,082.65
2,835.27 .
P g P p Y p Y p? p- archparc... 6/10/2016
htt ://www.townofbarnstable.us/Assessin / ro 'ert dis la scr'eenl6.as a -0&se
Official Website of The Town of Barnstable - Property Lookup Page 2 of 4
Sales History-Map/Block/Lot:009 1 013/-Use Code:1010
History:
Owner: Sale Date Book/Page: Sale Price:
JENSEN,ROBERT JR&FIONA M TRS2014-02-18 27990/235 $1
JENSEN,ROBERT&FIONA M. 1990-03-15 7114/163 $200000
MORRISSEY,JAMES F 1985-06-15 4579/1 $1
LUNNY,DANIEL J 1980-06-02 3105/2 $0
Photos 009 1 013/-Use Code:1010
Sketches-Map/Block/Lot:009/013/-Use Code:1010
FOPIV, r
� i1Sx
I" P s '
AS Built Cards:Click card#to view:Card#1
Constructions Details-Map/Block/Lot:009/013/-Use Code:1010
Building Details Land
Building value $113,200 Bedrooms 4 Bedrooms USE CODE 1010
Replacement Cost $188,720 Bathrooms 3 Full-0 Half Lot Size 1.02
(Acres)
Model Residential Total Rooms 9 Rooms Appraised $
Value 171,400
Style Conventional Heat Fuel Gas Assessed . $
Value 171,400
Grade Average Heat Type Hot Water -
Year Built 1870 AC Type None
Effective 40 Interior Pine/Soft
depreciation Floors WoodCarpet -
Stories Interior Walls Plastered
Living Area sq/ft 1,914 Exterior Clapboard
Walls
Gross Area sq/ft 3,082 Gable/Hip
http://www.townofbamstable.us/Assessing/propertydisplayscreen 16.asp?ap=0&searchparc... . 6/10/2016
i
Official Website of The Town of Barnstable - Property Lookup Page 3 of 4
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Roof -
Structure
Roof Cover Asph/F GIs/Cmp
Outbuildings&Extra Features-Map/Block/Lot:009 1 01 3/-Use Code:1010
Code Description Units/SQ ft Appraised Value Assessed Value
FOP Open Porch-roof- 64 $2,100 $2,100
ceiling
FEP Enclosed porch- 48 $2,900 $2,900
roof,ceiling
BRN5 Barn 2 Story 1144 $17,900 $17,900
FOPC Open Prch-roof, 240 $4,700 $4,700 1
ceiling
WDC Wood Deck w/o 204 $1,500 $1,500
railings
SOLT Solar Thermal 80 $0 $0
Panels
Sketch Legend
I Property Sketch Legend mm^ r
82N Bam-any 2nd story area FPC Open Porch Concrete floor REF Reference Only
BAS, First Floor,Living Area FTS Third Story Living Area(Finished) SOL Solarium
BMT Basement Area(Unfinished)FUS Second Story Living Area SIDE Pool Enclosure
(Finished)
BRN Barn GAR Garage TQS Three Quarters Story(Finished)
CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished)
CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished)
FAT Attic Area(Finished) GXT Garage Extension Front a UST Utility Area(Unfinished),
FCP Carport KEN Kennel UTQ Three Quarters Story
(Unfinished)
FEP Enclosed Porch MZ1 Mezzanine,Unfinished UUA Unfinished Utility Attic
FHS, Half Story(Finished) PRG Pergola UUS Full Upper 2nd Story
(Unfinished)
FOP Open or Screened in Porch PRT Portico WDK Wood Deck
F PTO Patio
• - • .. Print Friendly
Contact ^
(Director of Assessing
Jeffrey Rudziak
http://www.townof barristable.us/Assessing/propertydisplayscreen 16.asp?ap=0&searchparc.-.. 6/10/2016
Page 1 of I.
Anderson, Robin
From: Scali, Richard
Sent: Friday,April 15, 2016 12:00 PM
To: Anderson, Robin; Estey, Stephen; McKean, Thomas
Cc: Crocker, Sharon; Hartsgrove, Elizabeth; Perry, Tom
Subject: FW: 77 Main Street, Cotuit
Robin,Otis and Tom
Could you look at this site and get back to me on these issues.
From: Lynch,Tom
Sent: Friday,April 15, 2016 8:20 AM
To: Scali, Richard
Subject: FW: 77 Main Street, Cotuit
Please investigate.
Tom
From: Jessica Rapp Grassetti [mailto:Precinct7@comcast.net]
Sent: Thursday,April 14, 2016 11:55 AM
To: Lynch,Tom
Cc: Ells, Mark
Subject: 77 Main Street, Cotuit
Tom,
A constituent complaint has come in regarding the activity at 77 Main Street, Cotuit.
Some of the concerns brought up were:
Running a business from the residence, deliveries,trucks, etc.
Rents home, is it registered?
Someone living above barn, is it legal?
Unregistered vehicles/campers
Old tires collecting water
Please inspect and report back to me.
Thank you,
Jessica Rapp Grassetti,President
Barnstable Town Councilor, Precinct 7
Box 1310
Cotuit, MA 02635 ,
(508)360-2504 (C)
(508)862-4738 (0)
Precinct7@comcast.net
www.BarnstablePrecinct7.com
4/15/2016
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,
Map Parcel ® 'i ,;f 2 . Application # 0 �/
Health Division Date Is6 ed l d Y.
q
Conservation Division Application Fee
Planning Dept. P Fee 'lU.��
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address / V
Village (rC)
Owner 0 �� T Q�/ Address 7 f
`Telephone 2.C)—0 S 6
"Permit Request e c!` (—
CA V\_d R6 C) r
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District si Flood Plain Groundwater Overlay
17
1 _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 tO new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION G-e.I,t � �� �3
(BUILDER OR HOMEOWNER) ;'� O
Name Dr cll
ett_4 e sy Telephone Number-
Address 7 7 NA f r j � License #
Co j—,, 47� Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DE RllS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
Tel
SIGNATURE DATE
0O�—Aj ,2
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
' �,,,FOUNDA—T.I.ONs �;� s:E-_--.:-. r• �w�{�:L i�-��r�s.
FRAME
INSULATI0N--_ -
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
t GAS: ROUGH'_ FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
s 1ne c.ommomveaan gmassacnuse=
Department of Industrial Accidents
007ce of fxpestigatlons
600 WashhVon Street
Boston,MA 02111
www.mass govAUa
Workers' Compensation hmwance Affidavit: Builders/Contractors/Electricians/Plmmbers
_Applicant Information Please Print Legibly
Name(Busmesslommiration/individual):
Address: 7
City/State/Zip: (,3 t 0-) Phone#: �j 1
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contwtor and I
employees(fall and/or part-time).*
have hired the sub-corif<actors 6 ❑New cons fraction
2.❑ I am a sole proprietor or partner- listed on the affached sheet. 7. ❑Remodeling
ship and have no employees These ors have 8. Demolition
worldng for me in any capacity. employees and have workers'
[No workers'comp.insurance coup.instrrance$ 9. El Bu ildng addition.
r ed. 5. We are a corporation and its 10.❑Electrical repairs or additions
I am a homeowner doing all work ' of have exercised their ILFJ Plumbing repairs or additions
myself[No workers'-comp. right of exemption per MGL 12.VM Roof repairs
regain]t, c,152,§1(4),and we have no
employees.[No workers' 13.[�]Other d
comp,insurance required]
*Aay.applicant that checks box#1 must also fill out the section below sbowing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
#Cowactors that check.•this box must attached an additional sheet showing the narnc of the sub-contractors andstctr 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 promfing workers'compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.# Expiration Date:
Job Site Address: 7 V�lal. -
� S city/st2ftop,
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 weIl 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 stafzment may be forwarded to the Office of
Investigations of the DU for insurance coverage verification
I do hereby certify vita the pains and penalties of perjury that the informaffon provided above it true and correct
S' Date: Z 'J
Phone#:
Offzcial use only. Do not write in this area to be completed by city or town official
City or Town: Permitllacense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massac itsetfa 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 m 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 e.nploymeat be deemed to be an employer."
MGL chapter-152, §25C(6)also states that"every state or Iocal 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 compIia�dce 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 contact for the performance of public work until acceptable evidence of compliance with the insuzance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checIdag 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
inern-ancc. 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-iusurance license number on the appropriate lime.
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 na any given year,need only submit one affidavit mdicatmg 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 bum leaves etc.)said person is NOT required t6 complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have aay questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commoniealth of Massachust~tts
Department of Industrial Aoddents
Glum of kvestiations
600 Wasbin�n Stroet.
Bo5b==MA 02111
Tel.#617-727-4900 ext 406 or 1-VTMASSAFB
Fax 4 617-727-7749.
Revised 4-24-07.
wwWm .gogfdia
Town of Barnstable
Regulatory Services
P�oFTKE To Richard V.Scali,Director
Building Division
t Reuxicr°urx Tom Perry,Building Commissioner
MAIM
16;¢ ��� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma_us '
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Pieaserrint _
DATE: I _
JOB LOCATION: I-7 /-7 Act ti ��,
number r �{- h street - village -
"HOMEOWNER": R O�E t5 I V G G1
name home phone# work phone#
-7
CURRENT MAMING ADDRESS: �. / 7
C-04 r--Ifi ✓�� o �63 �
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
proce and requirements and that he/she will comply with said procedures and requirements.
Sign of' eowner
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,RuIes&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:IWPFILES\FORMSIbuilding permit fDrmsIEXPRESS.doc
Revised 061313 '
Town of Barnstable
Regulatory Services
RAJIMAMIM
Richard V.Scali,Director
.
i6;p �0
639 Building Division
Tom Perry,Building Commissionerf,
200 Main Street,Hyannis,-MA 2
0 601 r
www.town.barnstable.ma.us J�
Office: 508-862-4038 Fax: 508-790-6230
_.-=-V
Property OwneT/Must
Complete and Sign;Tlus Section
If Using A Builder _
I, rJ as ierr of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorize by this building permit application for.
(Address of Job)
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q:FORM&OWNERPERMISSIONPOOLS
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l��13I1 K
okIKE Town of Barnstable *Permit#
Expires 6 months]om issue date .
* Regulatory Services Fee
* snaxsTasi.e,
1639 MASS. � Richard V.Scali,Director
.ejFD Mp'l A
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number ' 5 Co 13
Property Address 7'� Y V l(te t LL, 154 y-e 2-'"' CO+Li
[]Residential Value of Work$ ��� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address cl e N�Cz)-,/
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance �m�n ��
Check one:
❑ I am a sole proprietor NOV
�] I am the Homeowner C
❑ I have Worker's Compensation Insurance TOWN OF BARNS TABLE
ABLE
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Re uest'(check box) i
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)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance o`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
' [7,qAied.
SIGNATURE:
Q:\WPFILES\FORMS\building it fbrms\EXPRffS.doc
Revised 061313
C�
e
The Cornniorrivealth ofMassach'usetts
Department of Industrial Accicler:ts
_ - Offrce o,;t'Irnwtigations
' 600 Washington Street
Boston,MA 02111'
ivmv.ntass.gov/dh7
Workers' Compensation Insurance Affidavit- BuildersIContr-actors]E�lectricians/Pluinh+ers
Applicant Information Please Paint Legibly
Name(Bus-me ,OrgauizationTndi-vidual):
Address: M( I A/
city/stzate/zIP_ - -k-I 0�-6 Phone
Are you art employer?Check the appropriate boz: T of project, 1
4_ I am a general contractor and# Type p J (required):
1.❑ 1 am a employer with 6_ ❑New constaaiction.
employees(full and or part-time),* have hired the sub-contractors
2.❑ I am a sole prapne#or or partner listed on the attached sheet. 7. ❑Remodeling
slip and have no employees These sub-contractors b we g_ ❑Demolition
working forme in any capacity. employees and have workers'
[No workers' comp.insurance comp_insurance$ 9. E]Building addition.
regtiired_] 5 ❑ We are a corporation and its 10.❑Electrical repairs:or additions
3-N I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp_ riot of exemption per MGL 1'2.❑goof repairs
insurance required.] c. 152, §1(4),and we have no .
employees. [No workers' 13.❑Other
comp_insurance:required.]'
•',day applicant that checks box#1 1 also fill out the sectioa below showing their workers'compensation policy inforoaatica.
Homeowners who submit this affidax it indicating they are doing all work and,ihea hire outside contractors ran submit a new affidavit indicating such
:Contractors thaT cheek this box must attached au additional street showing the natneof the sub-conuactm and state-whether or not those eaiitieshave
employees. If the sub-contractors have employees,they must:provide their workers',comp.policy.number-
lain an employer that is prm ding workers'compensation insurance for ary employees. Below is the policy and job site
information.
Insurance Company Nance:
Policy 4 or Self-ins.Lie.#: Expiration Date:
Job Site Address: C:ity/StateMZip:
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 andfor one-year imprisonment,as well as ci,.al penalties in the form•,of a STOP'WORK ORDERand 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 DU for insurance coverage verification.
I do Hereby cet i nd re ins and penalties t?fpetyun7 thatthe itifornzativii provided aboi e.is true and correct
Simaature: Date:
Phone 9:
Official use only. Do not write in this area,to be completed by city or MIMI of Cal.
:City or Torn: PermitUcense If
bsuing.Authority(dicle one
1.Board of Health. Building Department 3.City1rown Clerk 4.Electrical Inspector 5.Plumbing,Inspector
6.Other
Contact Person: Phone d:
Town of Barnstable r'
Regulatory Services
P�°FtHE T°sy,� Richard V.Scali,Director
Building Division '
* BARNSTABLE, ' Tom Perry,Building Commissioner
y Mass. $ Y� g
i639. A.� 200 Main Street, Hyannis,MA 02601 .
lED MA't
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
GPlease Print
DATE: �
JOB LOCATION: 7 � Y�/)V l�i
num er, street _qq 9 Q- village
HOMEOWNER": O�`e!" °J e ti S 2Ai j V "'
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
procedur nd requirements and that he/she will comply with said procedures and requirements.
Signature of Homeow e
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
Revised 061313
A3
OF THE 1p�
i
+ BARNSTABLE,
039.MASS. Town of Barnstable
'DrFn nea'�a
Regulatory Services
Richard V. Scali,Director
Building Division
Thomas Perry,CBO
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.
Q:\WPFILEST0RMS\building permit forms\EXPRESS.doc
Revised 061313
c.
Town of Barnstable Permit#
THE , Expires 6 months fro ue dal
Regulatory Services Fee
+ +
+ BAPPMABL& •
MASS. $ Thomas F.Geiler,Director
039.
Building Division
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 I
Map/parcel Number ou3n
7Prop Address P
Residential Value of Work l Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
.
F_ibPa
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) PERMIT
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance APR 2 6 2013
Check e:
❑ a sole proprietor
I am the Homeowner TOWN OF �ARNSTA�L�
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Req (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)
❑ Re-side #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.
copy of the Home Improvement Contractors License&Construction Supervisors.License is
r quired.
SIGNATURE:
. n.�nmvrr ac�rnD71.fCV,..;1A:..n n�mit fnrmc� _.S'_doe
77je cowwomswal&of assachusetts
Depwtment of Industrial Acccidenft
Ofiice ofInveestiga ions
600 Washingtan Street
Boston,M4 #211.1 .
rrns*►v�rins�gov/rlia
Workers' Campensaian Insurance Affidavit- Bmlders/CoimtractorsMectrici-ans/Ph mbers
Appficant Iuform—ation Pjgase Fi int IV
Name - 'mldividml):
Add r : OLA _
Ci fStat&Zip: MMne#: 4 ZO L/
t�iEl
Are you an emplayer?Check the appropriate bom Type of project(regnir+ed)-
1.❑ I am a empleyer with 4 ❑ I am a general contractor and 1 6- [:]New cansftuction
employees(fan an&,orpattt=e)-* havehired the sub-contractors
I❑ I am a sole prqtriebor or partner-
listed an the attached sheet 7. ❑Remodeling
ship.and have no employees These sub-contractors have g_ ❑Demolition
employees and have wcdcers'
w Q for me inairy capacsty_ ���$ 9- ❑Budding addition
worms°comp.msura„ce camp.
5. El We are a ctaporatiare and its 1 D.❑Electrical repairs or additions
wed]Ism;a homeowner doing.all work n�ficers have exercised Vneir 11-❑Plumbing repairs or additions
-
mys [No warkers'camp- of exemptiniu per bIGL 1 ❑Rnof repairs
incur nce regnire&]T c.152,s§l(4),and we have no 13.❑other
employees-[No we rkm'
camp.insurance required.]
'Any Wpficam that chedm box#1 usast also M ow th,e%Kfi=below showing their wince'compensatkn policy i fb.mnx=
7{,H.,om-e�owne s who submit this affidavit indicating they ue domg an wat ad then hue outside co� io crs Hur st submit anew affidavit md=U119 such.
'l.D�iacm thatched this box most attached am a,wiiianm sheet y,whg the name of the mb-coixtracton red=ie whether Of not moose eniitees have
empicyem. If the mb<outmdaa have employees,&eY mnsi piavide their Wudrer'ramp.policy number-
law a7i empkv,er fliat isprovi&ng.workm l compmsrrtisn tnsuranc-e far aril'enrpin} Bdvtr is thapoili 7=d jab site
it�fOrtiftrrf�u. .
Insurance Company Name:
Policy-or Set€ins.Lin Fxpiraticn :
Jab Site Address: City/State/Zip:
Attach a copy of the workers'cmnpensation pOcy declaration parge(showing the palicy=tuber and mpirmt ou date).
Failure to seentr coverage as required under Section.25A of MGL c. 15_can lead to the imposition of criminal penalties of a
Eue up to S 1,500 40 andlor one-year in neat as well as civil penalties in the form of a STOP WORK ORDER and a fine _
of up to$250-0-0 a day against the vinh&r. Be advised that a copy of this statement may be forwarded to the Office of
Imest gatiens of the DIA for bmurauce cmmmge ve>ification-
i do hereby ce tlrepaiuts atnd s afp dint Ella irrfOrfraeiion prcrvir£sd is his and co .
St.
Bate: -
6FIDPhone#
Official we only: D#Batt awrfte in this trrer4 Av be completed by city or town affieiaL .
City ar Town:. Permmitucense#
ISSU ng Antherity,(circle one): _
. ..1..Boaredo f Heath y.Bu� g
.:a r ment 3.. Qtyfft m Clerk'
E_ l.ec.t.ri.ca..l inspector.5.Pmb ng.Empecter
C.Othr..
i
Town of Barnstable
Regulatory ServYces
51� Thomas F. Geller,Director
9Cb13�9. A,��
lea 3� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office:. 508-862-403 8 Fax: 508-790-623 0
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: G . C �e : �
JOB LOCATION: I 1 /77-1 t
nu r nn s et 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.
T undersi ped"hom wrier"certi 44,at he/she understands the Town of Barnstable Building Department minimum inspection
pr cedures and.require ents and that a/sh will comply with said procedures and requirements.
•D
Signature of Ho owner
Approval of B ilding 0 cial
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 perf6rming 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
ceitify 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. .
P_..%CNMQ CCQ A-
. . .. .. _
Of SME rqy, .
�� ti •.
KAMA
. Town of Barnstable
pTEp MA'S A -
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: 508-8d`4038 rFax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder '
1• ;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:
- 1
(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.
QAWPFILESTORMSIbuilding permit formslE)TRESS.doC _ . ._.
Town, of Barnstable 40/0 G
r �oFrruroh� Stable *Permit#
Expires 6 ,,Wlrs from issue(late
Regulatory Servi3BA3Rq5T kBLE, *' - ces Fee
.y m5s. -
,6Jq. Thomas F. Geiler, Director
$Arai t++A`I a
Building Division
Tom Perry,-CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ax:.508-790-6230
Not Valid without Red X-Press Imprint,
Map/parcel Number " 0(2g0 1 ?�
Property Address —7—7 �MC� h l l.Ot
91 Residential Value of Work �� �Q0 oc� .Minimum fee of$35.00,for work under$6000.00 _
Owner's Nam e & Address
q
Contractor's Narne - - •
Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) X-FR : ' PERMIT
❑Workman's Compensation Insurance �.P+ 201
Check one:
❑ i am a sole proprietor -C'OWN OF BARNSTAELE
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance m an Nam u ance Co p y e
Workman's Comp, Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request (check box)
Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to
tryA
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re'-side „
# of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .35) #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 the Home Improvement Contractors License & Construction Supervisors License is
quired.
.-IGNATURE:
�WPFILES\FORMSIbuildingpermit rms1EXPRESS:doc
_wised 0721 10
The +Corrlrrrorrivealtll ofildossachusetts
-- Department ofludustrral Accidents
4 ice of Irivestigaliorus
600 Washington Street
Boston, lFL4 0211I
Y6IMRFr117SS.gov1d a
'Workers' Compensation Insurance Aff`idalit: Builders/Conti,actor-s✓El+-ctiicians/Plumbers
(Applicant Information Please Print Legibly
Nalme. (Busine ^Orgauizafion'Individr�ai):
Address: �7 2 ff WA i In
Cityl`State/zlp: co#`� 02-6 3 � Phone #: ;j()��( �0'-'�'S
Are you an employer?Check the appropriate boos.: Type of project(required).
. I am a general contractor and I ' p ] (
1..❑ I am a employer With ❑ g 6. New constnzc
eaTloyees(full and/or part-:time).* have hired the sub-contractors
2..❑ I am a sole proprietor orpartnes- listed on the attached sheet. 7. ❑Remodeling
ship.and have no employees These sub-contractors have g_ � Demolition
working :for me in any capacity. employees and have workers'
[No workers' coup.ir-surance comp.insurance..
7 9. .Building addit
required_] 5. ❑ We area corporation..and its 10.❑Electrical repa
3. I am a.homeoi; er doin:g.ail work officers have exercised their 11.0 Plumbing repa
thyself [No workers',comp. right of exemption per IMGL 12.❑Roof repairs
insurance:required.]T c. 152, §1{4),and.-ve have-no
employees. [No workers' 13.0 Other
cemp.1rxsurance required.]
'Any applicant thst checks box#1.must also fill out the section below showing their workers'compensa:ti.on policy inform3tioa
t Homeowners who submit this affidavit indicating they are doing all wwk and then hire autsidc contractors must submit:a new effadat it indicating suet-
IConFractors that check this box must attached an additional sheet shon-ing the:nsure of the sub-contractors 9o.d state whether or not those entities have
employees. Ifthe sub-contcactors:have emplm),ees,they.must provide their workers'comp.policy number.
I a1r.t R1f eutpiny r titrrt is prai�idirrg ttrork rs'cr7rirpartsatian insrarrrrrce for raEy txl9rplv�eras. Mott,is the palicy and job site
informal:art.
Insurance Company.Dame:
Policy ft or Self-ins.I ic.-9: Expiration Date.-
Job Site Address: City/State/Zip:
Attach a copy of the workers'compeirsgtion policy declaration page(slimir ng the policy number and expiration date).
Failure to secure coverage as required under Section 2.5A of MGL c. 152 can lead to.the imposition of criminal penalties of a
fine up to S1.,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$250.DO a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnz :str ations of the D.IA for insurance coverage verification.
I ]ter by c rti trrde tPie arts artrl penath'es of p rjuty fltat lire infarrtiation prm irlerl above is tru/a and correct
i hu-e A Date: to
Phone#:
Official use only. D.o rtot.trrite iat this area,to be cotripldted by,cite or tota'n ofcnaL
City or To-"m: Permit/License#
Issuing Authority(circle one):
1.Board of Healtb 2.Building.Depurtment 3.City/To«n Cleric 4,Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
6
of ► Tok
• HARNSTABLE,
MASS.
9sbJ9•. Town of Barnstable
7 ��
prFD MAy A
Regulatory Services
Thomas F. Ceiler, Director
Building Division
Thomas Perry, CB0
Building Commissioner
200 Main'Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508 790-6230
,. .� i, • ,t_j�4 •
Property Owner Must
Complete, and,-Sign This Section
If Using A Builder F
as Owner of the subject property
hereby authorize - to act on my behalf,
in all matters relative to work authorized this building permit appbcation.for:.
(Address of Job) t`
t, .-T
Signature of Owner 'Date
Print Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Forma on the
reverse side.
QAWPFILESIF0RMSlbui1ding permit formsCEXPRESS.doC
Revised"072110
P�0tHEr°s� Town of Barnstable
Regulatory Services
If R
13�Aj�STB '$` Thomas F. Geiler, Director
Gb ra ,v Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnsta ble.ma.us
Office: 548-862-4038 Fax: 508-790-6230
- ----------------______—_
HOMEOWNER LICENSE EXEMPTION
(� / Please Print
DATE: /�l. lC�
I JOB LOCATION: AlaiPK- S t_
number street village
.HOMEOWNER"_ RoLiej-t �e IA.S� 0 jA/ `f.2-0— 76 1
name home phone# work phone#
CURRENT MAILNG ADDRESS:
0 2—6 _Z)5
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
" he undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws, rules and regulations.
0,
Adersigned"homeowner"certifies that he/she understands the Town ofBarnstable Building Department minimum inspection
equirements and that he/she will comply with said procedures and requirements.
n.er
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to.comp)y 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.
QAW?FILESIFORMSIbuilding permit formslEXPRESS.doc
Revised 072110
1,749
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