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0854 MAIN STREET (COTUIT)
r \ t 4 0 S V iT Town n a I ble *Permit Expires b mor tfjs from vssua date Fee Regulatory Ser Thomas 1 Geller,Dimttar. Build' . g Division Tom Perms,CBO, Building Commissioner 200 Main Street,Hyannis,MA 026,01 va�arw.to,vn-barnstab J e.Yna,uS Fax: S0827 623- office: 508-962-4038 RIESIDENIL EXPPJI Not f,'a id without XCed X4ress Lnprint h. .v %rats �a''lirnbex- --rfap 1 ' _ - igrGz5i:1'C`f.Ad&� Value of Wort tni�aitra fee of$Z5,CIR3 for�ark under S613(90.€3C3 C wte�r'<Narne a i Address Telepl�a1e avumb Cunt=torts N Home Improvement,Couiractar Lice=#(if applicable)------ CoY.st:vct.on Superv��or's License#(if applicable} _- IT r� _rj,a,,,sCO.Vem tianSnsurance MAY 1 9 2010 Check one: E] I am sole proprietor TOWN OF BARNSTABL I am the Homeowner g,,"bLave Worker`s Co=pensfatzon Ins'arance W�s,zrxnLe Company 1�F°u /��', ��� . Wi:rxan's Cautp.Policy 0- Copy of(assurance Compliance Ce c�5e mustbeHsu�2ee . 'ems niu Request(check bo)() 1 I of(strippingbid sl les) All construction debris .be taken Re-roar not strippnig- Going over�" existing layers of roof) j Re-side E Replacement Windows/daorslsliders. L7-Vsl�e� (maxismti�n.441' tnWiter�required: .tssuanee of tisig perrmt does not exempt co mpliu=with other town department regulation.,i.e.�€stem,Conservaacl a=c. '. K ate. property Owner must sig jytrty Owner Letter of 'ea rrrlssiol3 ., o�ement ntractors License is requir A copy me 9tne ed. Co s The Commonwealth of Massachusetts Department of Industrial Aecidents Office q f Investigations 600 Washington Street Boston,MA 02111 www.mass.govINa Workers"Compensation Xnsurance-Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name(Businessrorganization/Individual):. Address: City/State/Zip: /�'! �• Phone-4: Are y u an employer? Check the appropriate box: -Type of project(required)•, with 4. [] 1 am a general contractor and 1 6 (�New construction - 1. I am a employer ___�-- have hired the sub-contractors employees(full and/or part time).* listed on the'e.ttached sheet. ?, ❑Remodeling 2.❑ I am a'sole proprietor or partner- These sub-contractors have 8. n Demolition _:��'?,K�� ship and have no employees employees and have workers' working for me in any capacity. 9. []Building addition comp.insurance.$' [No workers'comp.insurance 5• ® We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their I1.0 Plumbing repairs or additions 3.❑ I am a homeowner doing ell work right of exemption per MGL 12oof repairs myself:(No workers' comp. c• 152,§1(4),and we have no insurance required.]t o workers' 13.0 Other employees. [N camp.insurance required `AnY aPP licant that checks box#2 uasst also fill out the section below showing their workers'compensation Policy information. t Homeowners who submit this off davit indicating they are doing all work and$ten hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of mP snub-c tractors and state whether or not those entities have employees• If the sub-.contractors have eniplo ees,they must Provide their woAmrs co Policynumber. d am an ern 1 er that is providing workers'compensation insurance for my employees Below is the policy ob site a n j I Po nr .Insurance Comp any Name: #• Expiration Date: Policy#or Self-ins. -• e Job Site Address: 'City/StatelZip• / .— , 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-yeaz i>aprisonment 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 Iuvesti ations of the DIA for ins covers verification I do hereby ce der the ' s• d p alti perjury that the information provided above is true and correct: Date: — Simatvre• P one Offcia!use only. Dv not write in this area,-to be completed by city ar town affufat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone rontact Person:_ #: -6%005/19/2010 09:08 FAX 16173505522 CHILD GENOVESE INSUTRANCE Q 001 ® / DATE(MMMDDI ■ ��RG� CERTIFICATE. OF LIABILITY INSURANCE OP ID JD YYYY) 05 19/10 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ANT: If the cartificate holder is an ADDITIONAL INSURED,the policy(ies)must be en orse —IfSUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not confer rights to the certificate holder in Ilau of such endorsement(s)_ - PRODUCER NAME: Child—G,dnovese-Ins. Agancy' Inc /c,A111,E(cD: (AIC,Not: 60 Temple Place ADDRESS: Roston I+JP: 02111-1306 CUSTOMeRID0: DANFO-1" Phone-617-350-5511 Fax.617-350-5522 INSURER(S)AFFORDING COVERAGE NAICs INSURED INSURERA: COLONY INS CO James Danforth. dba INSURERe: TRAVELERS INS. CO. Jaynes Danforth Remodeling P.()- Box 973 INSURER C: CO':IIit MA 02635 INSURERD: INSURER E INSUREWF: COVERAGES. CERTIFICATE NUMBER, REVISION NUMBER: THIS IS TO CERTII'Y THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT411THSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTMCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAN BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.' LTR 'r.'PE OF INSURANCE INSR WVD' POLICY NUMBER (M�LDD/YYY'n (MMIDD/YYYY) LIMITS GENERAL LIA'fUJTY EACH OCCURRENCE S1,000,000 A X COMMER 71AL GENERAL LIABILITY GL3643403 09/02/02 Ov/M2/10 PREMISES Ea occurrence) S 50,000 CLA MS-MADE �X OCCUR MEO EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $1,,000 000 GENERAL AGGREGATE $2 OOO,OOO GEN'LAGGREsATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2 000,000 X P GY €JEC LOC . S AUTOMOBILE LIAtfurY COMBINED SINGLE LIMIT $ c t (Ee accidem) AI V`AUT BODILY INJURY Tor person) $ AL1L 9WA F T05 BODILY INJURY(Per acddml) $ SGfii0U•.ED AUTOS PROPERTY DAMAGE ( ) $ KM)ZEOAlIT&' 1 Peraocldenl N.�T•OW dED AUTOS M F UMQREL A,LIAB " 'EACH OCCURRENCE $ ,�••� OCCUR - E7rEE33 LIAB` ' ,,.._ ,�a CLAIMS-MADE AGGREGATE S DEDUCT OLE — $ RETENTION. S g B WORKERSCMIMPENSATION 6KUB A05 00/Za/09 ve/Za/3M.. X TORYLIMIT$ ERDTFA AND EMPLON ERW LIABILITY YIN ANY PROPRIETORIPARTNER/D(ECUTIV N I A E.L.EACH ACCIDENT S100,000 OFFICERIMEP IBER EXCLUDED? E,L.DISEASE-EA EMPLOY S100,000 (Mandalnry In NH) ' Ir yes,descrlb( under E,C,DISEASE-POLICY LIMIT s500,000 DESCRIPYIOP OF OPERATIONS below DESCRIPTION OF C PERATIONS I LOCATION5I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,IF more sp2ce IS required) THE WORKE-kS COMPENSATION POLICY, DOES NOT PROVIDE COVERAGE FOR Jh►MES DANFORTH. CERTIFICATE'iOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- HENRY CHURBUCK , AUTHORIZED REPRI SENTATIVE 654,mAIN STREET COTUIT MA 02365 y4 . - 00 D TION.'A rights reserved: ACORD 25(20)9/09) The ACORD,name and logo are,r"istered marks of ACORD O f�cc of Consumer Affa�rs&c Bnsmess.(e�u<i:o z LIce,nse or registration valid for i, iv►del use nn� l ' 4 y i1 . HOME IMPROVEMENT. TRACTQ Yx< &r s , Uefore the expiration'.date..,If foun_d return to a , RegistratKorr 114$13 0Park P- 2� 4 Office of Consumer Affairs and Business Reg ullt�iit� l . laza Suite 5170; �xpira +0�0/�712Q11 Try',k�$ 04' � ,, x _ - TYp?-)-inaw lial ikK �itBuston,MA 02116' p JAMS D DANFAN OT # EMOD r s , ;JAMFS DANFOO:RTFf�."�''�.-.,;� '� COTUI'f; MA 02635�, ,._��-.�•� , �LJnde e::"r �`��`3 � `,'TwF f - , ,4.": • v C S c it�rr r o .s a*ure �r s_•_ NLa�sachu�etts'- Department of Public Safety 1 « nulutions xnd_StandIMB Bo u d of Build�n'- - Gonst�uction.Supervisor License CS 8267 k ~' ;,License: r Restricted to: 00xc } , JAMES D :DANFORTH i PO BOX 973 R e u ITCOT • MA"02635 Expiration: 5/20/2012 ' Tr#: 26124 ('onunissioncr Construction Supervisor Home Improvement License Number#008267 Contractor Registration#114813 Home Phone#508 420-5131 CELL PHONE#508 280-0802 ESTIMATE JAMES DANFORTH P.O.BOX 973 COTUIT, MA: 02635 Henry Churbuck 854 Main Street Cotuit, MA. 02635 May 19, 2010 Work to be completed on entire house and garage roofs, as follows. Install a 50-year CertainTeed roofing 9hingle over the existing roofing material., consisting of one layer. ' Material and labor $9;500.00 All materials are guaranteed to be as.specified.All work to be completed.in a workmanlike manner.according to standards practice.Any alteration or deviation from shove specifications involving extra cost will becorpxtra - charge above the estimate. Our workers are fully covered by Workman's Compensation•Insurance. DATE OF ACCEPTANCES CUSTOMER SIGNATURE CONTRACTOR SIGNATUR f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map v b�='. Parcel �/� Permit# . S 9 1 LI Health Division D � 0 �.11Pi� �'"' 'D°`� ����" Date Issued t0�25'/Q>' - ..,=' y Conservation Division 1 1) GS , , f_.t .j �2 ®� Fee Tax Collector /-0/-, �S ' �.�� ®� Application Fee d R'l> Treasurer QA Ok0 Checked in B / Planning Dept. � Y Date Definitive Pldwp4els n Aroved �rvalt ard ��O Approved By A, Historic-OKHOn/ �nnis O Project Street Address `l5`t -� v Village rb-_v�4_ i Ni.A— .0`Z4, 3 5-- Owner ALv\C� C- C ,10b11cy- Address '95'`f vAA�-i"` Telephone �� — `f'La _y S, Permit Request I to S + to[�.J 0 ujuj a., e �w.�v J �-9y D a® ✓� Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new CValuation f6�oc�r� a� Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. � Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 70 z-s) Historic House: YYes ❑No On Old King's Highway: ❑Yes R o 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: O Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 2 No , Detached garage:M9 existing ❑new size Pool: 0 existing 0 new size Barn:O existing ❑new size Attached garage:Cl existing ❑new size Shed:2f existing ❑new size Other: Zoning Board of Appeals Authorization El Appeal# Recorded❑ G�Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use' BUILDER INFORMATION Name A r,,ry d b� Telephone Number 50 ' 22 L( " o �� 7 Address �571 ��-�� �'P License# � Home Improvement Contractor'# f>q-6g> 5— Worker's Compensation# - ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO DATE SIGNATURE s fa(Z� ,j FOR OFFICIAL USE ONLY ` PERMIT NO. DATE ISSUED ' MAP/PARCEL NO. ADDRESS VVILLAGE OWNER DATE OF INSPECTION: E FOUNDATION FRAME - ®�� INSULATION ,.�,j• +��' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: Y ROUGH FINAL GAS: ROUGH FINAL FINAL-BUILDING DATE CLOSED OUT ` ASSOCIATION PLAN NO. i ne,L ummonweairn of wjassacnusetts 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/P'lumbers Apl)licant Information Please Print Legibly Name (Business/organization/Iwividual): WC. C1L Address: c�G-4 City/State/Zip: �'v ti —, V-4,,A 6.24-31--Phone#:��0. > y.7-0 — Are you an employer? Check the-appropriate box:. Type of project(required): 1.❑ 1 am a employer with ` . 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8' ❑ Demolition Working for mein any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or.additions 31 I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers'' ' la-C✓� a f�Scr ✓�_5 comp.insurance required.] 13.(�( Other rq _ . S P , LArt � csv.r *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 =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'-comp,policy infor ation, 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: 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 forwarded to the Office of Investigations of the DI A.for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: Si afar .. Date:. l P ?L-i d 5__ Phone#: Sag k u y S q-7— L S-a 0. — 2 S 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 6. Other 5.Plumbing Inspector Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires`all employers to provide workers' compensation for theit�emp10 ees. 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�; �?��.- �.:P���P " du , association,porpora#on 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 o trust ee of an individual,partnership, association or other legal entity,employing employees. How0ver:the r hiP� 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 woikvn such dwelling house ppurtenant thereto shall not because of such employment be deemed to be an employer." or on the grounds or building a " r local licensing agency shall withhold the issuance or a MGL chapter 152, §25C(6)also states that every state o 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.of necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) th 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 I.LC 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-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 bom 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 moist 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 bum leaves etc.)said person is NOT required to complete this affidavit hike to thank you in advance for your cooperation and should you have any questions, The Office of Investigations would 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 0211L Tel. #617-727-4900 ext 406 or-1,877-MASSAFE Fax#617-7274749 Revised 5-26-05 vAwmass.gov/dia Town of Barnstable Regulatory Services Fro, Thomas F.Geller,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 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: o©J- 4- we�c3 M. a -S`�<<.$c�e,�Estimated Cost wD o-r' Address of Work:,_ Owner's Name: Date of Application: E �'ZA b I hereby certify that: 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: Date Contractor Name Registration No. OR Date _ Owners_ e Q:forms:homeafdav oF Town of Barnstable t� P� o� Regulatory Services t Thomas F.Geiler,Director MAM Building Division Tom Perry,Building Commissioner 200 Mafia Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 509-790-6230 Nice: 508-862-4038 --_— HOMEOWNERUC-ENSE-EnIVI--ON Please Piiit DATE ;r1 Stt .JOB LOCATION; street village number IROMEOWNElt': � home phone# work phone# namee CURRENT MAU240 ADDRESS: cityhown 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 re ' eme ts. I ature of Ho er ` 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. oN HOMEOWNERS EXEMYTI from the revisions The Code states that: "Any homeowner performing work for which a building permit is required shall a exempt p of this section(Section 1o9.1.1-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 are unaware that they are assuming the responsibilities of a supervisor(see s,Appendix Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly whe4 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 foma/certification for use in your community. LA.,( s� C-o s� r: { rl�D .Y.S o LAI I�DiNb r rr `� W ttit101US {� ws. L I . .dam% - . w � ! � �qo 5 �` �� �► �Lt ��� t.rc)a�atJ� So TD T �ru-C l,)tu�ecv l r tAk5+w(k &Ct gow- Dooms 0, �4f 77-�Ca ^ � ...b October 18,2005 To: Town of Barnstable From: Henry C. Churbuck As property owner of 854 Main Street in Cotuit, MA, I, Henry C. Churbuck, hereby give my permission to Don Boynton of Cotuit to obtain a building permit to install 5 5x5 foot sliding windows and two doors into a 3 season porch at my residence. Sincerely, C W tCV I or Henry C. Churbuck O /L- a a�� ,:�. -. �,. +Y f!� t. • • � � .. !`�� ,, - ��_ ,� . , .. - .t - - -._ .�,,� ram, '� l� ��/ ,. . ; - �� � +y V �_ "-,- _ J ,. . ,; h � �'y � } sR �.J � `\ ..... -.� } a E � � E E { , i � t � E E � i � i i t 1 i 1 I j. -__.. -- - f a i d L — R I a IN Engineering Dept.(3rd floor) Map 03.5- Parcel 6 —Perti it# House# ?5-4 ate Issued' ss ed 'Z Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) --SEPTIC SYSTE E 19 INS��11I E ABLE. , t T TOWN OF BA`RNSTA F= TOYVN REGULATIONS Building Permit Application Project Street Address �� Mai J (:OT � Village•. Owner am d Cbk(((y 4&" Address .56f m,& Telephone W U 0 Permit Request ho L officz, Lbo& lr f l5 u First Floor square feet Second Floor square feet V Construction Type Estimated Project Cost $ 10 066 50 Zoning,District Flood Plain Water Protection Lot Size I Grandfathered ®Yes ❑No Dwelling Type: Single Family ® Two Family ❑ Multi-Family(#units) Age of Existing Structure 1 670 Historic House ❑Yes ❑No On Old King's Highway ❑Yes p No Basement Type: ❑Full W Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 10 Number of Baths: Full: Existing , New 1 Half: Existing New No. of Bedrooms: Existing 3 New 2 Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: J&Gas XkOil ❑Electric ❑Other Central Air ❑Yes 0 No Fireplaces: Existing I New Existing wood/coal stove aYes ❑No Garage: ❑Detached(size) I Ll I,Z Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) 10 X Z" ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ANo 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 SIGNATURE 14 — DATE M BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) _mot FOR OFFICIAL USE ONLY 1 PERMIT NO: DATE ISSUED ' MAP/PARCEL NO. j ADDRESS t ` VILLAGE OWNER t DATE OF INSPECTION: ' FOUNDATION + FRAME INSULATION -- FIREPLACE ELECTRICAL: RAH _ FINAL - - PLUMBING:• FINAL GAS: ? FINAL FINAL BUILDING s+ae .Tv1. l DATE CLOSED ASSOCIATION PLAN NO. r5 I r{� a� •• ' 1- 11 i . The Town of Barnstable • UsivsrAIM • � & ' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 1 f Building Commission( For office use only Permit no. Date , AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ' MGL c. 142A requires that the "reconstruction, alteiations, 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: memo [WP Est.Cost 10 .000 . 0D Address of Work. ?94 MW 5-� (0fa IMA 0243�" Owner's Name Dad Date of Permit Application: I hereby certify that: 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. Date Contractor Name Registration No. OR i \ Jeri♦ • The Cunintun ivealth of Afassac lr usetts -•- 1: Department nt of Industrial Accidctrts ( Olrcea//avest/ga1/ores 600 !f'ashlarwir Street Bnstotr. A1ats 02I1! Workers' Compensation Insurance Affidavit i It ant information• Please PR11VT Y► nI (SA c � 1, namc:VNYll I W 4 1 P 41!i, V city nhonc# f;� n X1 am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity .. �-r.. ._.+�.�-+.—r..s....._........._n...�.�n�+..a+.�_s+.�src7�..wwwr�'J.'7�+'��-..i'�•....-,+r.w��n.�.��.w�. w... .w.•+...w.•—_►....++.__....--.. .. ❑ I am an emplover providing workers' compensation for my empiovees working on this job. enntoam• name: address: MI.- Phone#- insurance co. nolicv to ❑ 1 am a sole proprietor. general contractor. o0omeown (circle one) and have hired the contractors listed below who hay e the following workers' compensation polices: cmmn:im• name: addreSS' nhonc#• insurance rn. noiic� # � . •l J:•'-.. V�`T.-- � '�,..t..._.... ...:_- .__ Sr�:b':��\L iT..T!'�ww.S .�1r..._ ..-;+-...p.ti...�.-._...-.7- _-..__._.... cnmomn.• name: address• cin Rhone#• insurance co, noiicv tY Attach additional sheet itneccs_sary-=•-' •:^-=+ --+�~'•�.� •'e "�"%�%' •• +•-•--"� •r----�'�-"'�" 7- Failure to secure coverage as required under Section:5A of.111GL 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 andiur une wears'imprisonment:(.well:ts civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a dad•against me. 1 understand that a cope of this statement ma} be forwarded to the Office of investigations of the DIA for coverage verification. 1 rlo herehr certift•tinder the pains and penalties of perjure•that the information provided above is true and correct. q Si_natureP&IMADate N�nl l��1"i Print na Ma oh n,(, &tw bxdz� Phone>* q i/v Ca q q q t official use univ do not write in this area to be completed by city or town ofTcial . •+ citw or tntvn: permit/license# riBuilding Department ' OLiccnsing Boardcheck if iminediatc response is required �sclectmen's Omcc _ C311calth Department contact person: phone#: rl01her�— i. information and Instructions Massachutietts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employees. As quoted from the an emplt ree is defined as every person in the service of another under am• contract of hire, express or implied. oral or written. An empinrer is defined as an individual. partnership, association. corporation or other legal entity, or any two or mor 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 th. owner of a dwelling_ house having not more than three apartments and who resides therein, or the occupant of the dw0ling house of another who employs persons to do maintenance , construction or repair work on such dwelling= ho or out the arounds or building appurtenant thereto shall not because of such employment be deemed to be an employe: MGL chapter 152 section 25 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, 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 I- been presented to the contracting authority. Applicants Please fill in the workers* compensation affidavit completely, by checking the box that applies to your situation and supplying_ company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law' or if you are required to obtain a workers' compensation policy. please call the Department at the number listed below. City or•I•owns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o: the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plez be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t the Department by mail or FAX unless other arrangements have been made. The Office of In'estications would like to thank you in advance for you cooperation and should you have any question please do not hesitate to :anve us.a call. �,•..y,.._r•..•._. ...._..— ..�...w�.-...••:e�.v.�..vim-s.��.... ..—�n—r*w..r.!.+�• ....:.. ..w-r�..wwanr...+r•r.�.�•�s.w-._- The Department's address. telephone and fax number: The Commonwealth Of Massachusetts - r Department of Industrial Accidents Office of Investigations 600 «'ashington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE lqqq JOB. LOCATION Hain �trc& Number Street address Section of town "HOMEOWNER" "N a& t-Oa U Ch r 7_0 90 3. ' Nbme Home phone Work phone - ` 1 f PRESENT MAILING ADDRESS 90k 7 2D COW 0 City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Officia on a form acceptable to the Building Official, that he/she shall be responsibl for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance "With the Sta Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply- with said pr,,pcedures and requirements. HOMEOWNER'S SIGNATURE. allAnO APPROVAL OF BUILDING OFFICIAL- Note: Three family dwellings 35, 000 cubic feet, or; larger, will be required to comply with State Building Code Section 127. 0, Construction Control. I � HOME OWNER' S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person (s) for hire to do such work, that such Home Ownez shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for • licensing Construction' Supervisors, Section 2. 15) . This lack of awareneE often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home '•Owner actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/bier responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the lazt page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. T„: , 1 i �. t � �- ��� � ��'G��� . t l s ch rbUr 5 ncu.�" t- cofiact� N K$u 12 f r ! f . ' I -}- ! i I i � ! ! i i I i I I � i � [i -=� i i t"` ,!�.•�i i � l i ! ) „ ! Q !--P�CI 51►' - L-�7Y1 S =�— - - I — - i L7l'•' '�1_u+�alfs_ 2k�; �6 o c, -�---- =- ---- - ! ��-IO_i'}�JG_D�(G_G_ --- � I -- ' --_ ' '-' ---'-------- - - $ :x` s I . . loQv 3/.�►.'_'_sUblody 1 i I - °� _L new'inlln�6-W-----L1�` --- - ----- ------ - --- - - =- - - - '---- -- - ---- ----- - - - -- -- - - - I I I 4�4s�xa � i � I fo JeF , , • � - � ----�� Ia �n. -1}i� fry;' - � - � - --- - - ----- ---''---- ---=--! --- ---- - -- ------- -cf -- bLL�I�a! I ' rat ' I ! , l � ' , I I ! i I • t t _ - I i I i i 1 B^^STASLE, TOWN OF BARNSTABLE BUILDING INSPECTOR J // APPLICATION FOR PERMIT TO .zTYPEOFCONSTRUCTION TO THE INSPECTOR OF BUILDINGS: The-wndersigned-lTCrebyapplles for a ^errn^acc(^lT>g to the following Information: Location d.19^..^ Proposed Use Zoning District ^^.^..Fire District .y Address Nome of Owner Name of Builder Name of Architect Address Number of Rooms .^our^plation 7 ^-/ Exierior — Floors Interior oo^g Heating Plumbing Fireplace Approximate Cost Difinitlve Plan Approved by Planning Board 19 .Sr> Diagram of Lot and Building with Dimensions I hereby agree to conform to all the Rules and Regulations of the Town of Barnstoble regarding the above construction. Name yl-'f Churbuck,Henry CfJ No Permit for family dwelling Locals, Cotuit Owner Type of Construction .1!?!^??® Plot Lot Permit Granted 19 ^9 Dote of Inspection 19 Date Completed 19 ^^ PERMIT REFUSED 19 Approved 19