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0283 MARINER CIRCLE
aP3 /Llaiuw- Ci.�4 � � Town of Barnstable Building t Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept i • r3aswsra�t� MA 6& Posted Until Final Inspection Has Been..Made. . Permit i - Wkiere a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made Permit No. B-19-1870 Applicant Name: MADDEN,JOHN J Approvals Date Issued: 06/21/2019 Current Use: Structure Permit Type: Building- Deck Expiration Date: 12/21/2019 Foundation: Location: 283 MARINER CIRCLE,COTUIT Map/Lot: 039-021 Zoning District: RF Sheathing: Owner on Record: MADDEN,JOHN J Contractor Name -' Framing: 1 Address: 283 MARINER CIRCLE Contractor License: 2 COTUIT, MA 02635 Est. Proje t Cost: $6,500.00 Chimney: Description: Deck Permit Fee: $ 110.00 Insulation: g Fee Paid: $ 110.00 Project Review Req: " Date: .6/21/2019 Final: Plumbing/Gas Rough Plumbing: \ Building Official_„','.� _b Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures'shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. f ' l . �,. �... Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for'All Construction Work: Service: 1.Foundation or Footing 2.Sheathing Inspection _ Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:4.Wiring&PlumbingIns Inspections to be completed to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health 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). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: 4 O Application Number....�?............................................... BUILDING DEP 0 Q . CEO * SARIVSPASLE, s MASS. Permit Fee...v...............................Other Fee........................ 1639. •� JUN 0 6 2019 FO Mfg� TOTotal Fee Paid............................................................... ...... WN OF BARNSTABL TOWN OF BARNSTABLE Permit Approval by........ ...................on.....0 t.� BUILDING PERMIT Map.......r�.� .............:.......Parcel.......... ...................... APPLICATION Section I — Owner's Information and Project Location Project Address Z b I" "',nLr �.b.-c.e Village Owners Name �1sti� Owners Legal Address Roe,w-&,e' 6e+-.- City 6i4.A- State M A Zip OZ&3-5- Owners Cell# 7'1`t-`-[V 7 -1 cg I" E-mail Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ FireAlarm Rebuild ❑ Deck Apartment © Sprinkler System ❑ Addition ❑ Retaining wall ❑ . Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 - Work Description ec,K l r, i Application Number.................................................... Section 5—Detail Cost of Proposed Construction SID Square Footage of Project 5 .M Age of Structure Dig Safe Number # Of Bedrooms Existing Total# Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ,❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors Plumbing Gas ❑ Fire Suppression El Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private J Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes 0 No Section 7—Flood Zone i Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed i Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No A T a&v nAa+PA- 11/T i/ M 2 T Application Number.;.......................................... Section 9- Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration.Date Contractors Email Cell # I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11=—Home Owners License'Ezemption=== Home Owners Name: mc_A41 Telephone Number Cell or Work Number '7 7`I -(-f b 2 -(07 I understand my responsibilities under the riles and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation re 8 and the Town of Barnstable. . f Signature `�- Date=D APPLICANT SIGNATURE r - `Signature '' -Date- CL e Print S - (Telephone Number -- E-mail permit to: r r Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ I Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13 — Owner's Authorization i 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 l i- I IT 1 i ax ol ci16 r' ,i v o III e W 'ate SIm �t/Ir�t� ZOIA I jU � I 1 BARN rA !- i ANIL 4- 1 1 i— �� — �—�—. � 1 Q o�I Q p �o ® • b o q s — I ' —L I �� ICI cX �� �__ � _ I. 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FOUNC'ATION 1S —O r> CATEO, tH"or �?y r �. ON TNF C • T �cT R T zH �� � z sR •:. LO,t A'5,5SHUWV 'AA O CONFORM . O NE i)WN 4 , OF BdRNSTABLE �QN.,, ; kf �l-'.ATr0^+� RED Apr'Ih� �' � � mWR8An � `^ ry4 4 SETBAi,KS FKOM STR£ET _EPJES AN^ _OT LIiV'ES . $" 6ROSSMAtr_ w z# E 12715 ' yrc >> i,t f .,fJ�,�1l�la.... - .����"/T' +° ' �@ �► • ,;`J '�9t a a'�`.�s.,,. I `N0RUAN GRO5_S Ar1l._P:t R<s_ S: �' w ,"•DATE{ 7, 1 5. •�o'"" .� TOWN OF BARNSTABLE Permit No. --------_—---------___-_- .` ° Building Inspector cash OCCUPANCY PERMIT sons ----___--_--- No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. .....................................................1 19......_ _ ................................,..............................._..................... ......_...._._.._-- Building Inspector y; Jd L 0T a o 1. ° v { N N 1 /zS-000(o Q a � �w k; I+ woo WZ — w • ' ,I� C)Pu 't s, Q � ZI I 10ow I ©V - �1 Q < Z �� s. Z>). PLAN\ SHOWING ajr-ji* °w . 00 vo 0Z FOUNDATION LOCATION i w A w w _ C 0T UI T, MASSACHUSE T T S zJZ� } Z 'y � w 40MLL 0WIVELD BY SCALE / "= 50 DATE NGRMAN GROSSMAN---- - - REGISTERED LAND SURVEYOR HEREB( GF_RTIFY THAT TglS FOUNDATION IS LOCATED �titN or r,+ ON THE LOT AS SNOW.V ANO GONFORMS TO THE TOWN OF BARNSTABLE =ON,N'G kF5 %..AT�Orr� RF ;AR;,1YG. noA SETBAGK5 FkOM STREET - NES ANC -OT LINES . GROSSMANSS .A 12775 C Q� SURy""�� r - I N'IRMAN R. S.GROSSMAN R S DATE j r � , ell 77. Assessw's.ma'P' and lot nurn��.. es,TH E 7V 1 ,Sewage -Permit number' .........71......6................................ SEPTIC SYSTEM MUST P INSTALLED IN COM ARNSTABLE, House number ...............j;;I,?..........W..?�..................: MAG& WITH T 71 r 1639- 0 MAY A" TOWN ;OF BARNSTABLE N-1, PECTOR BUILDING I APPLICATION FOR PERMIT TO .................& .................................................................................... TYPE OF CONSTRUCTION .....AKV .:2� ....................................................... ......................19........ .....................19........ !0 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 1 10110t 6....�-, Location .. ............J..I/........................... ...../1..................... ......................./........................................... ProposedUse ..... .. .... ............ ..................................................................................................................I......................... Zoning District ........ ................. District .............................................................................. Name of Owner ............ .... . .......Address ....... . ......................... Nameof Builder ... ....................................................Address .................................................................................... Nameof Architect ...........77.................................................Address .................................................................................... Number of Rooms ..........d�L �..........................................Foundation . .. .................... 2IW .41. Exterior ..................Roofing Floors ..Z�14.... ..... ...................................................Interior ....A 4 ................................................................................ ..........Heating ...............Plumb�ing............... ........................................................... Fireplace ......&�e....................................................I.........Approximate Cost ......... ... .42 ........................ ........ Definitive Plan Approved by Planning Board ---- ------19 Area .... J_ j 4-- 00 ............... Diagram of Lot and Building with Dimensions Fee .......... A .............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 41 4 qo I hereby agree to conform to all the Rules and Regulations of the Town of Barns able regarding the above construction. 01 Name - . .. ..... ................................................. Cedar Acres Realty Trust s No 'f ••21$45. Permit for •.J...stary..dw®11.i g ,{ .......................................................................... Location .......lot..#5•7•....28a..Mar.inen••Cir -' - ........................ .......................................... Owner ........... Type of Construction .........frames...................... 1 ............................................................................... Plot ............................ Lot ................................ - f Permit Granted Ncv � ................ e....26....... .19 79 , •' ' ` - _ _- Date of Inspection ....................... :.......19 I I Date Completed .................. ^.... ...19 - • � J f 1 a PERMIT REFUSED "............................................. '-19 777 ....... ................................................... _� �! •j' - itt .-1 ,,.,/y' f.:��f�/f.+ e «!m.✓" ...... ........................................... 1 f ...... . ............................................................ M / i Approved ................................................ 19 ............................................................................... ..................... ...................................... ............... L. ..77 Assessor's map and lot number ......................K...i. SINE Sewage Permit number ............................................ BAR3 STAXLE, AG& House number ............. ....... ................ ................................ N6319. 0 MAI TOWN OF BARNSTABLE BUIL0.ING INSPECTOR APPLICATION FOR PERMIT TO ................. ..................................................................................... .. •. ....... .......... TYPE OF CONSTRUCTION ..... ...................................................... ..19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 4 4.47.......... .. Location .... ..... . ............................. ...................................................... ............................................... Proposed Use ...... ................... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner ........Address ........j... ....................... Nameof Builder ........ ...............Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .......... ...........................................Foundation ..................... ......................................................... Exterior (4, ....................Roofing . ....................................................................... v/ Floors erior .... ............................................Int ........................................................... Plumbing ...... .... Heating .I�A ......................0..................................... . .... ....................................................... Fireplace .......&e............................................................Approximate Cost ......... �7 ,V7................................................... Definitive Plan Approved by Planning Board 13------19 7 Area(Q 0 10 ..... ......................... Diagram of Lotand Building with Dimensions Fee ........�73 ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH yU I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... .............. �4r................................................................. � Cedar =_rp9 Realty �rum f / ~ ` �� _ � ' - ��' No ...... Permit for ...1...a o ' . --.+—'----.--~--.-----~---.--Localion � r —l0 L..#-'�7....2-a3'JMay4-noiF,'-C-ir;...... ' .....................{.Qutit--.-----.—.-----.. "~.~. ^^~.a^ ~.^^°° °°=aj. � Type of Construction . ` ' Plot ' .................. Lot .../........................ ' . Permit Granted .............ZQV-....26..........19 79 Date � � . ofPERMIT REFUSED � ~~ � o � ' ............... lV ^ ^�� ---...—^�.� .�` . ��L—. ..x..=---- —'— ........................... '''' ----'-----'' —.---. . ----' ...................... —'' ' � [ ^ .---.—...—..1�--.!—...--..—..---..— . . Approved / ................................................ lQ � --------.--.~----....---------. --------.--.._.—...---.---..—.—.. | � | ' Town of Barnstable th .--- ,-.� .r m�. Building BA PP '- Post This Card So That�t is_Vis�ble,From the Street-.A rove&Olans Must be Reta!ned on Job and is Card Must be Kept MAM `�$ Posted UntiI.Tih Inspection Has.Been Made.. .:. '- ;, . u t t Permit rug+° WW ere a'Certificat-ebof Occupancy i ,Required;such Building shall No#�beTOccupied un- til'a Final Inspection has-been - ade Permit No. B-18-3357 Applicant Name: Mark Lemon Approvals Date Issued: 10/11/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 04/11/2019 Foundation:. . Location: 283 MARINER CIRCLE,COTUIT - Map/Lot: 039-021 Zoning District: RF Sheathing' Owner on Record: MADDEN,JOHN J Contractor Name'''' MARK J LEMON Framing: 1 Address: 283 MARINER CIRCLE f Contractor License CSSL-100207 2 COTUIT, MA 02635 -Est. Project Cost: $9,000.00 Chimney: Description: stripping roof and sidewall and.reinstalling new shingles Permit Fee: $45.90 y Insulation: Project Review Req: Fee Paid- $45.90 Date, 10/11/2018 Final: Plumbing/Gas .. 'E Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within siic months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and theapproved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road.and shall be maintained open forri-,public inspection for tfie entire duration of the work until the completion of the same. d Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:! 1.Foundation or Footing ' Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health 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 Final All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 0 14 tX PA V, Town of Barnstable Building )PostThis�CardSo That tt is=VisibleFrom�the StreetApproved�Plaps Must be Retamed�onJob�and'this Card.Must�beKe t���' • �- A �.d',`'?S�A..; r e', -' "d t,,.. i 'a� i£�r� �"'� -� Hof�, ,3,:.� �� f �S'*f". �; } " ' M"� ,�` Postei!•tlntil�Final:lns ection Has�Been�Nlade �,. ,�r �:�t���� �' "° �`�F��' �.. �' � � '� ��. � • Where a:CertificateofiOccu anc ;risRe ured� uct�Buld,m -shall Notbe Occw iedunt�l a Final Ins ectionFhas'been;made Permit - ti�..,.-,.w;ex. i>4ru £v e... �?.>,:�a s���E:;��a. r�.a"�:;,,_ .' �A, .u,..�«6�., � �; ��, ...•,.,.� ..,! p.e�.,i<.®,+,..,6 �i-..;.�:u�..ii.��E _p .r.,,,, k;:,'s „�.. F7 ;:6, �' - - '- Permit No. B-18-1743 Applicant Name: MADDEN,JOHN J Approvals Date Issued: 06/21/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 12/21/2018 Foundation: Residential Map/Lot 039 021 Zoning District: RF . Sheathing: Location: 283 MARINER CIRCLE,COTUIT , nt rac t or Name Framing: 1 Co Owner on Record: MADDEN,JOHN J Contractor License: 2 Address. 283 MARINER CIRCLE Est' ProJect Cost: $500:00 Chimney: - COTUIT, MA 02635 Permit Fee: $220.00 Description: Replace Drywall in Kitchen/Dining Area Fee Paid: $220.00 Insulation: Project Review Req: Date 6/21/2018 Final: Plumbing/Gas Rough Plumbing: a 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. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zornng.by laws and codes. This permit shall be displayed in a location clearly visible from access streettor road and shall be maintained open for public rnspection for the entire duration of the Final as: x work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Building and Fi m,Officials are provided: this permit. Minimum of Five Call Inspections Required for All Construction Work ` Service: 1.foundation or Footing q . �', Rough: 2.Sheathing Inspection .••,,, „ 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons cont 'ng with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).. �. Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: VE -� AppHcation Number. ... ......... .... f BARNSUBM . ; + Other Fee..... MA88. Permit Fee....................................... ...........:...... 1639. Total Fee Paid.................. ....... ... .. . .. .. TOWN OF BARNSTABLE permit Approval by.. ... ...._.............on,..:..... ....... ......». BUILDINGPERMIT ..................................ParceL............ ................................ APPLICATION Section I— Owner's Information and Project.Location Project Address 3 � �► -�s f�1� Village Co, Owners Name Owners Legal Address- I S � y City f�1��, ..� �1A S c state Owners Cell# 77`1- `i67 I612 Email Section 2-Use of Structure I Use Grroup ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3_: :Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment Sprinkler System ❑ Addition [] Retaining wall ❑ Solar ❑ Renovation ❑ Pool El Insulation Other—Specify Section 4 -Work Description} MAY i - � j T Acr andated-219=1 S y Application Number..................................................... Section 5-Detail Cost of Proposed Construction Square Footage of Project Age of Structure L Dig Safe Number # Of Bedrooms Existing, 3 Total#Of Bedrooms(proposed) 3 - 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design " Section 6—YProject Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas "❑ Fire Suppression ❑ Heating System ❑^Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility. I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last=datEd_2/9/2019 Application Number............................................ Section 9—_Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section-10—Home Improvement Contractor Name Telephone Number Address City State Tap Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and . documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your RIC... Signature Date Section_11 tiHome Owners_l icens_e zemption Home Owners Name: ,cam. Telephone Number Cell or Work Number 7t-1 -Lf I ? I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation requir 78 and the Town of Barnstable. Signature Date r ` APPLICANT-SIGNATURE Signature Date 5 Print Name �64w �( Telephone Number A,,27L-f - 191-16,(7 E-mail permit to: al / J T n/nnni o ... ........... Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's.Authorization L , 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 j ob) Signature of Owner date a Print Name i t i i 1 I i I a last undated:2/9/201 s i' The Commonwealth of Massachusetts fA Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizafion/Individuai): Address: I City/State/Zip: Kr�_s F 115 'AN 0 J&V Phone#: Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction employees(fiill and/or part-time).* 2.El I am a sole proprietor or partner-; listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'comp.insurance comp•'ns'rai'ee.t required.] 5. [] We.are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumb' repairs or additions 3.❑ I am a homeowner doing all work ❑ � P myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152, §1(4),and we have no 13.El Other employees.[No workers' comp.insurance required] *My applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and.state Nybcther or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy uumber. . I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: r CitY/ /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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pains and penalties of perjury that the information provided above is true and correct Si e: / Date: 5 3a i Phone#: 771/- Eig7-6. 7 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.EIectrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: L TOWN OF BARNSTABLE PERMIT CHECKLIST Sign cuff hours for Health and Conservation are 8-9.30 a.m. and 3t30-4:30 p.m. A complete permit application includes filling all sections 1-13 1. NEW STRUCTURES/REMODELING/RENOVATION/ADDITIONS ❑ Site Plan showing setbacks of proposed and existing structures Commercial—One complete set of full sized plans one reduced 11"x17" (plans may require a stamp by an architect or engineer). 11 Residential -6Sets of floor plans no larger than 11"x 17" smoke/co detectors marked ❑ Worker's Comp.Affidavit and policy(if required) Res Check or COM check from the 2015 International Energy Cod Council(IECC) ❑Letter of financial Interest for new houses only(not required for rebuild after teardown) ❑ Performance bond made out for$4.00/foot of road frontage.(new construction only) 2. DEMOLTION OF A BUILDING (NOT PARITIAL) ❑ Everything above plus shut off letters from following utility companies:' ❑ Gas ❑ Electrical ❑ Water ❑ Sewer(if required) 3. DECKS/PORCHES/GAZEEBOS/INSULATION/SOLAR/POOLS/SHEDS ❑ Site Plan showing proposed location ❑ Construction plans showing framing detail (if new framing), ❑ Pools—Barrier details,pool specs (engineers design) ❑ Workman's Comp Affidavit and policy(if required) FAMILY APARTMENTS ❑ Section 1 Plus: ❑ Family Apartments are subject to approval from the Building Commissioner. Agreement must be signed, notarized and recorded at the Registry of Deeds and returned to the Building Department. - FAb Town of Barnstable *Permit.# 6-/ Ex�ues 6 months from issue date. g k. Regulatory Services Fee snar�srwaca W m taAM � Richard V.Scali,Director F� � 059. /2 Building Division © � ?© � Paul Roma,Building Commissioge� 3 200 Main Street,Hyannis,MA 02601 ! �: www.town.barnstable.ma.us RAIS Office: 508-862-4038 Fax: 8690-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY q Not Valid without Red X-Press Imprint Map/parcel Number -D�J a ! 6 C2 Property Address Z� Kr,yxer. 6,rc,Ie- Mk 02(03� SResidential Value of Work$... 3_c�� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address !oy,% g- h�c�►�,, Mtacaw's M 1,� 1�►A. o?rfo�-1� Contractor's Name ,--n6v% MoAle, Telephone Number 7794- H87 - 107 Home Improvement Contractor License#(if applicable) Email: ` tv C4" 1 :i • a Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows i 3 ,r 1�l #of doors: r *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 e uired. A SIGNATURE: QAWPFILESTORMSUilding permit formsTYPRESS.doc 01/25/17 7m G'ommaztweaM ofMassadimset& _ ��r�t�e�rt a,�'lfarl�strial�cc�c�e�rfs - t fI,f e of 1m gatims ' 600 Washui mi Sitreet Gaston,-AL4 02M -mviummngarldia Workers' CGm13ensai mnInmimince Affidav&' BcdlderslCa-a ra.ctarsMecfiicianslPhM3hers App�ica�Inf 3i �a Flease h iu Eye T Name a>Sa�e an onrIndFvrdual �1,r: J- f''1 r. Ad&,ess-- 61 Mocs�.s fNS\\s' Alt--' Ciiyf tatel \\ c Phcne-tIrk, 774-.'-1-3 7- 1(fl17 Are you an employer?.Ch-eckthe appropriate ban ' Type of project(required): I_❑ I am a l with 4. El am 191,11 confracWf and I �P� 6. ❑New oonstructio>:, employees.(fif andforpart-time).* l avehuedthe sulr-contractoxs 2_❑I I am a sale pz opxietoff orpartner-.n listed on. attached sheet, 'I_ ❑Remodeling These sab-conIxacxors have sbip and�e no employees $_,0 Demolition o wor3dng far�z In any capacity. �I yees andhace wo&ers' 9. 0 Building addstica. h INN hers' comp-iasu=e comp.n,� $ • 5_ ❑ We are a coaporaf flu and its 1 ❑Electrical repairs or dditnoureqaked] s ofFcers have.xanised their 3_�I am.a bomeayener doing a1}'work1LQ P3ntubiagrepaiss or additions. self o workers' _ of exemption per MGI. . insuxneereSuirpd]i c.152.§I(4k and we have no 1-.0 Roof repairs employees.(No workers'' 13: Ofiier rn/-nA- S + comp.insarmce required.j 'Any apg&c=dstchedImboxRamstalsofaloaittheswfioaberowsho ingdieirwodcezecompeasafianpoIicyiafosms6aa. fi&auleowaerS Wl90 saba�tl1iS�da<<u ia�C�P dwp.axe+�m�811 Wadif sad:tbenlae autsidetanTaicdorsamd.5abmitaneW s�d4IIit IDdiC9�IIo SiICIl rCo=ctoaffLst chw*iIas boar roast wed m sddiSnnsl shEd sUwIng dienme of the svb-�m end stste atlpedm arnotihose enritiesbrm e03p9o3ees.Ifthesab-c=±=±aeshve e=RIgEe%dfieymmsCpmride xheu trnrkrxs'camp•Ra F mm�beL law an ersplapr float is prauP&g-markers'campemaiian insrirance or my em pf y ee.. B0101V is f7iepa cy and jab s&ff in onnatiorL Insurance CompanyName: - ,Policy TAe Or&E--im lie-41kI piaatiauDate: Job Site-A-ddre= Citylstddzl p: Attach 2 copy of the workers'contpensatioapalrc_-dechra4ion page(showing the policy number and expiration date). Fatinre to secure coverage as required under Section 25A of MQ.c.15-7 can lead to the imposition of criminal penalties of a fie up to$L50 OU aadr'ar ores year imprisonment;as well as civil penahies,m the farm of a STOP WORK ORDERand a f of up to$250_00 a day agar the violat.m Be adsdsed that a copy of this sstatemennt.maybe forwarded to the Office of Investigations of Me DIA far-since coverage vedficatirrn.. I do hereby under the pars and palaWks efgedjury firatffie ar;f ornrcagwi pro au£ed abaile is bars arzd arrrect Signature: � ]yate: V Phafle i�• �7'-f- NQ�- 1(0l? • t�,�ciaL�ara£}� Dn .rat alrifa Err fF�grea,try be crrrtrpleterI bg t�artnmr�n�cict City-or Town. PermitTicense# Inning Aarthar€fy*(cndeoae): L Board of Heahfi I Building Deparhnent 3.CxLylrowa Clerk 4.Electrical hmpector Plambing Inspecter 6.Other Coact Person: Phone --- 6 ormation and 11nstruefionshfits ' sack seffs Geb=al Laws chapter 152 requires aU employers`fn provide worker'c0a3ge LMtion f r their eo3pIoyCM P this'statzIL;an.Wg7Loy=is defined as`�:�YPersonm.$ie service of muyff=7 u den amy coutract ofhae, t express or impHed,-oral or wEhM." All ar'F&yer is defined as-aa.individnal,partner,assod2duA coipa don or other legal entity,or any two at more of i$e foregoing is aJojot Vie,and inclndmg tine legal reprwentatives of a deceased employer,or the receives or t mstee;of an individual,per,association or other legal entity,employing ploy - HoweQes the ownear of a dwelling house having not mare than tbree apartments and who resides them,or the;occupant of the- dwelling house of ano�.er who employs persons to do magic,r.,r,efrRr Fi rsn or repair v on such dwelling house or on.the grotnds or budding app�Ih=to ffi0notbecanse of suzh emplaymeattbe deemedto be an employee" nce MGL chapter 152,§25C(6)also states that aevexp state or local Ticensmg agency shall yitbhold�e issa r ewal f a license or permit or o to operate m basiarss or to contract buildhgs in the-co—oawealf3i ren for arrp aPFhcantTFho has notproduced acceptable uddencm of compTra�rc�wiHi fire msuranc�coverage regaard-" AddifionaIIY,MGL chapter 152,§25CM states-yD ther the comm9i weal[h nor�qy ofits Political subdivisions shall enter info any couixa'et fin[the peafoIM.amee of pnbho work una acceptable evidence of complia awn 9ie msm-3110e.- oft3is chaptrahaveBeen.p=mcbr dto the midi cting.aniho>ityy." AppIicaafis ' Please fill oht flee wow'compensation affidavit cDmpjetely.by ch=.Fmg the boxes thatapply to your siniatian and,if necessary,snPPIY sub-contractor(--)name(s), addresses)and phone nnmbes(s)along with their cerfficate(s)of z►sra-ance. Limited Liability ComPames(LLC)or L=tEdLiabUity Partnerships(LI P).wnno �loyees other thintho members orpmtaeis,are not r�ganedto carry worms'compensation.msmanca. If an Id1CorLLP doeshave eanpIoyees,apolicyisrequl-ed. BeadvisedthAthisaffidayltmaybembmittedto,f=,DepartinentofIndustrial n�n of insurance covee rag Also be th sore to sign and date e affidavit Tho affidavit should Accid�for co d b e-mt=ed to$e city or town that the application for the permit or license is being regaes not th e Department of LnAnstizl A jai V-:b Shonldyou have auy questions rdgardmg the law or iEyou are required to obtain a wogs' compensation pplicL Please call the Dep artmeat at the rnm[bes llste:d belov�: Se1f-msanxi companies should entt-r their self-msaraace license nmber CM the appzopria line. City or Town Ofa als f Please be sore tarot the affidavit is comple#e andpriofedlegdily_ The Department has 13m-v ded a space at the boffnm of the affidavit for you to fUl out in the event the of oflnvestigatic ms has to coact you-reg=ding the applicant Please be sure to fl7linti�epe /IicensenumberwhiclrwiilIbeused.as are�cenDmber.In.addition,anappTicant that must sabmit ravlliple pennitlIireose aPplioat=m.any given yew,need only sabmit one affidavit indicating eu¢eut policy mformatian(if neces�y)and ender-Tob�e Ad&e& the applicant should write-allocations in ( Y or P wn)-'A copy of the affdavittiiathas been officially stamped or'malmdbythe ci[y or town maybe provided to the ' applicant as proof that a valid affidavit is oa file for future p=n s or licenses. Anew affidavitm st be:filled out mrh year."Where a home owner or citizen is obtaining a license or permit not re7atr d in any business or commercial vdntII$ a dog licenseorpmmhtobumleaves eta.)said person is NOT reganEdto co•IDpleta this affidavit The Office of InvczbgatI=wovldlfim to thank you in advance for your cc operidion and shmad you have any quEs =S, please do notbesifatn In givers a ME The Departm ent:a address,telephone and f m nm abcr - CaMMM:-9?MSiir of Sach-usef g Depadmmt cif][ d Awide to MA 02111 Ta 4 617-' -4 cEt 4-06 or 1477 MA SAS Town of Barnstable Regulatory Services dl ' Richard V.Scali,Director Building Division t � Paul Roma,Building Commissioner .19. �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: 01 L03/1-7 Please Print `-� JOB LOCATION: ? O �a�111� G rc•le number street village "HOMEOWNER": eS uL,,, , - �c a 'I—�I?� 7 -I CD 1-7 name work phone# CURRENT MAILING ADDRESS: I Jet �Cvww�S�+n �tr� 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 be/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 procedimm and requirements and that he/she will comply with said procedures and requirements. Si Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lackof 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EYPRESS.doc 06/20/16 Town of Barnstable Regulatory Services Richard V.Scab,Director ► Building Division. Panl Roma,Balding Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I ,as Owner of the subject property hereby authorize to act on may behalf, in all matters relative to work authorized by this building permit application for (Address of Job) **Pool fences and alarm 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 QYORMS:OWNERPERMISSIONPOOIS TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Via, _ �.. Map Parcel-' Application # 009 1- 30 Health Division ✓79, 7yK Date Issued Conservation Division Application Fee Planning Dept. . Permit Fee CIO Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address C2 Y1,7"14,e-r Village �pfv Owner I e l 1 A D Je ue V4N 1 Address 1160 r/<— Telephone cua � / nL Permit Request :__ e-� C."r C`or� T" t,Jet It ® �� re /1Z el- - Square feet: 1st floor: existing proposed 2nd floor: existing propo:sed dotal ew Zoning District Flood Plain Groundwater Overlay Project Valuation 040 Otonstruction Type Lot Size _ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No , Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ,❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name OeQ4,M) C_ P1109 /A Telephone Number Address rn&-l'14A r C CPC Ile., License # C- c y4A, 0cp(03 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �acl`flS a b l e fit?v>'t� L 0,-J l SIGNATURE w DATE FOR OFFICIAL USE ONLY s APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER F:. DATE OF INSPECTION: t FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL `g GAS: ROUGH FINAL F FINAL BUILDING Of-//V 0 y DATE CLOSED OUT q[([(r ASSOCIATION PLAN NO. - - - - h Tile Commonwealth of•(V.tassacnuseus Department of Industrial Accidents office of Investigations 609 Washington Street Boston, Mf( 02111 • www.mass.gav/dfa , Workers' Compeusation Insurance Affidavit: Builders/Contra ctorslEIectri�cians/Plumbers Applicant Information Please Print Le6bly Name (Business/Organizaticn/LndividuO): Address: '3 i'n a.J`j nA-r- G J P C _ City/State/Zip: Co ty;l- Y'1 A-, 0057 Phone.#: Are you an employer? Check the appropriate box: Type of project(required): [2- m a.❑ I am a employer with 4: ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sib contractozs ❑ I a 'sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition ee loys and have wo rkers' working for mL in any capacity. emp 9. ❑Building addition • . [No workers' C C7IIZf].insurance comp.ins„r�se.t S: ❑ Wo arc a cozporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers}lave exezctscd tb_cir 1 LE]Plumbing repairs or additions mysdL [No workers' comp, right of exemption per MGL 12.❑Roof repairs incr,rance rC t c. 152, §1(4), and we have;no employees. [No workers' 13. Othcr comp.insurance raltured] 'Any applicant that checks box#1 room also full out the section below showing their worked'eoroparsaYion policy info,zrmtion. t Homcowncn who submit this affidavit indimfing tbcy arc doing all work and then bin:outside contractors must submit a nrw affidavit indicating such. tConhactors Out cbcck this box must atfacbod an additional sheet showing tl-he name of the sub-otttraetors and rLdo wbcthcr or not thosC cmtities have cmploycm. if the sub-contraetArs have employees,thcy must pra vi&their workers'comp.policy mrnber. I arri an employer that is providing workers' compensation insurance for my employees. Below is the policy and jab site information. Jnsurancc Company Name: Policy#or Self-ins,Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coveragc as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 5no up to $1,500,00 and/or one-year imprisonment, as well as civii penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Bc advisod that a copy of this statcmezit may be forwarded to the Officc of LaYC&ti atians of the DIA for inst,rance coves e verification. I do hereby c�dzns•and penaltiees of perjxcry that the informadon provided above is true and-carrez4 C_ d Date: 0 b d o Si afore: — Phone# Offuin!use only. Do not write in this area, to be completed by city or town ofjXLQL City or Town: Permit/Licease ff Issuing Authority (circle one); 1. Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Massachusetts General Laws chapter 152 requires all cmployLs to provide workers' compensation for their employees: pursuant to this statrrte, an employee is defined as "...every person in the service of another under any contract of hire, •"1 express or implied, oral or written_" An employer is defined as"an ipdividual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal represcntativcs of a dcccasui employer, or the receiver or trustoe of anindividual,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, constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not becaust of such employment 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 notproduced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL ohapter 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 in-surance requirements of this cbaptcr have been presented to the contracting authority. tlpplica.nts °Ieaso fill out the workers' compensation affidavit completely,by checking the boxes that apply to.your situation and, i.t lecessary, supply sub-contractor(s)name(s), address(as) and phone numbcr(s) along with their ecrtificate(s) of nrnrance. Limited Liability Companies(LLC) or Limited Liability Partnerships (LLP)with no.employees other than the ncmbers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have :mployees, a policy is required. Bp advised that this affidavit may be submitted to the Department of Industrial lccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should or. rne retud to the city or town that the application for the putt or license is being requcstrd., not the Department of ndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' .ompenuEon policy,please call the Department at the number listed below. Self-insured companies should enter their elf-insuranro license number on the appropriate line. ;ity or Tower Officials lease be sure that the affidavit is complete and printed legibly. The D cparlment has provided a space at the bottom f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant lease be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant Lit must submit multiple permit/license applications in any given year, need only submit onr,affidavit indicating c=cnt olicy information(if necessary) ant under`Job Site Address" the applicant should write"all locations in (city or wn)."A ct7py of the off davit that has beta officially stamped or marked by the city or town may be provided to the )plicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each Mr.Where a home owner or citizen is obtaining a license or permit not related fo any business or cormncrcial venture .e. a dog license or permit to burn leaves etc.) said person is NOT required to completz this affidavit io Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ease do not hesitate to give us a call e Dcpa;lment's address, telephone-and fax number. The Cammonvcrealth of Massachusetts Depar Dnt of Iadusixial Accidents Office of Iuvestipfians 600 washingtn street Boston, MA 02111 Tel. # 617-72 7-490.0 ext 4-06 or 1-M-MASSAFB Fax# t517-727-7749� d 11-22-06 www.mass.gov/dia r k` 283 Mariner Circle, Cot. 6/26/08 -ik L� A, 'e 283 Mariner Circle, Cot. 6/26/08 t All to ;.6H 283 Mariner Circle, Cot. 6/26/08 283 Mariner Circle, Cot. 6/26/08 �� YS 283 Mariner Circle, Cot. 6/26/08 Ytd, -3 r 3.. G, r .Tv 283 Mariner Circle, Cot. 6/26/08 rr r I 8 283 Mariner Circle, Cot. 6/26/08 s' Town of )Barnstable Regulatory Services Thomas F. Geiler,Director 1.ARNSTAB . MIMS. 16.1 ,�� Building Division PTfO µAt a Tom Perry,Building Commissioner 200 Main Street, Hyannis, NfA 02601 wwvw.town.barnstabI e.ma.us face: 508-862AO38 Fax: 508-790-6230 HOMEOVMER LICENSE EXEMPTION g Please Print DATE: JOB LOCA77ON: t9 C 14,c Ile, ,ppnumber //�� /�yJ 'I street Lvillage HOMEOWNER":_InIcHAP, � C PJDRIAJ 5-07-/��—�a8b� name home phone# J work phone# CURRENT MAILING ADDRESS: c2 3:3 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 ROME0WNER 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 fv✓o-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 requ' em nts. ignatvn:of Homeowner , Approval of Building Official. Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the hate Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeownc performing work for which a building panit is required shall be exempt from the provisions f this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for.hire to do such cork,that such Homeowner shall act as supervisor:" Many homeowners who use this exemption aic unaware that they arc assuming the responsrbilities of a supervisor(see Appendix Q, er .u)es&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly hcn the hotncowncr hire unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed npervisor. The homcownrracting 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, at the homeowner certify that he/she understands the respormbilitics of a Supervisor. On the)ast page of this issue is a form currently used by vcrel towns. You may care t amend and adopt such a form/ccrtification for use in your corrvnunity. 'Town of Barlastable Regulatory Services aAaresrear.Er v Muss �► Thomas F. Geiler, Director. ohv � Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnsta ble.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 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 th'e reverse side.