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HomeMy WebLinkAbout0288 MARINER CIRCLE s �8��i � \ 4 /` TOWN OP'BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # 76 S Health Division Date Issued Conservation Division Application Fee 5_0 Planning Dept. Permit Fee �� 36V Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address -Y� )7k Village 1f J'• Owner Address Telephone V6_55t Permit Request "Ji,,,r,zJ,_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation )Yam-- Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2"' 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# rn Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) . Name Mike McCarthy Construction Telephone Number PO BOX 52 Address West Dennis. MA 02670 License # Cell (508) 280-6964 CS- l -58633— HIC-169-39-3 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL a GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r 1Y I e. Town of Barnstable 4 Regulatory Services MASS Richard V.Scan,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 viww.town.harnstable.ma us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Signs This Section I_f Using.A Builder ' as t hrner of the subject propnity hereby atrthorvx A4 U G�loti)to act on my behalf, in all matters relative to work authorized this building permit application for. (Address of Job) 'Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. � ��- �f-%�C Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS'OW'\'ERP:.Rl.t]SStONPWLS i ;i i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-058633 WS MICHAEL J MCC kR PO BOX 52 s W DENNIS MA 0267 Expiration Commissioner 04/10/2016 C-9 Office of Consumer Affatrs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration 6/16/2017 Tr# 264961 MICHAEL MCCARTHY MICHAEL MCCARTHY -- r P.O. BOX 52 WEST DENNIS, MA 02670 w Update Address and return card.Mark reason for change. _t Address Renewal CI Employment ❑ Lost Card 20M-OS/71 The Commonwealth ofMassachttsetts Department of InthistrialAccidents I Congress Street,Srtite 100 Boston,MA 02114-2017 www mnss.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPhinibers. TO BE FILED WITH TILE PERATITTING AUTHORITY. Applicant Information ,.,f.,__ McCarthy ,,4t1:,,EVgVXrint Legibly Name(Business/Organization/Individual): PO BOX 52 - Address: Nest Dennis, MA 02670 City/State/Zip: CS�ka§ 33 HIC-169393 Are yor an employer?Check the a propriate box: Type Of project(required): 1.7m a employer with employees(full and/or part-time).* 7. F1 New construction 2.0 lama sole proprietor or partnership and have no employees working forme in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.Q 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 E Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3.❑ROOFrepaltS These sub-contractors have employees and have workers'comp.insurances 6.rJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[(Other 152,§1(4),and we have no employees.[No workers'comp:insurance required.] *Any applicant that checks box MI 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. IContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer/lint is provl(ling)porkers'compensolion insurance formy employees. Below Is the policy.and job site information. Insurance Company Name: AT/ ' 1 1J Policy#or Self-ins.Lic.#: j/ 1 -7CS1---101 Expiration Date: Job Site Address: ✓�'a J �w��i `�-�I-i City/State/Zip: Attach a copy of the workers'compensation policy declaration pag&(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. ]52,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER-and a fine of up to$250.00 a day against the violator.A copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un t! al sand allies rjuiy that the:informalion provided ab ve is true and correct. Si nature: Date: Phone#: Official use only. Do not wrlte in this area,to be complelerl by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMPA.GE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 800 876-2765 NCC(N0 26158 . POLICY NO. I VWC-100-6017656-20146 PRIOR NO. I VWC-100-6017656-2014A ITEM 1. The Insured: Michael McCarthy Construction Inc DBA: Mailing address: P 0 Box 52 FEIN:"*"3862 West Dennis, MA 02670 Legal Entity Type: Corporation 9 tY Yp rP Other workplaces not shown above: See Location, 2. The policy period is from 12/15/2014 to 12/15/2015 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease. $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 0712979 INTER SEE CLASS CODE SCHEDU E Minimum Premium $550 Total Estimated Annual Premium $29,332 LSTATE GOV Deposit Premium $7,748 CLASS 5479 State Assessments/Surcharges. $28,601.00 x 5.8000% $1,659 This policy,including all endorsements,is hereby countersigned by 12/15/2014 Authorized Signature Date Service Office: Bryden &Sullivan Ins Agcy of Dennis Inc 54 Third Avenue PO Box 1497 Burlington MA 01803 So Dennis, MA 02660 F�� WC 00 00 01 A(7-11)Includes copyrighted material of the National Council on Compensation Insurance,used with Its permission. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map. O lq ! Parcel I tQ -0 1 App ication # Health Division Date Issued Conservation Division Application Fee US® Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis ' Project Street Address �6? f�1�f� ��,��k Village L � Owner Address Telephone Z9 —L21 7JP(Y:S Permit Request CAVIVUlf �Ja ✓J eIf 0/ ©", Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation J r 6w Construction Type lZzl.,Jz( 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 7 new 0 First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing mod/coal s�teve: l Yes ❑ No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Bad Ll existing ❑:raw size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Othef v Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ " n Commercial ❑Yes ❑ No If yes, site plan review# Current Use ►/1 -�c- Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name � �i►-► JVtio�� Telephone Number Address i�6�ua.l�'�' L License # (5— Z 3 i1A A �2��� Home Improvement Contractor# 't1 62 Email (A h4 5 4 f).^5{r,.,&a^ n c Worker's Compensation # PIA ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1 V�Y► I�;ar1� SIGNATURE -- DATE i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION j FRAME CO L76'Afe 't INSULATION w FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING f DATE CLOSED OUT ASSOCIATION PLAN NO. I �7xs�a�trxo�fsFeYiltTi o;�1Ylrassae.Ftrrsetts Department of fi ustrizd Accidents Office of finvestign#ians 600 Washingtan Street f Boston,,AM 02111 Yl ov.itjasmgm-ldia orkei-s' Compensation Insurance Affidavit.Builders/ContractnrsMectricianMumbers Apjg'Licant Information �' Please Print Legibly Name(B+ssme�OWnizalion/fn&ndwl)- ,)AID U&L Address: 7 i� 1^ CiWStatt-Mp- Oyr",^!s AA o2Gv x Phone 97 "7 7 4 —S.2 1 7431S Are you an employer? Check the appropriate box: T of o-ect r uire 4. I atat a ctm6ractor and'I 3'� Pz' J �e4' �� 1_❑ I am a employer with ❑ t 6_ ❑New congauction. employees(full andlor part-time).* have Mred the sub-contractors. 7_ I am a sole proprietor orpartne— listed on the attached sheet:; 7_ �Rrmodeling ship and haze no employees These sub-contractors have g_ ❑Demolition. working for me in any capacil,. employees attd have workers' 9_ ❑Building addition [No worbus' comp_insurance Comp.iusurallm_1 required] 5. ❑ We ale a corporation and its 10-❑Electrical repairs or additions officers have exercised thm— 11_. Plumbin airs or additions 3.❑ I am a homeowner doing all viork ❑ g myself [No workers'comp- fight of exzemptionper MGL 12-.❑Roofrepails insurance required]F c_1.52, §1(4),and we hative na employees-[No workers' 13_.0 Other comp_insurance required-] "Any sppTic mt that checks box€1 most also fill out the section below showing policy infbrmZtiffii T aomeownem who snbtnit this affids-At ni&c3tiag try are doing all croak and then hire a new afdsvit indacstin mcli_ lconhsctors that check this book must attached an additions)sheet showing the name of-the sa b-caiifr3cbm and state whether or not these edities h3ve zmplQyees.. If the got ontracto.rs have employees,they must piuvide their workers'comp.policy number_ I am as employer drat is prm izU g ivorkers'comma-Lion invirance for azy employees: Below is the policy and,}ob site inforwtation lasumrtce Company Name: PIA Policy tII or Self-ins-I.i-c-4: VIA- ExpirationDate: Job Site Address: �,� �t d r1 r 4r ( r d r�L -Cify75tatelZtp= 1 B �A J�' t AA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of M-GL c. 152 can lead to the imposition ofc-ricreireal penalties of a fine up to$1,500.Oa andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance;coverage verification_ Ido hffeby czrtify cinder the pains nifdpenaWes ofpetfury that the information provided abmre is true and correct Signature: _ Bate: t! 1/2 A Phtme#- 7 4 — L2 l 1°cP S official use on[y. Uo not write in this area,to be competed by city or town officiaL City or Town:. PermitUcense# Lssuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitOFown Clerk 4.Electrical inspector S.Plumbing Inspector 6.O;thes Contact Person: Phone#: -- 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written_" An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or 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 a uy applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es) and phone number(s)along with their cep. ricatc-(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Depat-tnaent of Induusiiial Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit 'I lie affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitJlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonw alth of Massachusetts Depaitaaat of Industrial Aecidtats office of kvestigafiaas 1 600 wash agtaa Street Boston_l A 02111 TO. f I7-727--4900 Qxt 406 or 1-7 KA-SWE Revised 4-24-07 Fax# 6I7-727-7 49 �-FT�.ruass;gQ�Idia p die Ipa/,vnaoaacue�cl o�C�///�a�o�.,c/c�eCYa" , Massachusetts -Department of Public Safety \' Office of Consumer Affairs&Business Regulation 1 Board of Building Regulations and Standards OME IMPROVEMENT CONTRACTOR i %oilsi;iiCiivii SiiTe;,'i>ii, = egistration: 147624 Type: i i" Expiration 7/25/2015 Individual i License` CS-096833 SAM NAOOM 4 I SAMUEL F NAOOM f 76 VANDERMW:f LN I SAMUEL NAOOM Hyannis MA 02601UVI 76VANDERMINTLN >9 �: HYANNIS, MA 02601 Undersecretary Expiration Commissioner 11/10/2016 - _ - z License or registration vat individul use only before the,expiration date. If found return to:. Office of Consumer Affairs and,Business Regulation 10.Park Plaza-Suite 5170 4 Boston,MA 02116 I I. Not valid Without,signature anxxsrneie, MASS Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder S !1 r CSi C /A ,as Owner of the subject property hereby authorize �ok d VkOO k to act on my behalf, in all matters relative to work authorized by this building permit application for: ASV (Address of Job) �^ Signature of Owner Date � r\ Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN_D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 rp TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# 1 e50 Health Division Date Issued &l G GCIU ' Conservation Division { Fee-da1S. Tax Collector ,dg�Sk Treasure / d 100 Planning Dept ' Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Ad Q 6 i'�/ r (' - Aw Village ��� V I e� Owner /C il� Address Telephone Permit Request f 70 Sare feet: 1 st floor�exi)sting proposed 2nd floor: existing,. proposed Total new Valuation l/ v Zoning District Flood Plain. Groundwater'Overla Y Construction Type ' Lot Size Grandfathered: ❑Yes ❑.No If yes, attach supporting'documentation. Dwelling Type: Single Family rid' Two Family ❑ Multi-Family(#units) Age of Existing Structure aU Historic House: ❑Yes G34e On Old King's Highway: ❑Yes ❑No Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) /`/U 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: Cr-Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes U410 Fireplaces: Existing i/ New Existing wood/coal stove: ❑Yes &Mo Detached garage:❑existing ❑new size Pool:❑existing Cl new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:Urexisting ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes,site plan review# Current Use Proposed Use BUI ER INFORMATION Name Z� ���Telephone Number � _�� ~ Address License# Home Improvement Contractor# Worker's Compensation# —7--- ALL CONSTRUC,,TIO?D1 IS RESULTIN ROM THIS PROJECT WILL BETAKEN T / G��S SIGNATURE DATE l� �� FOR OFFICIAL USE ONLY 'T PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS _• VILLAGE " OWNER DATE OF INSPECTIONS a FOUNDATION FRAME , INSULATION - FIREPLACE , ELECTRICAL: ROUGH FINAL x PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL FINAL BUILDING 3/l 3 1 o DATE CLOSED'OUT+ ASSOCIATION PLAN NO. " The Town of Barnstable v.BARNS .ABLF. • 9�A " �m� Regulatory Services lEo N►e+°1659. Thomas F. Geiler, Director Building Division Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 .Office: 508-862-4038 Fax:/ 508-790-6230 Permit no. . Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW. SUPPLEMENT.TO PERMIT APPLICATION ;- t MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more thanfour 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: — Estimated Cost /`' z Address of Work: Owner's Name: _pa?`//C/AI Date of 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 -- w -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 actor Name Registration No. G' v Da Owne 's Name q:forms:Affidav —` "- The Commonwealth of Massachusetts • a =- -= Department of Industrial Accidents 600 Washington Street `4,r Boston,Mass. 02111 Workers' Compensation Insurance Affidavit i i name: location city hone# — ❑ I am a homeowner performing all work myself. ❑ I am a sole r rietor and have no one worki>1 in ca achy a I am an employer providing workers'compensation for my employees working on this job. com air .name:. ` < ntidress:'.;: ; . • - II hone#: QtV' fl :fi6Ur-3nCe EG!=�opri�et !=al XXX -tli # ❑ I acontractor, o homeowner ' cle one)and have hired the contractors listed below who have the followin workers' compensation polices: con► an ;name..; :::::::::::::::;:n:::;•. ::::::::::::::::::::::::::::::::.i:.i:.::.T".:: :::::. : :.:.::::::::� .i'::;:::o::<.::.:>::•::;}:::.>:;<;;•:a;:;::::::i;;i::::%;:>Ta::::::5::;:::%....:::::::>:::::.:....i:.i'.:ti.ii:.ii:::::.:;;:•:.;: •:.:?i"••:: .......:::ti.i: ::::::::::::::...tiJi::ii. ::•:::::.:::::::.::.�::::::.}::.i}i:.i:::.i?i :::::::::: : ::::::: ::::::.�.:::'.::.i:i::.::.iiii:::::::::::::::::. .: :::: :.� ::: :. "..::.::.i}F i' .:':i"i::'::..::::::::::::::.i::ry:ii?i}i:•: . :: .: :: :: :.. :v:..:::•::.�:::. i:•iiiii:?iii:ii .•:::.:'•i:•.:•iii' .: ::••:::•::::•:::: :i:::•::•::•::.:::•::•::::: :::: .:::.iii::i:i:iiiiiii :•ii;}ii:::: ......::::. .:V:• .. .. ... ...... .. .;z .:. : .;.: .::; time# » >:^ <. :< .X. .. c an;nam x. address. d h X. I'Muces T& LL _ _. till 1Y Fsfiure to aecmte coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of temen y be forwarded to the Office of Investigations of the DIA for coverage verification. I do h eby certi the pains n of perjury that the information provided above is trno cone Sigma e Date Print name Phone MM offidal use only do not write in this area to be completed by city or town official city or town. permit/license# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; -- ❑Other I�etised 9/95 PJI� Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a . dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 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 have 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 along with a certificate of insurance 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 Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the perniit/license number which will be used as a reference number. The affidavits may be resumed io the Department by mail or.FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Ofllce of Inllesugadens 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 Department of Health Safety and Environmental Services Building Division sAluvsTAISM t 367 Main Street,Hyannis.MA 02601 MAss. v &639. Ralph Crossen Office: 508-862-4038 Building Commissioner Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ' Please Print DATE: v JOB LOCATION: r " Tp er / street village "HOMEOWNER" work phone# name home phone# CURRENT MAILING ADDRESS: city/town state rip co de i 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, otn vided 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 ent minimum inspe procedures and requirements and that he/she will comply with said pr, ce a and requ' e n Signature of Homeowner Approval of Building Official Note: Three-family'dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127:0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see sing Construction Supervisors,Section 2.15) This lack of awareness often results in Appendix Q,Rules&Regulations for Licen . In this case,our Board cannot serious problems,particularly when the homeowner hires unlicensed persons proceed against the e. unlicensed person as it would with a licensed Supervisor. The homeowner acting as Sup communitieor is srre require,ately as part of the permit To ensure that the homeowner is fully aware of his/her responsibilities,many q P 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 to amend and adopt such a form/certification for use in your community. .Q:FORM S:EXEMPTN 4 7 s map and lot numb 3..�.. /4 ............. ®�) - �f F THE t0 f Y TEM mu-ST I �, Y....Sewa a Permit number .... ...... 4p ..2!. ............................ SEPTIC S e�P o� g INSTALLED IN COMPUANC WITH TITLE 5 i BaB1A IL LE, / gg House number ..................... . ...................................r....... . ENVIRONMENTAL C ONS AN °��o�pY•O a.0� TOWN OF BARNWAII` BUILDING INSPECTOR- . APPLICATION FOR PERMIT TO ................& ......................................................................................... TYPE OF CONSTRUCTION ......Y.!/dY ...a. ...... Ltl /// .................................................... `, .®.. ...........19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according tote following information: -� Location ....................... ...�!.. ...... ...... ... ............ .... .. .. .. .......... ........................................................................................ ProposedUse ......./D/— e!114... ....................................................................................................................................... Zoning District ............e.. ............................................Fire District ....CLaAl., . ............................................................ Nameof Owner .............. ...... ............................. ............Address ..... .. .... ........................... Name of Builder ..X/.: .... ...............................Address ....a?..`.. .` t ..: .................................... Nameof Architect ..................................................................Address ...................................................................................... Of � � Numberof Rooms ................ ...............................................Foundation .....�!............ .......................... ..... ...................... Exterior W .... � f� ............Roofing t� ....... /�//1/ .... -.....................�.. ..... Floors �f .Interior ' / .................................................... ,[/ .�. ..... Heating ! l i����� .�4....................Plumbing ........../ Fireplace ......f�.s:/.f��.� ...........................�.........................Approximate Cost ........�Y.. ...................... ............. y.. . /3�, s Definitive Plan Approved by Planning Board ________19 Area .......................................... 0/1 �I.................. Diagram of Lot and Building with Dimensions Fee ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH �13 Piz I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. /,� Name tom/. ........ .. .. ... ...�,44 ...................... Cedar Acres Realty Permit for ........one ........ single family ............................ ................. Location ............288 Mariner Circle .................................................... ...........................Cot.u.i.t....................................... Owner ..............Ced.a.r..A.c.r.es..R.e.alty.................. . .. .. . . .... .. . ...... Type of Construction ..............fjr.,Mg................. ............................................................................... Plot ............................ Lot ...............it.1 4........ Permit Granted .......... December17..19 79 . ............................ Date of Inspection ....................................19 Date Completed ....... ..............................19 0, /40 41 PERMIT REFUSED < .......;2..�................................... 19 ............... ................................................... .......... . .................................................. 7. 5, M R ................................................... ......1.. 'Approved ................................................ 19 ............................................................................... ................ ..........I.................................................. 4 Assessor's map and lot number ......�:?...,z........ .............. THE A5ewage Permit number .....(I ...........:... SAWSTAXLE, Housenumber ..................... ....................................... 16MAG& 39- 90 0 MAY TOWN OF ' BARNSTABLE WILDING INSPECTOR APPLICATION FOR PERMIT TO ...............j '1 ..l............................................................................................. TYPE OF CONSTRUCTION ....... ...... ..... ................................................... .................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: A- Location ... ...AMP*' e............... .............. ..... ....... ProposedUse ....... ....................................................................................................................................... ............................................Fire.Zoning District ........... District .............................................................................. ............ ..................................... Name of Owner ................. ............... .. ............Address ...... .4v 10 Name of Builder ...V�n!t�, .... ..........Address .... ..... .1.014..............:,?q................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .................1 ?..............................................Foundation ..; . ZV /- -z............................... 174 :, / ..................... Exterior ........ :�4f ............Roofing ................ Floors .... -A ................... .............................Interior .................................................... Heating ... .........................Z...... ..............................Plumbing .......... ................................................................... Fireplace ...... ..................................Approximate Cost ......... .................................................. ................................... Definitive Plan Approved by Planning Board B --------19 Area ..... ....... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .. Name ...................................... /C edar Acres Realty ' 1 .2 .8, 6 .... ..9..... Permit for ......one.........sto......r.Y.......... ............s.i.ngl.e...f am.i.l.y..dwelling................... ...... . . .. ........ . .. Location ..............2.s.s..Marinor..cirue.......... .............................. 0. 417. ..................................... Owner ................ .......... Type of Construction .......frame....................... .............................................../.......#13.4.............. ............... Plot ............................ Lot, Mlbe r 17 Permit Granted .... .............................19 79 Date of Inspection ..... ...........19 Date Completed ................/. ...................19 1 PE7.. 4EFUSED ............................. .. ...... ...4 .......... 19 ................. . . ........ ........................................... lei ............ .. .. .. .. ........ . .... ............... ......... ............ ........./............. ....................... ...................................................... Approved ................................................ 19 ..........................•I..................................................... ............................................................................... r r i /2 J QO D `O b NO Q N _p Vi NO i 441 h CL ? r, o � � PLAN SHOWING Wz FOUNDATION LOCATION �S � = C 0 TUI T, MASSACHUSE T T S OWNED BY Y Ll• c) r- ,o n .n SCALE : = 40 " DATE: OTC- GO t7u. NORMAN GROSSMAN------REGISTERED LAND SURVEYOR ✓'ASS fF �+:�,. I HEREBY CERTIFY THAT THIS FOUNDATION IS LOCATEDf� , ON PHE LOT AS SHOWN AND CONFORMS TO THE TOWNNORMAN OF BARNSTABLE ZONING REGULATIONS REGARDING GRC$;PAA, SETBACKS FROM STREET LINES AND LOT LINES . i"iS � + a NORMAN GROSSMAN R.L. S. DATE s .•�� p TOWN OF BARNSTABLE Permit No. ----------_---------- , + = Building Inspector Cash ee iejq. �,► OCCUPANCY PERMIT Bond ----________________L°I "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 llr-rA^ Rtz.41 f-v Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Ga-s 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. ....................................... 19_. ...................................................................._..................._......._....._._ Building Inspector d 5 w uj m oo< VIE ss 59,_G„t w gOmooun W 25m. W 0 v z (EXIST. CONSTUCTION) F F in a F SMOKE DETECTORS RMEWED REV.NOA ,A / u TAINT - Ui e-�ADe REQUIRED DATE _ A EXIST. BENCH STATE BUILDING CODE R CU!RE5 THE UPGRADING Or'*A79 UILDING DEPT. DATE SMOKE OETECTORS FOR THE ENTIRE DWELLING WHEN LONE OR MORE SLEEPING AlEAS ARE ADDED OR CREATED. j `IRE DEPARTMENT DATE ? NOTE: A SEPARATE �,T IS RP � z A m INSTALLATION OF SMOKE ETECTORS�u-D FOR TFI� BOTH SIGNATURES ARE REQUIRED.FOR.PERMITTING •A2 N THE EL�CTR,�1L X PEPAUT N0�SAT"St T HIS REUAREMEV T,_ w � U Z EXIST. _ _ JUL =) ~ r EXIST. Q 04 DECK (r] Q O Q EXIST.R UTOR. - - Z U , C EXIST. EXIST. EXIST. EXIST. ~ Cd — ea• W L1 F— _DW C/� lam- EXIST. I i r r BATH EXISTING O BEDROOM OII I I i LA W EXISTING �sT I KITCHENJ�1ViNC F¢�S (VAULT CLG.) L---------- ---J P 'V ON. -_ r-•I r. 7�' -H U __-- o R �y� 32" C.G. I < EXISTING ' o F--I 'C7{ ZTE F`9 D) W ---- EXISTING U� Z ----- LIVING RM. EXISTING BEDROOM x w W BEDROOM ~ � 0 LAV. I /ST OEXIST'*o EXIST. . EXIST. EXIST. EXIST. EXIST ~i Z 00 U� CV A z � a •• N 45,_O.,t (EXIST. CONSTUCTION) (EXIST. CONSTUCTION) O �. Q SCALE 1/4"= F-0" EX15TING FIK5T FLOOD PLAN DWG. NO.: Ex 1 °o� w as�Z a S 0KO�w O0�F r u1�w �N0 12 59'-0"t Z 0 9 K h ' (EXIST. CONSTUCTION) m O O zl z www �w O ���md�� REV.N0. :4 DATE: I -------------------------- I � i � I I ' z � I zd A3 z U EXIST. Z ^ I I w 0 Z Z ----- I ; z U66 Z — I Q rr1 x I UP 0 EXIST. FULL BASEMENT M w Z 0 0 ZZ Z F ~i oL) W w F 7 V 1 Z U F--"1 w ----- � W (1�--'"iiO W EXIST. FULL — U BASEMENT UP x CO U� N �� N 45'-0"t 14'-0"f (EXIST. CONSTUCTION) (EXIST. CONSTUCTION) SCALE : 1/4"= 1'-0" DWG. NO.: EX15T1 NG BASEMENT PLAN _ 011f ~O p 5 w (EXIST. CONSTUCTION) C!�F o a g V1wwp www pw REV. NO. :4 EXIST. BENCH DATE : 11/25/2014 U Z W m H (N A A3 z EXIST. EXIST. DECK - z E� U EXIST. Q Z ^W EXIST. MR. DECK SHOWER - _ EXIST. EXIST. EXIST. - Z U Z �- -Dw� "" _ > as u) dS EXIST. BATH � EXIS N �J' OI I I I v I x ® x W BED 0 O� �EX15TIN I .�. �_ W --- I -G - KITCHEN� �r.l i 5 C: L \ I (VAULT CLG.) I I �• sT C I ----- ) H v • , �------------------- - o �" O \ IN O W+i cFi DN ---- iv Z ��. -__- I c NO o _-__-_ ______ �\ I u N 5'TUB7® W Z 7 Z 33�t ilr�niY� � L"o Q v ai 5' VAN +s. REMODELED X EXISTING IVING RM. ) W BEDROOM I NEW. LAV. i I BATH in 20 1'6"x Z 6'8" rT, 0„4 tV NEW TEMP GIs. y�• a I I i *o F+-� I I EXIST. EXIST. EXIST. EXIST. W M�1 GENERAL NOTES: W o0 1.) CONTRACTOR IS TO VERIFY EXISTING CONDITIONS AND DIMENSIONS A V 1 N IN THE FIELD PRIOR TO THE START OF WORK A3 v j 2.) CONTRACTOR TO REMOVE EXISTING WALLS, DOORS AND WINDOWS ETC AS �^ REQUIRED FOR NEW CONSTRUCTION. 45'-0"1: 14'-O"t C 3.) ALL NEW CONSTRUCTION TO MATCH EXISTING CONSTRUCTION (EXIST. CONSTUCTION) (EXIST. CONSTUCTION) ,Zi •• N IN MATERIAL, DETAIL, AND FINISH. 0 .•-i W � 4.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT _ FIRST FLOOR TO BE 6'-10" ABOVE SUBFLOOR .•-i G� CV L1 5.) ALL WORK SHALL CONFORM TO THE MASSACHUSETTS STATE BUILDING CODE AND ALL OTHER APPLICABLE SCALE LOCAL CODES FIRST F LOOK PLAN 6.) ANY DISCREPANCIES, ERRORS AND/OR OMISSIONS IN THE NOTES, DIMENSIONS, AND/OR DRAWINGS CONTAINED ON THESE DOCUMENTS DWG.NO.: SHALL BE BROUGHT TO THE ATTENTION OF THE DESIGNER PRIOR TO COMMENCEMENT OF CONSTRUCTION. PROCEEDING WITH CONSTRUCTION LEGEND CONSTITUTES ACCEPTANCE OF THESE DOCUMENTS AND ANY DISCREPANCIES, 0 EXI5TING WALL CONSTRUCTION TO REMAIN ERRORS AND/OR OMISSIONS BECOME THE RESPONSIBILITY OF THE BUILDING CONTRACTOR. ® NEW WALL CON5TR ICTION B I C:_:) EXI5TING WALL CONSTRUCTION TO BE REMOVED 7.) CONTRACTOR IS TO DOUBLE ALL JACK & KING STUDS AND PROVIDE SOLID BLOCKING ®HORIZONTAL PLYWOOD SEAMS c I