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0153 MOORING DRIVE
,� ,� �� � � � a Town of Barnstable Building HAILNSMSM fPost This,Card So=That it is Visible Froin;the Street Approved Plans Must be Retained on Job and this Card-Mu be Kept m$ Posted Until Final`Inspection Has Been Made. �' _ �_ Where a Certificate of Occupancy is Required,such Buildingshall_ of be'Occupied.�until a Final Inspection has been made: 1 Permit Permit No. B-18-3454 Applicant Name: HIGGINS, ROBERTJ Approvals Date Issued: 11/01/2018 Current Use: Structure Permit-Type: Building-Addition/Alteration-Residential Expiration Date: 05/01/2019 Foundation: Location: 153 MOORING DRIVE,COTUIT Map/Lot: 024-120 Zoning District: RF Sheathing: Owner on Record: HIGGINS, ROBERT 1 Contractor Name: Framing: 1 Address: 153 MOORING DR Contractor License: 2 COTUIT, MA 02635 Est..Project Cost: $400.00 Chimney: Description: Replace front door platform and steps made from,concrete block to Permit Fee: $85.00 brick with wood frame and finish on same footprint Fee Paid: $85.00 Insulation: Project Review Req: Date: 11/1/2018 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: Rough Gas: This permit be deemed abandoned and invalid unless the work authorized b this permit i commenced within i m n r' n . p y _ pe i s co a ced t s x o the afte._issua ce All work authorized by this permit shall conform to the approved application and the�approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-Jaws and codes. This permit shall be displayed in a location clearly visible from acce'ss,street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical Service: 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: Rough: 9.i 1.Foundation or Footing `�_ �'•- - �- a 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low„Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. "ry`> ' Final: Work shall not proceed until the Inspector has approved the various stages of construction. 7. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT rs_�—'�T C`� f 0 Application Number........................................,.................. _ • + V a 11A61INSEA1= ]I�ABB. Permit Fee..........0 .......0.........Otber Fee........................ TotalFee Paid................... .............................................. TOWN OF BARNSTABLE �• •• ......._ Permit ..�. . .................Oa....����. t.. BUILDING PERMIT MT................. ....................Parcel.:......!. a......................... APPLICATION Section 1 -Owner's Information and Project Location Village Project Address / 1nQ0/L 10 J& D R. . 6orrU/`! Owners Name R n6e2:T 4t&-6-/fY c, _ 13UILU Owners Legal Address 1 /'�'� / �- D�.' 0C city �L/y�7" state M - Owners Cell# E-mail t-A t &Cs/A_,s -3oo i Q 14oL._,Ca 0nA Section 2-Use of Structure Use Group • ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet esingJe/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory St ucture,. ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ElFamily/Amnesty ❑ Fire Alan. Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Tool ❑ Insulation Other—Specify pf.A-7--F�w` S Section 4 -Work Description L. e rV-r dWIZ P( ,;_rr-0Q.(14 A-Iry D S M icWJ_f wiVcvLere b(o-C K Fr/V t 5lx ©/V 5 r+rn'e T Act nndated_2A201 8 --------------- Application Number.................................................... Section 5—Detail Cost of Proposed Construction -4-6 0._ Square Footage of Project Age of Structure ►_ 3 F 4,t-5 Dig Safe Number i # Of Bedrooms Existing z Total# Of Bedrooms 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist Design Section 6—Project Specifics a ❑ 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 an 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,mdated:2V2018 If I I I ' G I y � tO��RuU�yP� 6 F MVOe1A-)6 6e . C07-ulT tv vPPOwTs Z �1-1 ^" 'S"x coNc, FooTt N6, j� CU2►ve A- 6n-A- <e-7s r-t-Nil i I i r' i3 j3o 12D its L)p lam/ 2.a7- 16 � �a3 a , ' v 0 r k �?Z�srpr'' '� / y / C__J L_J i J/ y. ? 16 w-V Go Q P. r� The Commonwealth of Massachusetts Department of IndustrialAccidenty 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/Organization/Individual): If s e.pLT 6m,tAJ5 Address:' 15-3 moig/ // ,16 6A . City/State/Zip:6wWsd y/+bc.e MA. o z.6 3 5- Phone#: .i O T7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with .1 4. ❑ I am a general contractor and I employees(full.and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for mein any capacity.- employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10.❑Electrical required.] 5. ❑ We are a corporation and its repairs or additions 3.RR I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lic.#: Expiration Date. ' Job Site Address: /53 City/State/Zip:6Wz"-TAB 01, - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify andde/er the pains �and penalties of perjury that the information provided above is true and correct. Signature: �dlrsLi� Date: /D—i 7—l FS Phone#: Official use only. Do not write in this area,to be completed by city or town official t 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#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the ' dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall venter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for firture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachuseth Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AAA 02111 Tel.#617-727-4900 ext 406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.govfdza . Application Number........................................... Section 9—.Construction Supervisor Name Telephone Number Address City State �p 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 . 4 F Name Telephone Number ' Address City State Tip 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 IUC... Signature Date ` Section 11-7-Home Owners License Exemption Home Owners Name: 'u Telephone Number Cell or Work Number. �F 4F $( 7 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I-umderstand the construction inspection procedwes,specific inspections and documentation requiired by 780 CMR and the Town of Barnstable. Signature ::eDate ' --/7 —/9' n .41 A_-PLICANT SIGNATURE Signature Date /0—/7—/8 Print Name Telephone Number —1-76& 7 E-mail permit to: 1 N S 300/ 1CP_0 (._ ,fin Section 12—Department Sign-Offs Health Department ® Zoning Board Cif required) Historic District ❑ Site Plan Review Cif mquired) ❑ Fire Department ❑ Conservation For commercial work,please take your plans directly to the fn a deparbrtent 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 job) Signature of Owner date f i Prat Name a 1 V 1 Last updated:2/92018 essor's r 7- THE Lessor's map and lot numb ...................................... ...... 7f? 0 Sewage Permit number ... ......... . ...................... SMIC MSYM LE. House number .....................1-2S.73................ ........................... ION co WITH TITLE TOWN OF -BARNSrPAvjKqjNTAL CODE AND EGU.LATIONS BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............... . . ......... .I.......**. .*... . .... ........................................................... 0', . ................. TYPE OF CONSTRUCTION ......... .......... . ..... ........................... ...... .. .. Ie71-- P...............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned. hat/rAxopplies for a permit according to the following information: Location . ...... 45;4;?.�.................................................................... V . . ... ..... .. . Proposed Use ot�4v�........................................................................................................................................... Zoning District ... ................................................................Fire District ... . ................................................. . .,/ ................ . ....... ... . ........Address .... Name of Owner . .................................... . ......... ................ ... ... ..... ............... Name of Builder ... . . ............ ........Address ...................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .............. .............. ..............................Foundation ....4wwli� .. ..................................... 0, Exterior A71 .1e.................Roofing ... . .. ... . .......44 2 ................................ 7 . 7 Floors .... ...................................................Interior .... .. . —Heating— .... .A.............................Plumbing .... .. .................. ... ........................................... . If Fireplace ........je&41.........................................................Approximate Cost ........... V........................... .. . Definitive Plan Approved by Planning Board ------19 Area ........ ........ -IS—*' Diagram of Lot and Building with Dimensio/S4 Fee .......... .......... SUBJECT TO APPROVAL OF BOARD OF HEALTH .7/5�77 f A r 30 I hereby agree.,to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..019W... . .. ..... ...... ... a cot ...................... r T'zeo Const. 0 ..... Permit for ........one.:stor.:y..dwellt ng Location ..1Qt..#.9.Q2....... ...............................Cott.L.t................................... Owner ....Theo..QQnst........................................ Type of Construction .........frame...................... - , '-- J D ........................................................................ Plot :.....................j:m.. Lot ................................ Permit Granted ............... .Jul y� 2f.. .:19 79 � r, .T. Date of Inspection ` .19 ' # Date Completed �.....,� .. 19 PERMIT REFUSED................................................................ 19 . '"r •` f' ``, 6 S ............. .... .� .......................................... .... ✓' .�...............•' m . .........................,...fir 2•.).P. -... ff i r 0 .1 f Approve. ......! ... --............................... 19 i f ........... ...... ................................................ .a ............................................................................... Assessor's map and lot number {« $ 7y�_— 7-2 � �� - �pF TH E TOE♦ tl / Q Sewage Permit number ...... .................7.. -c ...................... Z DAWSTA BLE, i House number ........... ....1— Z.......... .............................. 9 NAB& e TOWNe OF - BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ................ z;e;! .............. ........................................................... TYPE OF CONSTRUCTION ......... ......�•-;f(...sr(..... ... ..................................................................... . . � ...............19........ r - TO THE INSPECTOR OF BUILDINGS: The undersigned he'reb�Xi ppJies for a permit according to the following information: Location ....fi' . ;/!f �� ....11.... .a...... ...r .......................:........:... ,,1 . ....................................................................................................................................:...... Proposed Use Zoning District .......................Fire District ..!.,�..., c :r/....................................................... Name of Owner r^ _ = .......4 ...z'.:....�G .......Address ...... 11 Nameof Builder ....... ....................Address ......................:............................................................. Nameof Architect .................. ...............................................Address ............. ...................................................................... Number of Rooms ..............'/.............................................Foundation ...r,:�`?f ......Tl �" , ....�i................................... f.�� �� Roofing I"------ �.f kl G✓ K.t Exterior ......:..•O..............-............... ...,/.......,..:...,....................:.... .,..... ............................... Floors .C�ir��rG ' ..........................................................Interior .... !..`..,,./ .y! ... ..... ..... ................................................. r /} Heating �/�'�"7" .[/ (` .............................Plumbing ..../..�.:/�•� 'c.F t s / 4 Fireplace ........f. '. ..........................................................Approximate Cost ........... Definitive Plan Approved by Planning Board __, � ___ _____19 Area ..........! ..?..................... Diagram of Lot and Building with Dimensions `" Fee .. +~ SUBJECT TO APPROVAL OF BOARD OF HEALTH fj 4 0- /z I hereby 'agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. r . Name � .... ...................... / Theo Coust. A=2ii-120 / . No2-1.5U.8...... Permit for -------------^-------'-----' Location -Iut..#1O2....3§-%. .�p"-.. . . - - .cotjAlt � Type or Cpnmn/p/pn ` . ' Plot � Permit Granted ......./... . ""'= of Inspection" � . PERMIT~ REFUSED � . ' ...................................... lg ' - ^ --- '' ' ' ............. ----' .... ^ - - P��-----'' ..................................... ^-----'--^'~^^^''---^-~^~--'--~~' Approved ................................................ l9 , / --------.-----.---..--..-..---. / -----------^----'-----^---^^' ' | / -�m TOWN OF BARNSTABLE Permit No. --------_ Building Inspector �— Cash OCCUPANCY PERMIT Bond A(z. 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 y- ,��� 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. ...................................................... 19...... _ .........................................................................................................._...._ Building Inspector . 4 0 r i3l �30 �29 i25.6�a ldl L-(nT a o 0 So-o n Z`y/ T c r ? D[.UJV�Za ASY . -,r'sY-0'4n Go�i/STT2 Co�.l�• r lea Yg " Ij Town of Barnstable *Permit it p� Expires 6 months from issue date Regulatory Services --- t anxxsrnsi.E. + ® — MASS, Richard V.Scali,Director 059. .. MAY 3� 2016 Building Division Tom Perry,CBO,Building Commissioner TOWN V 1 U OF BA R N STA B LE 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 f Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �o?y / oZ D Property Address l��2j fyl�> 0TL)!T Mi4— OResidential Value of Work$ 4, FIV, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /5 3 1n oy4-r-1(U& bye C07V 17" -/V1 r+ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable)' Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 2`1 am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value 0,'7 0" (maximum.32)#of windows f #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with.red S and inspections required. Separate Electrical&Fire Permits required. •Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors}License is required. SIGNATURE: - Q:\WPFILES\FORMS\building permit forms\EXPRES .doc Revised 040215 f 27z:e C nrnveakt-f•Afassa&m5dft wr�sft ext cfruxhrsIrid AccdeFap; 600 Masiiureon&met Basfaa,MA 02111 t ww.ma3YgvP1iia Workers' Ccm3pensadzcnl ce fE*Izvit-Snflders�Ccm c&M ' Lans Pimmbess AppUzamd Tidarsnafion Please print •MansenzinRrsnAnr� x7 Address: C am Phaw Are yt'►u an emplayer?Cfieckthe apprapriate bay Type of project{re m etc . L El am a employer wift 4. [J I am a general coati$ctor and I . * Isel�edthe sulr�b2dors b- ❑NeW consfruC6i 11 • emphs�(fa]I s�lor gart time. 2.❑ I am a sale proprietor orpmtaw- li ded ra<the attaiched sheet` 7- ❑R=odelirrg and haVa no employees. �sese sib-com�actars have wading Borme in aay opacity- emplayees and have wotimrs' Bull adr3�iorP IN4 wodmf3'camp.��o Camp_i -suranc 1 5. We are a coaporafifln and its I []ElfEfrica!repairs or adam 3_ officers have exercised duir I am.a faQmeoumer doitrg alE v�o� 11_Q Plnmbingrepaiss or additions MY IN()wwke�M'OMMP- right of emanV&m per +I --(M L_0 Root repairs ;n=rir-e required-]1 c.152,1I(4).and weInveno employe=[1- o t OADEss' 13.0'.Otfie� comp-;,,s�required_jl •�app��t cfie�st�oz�.�elsa fiIlowt�sed�oabeTaarshvs�g�••Tam�cers'c®peesaSa�tpo�gi��saom. - ?�n�oa+aes�rho sabot iris�fidasg;�Snag�3aig,¢1Fs�o�c��dzen�ocaa��amst�uFr�tanewsffia�t;^ate sar�t rConftmCI=s-ffix.fchecicil- 6mtmastwedMxArTiboes1sheetshhazngthga�a of these com2tscmo-g�dst e�hetheiarnott7�nseea[ilie�ha emn9opees.Iftbesn5 r bxm mmployee.%tfieyasstpmsjdeth iT srnd�s'tomp.ga MM3bM I ant ara enig�ic�r t7iatis pra�•�rrg nnriceas'r.Qagperesrr��rt irrstir�ca,�vr az}a aarpl�.�ees �SeIo09 it Ells paIicy anrI jQTa s� . irlforrtzal�� - . Iasnaace Conzpanri"�ame: Paficy 4'or SeH-in.7ie_ a Job Sits Addre= CiiglSta : AfUch s copy of the Workers'compm=fioapoPcy decathlon page(shswing the:policy giber and•-rPirx ion date. Faanre to serum coverage as required under Seim 25A o€MGL m 15-7 can lead to the imposidon of crimraal peQalfses of a fixe up to$L50D OQ ardor one-yearimpdsonmeaf,as weA as avr3 peaaRies is$e fo=of a STOP WORK ORDERznd a tine of up to WO-00 a day against the vioLd=_ 13e advised flimt a copy ofthk stab=ent maybe farwarded to the flffce of Izvesft4=o€the DIA far ffi utmaw coverage s-edffca&n. I da hgraby eff*uardar tkg pats andpm3altra s ofp& dIatthe irafar uc6va prmi&d abmw.&bus acid corm v 0. Phone OfiWQI arse ara�t Da rant mko in area tfr be m agfe a by diy artopru officid City or Taw= Pern*4tdT,�esse� IssMdMg-Uflw3 ty(&=Teone): L Saarfl of$•ealtfa .`r. fat 3.Hosea Clot~.4.ne-:C Insp tnr a'.Plnffibimg Iasperfir b.Cheer C6a#•act Person: Phone�: 6 cans • Information and ins Ma&sachwoft Gc=ral Laws ffiapt=M=CFMM au=pIq=`b prudae wman f�6�eg ea�Ioyee�. tb sib,as=Vkyee is defined as _ ype�soni�the se$vi=of ����y confra�ofbzre, expicss orirapl3ed,oral.orwr ." . Aa.=47bj�r is damned as"aa and rVIdnA pal n�,assocr am,�rporaft�or vi3�et IegaI enemy, any, o or m cm oft fo2egoing=PgeaM a Joint=t=p�aa(ijr, dmg_ffi=Iegal=F=fatjv of a deceased=3p�_or ffc recei4� �of an ,p P•associafon or ofiesIegal=tty,empbYiog=ploy=-5- Howcvezthe owner of a.dwv mg horse hav ngnot more t�tbrec ap�.e�andvvlm resides tllereia,or the occ¢paIIt office- d eIImg Ionse of mot tx who=OpIoys perms to da �,=*=6m cr reps work an sochh dvvelImg b�.se ,herein shaIlnntb=nse of such�ploymentbe dcemedin be an ear<ployen" • or on the gro�ds or bm7dmg . MGL chi §25C(6)also stairs that aevay, F fB or lord HcetlSm ag�cY shall wnhoId$le zasaance or ter I52, m the corumoaIt3i for any renewal of a]cease or pgmit to operate a business or fn construct b�rimgs applic=.twho has n,tprodu d acceptable evidcucc of c6mplTisnmwUk the 4ncaran rE rove rage r__ 25 states-Terf mfhc n.or�y ofitspoTifical=bEvLsians shall A�nna.Ily.MIL cbaPf�r ISZ,§ C(� - Rance wi13i fie i=u-.mr;.. enfnr into any co=ta.ct for the pe�cd ofpubli c PtZ acceptable cvi den ce of comp rCT3ir=CEtS of this have been prese�dtP isle ��a ority. . AgPlic.�nts easation affidavit comple�ly,by�.g�.e boxes�apply,to you On if � Please fa oil ilac�vorkras'comp their ems)of necessarY,SUPPIV s)name{s),address(es)aadPhmmnroaber(s)•alongwitii o fTiaaf3ie insnraace. Linsi Liability CoruparIIes(tLC)orL�LiabrTxtyPm ps.(LU)wino=3ployees mc±Lbers or pa<fn=s�,am not regoaed to cmay comOpensaflm ice' y m•L LC or LLY does have To ees a oIi is Be adYised$attbis�dayitmaybe mbmi�dtothcDepariment of IudnstdBl �- Y ' P c9 ALso be see to and date the afada4it: The affidavit should Aceirl for canf�- i ofinsarance cove-rag-e: s nottheD, admcuf of be re famed to fie cry or town that ti=appfiflan for�.e Pm or license is be mg m eP Irk 1�_rcid Monl3you have any, g fie law or ifyoa are requites to obtam =p saE poficy,please can thdDeparEmentattiiemm�br-rHs ndbelo�: pelf-insured compares should m rtheir sel&fia p hcMsenMbM on the4PPLLIine. City or Town.Of adals f _ Please be sm�that tine a$rdavitis CaMplef$andprfilb ed fly. TheDeparEmentbas pm4ided a sPa� tiie boifam ofthM,affidaTjtfor youth fM oat iathe eveoot the Office ofIavestigaiioas has to yammgm- mgtbe apPbM[Lt Please be sore 7n fll in tine p Iice ose:nmmber which I be as art5=m ntmbCr. won,as apPU•� that must sp=bmt uivbiple p=Miyrcense apPlicafams is any given ycu,need mly sobm..t ant affidavit mfficatng c=t �- a�v and nailer"Job�e Q�'i 'tom aPPhca�shoulder¢aU t06at�ns in (Cy,or Policyl�trna in bm Cif.,r �) ed or mazlo d bvlhD�y or town.maybe provided tb tlm ' town)-"A copy of�c•afHdavMiAhas bcea.officially sbmpJ . appfieant as_proof-tbat a valid affidavit is on f c for me pn=. or fir mw, Ancw aff ffit�b6 fMed.Dirt earJi alicease pe�ifnotre7at�rito any, m= aj ft year where a Imm a oWneg or c>jizen is obtao±g in�p�this affidavit ' Cie_a dog license orpennrtto btuleaves etc.)saidpegsoFn is 11OT The Office oflnve Waadl3einti=kpoamadvanceforyovr cDop=aionandsbovldyonhave;anyT=tLo= . please do nothesbdm to fM us a caIL Thu 1}ep s address,trlepb one and faz nnmbrr: M1 - '• ' • . '� ttF of l�assacll • - . • a �nfi o-� Acci��ts Of a=OfDweguNkti= �F11� • 1977 MA MAC Fag a7-727-TM B.evised�24-07 �c��� • , r snnxsensM ; MAM Town of-Barnstable , RFD MAr� Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601` t www.town.barnstable.mims Office: 508-862-4038 , '.`'• .. Y ; Fax: 508-790-6230 •t Property OV- Mer Must Complete and Sign This Section If Using A Builder 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 If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. , QAWPHLESTORMS\building permit forms\FMRESS.doc Revised 040215 • Town of Barnstable Regulatory Services oFTKE �1• Richard V.Scali,Director Building Division Tom Perry,Building Commissioner 1639. �� 200 Main Street, Hyannis,MA 02601 Ado www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 6--- -7> JOB LOCATION: / 3 /)1 0O re-1/lJ U WTy/T number street village "HOMEOWNER": /fp ebe2'T AC,&io_jS _,019 4zO• 9a1), name home phone# work phone# CURRENT MAILING ADDRESS:fir/r3 M0(J&jA )6- b2-, L oTU!T /� 4- OZ(O��" city/town state . zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildin&permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Si re of Homeowner tl Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0.Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 040215 Town of Barnstable *Permit Expires' 6 mo rom rssue date �T Regulatory Services Fees 63 16;q Richard V.Scali,Director . �6 Building Division � , • Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imptznt Map/parcel Number •E Property Address 15 3 1n,9V uA)& byL, em—V l l /Vwl- CQ3"Residential jValue of Work$ Minimum fee of$35.00 for work under$6000.00 Vr [Owner's Name&Address ����LT �6(s�-fllJ S ��3 /Yll�e.9/L«'l�G 1�►� Cf�tt�t i VYJ�+ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance 0� Check one: SS PER; ❑�I a sole propriet� 1VU 2 1015 NJt I the.Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNS TAB Insurance Company Name LE. Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(ch ce k boj) ❑ Re-roof(Hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side (Replacement Windows/doors/sliders.U-Value U e 30 (maximum.32)#of windows 2 #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. , Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SI�XTiJRE, Q:\WPFILES\FORMS\building permit forms\EXPRE doc Revised 040215 . 27ie Comnrortivea7tk of1Vassachusetts B'eparhmeut of Industrial Accidents u - - O3ffw.e of Imvstigatiens b00 Washingion Street Boston,VA 02111 • furvwu rrras�gr»��diri '"Torkers' Compensation Insurance Affidavit. Builder/( antractarsJEIectr cians/Plumbers Applicant Infannation Please Print Legib IVar�e�Bu�smessr�Drgan.QatiaafInciEvidual}. l�®�j�✓2-% /�"t C�'C-1/tUS. . �C t3rf tatel ip 27b 6 7- /'l'Jy4 ®-2(a 3 S ' Phase �;D$ (o �,O f -7 Are you an employer?Check the apprnpriate box: Type of project(required). _ I. I am a general contractor and I El am a employer v`rith. ❑ (S. ❑Netiv construction employees(full amdlor part-time)-* have hired.the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7_ ❑Remodeling ship and have no l •tees. These sub-contractors have �P $_ El Demolition working for me in any capacity. employees and lin a wodmrs' [No workers'comp.insurance comp.insurance.# 9_ ❑Building addition r d] $- ❑ We are a corporation and its 10:,El Electrical repairs or additions Q3 am a homeoumer doing all urork officers haveexercised their 11❑Plumbing repairs or additions ' right of exemption per MGL �'�€�o y��� �F- 12.[:1 Rnafrepairs . insurance required.]c c.152, §1(4�and we have na to o workers' 13.❑Other employees-� _ camp.insurance required_] #Any a"Bcs dhat cbedrsbos 91 must also fill a=the section below shavring iheirwoikeie compeasatinnpoTcyinfoamadmL Homeowners who submit this affidavit indiXatmg they are doing all wool sad gum him Outside contractors mnst submit a new affidavit indicating sigh tC'antractos fut.beck This boa must attached as additional sheet showing the nme of the sub-cemttactm and state whether or not those emities have employees.Ifthesub-contnutaeshave employees,theynnurpmvad�e their workers'comp.palicg number I ain an erspIoyer thatis prm din workers'congwisadian insurance for my enrpluf�es. Betoov is tl�apolicy arrf jab srte ircforraativn Insurance Company Name: Policy 4 or Self--ins.Lic.4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c_ 1572 can lead to the imposition of criminal penshies of a fine up to$1,500aOD andror one-year imprisonment,as well as civil penalties.in the form of a STOP WORK ORDER and a fine of up to WO-00 a day against the-violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the D7A for insurance coverage verification. Ido here-by cexlify under the pains andpenahYes ofprt Fury that the informativlr pros i&dd abmv is true grid correct �---- v Pht one " �f to+'3 L-0- -7 Offrciai use only. Do not wrke in this area,to be campieted by c4 ortoorn ofidat ' City or Town: PertmtUcense# Issuing Authority*(idrde one): 1.Board of Health 2.Building Department 3.QtylTown Clerk 4.Electrical Inspector S.Plumbing Inspector d.Other Contact Person: Phone#: Information and Mstr-ct ons Massachusetts Geheral Laws chapter 152 requires all employers to provide workers'compensation for their employees!, A, p: uan •LD this fie,an.amplayee is defined as."_.every personin the service of another under aay contract ofhiru, express or implied,oral or writ" An Moyer is defined as"an individual,partnemsh�p,association,corporation or other legal entity,or any two or more of the foregoing engaged in a Joint enterprise,and including isle legal representatives of a deceased employer,or the raceiver or trustee of an individual,pmtnmsbip,association or other legal entity,employing employees. However the owner of a dwelling house havingnot more than three apartments and who resides therein,or the occupant of the - dwPTTing house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtmzatthereb shall not becanse,of such employment be deemed to be an employer." 2vfGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct bnZdings in the commonwealth for=Y applicant who has not produced acceptable evidence of compliance'ePn the h mrance_coverage reuir qed." Additionally,MGL chapter 152, §25C(7)states"Neither the-cor m aawealth nor gay of its political subdivisions shall Miter into any contract for the perfcimance ofpublic womlc until acceptable evidence of compliance vlith the 7n sui ar+ce._ requirements of this chapter have Been presented to the confiacting authmity_" equm em Applicants Please fill out the woi3mrs'compensation affidavit completely,by checking the boxes that apply to your situation and,if e certfic s of ntracto s nam s address es and one nuinber(s)along with their ate() ecess 1 sab-co ) ,e(), ( ) Ph n �y�supply � _ ems ' s LP with no employees other than the or Limited Lich �Paris ) emp Y insurance. Limited Liability Companies(LLC) � mP � are not r to workers' compensation insurance. If an LLC or LLP does have members or partners, equaed cant' employees, a policy is required. Be advised that this aidayit may be submitted to the Department of Industrial Accidents for conlamaiion of insorance coverage. Also be sure to sign and date the affidavit The affidavit should , be retinned to-at-,city or town that time 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 regnh'ed to obtain a workers' compensation policy,please call the Department at the number listed below. Se lf-mSUjed companies should eater their self-iasu"a„ce license number on the appropriate line. City or Town Officials t Please be sine 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 peffiit/licrose number vihich will be used as a reference number. In addition,an applicant that must submit multiple pennit/license applitadans in any given year,need only submit one affidavit indicating current n olicy ins =ation(if necessary)and under"Job Site Address"the applicznt shOUM write"all mutations in (may or town)-"A copy of time affidavit that has been officially stamped or mam$ed by the city or town m a y be provided to the applicant as proof that a valid affidavit is on file for futn-e permits or licenses. Anew affidavit must be fiIle:d out each year.Where a home owner or citizen is obtaining a license or permit not rslai:ed to any business or commercial venture (i e. a dog license or permit to bum leaves etc.)said person is NOT rDgaked 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 nunber: CGm MoUWealtir of Massachuszttls ' DepaztEaent of I u5tial Accidents . (�it�e a��1.'fFe�f?g�fioaa� � ashintGu Bost MA EI�IIF Tf,-I.4 617 727-4900 Qxt 4-06 or 197TMASSAFE Fax 9 617-727-774-9 Revised 4-24-07 mas,5-gov/dia o� r r • BARNSr" MASS.16 Town of Barnstable iOTFp�► , Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ' t~4 _ .{ Office: 508-862-4038 - t : +•* Fax: .5.08-790-6230 rtY Prop a Owner Must ' Complete and Sign This Section. If Using A Builder h 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 If Property Owner is.applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit forms\EXPRESS.doo Revised 040215 Town of Barnstable Regulatory Services r tKE fi Richard V. Scali,Director Building Division :(BARNSTABM Tom Perry,Building Commissioner MAM 1 200 Main Street, Hyannis,MA 02601 m ATFD www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION �! Please Print DATE JOB-LOCATION: /5 3 /y70 0 P./AJ& i co-ru rr number street village °°HOMEO'JJNERT:eA 6CA T 14166*US 074ZO,3001 5'-W (6 4Ss 5Uc7 C-�L) name home phone# work phone# . CURRENT MAILING ADDRESS: /5 Gz)Tu'T iy1. 02.63 S city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures.•A person.who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signattre.ofHomeowne f Approval of Building Official' Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\JVPFILES\FORMS\building permit forms\E)TRESS.doc Revised 040215