HomeMy WebLinkAbout0287 OCEAN VIEW AVENUE ,/
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Town of Barnstable *Permit# U
Expires 6 months from issue date
X-PRESS Pjj$jWory Services Fee 26 . �w Thomas F.Geller,Director '
JUN 0 7 2006Building Division >�
TOWN OF B �f� �►� Building Commssioner
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 Imprint
Zap/parcel Number 0330 2 Z D D Z
roPeriy Address 287 V C:E A fj Yi E W Q V F- . Ca 7-111r /4.4 4 3-5 ,
Residential Value of Work 4 t--n _ rl Minimum fee of$25.00 for work under$6000.00
)wner's Name&Address c/t,14„� 44 Ar K Y 7
;ontractor's Name Telephone Number
come Improvement Contractor License#(if applicable)
lonstruction Supervisor's License#(if applicable)
]Workman's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department reoulatirns,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home Improvement Contractors License is required.
SIGNATURE: ? -
Q:Forms:expmtrg
Revise071405 '
r The Commonwealth ofMassachusetts
Department oflndusMalAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADDlieant Infarmation •Please Print Legibly
Name.pusiaess/organization/Individual);
Address' 3a 7 0C4EAn9 Y/E AYr,
City/State/Zip: CnF1f►r Ilia PhoneM 50 428- kS3,,,
Are you an employer? Check the•appropriate box; Type of project(required):
1,❑ I am a employer with 4• ❑ I am a general contractor and I
employees(fall 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 a: ❑ Demolition
worldng for me in any capacity. workers' comp.insurance, . 9. ❑ Building addition
[No workers'warp,insurance• ❑ We are a corporation and its 10.0 Electrical repairs or additions
required,] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself;[No workers' comp; c. 152, §1(4),and we have no 12.❑ Roof rep airs
insurance required.] t , employees.[No workers' 13,❑ Other
comp,insurance required.] .
'Any applicmt that checks box#I-must also fill out the section below showing their workers'oompe=t1on•policyinf0rmetion• .
t Romeowom wbo submit this affidavit indicating they sre doing all work a dthen hire outside contractors must submit a new affidavit indicating such.
rContractm 2at-check Ibis box must sttacbed an additional sheet showing'tbe name ofthe subcontractors sad their workers'comp,policy kfor�on.
lam an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insurance CompanyName:
Policy#.or Self-ins,Lie.#; Bxpiration Date:
Job Site Address: City/5tate/Zip':
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secnre•coverage.as required under Section 25A gfMGL c•. 152 can lead to the imposition of criminalpenalties of a
fine uP to$1,540A0 and/or one-year imprisonment, as well as civil penalties in the form oi'a STOP WORK ORDER and a fine
of up to$250.00 a day kgainst 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,
1 d ereby certify under thepains andpenalties ofperjury that the information provided above is true and correct,.
Simature: 1,��.a^ c . ���L�►� Date: 4 Z-7Z0j
Phone#:
Official use only. Do not write in this area,to be completed by city or town oyjiciaL
City or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 3.Building Department, 3.City/Town Clerk Q.Electrical inspector 5,Plumbing Inspector
6, Other
Contact Person: Phone#:
AL t.a.i M wJ V aI.
Massaqhusetts 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 dire; .
express or implied,.cral 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 buildingsiin the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
AdditionAly,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented 01he 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(,)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 Dep artment of Industrial
Accidents far confirmation of insuil ce coverage. Also be sure to sign.aad 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 comp anics•s1au-ld=ter$1eir
self-insurance license number on-to appropriate Eno.
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:M out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pern*/license number which will be used as a reference rsmber. In addition,an applicant
that mist submit multiple permitllicense applications m 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 messed 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, Anew 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 Jnvestigations would hike to thank you in advance fox 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel.'#617-727-4900 ext 406 or I-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 y VYV.Ma-ss.gov/dia
Town of Barnstable
Regulatory Services
+ Thomas F.Geiler,Director
SARNSTABLE,
y MASS. g
059. Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
("HOMEOWN
E: �—�A
LOCATION: .Z o (/GEA n� Y/�1/1f f1 V� �D T!I j I
ll number street village
ER :BHA � /�/`i IKZ K, ,106AJ 54 9- �—ZW,- Z630
name Q home phone# work phone#
RRENT MAILING ADDRESS: I O_ 4 0;[ /d 9
C,o!r411T AAA 02435
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
r uirements.
'gnature- -Romeo
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:forms:homeexempt
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
l �
Map 33 Parcel 2 2 - z Application# ado 5
Health Division
Conservation Division Permit#
Tax Collector Date Issued S ��(2 6 rn
Treasurer Application Fee
Planning Dept. Permit Fee L o�
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 7,91 f7 C I A nl yi E y l- A y F_
Village IJon]i T
Owner Q iw T. AkARY FF _Ri®Rr_,3Ar� Address Czrtfa LIZ4 3v
Telephone S - y'2$ - 2.63 0
Permit Request REPAtIZ. EEC.ISTitJC, I F—CK
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation -4 Z e—M Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family d Two Family ❑ Multi-Family(#units)
Age of Existing Structure (on 1�eAru- Historic House: ❑Yes dNo On Old King's Highway: ❑Yes 21No
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�O Yes ❑No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name. �� 0 ftn -Telephone Number
Address Q. e f` License#
Home Improvement Contractor#
1ik A-, CJ Z-t �Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
`, SIGNATURE DATE e,L
FOR OFFICIAL USE ONLY
4
PERMIT NO.
r
DATE ISSUED
MAP/PARCEL NO.
, I
t r
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
i
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office.of Investigations ' .
d 600 Washington Street
' . Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
kpplicant Information Please Print Legibly
name (Business/Organization/h&vidual): K 1 O Zb A n) J O H 1J T. 4
Address: P. U, 13ox i o 9 3o7 OCAS Jis� VENUE
City/State/Zip: CoTU o T MA o 2 b.35 Pone#: 5o Fs
Lre you an employer? Check the-appropriate box:. Type of project(required):
❑ 1 am a employer with 4. ❑ I am a general contractor and I 6
employees (fu and/or part-time).* have hired the sub-contractors ❑ New construction
ll
❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
Working for mein any capacity. workers' comp. insurance. 9• ❑ Building addition
[No workers' comp. insurance 5. ❑ We.are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or.additions
JC..I am a homeowner doing all work: .. right of exemption per MGL 1.1-❑ Plumbing repairs or additions
myself. o workers' co c. 152, §1(4),and we have no
y [N �• 12.❑ Roof repairs
insurance required.] t employees.[No workers' 13.❑ Oth
er-_QL4,w� iZL�pH°i
comp.insurance required.]
ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: 'K
iomeowners who submit this affidavit indicating they are doing.all work and then hire outside contractors must submit a new affidavit indicating such
Dntractws that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information,
rm an employer that is providing workers compensation insurance for my employees.'Below is the policy and job site
formation.
surance Company Name:
ilicy#or Self-ins. Lie.#: Expiration Date:,
b Site Address: Zits oAt,l YlEv�l Avg City/State/Zip:_ C,o�Ujf /AAA 02/e35
each a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ilure to.secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a
ie up to$1,500,.00 and/or one-year:imprisonment, as well as civil penalties in the form of a STOPVORK ORDER and a fine
up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
to hereby ce W under the pains and penalties ofperjury that the information provided above is true and correct:
G� �II
-mature:. am-_ Dater. 5/h �� L
.one#: 2 S 3 0.
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: a�-�
information and Instructions
dassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
'ursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
:xpress or implied,oral or written."
U employer is defined as-:`.`au individual,,,partnership,:association, corporation or other legal entity,or any two or more
)f the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
-eceiver or trustee of an individual,partnership, association or other legal entity, employing employees. Howev..er.-to
)caner of a dwelling house having not more than three apartments and who resides therein, or.the occupant of the
lwelling house of another who employs persons to do maintenance, construction or repair woik—on such dwelling house
:)r 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
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),addresses) and phone number(s)along with their certificates) 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 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 bt used as a reference number. In addition, an applicant
that must submit multiple permivlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"'the applicant should write"all locations in (city or
town)."A copy of the.affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a.valid affidavit is-on file for:future permits or licenses..A new affidavit must be filled out.each
year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Offuce'of Investigations would lake 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 Massachusetts .
Department of Industrial.Accidents
Office g(uVestigations
600 Washingfon Sheet
-_..____........__.........- _4
h Boston, MA 0211 L.
Tel. #617-727-4900 ext 406 or-1-877-MAS
Fax#617-727-7749
tevised 5-26-05 www,mass.gov/dia
°FINKS Town of Barnstable
Regulat®ry Services
■AWSPABLFs ' Thomas F.Geiler,Director
Mass.
1659.�A`�� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no. /a o 3,5 L-
Date 5 —it- 06
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: R,E,PA-I R I✓X IST i P G DECK Estimated Cost 2
Address of Work: 19 QGF AN Y I E w AVE Cea-U i i
Owner's Name: J o I Q "f AAA IK=Y F �1 io 2D A 1,
Date of Application: 5- l I- 0/a
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
wilding not owner-occupied
LvjOwner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR
Date U Owner's Name
Q:fomislomeaffidav
Town of Barnstable
OFZHE Tp�
Regulatory Services
swuvszAsi.E Thomas F.Geiler,Director
9 MASS..
q, 1659. �0 p Building Division
Tom Perry,Building.Commissioner
-- --- _ ----- - `— 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
,L ) Please Print
T I DATE: 1 lob*
1 A
JOB LOCATION: Z 9 1 0 Gl!A VIEW
IEW Ave . COT U 1 r
number street village
"HOMEOWNER': JOW� I . RI O RDAN �608-
name home phone# work phone#
CURRENT MAILING ADDRESS: O. E o y, in-6
_ rtIrr AAA 02439
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 buildingpermit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
re ' ernents.
Sigma a 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
If 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 personas 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 forrr/certification for use in your community.
Q:forms:homeexempt
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -
Map Parcel _ Permit# Y [ g 3_
Health Division Date Issued 7
Conservation Division - Fee � 00
k"Treasur - •
Planning Dept.
Date Definitive Plan Approved by Planning Board # ti
Historic-OKH Preservation/Hyannis
Project Street Address _ ( E"�( . �� (-=:-
Village C=to\O l
Owner _ AddressG\
Telephone
Permit Request
Square feet: 1st floor-existing 6a(X7) proposer 2nd floor: existing proposed r Total new
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type _
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. -
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age,of Existing Structure Far -_ - Historic House: '❑Yes 2-No On Old King's Highway: ❑Yes &No
Basement Type: ❑Full aCrawl ❑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 Lh<oo Fireplaces: Existing New Existing wood/coal stove: '❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing0 new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded O
Commercial ❑Yes ❑No If yes,site plan review#`
Current Use Proposed,U s e
BUILDER INFORMATION
Name Telephone Number
Address License# �2 D Ln 6 ,"
A � Home Improvement Contractor# f 0�0
Worker's Compensation# -���- 0 -7 5 fs�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE �� cr
FOR OFFICIAL-USE ONLY
PERMIT NO.
DATE ISSUED � t` � r', ., ,1 -*+ - *' .. -� Y a•
r r a }
MAP/PARCEL NO.
31
ADDRESS 's VILLAGE
OWNER ` •"
DATE OF iNSPECTION-
FOUNDATION
FRAME
INSULATION x t r+ '•< I f ,f
FIREPLACE
ELECTRICAL:, ROUGH FINAL
f e '., r•'i •f •
PLUMBING: ROUGH FINAL s • -
GAS: ROUGH FINAL
FINAL BUILDINGS
DATE CLOSED;OUT + .
ASSOCIATIONTLAN NO: .z
t
Assessor's office stFloor): /��Assessor's map and lot n mbar l� v
_,,� — — `�� SEP`PIC SYSTEM MUST
Conservation
`l� INST'ALLED IN COMPLIA
Board of Health(3rd floor. •
Sewage'Permit number — WITH TITLE 5 i DAU3TULL
Engineering Department(3rd floor): ENVIRONMENTAL CODE �o'�se3o`.
House number TOt°V `U'LATI0NS �o MAI►
Definitive Plan Approved by Planning Board - 19
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
.
TYPE OF CONSTRUCTION
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: e/J
Location iE�7 //ri 'LC/s7 12/� GJ �/l P�, i C. o )4m� T
Proposed Use O( eS/alp h G P,
Zoning District ' / Fire District 41 �
/�-�3 /so�
Name of Owner o �iD da`i Address v'Cor `a a,
J 1 ',�'k
Name of Builder 1.1��► litd Address `
Name of Architect Address
Number of Rooms—a Foundation _L 0 AlcA e,I-e Jo�' r s
Exterior l u ���At Roofing s a44
Floors Interior
Heating 410 e Plumbing
Fireplace A( PVT _ Approximate Cost
Area
Diagram of Lot and Building with Dimensions Fee
1 Al2,,LL, u, lbd t'x,'s-�,'n 4 ,,LLc�e c/, ! ,o Sa e-
a 0T"pr11t,l7 r<�ONS/Yr^o➢c Flee" r7rr�e.
Gt-� Ye�f!iG'P f/d i+y � /�tJOD�SLi 'H��BSi
V
aHaas-e bed
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
Name
Construction Supervisor's License v [/� -V0'
RIORDAN, JOHN
3.
35568 REPLACE DECK/REPAIR FOUNDATION
No Permit For
Single Family Dwelling
Location 287 Ocean View Avenue �.
` Cotuit
f
Owner John Riordan
d F
Type of Construction Frame '
Plot Lot _
Permit Granted December 14 ,- 19" 92
Date.of Inspection�'l� 19
Date Completed D1� 19
HOME iMFROVEMENT CONTRACTOR
RegiStieti0ii 104756
Type - 1NDIVIDUAI
EXpiidtiol 07/15/94
Willid(8.0. Wool
CLII�TV.O 15 Hiyiiidl6 A'va.
Cotuit MA 02635
ADMINISTRATOR
)1�SI7T�BLE, i //
r:u�. �.....
0/r \ r a
1639•
367 MAIN STREET
HYANNIS, MASSACHUSETTS 02001
COMMONWEALTH OF MASSACHUSETTS
WETLANDS PROTECTION ACT AND REGULATIONS, G.L. 131 , SEC, 40, 310 CMR 10.00
AND TOWN OF BARNSTABLE ARTICLE XXVII
EMERGENCY CERTIFICATION
FROMs -- Bagnstable Conservation Commission
TO% William Wool John Riordan
(Name of applicant) (Name of property owner)
-P.O. Box 1140 63 Nickerson Rd.
Cotuit, MA 02635 Cotuit, MA 02635
(address) (address)
DATEi _Nov. 25, 1992
LOCATION= 287 Ocean View Ave. Cotuit
FINDINGS:
1. The Barnstable Conservation Commission hereby certifies pursuant to 310 CMR 10.06
that the work described below is necessary for the protection of the health and
safety of the Citizens of the Commonwealth and will be performed by or has been
ordered to be performed by an agency of the Commonwealth or a subdivision thereof.
This Emergency Order in no way circumvents the application process under the State
and Town Wetlands statutes, and requires that the applicant file with the Conserva-
tion Commission for this project at their next regular meeting, or the next meeting
where the project can be scheduled for review,
2. A site inspection was performed on N/A
3. The agency ordering or performing the emergency^work is the Building Dept.
( name of agency) . (Not the Commission unless work
is on land owned or controlled by them, )
4. Describe below, the work which is allowed to proceed under this certification. No
work beyond that necessary to abate the emergency may be so certified.
* Temporary foundation stabilization
* Deck removal
The above work shall be allowed pursuant to a pending filing to address long term
cottage rehabilitation and septic system upgrade,
5. The above described work shall be completed by December 31, 1992 (date) .
Work performed under an Emergency Certification shall ^not exceed 30 days from the
date of the certification unless the Commissioner of DEP so approves.
ISSUED BY: Kendall T. Ayers, Conservation Agent
SIGNATURE: P I G l L
The Commonwealth ofMassachusetts
v 4 -
- Department of Industrial Accidents
oflmrestlgaUVMS
600 Washington Street �-
- Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
nameV V \/ i
imation:
vhone# '
city
❑ I am a homeowner pefforming all work myself.
❑ I am a sole •etor and have no one worlds m anv acity
workers' cessation for my employees working on this job.;>;;
l drag ::::.::::.:....::::::.:.::;.:::.::::::::::::.: :.:::::::.::.:::::;.: ::,:;.;
I am an emp oyez P�.............. .::.�::::....,::.. :.,..... . ... .-.:-:::::........ :.::: ..... ... :.::.::.�.:.....:.:...:...::::_
co anv
name:.
:.:;.:..
dress.. ...
:htm
o icv
am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
Iices:
win workers co t;nsatro p ................ ..: .:. ..
................... ...
the folio g mP .::::::.::::::.:,.::.: :: .;.- ..::.;:::::..:.::
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city'
.........::.:•:.:::%i '�:iiiiiiiiii:+j�i:;iXj!;:;�::ii Fii;6:?�ii:i..:.........:..:::•:::ii:'>:i•;:: :Y+•.. .i.:. .. .. ..... ::•i.....i:iiv:•i�:N•rill:%is`:ii:isti jUii:'vj;if;:v.'•:%;i i:jyy:•i:is%:}$•:j;'..�
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it0
ii f:Y
•o
0.00 and/or
ure Coverage as required under Section 15A of PUS"152 can lead to the hnposition of ainmnal penalties of
Failure to sec ER fine np to S1�0
one yam,imrieomnmt as weft as civil penalties in the form of a srOP WORK ORD and a 8ne of 5100.00 a day against me. I understand that a
copy of this statement may be fozwu,r led to the()rote of Investigations of the Da,for coverage verMcatlon.
I do hereby certify under and penalties of p that the information provided above is trw tend correct
Date
Signature
Print name loll 11101 pill
oincial use only do not write in this area to be completed by city or town official
permit/license# ❑Building Departmeld
city or town• ❑Licensing Board
❑Sdectmen's Otnce
❑checkif immediate response is required ❑Health Department
contact
❑Other
person:
(Mvuad 9/95 PIA)
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 cor—-
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 o:
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver
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 m the grounds c
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 reneF
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h:
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 inzi a*+ce requirements of this chapter have been presented to the conrac=-
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 members along with a certificate of insurance as all affidavits may be
submitted to the Deparanent 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 Departaieat of Industrial Accidents. Should you have any questions regarding the"law"or if y c
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 tt
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 refm=ce number. The affidavits may be retained to
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
011lce of IpY 0929082
600 Washington Street
• Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
The Town of Barnstable
Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
I.
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work- IIV Y7y�C� `7 Estimated Cost
Address of Work: 7 t
Owner's Name:
Date of Application: 7 1
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
rlJob Under$1,000
oBuilding 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 IlVIPRGU w�D UNDER MGOT LEc. 142A.
ACCESS TO THE ARBITRATION PROGRAM OR
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
` - 'F( 6 1
Date Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affidav
_ ;.NONE�IMPROVENENT`CONTRACtOR
Registration 120362 6 �.
�, rR
jYPe 11/3019 ` w
; Exp rat10n 9
8S<k 3
f-,.ayC'G f
ADMINIS-WAT�R„ COtUIT NA 02635 § "„
C SA4Btg
Iot.a Q��
� DB4AA Sdp81tVIS0R LICBXSX
� Bi'�Laate: `;
COXSRRDCt108 wit", 011Is11565
0111511515 'a
,065636 1G.
Rest�1cted to� .
QgtBR D IIBLD
QO BOI 16 02635
NOT TO SCALE
'"OP FAIDN.
FINISH GRADE OVER FTNI.TH GRADE
L • FINISH GRADE /0. FINISH GRAD' OVER DIST. BOX 9. 7• 0VER Tf�ENCHE'S 9. 9
SEPTIC TAI IK /0.3
.e•v.
42 MAX. / 1\ /i/\\\'/: • /. \ ../ \ti/: \\ .., \r
C O A• o....si�'fT: �Q.D�?1':;6 t;�e'er. OD.P'b.o��+.mod• ?. b'• '
'ea
p'•o Qo TOTAL LENGTH OF" TRENCH
OUTLET PIPE L EVE`L
• e 3 ,r d:
:o FOR 2 FT. MIN. 6.25
.e:'•�'0 9. 0� 0. _ - p. 1:+:o{ 'a' :x:: •o•: •v qF' »' ''''"":'-_" ..4
e.. e
CAI' OR PVC TEES �� 8.80 t�,t� ( 50 ��/^ ^ •-• `' —
°:-o b o �D rD' ! 8. r� r'T[J r / \ C� `•J Q C�
7. 6 19
I x 4, Bm
0 Q•'p 0.: va �: B• OF cRUShED STONE
1 ODO C,A L L ON Dis TR.•�"f. UTION BOX
0 �
a.o. 0 e p:
��.,, e. �o EL E✓. /. f-7a.J. G,/PNIa W TAP,.
INSTALL ON LEVEL BASE (Moiv�Tz�/PiN� )YELL /MST-vLGE.a� •
h ° PRECA S T C-?NCRETE
/� C l� c /-� .o ALL OUTLET PIPES TO BE EQUIPPED KITH
a H— 1 V RC I! I- Of 7 CED o; "SPEED LEVELER• BY TUFUTE OR EOUAL INFIL TRA TOR S YS TEM
.`if,•e�?• .c d,:Q•bd a••ba D;:o:a.:erQ..�.o�o. •vr.:p'o•�e•e•• °.i+'
v s.e .•n.•v,. .D••° •0•P. �. p.•p._�.e_.e.Q. .Q•nr0'Ob ,�Q•a' .b�P: � 8 /�EQu/�'�a�
SEP TIC TA NK 7f-fir=l�t�Cf .��'C 7'. GfV
INSTALL ON L :VEL 14A SE NOTE: EXr.A VA TE TO El-FV, 3 6 CA
LONER TO REMOVE ALL I.MPF_RVIOU.'
INflLTRATORS FILTER FABRIC
MATERIAL BENEATIJ T14c- LEACHING .4A? A CRUSHEDSTONE
. REPLACE EXCA VA TED MATERIAL YI71Y +
CL F_AIV, CLA Y FREE SANG
• u^
t'Yf3
GENERA!L A10 TES -
1. ALL ELEVATIONS SHONN ARE BASED ON NGVD
ELEV• 2. ALL PIPES IN TN,E SYST•M "PUST OE CAST 1PON
V E OR S Ci-1EDfJL E' /r s� PVC. C,60�VA T 70AI G T T'
.-,•..s'-`v.....-.,.- r..:Yu-. yF.G- w.. ., - 4 • ..� 1. ^ - •. w._- .--.. - _:.•,T.-rrt-ifs-...•..vim,...♦ .. _. ...
+. VIEW A �,� /�. M'� RI -�Ffs U�of� �er- J •� T,y r� sT t� .tFT- E A'r7 i E•17
Ea a,E °F 31 ' TO SACKF tL L ING PEf-YCCLA T_M RA TE
A•1 A'11po•0 \ 9 4. ANY CHANGES IN THIS PLAN MUST &.'F APP-170KE-0 2 PIN.IYN.
A•q9 4B to B Y TiVE BOARD OF HEAL TH ANC CAPE G ISLANDS HI TNFSSED ay:
SURVr- YIIV(3 CO.. INC.
o G.DUNNING
1h o D. PA TER IAL S AND INS TA/_LA TIC Al SH4L1_ PE IN
COMP)_IAA117E W1 TH THE 5TA TE' SA NI TARY _._.BARNS. B.P.O. OF HEAL TH DA TA
0T A �` COCE - TITLE E V -• ANO /_OCAL APP1__TCAPL E• CA TE.' - NO.V..5,._1992.
287 P.EGU1 I``L RULES AND T_AT O
U ypUSE FREE I. �, , I r I,IUMQEI� Or .9!-.C?ROG?I��S 1
0. 86 A F. 1fOPTH ARROY IS FR01t P_CORO PLANS ANG .0 M ,E- B.
it-\ a IS NOT TO BE USED FOR SOLAR PURPOSES GA PFA GE•DJ.SPOSA L ._..NO
xj 7. f-"L OOD HAZARD .ZONE V�7 TOPSOIL 6 7A IL Y FL 0
��_p GAL .
o �� m �� 8. h'A T•ER SUPPL Y TOhNAJEB S. SUBSOIL SFP TI. C TANK PEG 'D. _�000 GAL .
5000 GALLON •
Z� �cicrrAna� � �, �i' oar��, SEP TANK Pi9O��rf_IED ,100.0_ GAL .
I-_ \ ,�� 1_EA CHI.NG RFGUT.RED ..110 GPD.
i
a�
MEDIUM SAND
AA REG 'D = 1 10 GPD10. 75 SF/GPD = 147 SF,
EflFfir% 8 1 $�' �i d G" ea h ADJ. C�h�uNDN�7TE� AA PROVIDED = 13.5' X 13 ' _ 175 SF..
/ o
I/4PlLTRATQ9 � E'L. 4 G FIELD � ,� ' �'f � '
PROPOSED ELEVA TICAJ 10,9
All EXISTING CONTOUR
6,a �►, 8 8 ;'.."'�'°' ,° h�x� / :�, SEP TIC S YS TEM REPA IR
`1 1� �� O \. �' 50 OBSFR. VA TION PI T
4 '�, i, / 9 � c �.�-,> ❑ DISTRIBUTION Cox /ti oF
}'S\T
s� j' DAVID
/ __ /it/,�•�LTiP4?d/F r C' SANlCES - - - —_—
zeo�5 PREPARED FOR JAN 81993
•��s,x �� �t .1�' o o SEPTIC Ti�NK ,'p,FcrsrEa�� /' I i,,
�%Ar 1'' �JOHN 6 MARY RIORDA , ICI
LOT A (HSE 287) OCEAN VIEW AVENUE
ALL IMPERVIOUS GI9 UNSUITABLE' MATERIAL � /
MI THIN !0 FT. Cis• THE LEACNIN6 FACrLITY IS T �'�•x �� _. r ��•-�•i�•r, .,\,
BE REMOVED A117I REPLACED MITH CLEAN sAnm � �_._� RESERVE Ar?cA ^ � �t �-:'-: , BARNS TABL E — CO.TUI T — MASS.
`7 7 ,.icw. �J yc 4'i�
y�� PT.PF INVF_RT E2 EVA TION
i Psc: x?L`.q DA TE.• Nov
PLOT PLAN /'' , ?/9 92 CAPE <9 ISL APOS ENGT.NEFRIAIG
/ 3re 3 rr• ••f », . ! f♦ � y� 1�'.=' / "fS�C� A L1^1 L /'?/5 tJL O J TEED I ~' FA L +GU7H. R O/�D - SUITE GFSCALE. i =30 2� 2 q 28 A4 SiFEF. 1-j"Ar >„
a .�