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0024 OLD SHORE ROAD
C2 Z� alp° slm6e kooc oz '. I a i PROJECT NAME: Cry ADDRESS: 10-�jti PERMIT# 0�1. PERMIT DATE: LARGE ROLLED PLANS ARE Ilya BOX SLOTS Data entered in MAPS program on: 1 I v BY: q/wpfiles/forms/archive �� *.. F 1He r Town ®f Barnstable ermi o tt 4 Expires 6 nronllrs jronr issue tr Regulatory Services Fee + BARNSTABLE, MASS. Thomas F. Geiler, Director �A 1679. lfD MP'!A Building Division 01a Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Officc: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number_.._ 0_3 5 0 ( ropurty Address .___. X Residential Value of Worl.4, .>--D -©z:> I Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address �5 i—::Ve C-7 oy L`D Contractor's Name_ /-I& 42 ®G`1YLZIL. Telephone Number I lome Improvement Contractor License#(if applicable) Construction Supervisor's License # (if applicable) PERMIT ❑Workman's Compensation Insurance � ° Check one: :,SUN _.. 1 200 g. ❑ I am a sole proprietor �1I am the Homeowner 1 have Worker's Compensation Insurance I'OWU OF BARNSTABLE 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/doors/sliders. U-Value s3. 1 (maximum .44) '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 is required. SIGNATURE: i�.'WI FII.B\FORMS\building permit forms\EXPRESS.doc Revised 100609 0! The Commonwealth of Massachusetts Department of Industrial Accidents 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 LeLTibly Name(Business/Organization/Individual): 6700 Address: d2 �/ ®/ i7 City/State/Zip: &, f y l f 0?635- Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. Fj I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the stab-contractors ..2:0 I am a sole prpprietor or parther-' listed on the attached sheet 7. .0 Remodeling ship and have no employees These sub-contractors have 8. 'Q Demolition working for mein any capacity. employees and have workers' 9 Building addition [No workers'-comp.•insurance comp.insurance.* required_] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.[A"',am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself.[No workers' comp. right 6f exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13Other (�/ ) f } ` comp.insurance required.] 6�iLl *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. tContractors 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 employers,they must provide their workers'comp-policy number. lam 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: C2 City/State/Zip: loi/�tr Am, oz,6 .- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure fo secure.coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimiuial penalties of a fine tip 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 certi' der the p ' sand p nalties of perjury that the information provided above is true and correct: Signature: Date: ?/ _ Phone 5 669 V;�q " d V Official use only. Do not write in this area,to be completed by city or fawn official City or Town: Perunit/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#: 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 7 - ofthe foregomg engag in atom en rp�imcluddm�he leg •represehuxtiWk—uf- iiec aseiiempiuyez�r 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( )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 ins-ura-mce 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-•contiactor(s)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"A-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 oitizen is obtaining a license or permit not related to any business or commercial.venture (Le.a dog license or permit to bum leaves etc.)said persort 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: Tho Commonwealth of Massachusetts Department of Industrial Accidents Office of Iavestigatfans 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext-406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Town of Barnstable Regulatory Services R I R WCTL Rr=' Thomas F. Geiler,Director 1dA34. .�$ . �6S9.. Building Division pjfD Tom Pe rry,Building Commissioner www.town.barnstable-ma.us Office: 50 8-862-403 8 Fax: 50 8-790-6230 HOAMOV NER LICENSE EXEMPTION (� n C} Pleate Print DATE: 7 v ` JOB LOCATION: ('� 0 L b S /ze ;2d number / street village (`: "HOMEOWNER': S -e-ye— ,)o Jd SO CJ Y2-g-o yz o 56Dcy- -2 (?v-g O p 2D name Chome phone# work phone# CURRENT MAILING ADDRESS: �• O (e .✓ cityhown statz rep code The Current exemption for"homeowners"was extended to include owner-occupied dwellinks 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 sizuctures accessory to such use and/or farm stntctur6s. 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.."hommwnei"cortifies that he/she understands the Tpwn ofBar s.table,Bui.ldiug Department r1nnimnm inspection procedures and requirements and that he/she will comply with said procedures and r `Sign\rtf1Uf Homcown Approval of Budding 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 F-XENCMON The Code stairs that Any bomeowner performing work for which a building permit is mquired shall be exempt from the provisions of this section(Section 1 D9.1.1 -Licensing'of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall art as supervisor." Many homeowners who use this exemption arc unaware that they are assurrring the rrsponsibilities of a supervisor(see Appendix Q, Rides&Rcgulations'for licensing Construction Supervisan,Section 2.15) This lack of aware =S often results in serious problems,particularly when the homeowner burrs unlicenstd persons. In this case,our Board cannot proceed against the nrnli=scd pcgxrn as it would with a liccnstd supervisor. The homeowner acting as Supervisor is ultimately Tcsponstblc. To ensure that the homeowner is fully aware of his/her respo='bilitir_c,many communities rsquirc,as part of the permit application, that the homtowncr certify that(nedshe understands the responsrbilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may cart t amend and adopt sucb a forrn/certifrcation.for use in your community. Q:forrns:homccxcmpt zrotti Town of Barnstable . Regulatory Services Thomas F. Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to w n.b arnstab 1 e.m a.u s Office: 508-862-4038 Fax: 508-790-6230 Property QwnerM Complete and Sign Tbi Section If UsingABu' der as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work au d by this building permit application for. .(A.ddre of Job) Signature of r Date zf'Prope rty Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION y: ,Map }' Parcel 0 71 Oo 1 Permit# Health Division l� ��� . ;r> E Date Issued 06 0 b.S Conservation Division 23 3 "u" �.t :EFee Tax Collector Y,z�as-'/� Treasurer .� ':.rx ;.:i �O. U Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street Address S 4 S 46 F—F— N X) . Village Owner 1' ,1 y Address 2 °� 0L-4b Telephone .5_0 —0 14 � Permit Request o LS� te-- O Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation 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 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout Cl 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 Cl No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use x. = Proposed Use r-- Lcowwr BUILDER INFORMATION Name re"P� C,-�S Sow Telephone Number S 6 Address P d� wK 89 License# - C&t-)_5� f P A o 16 3 j Home Improvement Contractor# 1 (6 2- -Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO B ^�s� �-� 5 SIGNATURE DATE FOR OFFICIAL USE ONLY e 4 X , 1 PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS'. VILLAGE OWNER f DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE 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 T Office.of Investigations " 600 Washington Street Boston,MA 02111 ',M s�•' www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orpnization/individual): P P<D' 6,f45,E4— W SOcAf. Address:®. a09C City/State/Zip: COY m- d M-1 a?-6 Phone#: Are you an employer? Check the-appropriate box:. Type of project(required):- 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6• New construction ,employees(full and/or part-time).* have hired the sub-contractors 2.U I am a sole proprietor or partner- listed on the attached sheet $ odeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition 5. We are a corporation and its . insurance ❑ o workers co rP comp. officers have exercised their 10.Q Electrical repairs or.additions required.] . . 3.❑ I am a homeowner doing all work' right of exemption per MGL 11.-❑ Plumbing repairs or additions myself.,[No workers' comp. C. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers` comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: `e t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees.*Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration.Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500•.00 and/or one-year imprisonment, as well as.civil penalties in t}ie form of a STOP WORK ORDER and a.fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby a ;fy unde the p ' s and penalties of perjury that the information provided above is true and correct: Signature: Date:' 8 2.L 4S Phone#: -IT-0 " 4 2-6 If N'1-- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 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. « , association, Fgiporatiou or other legal entity,or any two or more An employer is defined as..an indivi¢ual,.;partnership : :.. . . 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. Howover-the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the persons to do maintenance, construction or repair worknn such dwelling house dwelling house of another who employs 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 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 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' lease call the Department at the,number listed below.. Self-insured companies should enter their compensation policy,p 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 pernnt/hcense number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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..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 bum 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 Massachusetts . Department of Industrial.Accidents Office of Investigations f 600 Washingfol�Street Boston,MA 021111. y Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Town of Barnstable ti ° Regulatory Services • BAMSTABLE: r MAss. Thomas F.Geiler,Director 1639... �� '�Eo,r,pr& 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 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: _no -.yA S V"kat ir hJ Estimated Cost D 00 Address of Work: 2-4 6 Ub S {-o tZV_ Owner's Name: ST-T- i Q 0 f✓� Date of Application: ITV 0a I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED PER PENALTIES OF PERJURY I hereby apply for a permit as the age of a owner: 8 2z os [q 627,E Date Contractor Name Registration No. OR Date Owner's Name Q:forms1omeaffidav t , oFF ,,t Town of Barnstable . yo Regulatory Services BARNSTABMTho 1.bsy. mas F.Geiler,Director s ,0�' 'OrF639 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 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize COW-'" &"S M to act on my behalf, in all matters relative to work authorized by this building permit application for: 2-4 o� (Address of Job) S 1Z'L/0 s- - Signature of Owner Date 6 Print Name Q:FORMS:OWNERPERMISSION , — 3D RplB�i G — 2 - � n 1� ? . �' 'v �4• !cf P--` n' '( i ''--4..•. �q�ir;J3%j,M,V�t••` L�, 1 i , I l o _ i�5 tst f - T_-1 s k . , , k .; I 1 y 1 _ 1 ft c f -T T t[ � 44 i k F i 4 i { —t,—f-- �--,--�--2=x-+� _.::__.�•__ - .+��--L_—i--_— _::•�--: ' :—.--i—.—r-^'^'._,.:.._—sue ' s r 9 � Li tt ! jt- 4---- -1-- —� — 4— — + + --» r— — — LIN 9/t -� , Board of Bu�ingRegpulateiensq-`andStandar s One Ashburton Place:- Room 1301 Boston. Mass usetts 02108 Home Improvemen actor Registration Registration: 146276 Type: Individual Expiration: 4/8/2007 CONRAD GEYSER CONRAD GEYSER CT P.O. BOX 89 t COTUIT, MA 02635 �< Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card 41 is 50M-W04G101216 fie �oorvnaoozufea�l/ a�✓�aaoac/ucael�a Q Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Reg istraU146276 One Ashburton Place Rm 1301 Ex a 2007 Boston,Ma.02108 t�ual F~ 1NRAD GEYSE x' — >NRAD GEYSER, r { OLD SHORE RD' )TUIT,MA 02635 Administrator Not valid without sign ture e i Assessor's office (1st floor): �y CF TH E TO Assessor's map and lot number Board of Health (3rd floor): Sewage Permit number .......... NJJ 1............... ..�/.......`../,./,/ � Z BAHd9TSDLE. Engineering Department (3rd floor): o rb 9- House number ............................. 0s, 3 e 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 BARNST B ` E BUILDING INSPECTO-ni APPLICATION FOR PERMIT TO ...... f3eRlTr'�l�C' .....� �r��.......................................................... TYPEOF CONSTRUCTION ... .............................................................................................................. c' c"*..... IV.................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locationf�...... .1It�. ...�.��...,.*.... " �7G.1/..j........................................................................................ ProposedUse ............, r. .................................................................................................................................................... Zoning District ........................................................Fire Districtf .` R..F Name of Owner t �r' 7....,� a './t:�frr............Address ..... �... l..1/G- Name of Builder +wed..�.........,/..�V I.,I...... ..........Address ...................... 6 Name of Architect .��tU .. / 4;..........................................AJ Address ..7, ja�.., / ✓./ .��' ! ... ./. 1... - —.:....... Number of Rooms ....... 1 .................................................Foundation ...F:ir.. ............................................. Exlefor .........6/ ,.�,.,f?`................................................................Roofing ...... . ................................................................ Floors .............��/.. .............................................................Interior ........ Heating .........._... 9 ......A ................................................................ Fireplace ........ /'?f..A............................................................Approximate Cost ..... .. ��`-- . ................................... Area ...? .. /. ��'.. �..... Diagram of_Lot and Building with Dimensions Fee �V f OEr-k ! Ll _r � © d ' OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ()Q) -5 Hp R E R. . -- ~-----I—tT&eb—a ree to_conform to all fF�ie Rules and Re ulations of the Town of Barnstable regarding th e above Y 9 9 9 9 construction. Name Construction Supervisor's License 0.3Q..lly.c6,....... DOERNER, HORST A=035-071 . 001 .1No Permit for ...Add..Deck. .. .. ............. Single Family..Dwell,ing,........ Location ......24...Old...Shore...Road . ................. Cot .................................u... ...t ........................................ Owner ....Horst. Doerner . .............................. Type of Construction ....FY ame......................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ......November. 28.,...19 88 Date of Inspection ....................................19 Date Completed ......................................19 Assessors office (1st floor): THE �/� � ° �� Assessor's map and lot number ��.r ...3. ::..�-�............./" aEPrC �o o�♦ Board of Health`(3rd.floor): �� Sewage Permit number .......:. ; Engineering'Department (3rd floor): a ' .t �t►. moo rb7 9, TAL House number .............................................. � �9 pp v g = = TOWN RE6tILAT10NS Definitive Plan Approved b Planning Board *__ _19_____ APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only. P TOWN .,-OF BARNS 4 eratiaC. mmiffieto>a . BUILDING INS�PE igssd Date APPLICATION FOR PERMIT TO ....... ��V`� T-..... G�X.:...: .................................................. TYPE OF CONSTRUCTION .... .Q.C)............ ...............................:..:.......:...::.......:,......:..................: TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the'following information: Location ..4 Y.....OAL P... ..:7.19.0�4..�U..yi....00 17.. ......................................................................:........... ProposedUse ............D.Ock..................................................................::.....................:............................................... Zoning District :�...............................................:...:...Fire District .. (✓.l..N : -+l.. .... Name of Owner . —7.7....� Cam' � .����'........Address .�k. .....�7T �� /GL....:................. 057e.Name of Builder . . �.`�. ../.f./ !1��. .... .......Address .x.31QU................... .. •Name of Architect ��.. ....>1 �®. .............................Address .•/1 // >1...�....` .7..(C,l�..(/.�` !'-.. ... « . Number of Rooms .......� ..`...............................................Foundation ... - �Ns Exterior .........it/A............................................................:..Roofing ......A 41....................................... ................ Floors :.......... •/7 . ................................................. .......Interior ................... ' ........................... .............`........... . Heating .......././T.!..............................................................Plumbing ... !�/..4!. .......................................................... Fireplace .......d•VII..r............................................................Approximate.Cost ...........•e t-9 0 ,d.............................. .... � Area + .../.. ® r..1...gp..:... Diagram of Lot and Building with Dimensions Fee �4 t. NEW r 0 ff-K , .j OCCUPANCY PERMITS REQUIRED FOR NEW WELLINGS RE k- i("t ere y'�agree To con orm to oil The Rules and Regu lotions of.the Town of Barnstable regarding the above construction. Name Construction Supervisor's License � DOERNER, HORST, ' t - '�No 324.61. Permit for ...Add..Deck............ rt n j r ....iTxgXe...k`s 3 location 24 'Old,.Shore Road . • - Cotuit .r •. .� - ; „ r` �. 4 4 > Owner .. Horst D66hhdf,....... .... .......... ... ..: ..... ..... Type of Construction Frame...... ... .+.. .? .fJ x� ..... .. ........ Plot ........................ `.+...... u ` Permit Granted ...No.T7,ebbe.]:...,2.8.i......19 88 Date of Inspection .... ........ ...19 'Date Comple#ecl `...". !.'""'... ....19 is CA r tj i10 .. y TOWN OF BARNSTABLE BUILDING PERMIT . PARCEL ID 035 07 001 GEOBASE ID 2106 ADDRESS 24 OL10' SHORE ROAD 1 PHONE Coiat2t '/. ZIP — LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CT PERMIT 20053 DESCRIPTION EXTEND DIN-RM.BY 5' X 10'8" PERMIT- TYPE BADDI TITLE BUILDING PERMIT ADDITION CONTRACTORS: PROPERTY OWNER Department of Health, Safet3 ARCHITECTS: and Environmental Services TOTAL FEES: $25.00 BOND $_00 OkI CONSTRUCTION COSTS $5,000.00 434 REBID ADD/ALT/CONV 1 PRIVATE P Q ; * �A�N3TABI.E. s MAS& OWNER COULD, STEVEN C TR i639• ADDRESS P 0 BOX 161 ED COTUIT MA BUIL ION B DATE ISSUED 12/18/1996 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF FOR .OCCU- ELECTRICAL,PLUMBING AND M FOR (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. CH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 2 BOARD OF HEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. (� .' The Town of Barnstable • AEM.E, ; � a ��' Department of Health Safety and Environmental Services 1 Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner PLEASE FORWARD THE ATTACHED PAGE(S) TO: TO: ATTN: FAX NO: FROM: q DATE: / PAGE(S): (EXCLUDING COVER SHEET) TRANSMISSION VERIFICATION REPORT TIME: 01/06/1997 12:34 NAME: BARNSTABLE BLDG DIV FAX 1-508-790-6230 TEL 1-508-790-6227 DATE,TIME 01/06 12: 33 FAX N0. /NAME 94286936 DURATION 00:01: 17 PAGE(S) 02 RESULT OK MODE STANDARD 2 6 6.0 7 STONES J�'E S- ►ate - =" ALK - . PA TH v �� ; ►Q2� O C TE . F I , i HAS E SE /A P�IA � 1 1 l I I / � coTORY / I P l J,LO S 12 MAPLE+.. 5MAPL / ; I . I PI / CONC PAD :T Oq42" LOC ST MAPLE I PIPE Q',` / o HASE \ 4- HEMLOC 2. APLE „ ` / APLE Q 18 MAPLE O / x 172.E -- ` f _ 3 W 7�L0 HYD. - 2 0 / OTVC.GUARD POS PPE _� 10 20 40 FEIT ... ..._._..-+xnz..n'w.t�i� Ti'+�rer`rv°vaeR.'v:w.'atea.v�.�aa n.a.G:�— ._.an�y� •. �.••yy.. r. --------------- --- .......... , G.C- Engineering Dept. (3rd floor) Map 13 Parcel 7� -' d Permit# 2-o® �3 House# ,may 11VA-;6 Date Issued Board of Health(3rd floor)(8:15 9:30/1:00-4:30) Fee a�- ,, Conservation Office (4th floor)(8:30- 9:30/1:00-2:00) I � Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC �TE 1HE roi Definitive Plan Approved b Planning Board 19 ALL D.IN PP Y g �;�ALL�® 9R9 WITH T9 9 TOWN OF BARNSTABI&NDAENTAL AN1® Building Permit Application Project Street Address Village Owner sleJ-0--\ G-"o Address Telephone `(-L� Permit Request �x/c First Floor 5 square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size r{8 Grandfathered ❑Yes ❑No Dwelling Type: Single Family/b,", Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ,Sio 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 No.of Bedrooms: Existing -3 New _ Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: as ❑Oil ❑Electric ❑Other Central Air/6"Yes ❑No Fireplaces: Existing / New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) • ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes .ANo If yes, site plan review# Current Use Proposed Use Builder Information Named Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR i w` DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) �e• FOR OFFICIAL USE ONLY r - - PERMIT NO. -t a DATE ISSUED MAP/PARCEL NO. • J, A ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION �J FRAME INSULATION FIREPLACE =- ELECTRICAL: ROUGH FINAL PLUMBING: 'ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r i q DATE CLOSED OUT ASSOCIATION PLAN NO. Assessor's office(1st Floor):.--. Assessor's map and lot numb ( , �E��O�SYSTEM✓ �a th(3rd floor as THE TO`` Conservation tarn Floor): a INSTALLED IN COM �w ' Board of Heal WITH TITLE c Sewage Permit number s�y nrc �� ENVIRONMENTAL C��.' Engineering Department(3rd floor):' House number a`f d LcQ Sim �ZA TO1VN REC.aj? Definitive Plan Approved by Planning Board 19 }V� APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only ' l TOWN r OF BARNSTABLE ` 'BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION _1Jooc� 19 _ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Proposed Use Zoning District F Fire District �—'✓ T � Name of Owner 3�c ���'� Address Name of Builder Address Name of Architect Address Q� Number of Rooms 1'� s� � - •�` �►^a-� Foundation -Y`�'"— Exterior ! \, Roofing Floors Interior t t.x t - Heating Plumbing Fireplace `�� Approximate Cost 60 ©' 1176 . LIr �— Area Diagram of Lot and Building with Dimensions Fr10� lJ F OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable reg ing the above construction. r Name Construction Si ipervisor's License Lti �773 No �75`1,,2 Permit For Ur41 - Location .V,�1 0-a<She)re )ad' _. r Owner, Ila/7 wU/ - Type of Construction i - Plot Lot - 1 .14 { der:± i •-+. _ . P.er'mit Granted 19 t Date of Inspection. j t Frame 19 f Insulation 19 f = Fireplace - 19 Date Completed f 19 - t l I i r COMMONWEALTH OF MA.SSACHUSETTSz, =E DErARYMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREE't BOSTON, MASSACHUSETTS 02111 lamesGamaoe1 WORKERS' COMPENSATION INSURANCE AFFIDAVIT. (l i cc n scci perm i ttcc) with a principal place of business/residence at: (V� Q'7� (City/$talc/Zip) do hereby certify, under the pains and penalties of per)ury, that: ( ] I am an employer providing the following workcrs' compensation coverage for my employees working on this job. lnci�ranrr �mm�?m. Policy Numbe r.,• ( ] I am a Solt proprietor and have no one working for me._. I am a sole proprietor, gcnerai contractor ord omcowncr `circleone) and have hired the contractors listed below who have the following workers' compensation, nsurancc po iciest Dame of ContractorF "--J- Insurance Company/Police Number Name of Contractor - lnsurancc Company/Policy Number Name of Contractor Insurance Company/Policy Number Q I am a homeowner performing all the work myself. N''OTE: Please be aware that while homcowncrs who employ persons to do maintenance,construction or repair work on a dwelling of not more than three units in which. the homeowner also resides or on the grounds appurtcnant thereto arc not general))' considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)), application by a bomeowner for a IiCCDsc or permit may evidence the legal sutus of an employer undcr the Workers' Compensation Act. I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for.eoverafc verification and that failure to secure coverage a required undcr Sccuon 25A of MGL 152 can lead to the imposition of_mimmaj penalties eonsisong of a fine of up to S1500.00 and/or imprisonment of up to one year and evil penalties in the form of a Stop Work Order and a fine of S100.00 a day against mc. Signed this 1 da of - —v , 19 g day Li nsce/Pcrmincc Licensor/Permittor P�Of�ttE T�i The Town of Barnstable 1 Hc.1lth ""afov and I nvir-olinlental "Sep", ces Building Divisio❑ 367 Main Street,Hyannis MA 02601 Office: 508 790-6227 Ralph Caen Fax: 508 775-3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,reno%ation,repair,modernization,conversion, improvement, removal, demolition, or construction of an addition to arty pre-existing owner occupied building containing at least one but not more than four dwvffling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. T}Pe of Work: 0, Est.Cosh C�;d. E Address of Work: �j( ._ wF CLA 3 S Owmer Name: - P ���v-� p 'A C?l Date of Permit Application: Cal -7 I herd-cerdfv that: Registration is not requirod for the following reason(s): . Work excluded tn,law Job under S 1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING N�TrH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVBIENTT «'ORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARAt.'7Y FUND UNDER MGL c.142A SIGNED UNDER PENALTIES OF PERJURY I hercby apply for a permit as the agent of the owner: Date Contractor name Registration No. OR Date Owner's name y . TOWN OF BARNSTABLE BUILDING DEPARTMENT _ HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION oZ 01 a Number Street Address Section Of Town "HOMEOWNER" Te t/� �p�l� � c) :;�D Name Home Phone Work Phone PRESENT MAILING ADDRESS ,' 011 C)� City/Town State Zip Code The current exemption for "homeowners" was extended to include owner- occupied dwellings of six units or less and to allow such homeowners to engage an 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 to six 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, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. KISC5 Y I / r` 9Y HOME OWNER'S EXEMPTION The code states that: "Any Home permit is required shall be ex mptwfromner ptheerf orming work for which a (Section 109.1. 1 - Licensing of Constructionp upervisarsf this building .., Home Owner engages a person s section Owner shall act as supervisor. " hire to do such work ) ' provided that if that such Home Many Home Owners who use this exemption are unaware that the responsibilities of a supervisor (see A for Licensing Construction Supervisors Appendix they are assuming awareness often results in serious ' Section 2.14' Rules and Regulations -Owner hires unlicensed persons. problems � • This lack of against the unlicensed erson as it wool casePOur1Board1 cannot y when the Home Home Owner acting as supervisor is ultimately hresponsible.licensed supervisor.Pceed The To ensure that the Home Owner is fully aware of his/her many communities require, as permit responsibilities, Owner certify that he/she understandstthehe re responsibilities that tervisoe On the last page of this issue is a form currentlytees se a supervisor. You may care to amend and adopt such a form/certificate by several towns. community. ion for use in your i I 266.07 1 G C�l�- STONE S E PATH � � I la,�l 0� I ` / .� ` '�' O �"� NCO C TE ALK / • R� I P A4E 1 �%aLon R I I 4 ,! r7 A'SL' PfHA , IACQ m SE � . Ico i '-iTORY LO S / o to MAPLE f I I ,�' O (o 5 MAPL / - PI / ONC t 0 ^ ^0 C PAD POST E / PIPE ' 12 LOC ST �MAPL / J I O� HASE' �P HEMLOC 2. " APLE / � p,� APLE 18��MAPLE // 1 72 1 8/ 0- 3 W � �„_ 20' s S 7�L H Y D. R /� / �OTIC.GUARD POS P�vE -A .. _ --- 10 20 40 F -•�.� -_-..___ -�_ __. n.�:i" �..» ;\ •�\\per\./ - ._._. ` _� Z L1y61 �►�G j \ i! J � h . jr TOWN OF BARNSTABLE, MASSACHUSETT tom, e� 'PL • V ���' `� �u�` \pa►�� ASSESSORS MAPS O ^ w I.04 N••p•af 1.0164 69 w fo'� y 10 se • J� 75 ,a►� 4'o a.� T 7 • ` 1 $ 46 y� WAY Q 87 47 AC L SSAC88 . _ ktJ(' gas°8C C O 6 f U / t A ��" ,r 82 • °rf - OAC R • ' .SAC' \'2/4C-S a7Q uoAC (dl I+40 ,�� dew bell ,�•� l�w3�wS Ip r J - pirtHE The Town, of Barnstable HMMSTna[.E, • 9� 16 9. `0�' Department of Health Safety and Environmental Services ArEc '�" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW _ SUPPLEMENT TO PERMIT APPLICATION MGL,c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: (�-- Est.Cost �O Address of Work: L4 O Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name Tltc' Ct1111111011Health of AltrssaC1IU.Vrtts t • .�:� _._, �;..� Department nJludustrial.4cridents OfficeofiIIY9Sffg211ooS `'; 600 11'a.0itlrton Street Boston, Alan. 02111 Workers' Compensation Insurance Affidavit �nitcant tntormation- _ Please PRINT IebJ,y_ , name location Ccity �-� c phone# 4 )Ej'l am a homeowner performing all work myself. I am a sole proprietor and have no one working, to any capacity ._ .,..,,.... .+..:-,.--T� ---f!`:•--••Tn..�..r,...,iTFT-�-R7�F'+'.�'�!p - •----�-----•:-.'^-�T---'.'•N�"^r"""-•.•,.r{,...,..__e.-. I am an emplover providing workers' compensation for my employees working on this job. enmimny name: address: - city: phone 1!• insurance co nolicv# ,- .._. _ .;r. ---�n•..-Y..--•--.n...-..;•--«7^--�•.-........,....... ........,�r,..wo..,.-----fir.-� _ - I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who hay the following workers' compensation polices: comunnv n•tme• •tta(iress• cit phone#• insurance co poliev# •1V:•+L•���o:'e .-T•'t•-r - _ __ �r+r-ab��n4�T'Jr� .:.s,if._ _•_T•`� _ com an-• name: iddress- city phone#• - insurance co policy# -----�----•-c --•---^+--- Tom`--;*�_�-�': _,..- Attach additional sheet iftiecessr.; T.r v.ref:_« ►Fr.'f`;�`�`vi.:�r_c.a,.:3 �£.•�..:�"" �. ,• a..1..3� :Y► te�.. .••Ms..yr Failure to secure coverage as required under Section 25A of A1GL 152 can lead to the imposition of criminal penalties of a tint up to S1SOU.UU and/or one wears' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the ORcc of Investigations of the DIA for coverage verification. 1 do hereht•certifi' cr i"e pains and pcual ' jperjun•tha Ire information provided above is true and corre . Sisnaturc - Date Print name v:e"",) `� �� Phone# official use oniv do not write in this area to be completed by tiny or town ofrtcial r , troy or town: permitflicense# rIBuilding Department OLiccnsing Board check if immediate response is required [3Seleetmen's Office Dlicalth Department contact person: phone#• r(Other information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' ccmtpensation for their employees. As quoted from the "law", an etnplaree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An etnpint•er is defined as an individual, partnership. association, corporation or other legal entity, or any two or more the foregoing engaged in a joint enterprise, and including the le-al 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 haying 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 hot or on the arounds or building appurtenant thereto shall not because of such employment be deemed to be an employer MGL chanter 152 sefion 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 iwho leas 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 1� been presented to tine contracting authority. .- 'is .. .... .- �:•.�.. , Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplyinry company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for tlae permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are requires 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 c the affidavit for you to J-111 out in the event the Office of Investigations has to contact you regarding the applicant. Pie be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned the Department by mail or FAX unless other arrangements have been made. Tile Office of investigations would like to thank you in advance for you cooperation and should you have any question please do not hesitate to give us a call. y.,su.-.,-.._...........�..-.�..v+..r+• . ..—.wws+r•�.•.rn��.�.•.v.r.s..�... ..n"��. _ 9'!!:�w.'�.r'�� _ _ - -r•v�!•� ..•F' 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 fax #: (617) 727-7749 nhone #: (617) 7 -'`100 ext. 406, 409 or 375 I 3 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE GC w JOB LOCATION Number Street address Section of town "HOMEOWNER" c�e,�-� �CD Name Home phone Work phone - - PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official on a form acea-ptable 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 Stat Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands ...the Town of -Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply w' aid pro § and requirements. HOMEOWNER'S SIGNATURE , APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME. OWNER'S EXEMPTION The code state that: "An Home Owner ^r,M y performing work for which a building permit is required shall be exempt from the. provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for .licensing Construction Supervisors, Section 2.15) . This lack of awarene; often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed. Supervisor. The Home "dwner actir as supervisor is ultimately responsible. To ensure that,,the Home Owner is fully aware of his/her responsibilities, mar communities require, as part of the permit application, that the Home Owner 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.