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HomeMy WebLinkAbout0592 POPONESSETT ROAD ���3 �a d��ss�e7T �c{ .� _ I �. -� t BARNSTAIIIX i ASS. 039. Town of Barnstable ' Regulatory Services Richard V.Scali,Director - Building Division Thomas.Perry,CBO Building Commissioner ' 200 Main Street, Hyannis,MA 02601 www.town.bamstablema.us Office: 508-862-4038 a Fax: 508-790-6230 t Property Owner Must Complete and Sign.This Section If Using A Builder L-A,oo (E , as Owner.of the subject property_ hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for.Po(00y) ' F_5'_t Q&J'�CL( ddress of Job) Signature of Owner " Ate )L)S-ax)h: L)o( ` r f Print Name s If Property Owner is applying for permit,please.complete the Homeowners License Exemption Form on the reverse side. ' . . QAWPFILESTORWbuilding permit focros\EXPRESS.doc Revised M15 Town of Barnstable Regulatory Services 04Wyr Richard V.Scali,Director Building Division sASNsrABIX ' Tom Perry,Building Commissioner KAM ► � 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: cityhown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official . Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see 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`,WPFILES\FORMS\building permit forms\EXPRESS.doe Revised 040215 VE Town of Barnstable *Permit h/1,�Wdowki VVV Fapues 6 months from issue date Regulatory Services Fee KAS&16.19. Richard V.Sca14 Director_,; 5 S . Building Division PRESS, s Tom Perry,CBO,Building Commissioner 200 Main Street;Hyannis,MA 0260� SEP 2 5 2015 www.town.barnstable.ma us AWN office: 508-862-4038 OF-` BARVS- VEO-6230 EXPRESS PEinUT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �//(� �'os75o-'S .; ❑Residential Value of Work$ /y, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address � �. � Z l 7 r'(i"c1-2.,.,;� .Sj• ..r�j��✓ �-,fzl-�r % � - Contractor's Name � --1y� dsP Telephone Number .7 V`/ Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) Do Cam, co to ❑Workman's Compensation Insurance Check e: na sole proprietor ' ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Reques eck box) a , e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken,to f�c3 Z�o_S ❑Re-roof(hurricane,nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 1 ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is W quired. 4 ' SIGNATURE: QAWPFILES uilding permit forms RESS.doc Revised 040 =� - - _ �a'a 7f:1•' v:a37- - •�JiiTa i a_l:t �•:Sl'rim-�!J_-a= �y.J1TS'!] �Y± �wi 1.1.Ii 3 \= i'R a3 ilia i-.Na\ .ai w- 171r!• Jf i ii f - alai\ _.wfal iY:�w\rl.wtrU a rlf3r\'► p.p f9►.fi6 g777 r1 i. .7\3ai7mi • [ou�a aaun - .n - •.n:r a.►r• >. ■ if- .. - .:.nn.a._r.■ a. u ■ .•3 mow..r ■:n+:•c _.nu n.- ■i• �. �• ..1.r\w■_ •.�t.,. \Ja ti iT_�ii[tn`._•:I •i1 a � � _ _,tar � .i: - .:• - — nun•- ..\•-. ■ ii.:. .i+ _:.r..a �. l rl .n,.• - - w.•,.es.-.•.nr.,. arw�..r.r� • _..■r•♦ � i:. � - .,a ra" •r s.r rr w _.• in' .\az ••au p.v:.nr. ■• !:. .• - -,[a c aar_ ■. - z.. .u r .• -- ..■ ter:.-- �•...� mr� -oc.0 dC: T rn � .• ur ..■.... • •\none ..:u� o •: ... t• 1 1 E71 ..u.ar-:....ra_�. �I w. _r a•:. n i.- ■•,.n �' 1)t �' /'$: - ■r •a a• _ 1 i't _ •: .•s..n.� is- • •.:7w� :..• - ir.:! t u. .xran�n a.r a- n: •�. n ir,- is•- • __ dr . ]a . • ii/rrub __ r la^�, . i q i - Ja.' .ra a = - a r .- »a r _ ' +� � vim«• ' - - Jej-.�,r _�-_...--). u. - haw .r = w,r..vr�. - .rn• J. 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Commissioner 03/01/2 16 - � ..,, f r ,tom C��ie�par�vrrw�rzuiea�a�CacfucaeL�a_. Office of CUnsnmer-Affairs-"vsiness Regulation UxME 552 IMPROVEMENT CONTR.?CTORgistretion: 02 Type: piration: -:12119%20;15 Individual L JOHN MAHON,EY Unrestricted Buildings of any use group which contain-less than 35;000 cubic feet(991m3 enclosed space. )of Failure to possess a.current edition of the Massachusetts State Building Code is cause for revocation of.this license. For DPS Licensing information visit: www•Mass.Gov/pp5 ' or registrat'"vabd for 1 before the ex 1 ndlvidul li ' Office P ration-date. ffouni�return se only, of Consumer Affairs and tb- ;• ' 10 Pack Plaza-Suite Business Boston 5f 70 Regulation MA 02116 Not valid wit 1 out ' TOWN,OF BARNSTABLE BUILDING PERMIT APPLICATION Map 0C ' T Parcel d ` '4' OF BAR STABLE Application #Of U 1 407W� Health Division Date Issued 2t)I N Conservation Division Application Fel '�Y 'V Planning Dept. Permit Fee Lio' Date Definitive Plan Approved by Planning Board tk/11_'7 Historic - OKH _ Preservation / Hyannis Project Street Address ter'—�,�?06 re,�> e CIS z7J'`_gZ Village 00 „' 7-- Owner ,5'os o n4 - Z q J--'o o' Address Telephone Permit Request rr- f( lzaf-nr. 017 7/� �1—�✓ �/>Y �4/'�Y r�v� %/l��.r�� cSrh�r//,�v- �ci��A�pS Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation D 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 ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 4 Name .12 6/1 iA4/, Telephone Number _2V c9y Address _4 �s�_ ��- �r License# 4-3 6 a �a Home Improvement Contractor# f'7,9-v_, Email�j�ho o-) go4on s1 Workers Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ia,x �;: �2 -Jo/G/OD%1 S2� 5�-� Y u!� +� S�✓ f' d!J f SIGNATURE - DATE >/14 �,/ ti 4 FOR OFFICIAL USE ONLY f APPLICATION# t t DATE ISSUED i MAP I PARCEL NO. c ,r ADDRESS VILLAGE OWNER DATE OF INSPECTION: a FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH ` FINAL } i PLUMBING: ROUGH FINAL GAS: ROUGH FINAL - FINAL BUILDING f- . DATE CLOSED OUT F ASSOCIATION PLAN NO. _ s _ t � - The Commonwealth oaf Miassachusefts . Departatmt of 1ou k3rrhd Accidents - t3p, Ce triestigotie7ns 600 Wayhi gtom Street Boston,,MA 02111 l rvnhv.inass.gznAdia " Workers, Compensationluaumuce Aftdavit:Buildersl�Cants-actorslElectricians/Plumbers Apylkant Information Please Print Legibly Name(lu� onlFildividuao: n /,a ZW /Li4tj AA&e-ss-- 1 '-)— ti 1�.-: City/Statr/Zip: . i Are you an employer, Check-the appropriate b= - Type of: o'ect .r 4_ I s�a ctmtractor and I 3'l3e �' J �•�'�'�`� 1_❑ I am a employer with ❑ 15_ ❑New c=s&actim ogees{full and/orpartAime)* have an th a subad shoe ors �_ am a sole proprietor or partner- listed on the attached sheep +. ❑Remodeling ship:mid haves no employees These sub coatractors have S. 0 Demolitioa working for me in any capacity employees and have workers' g_ ❑Building addition [To,workers' comp_insurance comp-rnsurauoe_I regnsred-] . 5_❑ We are a corporatiorrand its 10-❑Electrical repairs or additions 3_❑ 1 am a homeowner doing all work officers have exercised their 11_0 Plumbing repairs or additions myself [No workers'come- right of exemption per MCL 110 Roof insuranceregniitd_]1 e_152,§1(#),and we ham no repairs employees_[Ncyworkeas' 13_❑(Other comp_insurance required-] *Azry appl>mat that ched:s boa 91 mmst also fill ott the sectioa below showing Their hers'eompensatiampolicy iufar� T Homeowners orho snbidt this s$idsvi t in is g tLey are drying s11 srotY and Siea hilt=outside coutractoxs must subnnt a new affidavit mrricshn sarh- tractors that rhx-k this b re most anaclrad an additional sheet showing the name of the sob-cnnh-actuxs and state whether ornot those mdi have employees- If the saVcont mdors hale etmployues,they must ptuvide their workers'comp policy number I am an emp r that isgrm idirrg workers'conWensaddn irm4rance far nzy amp7nyeas Hdow is Sse policy artd,}ab site informat4am like Company Dame: Policy#or Self ins_Uc-4-: ExpirationDate: y Job Site Address: t-4 2� City1'Stafi-- t : Attachh a copy of the workers'compensa6m policy dedaration page(shoving the policy.number and expiration date). Failure to secure coverage as regaired under Sectioia 25A of MUL c, 152 can lead to the imposition ofcriminal penalties of a fine up to$1,50D.OG and/or one yearin3prisovment,as well as ciial penalties iri the foam of a STOP WORK ORDER and a fine of up to S250-00 a day against the violater_ Be sdvised that a copy of this statement maybe forwarded to the Office of En-estigatio€is of the DIA for insurance covmge wi fication_ Ida hembyce&jyzznd--rt'hopirihsaiidpa Mies vfpedwytlsatehe ara omtttfcun rm2darl ab t e is.bzra and correct Si>mature: Bate: 7/ a use arrt ;fa ba con CYfv or Town:: PeriuibUcense# Issuing Authority(circle one): 1.Board.ofEedlth- 2.Budding Depailment 3.CiWrown Clerk 4.Electrical luspector S.Plumbingluspector 6.Other Corsstsct Person: Phone#: 6 F Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied., oral or written.,, An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or IocaI licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonivcalth-,`-or ally 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 pub inc work until acceptable evidence of compliance writh 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-contractor(s)name(s),addresses)and phone number(s)along with their certificatc-(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no en-,Ployees 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 Depai-bj,-ent of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit 'l'lre affidavit should be returned to the city or town that the application for the permit or license is being requested.,not the Dcparttnent 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. Sell insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations ILI {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 homeowner 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 It-ayes 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 Comraanwtalth of Massachusetts Depaiinent of Industrial Accidmfs Q#xee of kvestigatians WO Washingtoa Street Briton,ILIA 02111 TeL A 617-727-4900 Qxt 406 or 1-977-MASWE Revised 4-24-07 Fax#61 `27--r/49 viNm mass-gavldz'a Massachusetts -Department'of'Public Safety Board of.Building Regulations and Standards Construction Supervisor License: CS-000506 V .` JOHN J MAHONFV 12 SPENSER DR HALIFAX MA 02338 Ezpir�t 6�� Commissioner•, 03%01 1 � ,}�. vlze cpanzir�ioascueal�o�C%aGctaaa�c�eG� - Otlice of Consumer Affairs-&-Business.Regulation OME IMPROVEMENT CONTRACTOR': egistration =158202 Type ` xpiration 12/19/20.15 Individual `! JOHN MAHONEY i t� I r t . JOHN MAHONEY } 1,2 SPENSER DR. HALIFAX, MA 02338 Uuder4cretary .� Massachusetts _.Department of'Public Safety . Board of.Bpilding Regulations and Standards Construction Supervisor. License: CS-000506 JOHN J MAHONF ' / 12 SPENSER DR HALIFAX MA 02338 I y EXptr tton Commissioner, 03/0112 96 'befo he expirat" d teh-If found or in �re vi ul use only turn t)...- re. r r Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite.5170 Boston,MA 02116 - I• Not valid without s� _._ � E rqf, Town of Barnstable Regulatory Services �anxty SS- Richard V.Scali,Director $A i639. ♦0 r61;9.c a 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 I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized bythis building permit application for. J po-,OC-M� r (Address of Job) "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner ,.% ignature of Applican S c3� 2A VO l Print Name Pint Name �-3 2� r ,. Date - Y Q:FORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services �N10 rOicy� Richard V.Scali,Director , Building Division Mnss. aaaNSTn LK " Tom Berry,Building Commissioner 3.639- $ 200 Main Street, Hyannis,MA 02601 prEO �a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village- -HOMEOWNER": name home phone# work phone# CURRENT 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 homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned`.`homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a persou(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,RuIes&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 b several towns. You may care t amend and adopt such a o ce Y Y p f rm/ rttfication for use in your community. QAWPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 061313 Coro ' a .ram N� . P �o �I 7D Y Al'e cJ vef s7 e"" I r rile Ir7 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ct Map Parcel �P;PQion # Health Division Date Issued ` Z' 3 Conservation Division Application Fee d Planning Dept. Permit Fee 4 1 Z- Zb Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address �✓ Village Oaf" Owner = �,:Z ya.`Y Address ;(—9�-2 Telephone 4 el !R 5-i e Permit Request r-e *'qo C//-r 0 9/ Cob 74­0 r•ov4L ,V/a 67.-_dr , :,m2 eyeJ �✓r?�rJ�h l Gj��s�---e 4,* 4_0 -e Ake �y ,el 0 /v .� P,/� �•-•`d dam' r�®vim 0/1�� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay c --i Project Valuation nilc> Construction Type , % Lot Size Grandfathered: ❑Yes ❑ No If yes, attach:supportingxiocentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑des ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other � rrs Basement Finished Area (sq.ft.) Basement Unfinished Area (sgft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number 7i �� a2� Sim Address !�� � s License # "y 6, Home Improvement Contractor# ,�� gf,p� mal ° Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C'v 4,c3,7!�4 SIGNATURE /L DATE ? 1. FOR OFFICIAL USE ONLY APPLICATION# =DATE ISSUED MAP/PARCEL NO. .. f , Y ADDRESS VILLAGE OWNER t DATE OF INSPECTION: q FQUNDATION; u ; " 'FRAME . INSULATION._ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL Iw FINAL BUILDING f DATE-CLOSED OUT f ASSOCIATION PLAN NO. =-++ 4 The Commonwealth ofMassachusetfs - Departrnent of Industrial Accidents Office of Investigations vi 600 Washington Street Boston,MA 02111 www.mass.gov/dia _ Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businessiorgmizdtion/IndividuaI): / y `/o 1 Address: Z Z C P-ex-1 City/State/Zip: r Phone#: 7 / Are you an employer?Check the appropriate box: • Type of project(required): 4. I am a general contractor and I � p J ( �� � 1.❑ Wama mployer with ❑ 6. ❑New constructionees(full and/or part-time).* have hired the sub-contractors 2. I am a sQle proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees 'These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp,instuance.t r��] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ � P myself-[No workers' comp. right of exemption per MGL 12.❑Roof repairs hmuance required.]t c.152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arr doing all work and then hire outside contractors must submit s new affidavit indicating such $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they mast provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: _ /o O n y,P s 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$1,50-0.00 and/or one-year imprisonment;as.well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pains and penalties o perjury that the information provided above is true and correet Signature: Date: f/ Phone �- -?�/ -� Sk 9 a C:7— i9j)7cial use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# 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. Pursuantto this statute,an employee is defined as"_..every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as."an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,-or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for 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' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for 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 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 Cor o awealth of Massachuscits Department of Industrial Accidents Gfftce of luvestigatfons 600 Washington Street Boston,MA 02111 Tel.#617�-727-4904 W 406 or 1-377 MASSAFE Fax#617-727-7749 www.massgov �a EVE . Town of Barnstable i F Regulatory Services g Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Stteet Hyannis,MA 02601 www.town.barnsfable.maus - Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and, Sign This Section If UsjUg A Builder I, as Owner of the subject property hereby authorize to act on ay bebA in aA matters relative to work authorized by this buRding pettait Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools 1 are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner ' Signature of Applicant . �4uotz Print Natne Print Name Date SIO OIS 6=12 Town of Barnstable Regulatory Services Thomas F.Geiler,Director X� 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 DATE: JOB LOCATION: number street YMage .•fiOMBOWNER": name home phone# r work phone CURRENT MA=G ADDRESS: city/town State rip 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 Persons)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,afta:ched or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatrun of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger w11I 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 thai 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 responsffiIe. 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 rare t amend and adopt such a form/certification for use in your community: C.\Usas\deoonik\AppData\I.ocd M=soft\Windows\Temporary Int met Ffles\Contmt0uflook\QRE6ZUBN\ID2RESS.doe Revised 053012 ✓!ze �o.w.,w.�..�ealt/ /�aaa�z�lr aetia License or registration —1 Office of Consumer Affairs&c Business Regulation g'stration valid individul use only M; HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to. . 'Registration1,5$202 Type: Office of Consumer Affairs and Business.Regulation :1:2 Expiration: . /1912013 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 _ . JOF-W MAHONEY,1 E } a 12 SPENSER DR = t s: HALIFAX,MA 02338 - t. 'h Undersecretary Not valid wit o t signs Moassachusetts_pe and, g.uildin Partrneryt of 9.Re Public Safety mstr 9ulations and St r u�tir,n Sd cn.• andaed I License: CS rsoF,. s -000506• ' JOHNJ 12 �ENSE�R - HALIFAX $233$1 S I_ Commissioner 11 1n�.. Expiration 03/01/2014 o ,. TOWN OF PARNErl ,� EL: 2�8 Z013 19 8 { EL:24.q' f IS rr _ , 5J' EL: E EL 24.1' PERVIOU5 L ' FOUNDATION Krrcrr 1 AGE - 6, b� BEOPOO EXISTIN `0. 15' DWELLING - P R .. \ 10' . r-L EL 24.2 —SCHE IC:DEsIGH `EL}:24.81 EL:24 q' ARCHI-TECH ASSQIIATES>INC. — E6 4.1' 5 3' - - Et 25b' L:26. ................ _. _._..----___..._ _ - --g - ---- -- - ....._.. ........._......_... li be rvcYYl i i ruo ri - �P � I Since 1955Ilk GACOWESTERN T - , Insulation•Certificate �y Date installation completed ';--3 Building address p ,n RuA- r5e--Y— City/State/Zip ,,��'�'`� Application Contractor(company name) Co C.,kon, e2 Address -a City/State/Zip P Phone Areaslnsulated Exterior stud wall Average thickness R=Value Ceiling Average thickness °®' R-Value, Roof deck Average thickness .R-Value Crawl space/basement Average thickness """ R-Value Additional areas insulated I(print name) as an independent contractor,certify,that,the GacoWestern insulation installed on this.project was applied in accordance with the GacoWest&n recommendations and specifications as stated on the product data sheet and the,GacoWesternApplication Specifications in the amount as indicated on this certification. `' /�✓.r.�-�.� .. (signed) Date �4— GamWestern Aged R-Value{hart Dimensional Lumber 1n 235. 3" 1 411 5- 6° '7n an GacoGreen 4.2 8 12 16 20 24 28 32 36 14 "22 29 Gacofirestop 3.7 7 11 15 19� 22 26 30 33 13 20 21 183M 6.4 1 13 20 27 33 40 41 53 60 ;23 37 48 18V 6.1 13 20 27 34 40 47 54 1 60 24 37 49 193 6.2 13 20 21 34 41 47. 54 61 24 31 49 "Based in initial measured H-values. - GacoWa11 oam ... , SPRAY POLYURETHANE FOAM INSULATION www.gacowall oam.com,I S,00.456.4226 . 1 :P ' '.: ' .L:: li. N Waffoam System 1 4 . Gaco Western WallFoam 183M is an HFC-blown(zero ozone-depleting)liquid spray sgstemthit cures to a medium-density rigid polyurethane insulation material.Gaco WallFoam 183M contains polyols derived-from naturally renewable oils,post-consumerrecycled plastics,and pre-consumer recycled materials.Gaco WallFoam 103M does not contain CFCs, . H CFC's or other gases harmful to the environment.This system can be sprayed on clean,dry substrates down to 35°F(2°C).Gaco Wallfoam 183M is a class I fire rated foam that meets the requirements of ICC-E5 AC377 Acceptance Criteria for Foam Plastic insulation.Gaco WaliFoaml83M meets the requirements of AC377 Appendix X for use in attic and crawl spaces without an additional ignition barrier. ., 1 1' 1• 1 1 •1 1 1 , 1 1 1, 1 : ,. PROPERTY TEST TEMPERATURE ASTH TEST UNIT VALUE Nominal Density(Sprayed In Place) 17°F(15^q D 1622 03 Ihs/ftj 18>2 2 R-Value see Note Below 75°F(13,90C) `•ftt °F/Btu R 64 at 1 { ftt Btu R 33 h , 3at35 Compressive Strength(Parallel to RIse) 77°F(25°q D 1621 04a PSi; 32 Tensile Strength ' 71°F(25°O D 1623 psi 64 Water Absorption 77°F(25°C) ° % 0 45 Water VaporTransmisslon: 17°F(25"C) E 96 05 , perm m 112 Dlinenslonal 3fab111ty(7 Days) 158°F(l0°q/95%RH D 2126 99 %linear change L 6% W 5%�T 3% 4o°F to 2004. 40°[to 93°[) Recommended Servue Temperature Range r - Closed(ell Content 11°F(25°O b D 6226 05 Air Permeance:@ 75Pa(Inhltrahon/EzhltraLOn) 77°F(25°O E 283 04 L/s/Iits 0 000/0 000(@ i thickness) SYSTEM THICKNESS FLAME SPREAD INDEX SMOKE DEVELOPED INDEX WellFoam163M 4"(10 2 400 Appendix t t t l 1 1 LOCATION FOAM THICKNESS Walls Up#0 9 \413 cm) UpOhl Val to 11 (27 94cm) t i 1 1 T 1 1 1 1 1 •,FMI R MI11 1 1 11 1 1 1 1 1 1 1 PROPERTY TEST TEMPERATURE ASTH TEST UNIT VALUE Viscosity:.'A°Component 77°F(25°q < D 2196 68 cps 180+20 11 v 750+50 Viscosity B ComponentWd Speafic Gravity 'A'Component 17°F(25°C) D 163810 S.G. 1`22 Speafic Gravity "B Component 1,20 Weight/Gallon A Component 71°F(i5°C) Ibs/gal 10,2 Weight/Gallon `11 Component 10,0 Mixing Ratio A & B 'Component 71°F`(Z5°C} By voluma 11' ftabihty Wheh Stored at 50°F to 10?F Months "A"(Dmponent 1 year (1.0°C (omponent 6.months EQUIPMENT „f l I, 1 SETTING VALUE CHARACTERISTIC VALUE P.re Heat Iso(A) 115°F 130°F(461°[ 54 4°C) Cream Time 0 1 sec Pre Heat Pply(B) 115°F 130°F(461°C 54 4°O Rise Time 3 5 sec Hose Heat 115°F 130°F(461°C 54 4'O. Tack'Free Time Recommended Spray Pressure 800 l OOO psT(dynamlc) Cure:Tlme A.hours The luramration herein is believed to be reliable but unknown risks may be present,ALLWARRAKIIES OFANY KIND,WRESSED OR IMPLIED,INCLUDING WARRANTIES OF FITNESS FOR A PARTICULAR PURPOSE AND THAT GOODS ARE OF MERCHANTABLE QUALITY,ARE SPECIFICALLY DISCLAIMED.See Gate Western farift moon Concerning its hired wamnty and its amDalbiRg. - - 5, ax-f1,� 6�k'P.,xp '9�y�-`.L £L��� ��$�,�r.`i.���-,)i� ��y.'ryYcT{'f- �� rl-•f�'-. �� .. z�-r t s °SxY�`i�°';�ap�'z'" a 4rit�s��3°r, - "+-�is'�ia'r#':w&l��'��">,:.. x «?�«�.-�' ,1i.41+..,•v_+�..y'if=- -c X"� .._ - f _ ^ icc � e 1, o WE"R -- -; .. :.: 'YW w ► C bWoAl, NAS1 ra mN'b -r-,;. '�,. '� ENERGY SfM a✓ i :.;^�- W .�dhudri, b..bo.4 a :1 � . � tT �nG.<vW bujn flomloilb lavuuli.v SaLabv. .+ i .vfcra*:.r•°' b�,,� ,zri�t�,#Yz {�3� �1 •'.�.�'is^y'eQ��� rs��(�.��-' � - .. 1 .r . ,ins yL�r�.?�` �ta�� �r.,.,..� g_y�F�r '('`�' ins"�` ��a-..,�° •�'�''���,�,.{,:,Y»-c_y"�'0._.�'` _ _ ,. .. � Y 51 X+ ProductA6WFf75Y 02/12 Toll-Free: ww 877-699-4226 w .gaco.com " 't t . �YA , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V�' Parcel Application # aoove -17 Health Division Date Issued `� t , Conservation Division '' a ' '' Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis r Project Street Address Village Owner S,044 YYe_ Address Telephone ?-2 (" DDa® Permit_:Requesti� d� I� ✓��.� n� e/Z '%D' 'l�za•< Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay r ffro�ectValuation��1 hom•®0 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 19*7`4 Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes No Basement Type: IS Full a Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ Z. new Half: existing / new Number of Bedrooms: .3 existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: 0 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:14 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ - .KL4 JN f Commercial ❑Yes ® No If yes, site plan review# p ? - Current Use Proposed Use NO APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ��S*-oYNe �-4uo; Telephone Number Jo Yaa, .6 Address T�L �d�°kes�er' License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 7-/I.73lt j�fYddS7��,e r7F%�a✓�! SIGNATURE DATE Z FOR OFFICIAL USE ONLY APPLICATION# NATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER 4F� DATE OF INSPECTION: FOUNDATION FRAME S4 (o,� w ,,t �d 5� 0 3 [c7�2h1ck, INSULATION F>✓ i�3 [O R � FIREPL ACE k' .ELECTRICAL: ROUGH FINAL e - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL a FINAL BUILDING I �[ DATE CLOSED OUT ASSOCIATION'PLAN NO. — _� r Town of Barnstable Regulatory Services hotnas F. Geiler,Dixector. KA , I6y9 ���� Building Division ro Mk Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyaor s,MA- 02601 www.to-wn.barnstable.ma.us _ Fax: 508-790-6230 Offices 508-862-4038 PLAN REVIEW 007 Map/Parcel: 00 Owner: oZ P Gjft__� Builder: .7iytE- Pzo�ect Address —e- The following iten-Is were noted on reviewing: dE 7"oloWe— ffc 5 G—c(�oJc how�O7 ? p r 5 T! SE Reviewed by: - O 7 /0 C . pate• i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111: www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): S L' m 0-6 & o/ , Address: _-2 D an E >✓ City/State/Zip:O'� Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions / myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance requited.] *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 employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for any 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 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 ce ify under the pains a penalties of perjury that the information provided above is true and correct. Signature: I M Date: 2 Z� , Phone#: 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth not 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-contractor(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"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 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 .600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE. AND TWO-FAMILY DETACHED RESIDENTIAL•CONSTR•UCTION (780 CMR 61.00) Applicant Naive: � �r�i-e �.c vo j Site Address: fF.2- e 7 7 R print Town: h5 Applicant Phone: Applicant Signature: Date of Application: NEW CONSTRUCTION: choose ONE of the followin two—options) 780 CI!'xR.TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE-AND TWO-FAMEEX BUILDINGS hCUMtUM Ceiling or Slab aOption I: Basement Fenestration exposed Wall Floor. Perimeter AFUE U-factor floors R-Value R-Value wall R=Value HSPF SE R.Value R Value and Depth National Appliancc Energy 3 5 R 3 8 R-19 R=19 R-10 R-10) Consu-Yati°n Act(NAECA) 4 ft. 1997 as ammdcd,minimums grmattr as iLpplicabir Note: This form is not required if you choose either of the two versions of REScheck as listed below. 0 Option 2: RES check Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 R:EScheck--Web which can be accessed at http'.//www.cnerQYcodes.goy/rescheck/ ADAITIO1VS-OR`AY,T)�RA;TXONS.TO EX[STl'N*' R`5 FEARS OLD* *]Buildings under 5 years old must use option#1 or#2 in New Construction section above. Complete the following formula to determine the %o of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b_a) SF 100 x - _ % of glazing (b) Glazing area equals SF' a_ If glazingis<40%.uSe the chart beloW. If glazing is> 40 % rgceed to"SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS hUNIMUM Fenestration Ceiling and Slab Perimetc -Wall � Floor Basement Wall� R_Value Exposed floors U-factor R-Value R-Value R-value R-Value and Depth .39 , R-37 a R-13 • R-19 R-10 R-10; 4 fee a R-30 ceiling insulation may be used in place of R-37 if the,insulation achieves the full R-value over the entire ceiling area(i.e.not compressed over exterior walls, and including an access openings). ' SUNROOM—An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form found in Appendix 120.P Town of Barnstable R6gulato>ry Services Thomas F. Geiler;Director RAM Building Division pTfDy a 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 DATE: JOB LOCATION: number street village dad "HOMEOWNER!':"HOMEOWNER': �pS"IIre_ 1,9pei e .4ap'124^dG phone name rn� home phone# workP CURRENT MAILING ADDRESS: j7 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 spection procedures and requirements and that he/she will comply with said procedures and in rejuirements. ignature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see 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. N Q:\WPFILES\FORMS\homeexempt.DOC ` j Town of Barnstable Regulatory Services r HARNSTADLE, • Thomas F. Geiler,Director 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 wilder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aut orized this building permit application for. (Address of Job) Signature of er Date Print Name If Property� Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. Q:FORMS:OWN ERPERMISSION PROJECT NAM O E. ADDRESS PERMIT4:2?0l0 0 PERMIT DATE: //�l D M/P: � LARGE ROLLED PLANS ARE IN* BOX SLOT � y ]data entered in MAPS.program on: o BY: a/.wnfiles/archive, - .. Town of Barnstable BARNSTABLE. Regulatory Services - MASS. 'Ol t639 s?0� Building Division FO MAC 200 Main Street,Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection Gy Location Permit Number Z i 0 Owner Builder One notice to remain on job site, one notice on file in Building Department. The fol wing items need correcting: Ile Ze7�A: -Cf'7) 7 ado D. ' o �Please call: 508-862-49.AWor re-inspection. Inspected by '/G% /el-t.,�-� Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION AP 07 Parcel Permit# h Division `�. u y �e�sPp�,� Date Issued Health l Conservation Division F� p 6f4d Y7 6�/S &O Application Fee Tax Collector Permit Fee Treasurer Planning Dept. oll We Date Definitive Pla �Aed by Planni g Poard Historic-OKH Preservation/Hyannis Project Street Address Village Owner Address �9 Telephone Permit Request 1,& 0 JJJi M-e-C A.) . // 7 �Scc.r► _ern rich a t' Square feet: 1st floor:existing AWf proposed 2nd floor:existing _ proposed �_ Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type .SG�3�c�i�hki—) Lot Size �A=) Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes O No On Old King's Highway: ❑Yes 0 Basement Type: ❑Full &yawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) �1/& Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new D Half:existing new O Number of Bedrooms: oxisting--4._ new 0 Total Room Count(not including baths):existing new First Floor Room Count 9 Heat Type and Fuel: ❑Gas [1Oil ❑Electric ❑Other Central Air: ❑Yes 211(o Fireplaces: Existing _� New D Existing wood/coal stove: ❑Yes Cho Detached garage:❑existing ❑new size Pool:❑existing ❑new size Bam:❑existing ❑new size Attached garage: existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes wl If yes,site plan review# -- - Current-Use C _ /Proposed Use BUILDER INFORMATION Name SALE h0 C. Telephone Number Address Ig on ��c�c.,, 57 License#=1&,e 'r,"M Ed Ut 10&1d = &Z's—h elY. Ala , eU5 D Home Improvement Contractor# 4Uz 76T Worker's Compensa on# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE `� DATES' �OFTHE rot TOWN OF.BARNSTABLE OFFICE OF 31esa9TaSL s BOARD OF HEALTH rasa ao 1639' `em 367 MAIN STREET. �0 MAY k. HYANNIS, MASS.02601 December 7, 199.8 Susanne Lavoie Lo 592 Popponesset Island Road Cotuit, MA 02635 RE: Cesspools On Your Property Dear Ms. Lavoie: The Board of Health unanimously voted to grant you permission to maintain the existing cesspools on your property located at 592 Popponesset Island Road, Cotuit, Massachusetts. This permission is granted with the following condition: • The septic system shall be upgraded to conform to the State Environmental Code, Title V and to all of the Town of Barnstable Health Regulations prior to obtaining a building permit to alter, renovate, or construct an addition to your dwelling. This condition does not apply to any building permit to repair the roof. The existing cesspools are located in close proximity to wetlands. One cesspool is only 23 feet from the top of a coastal bank which is subject to tidal action and only 53 feet away from the edge of a vegetated wetland. An inspection conducted by Bruce McCallister revealed that the septic system"failed." It is the opinion of this Board that the septic system should be upgraded or replaced at the time of a building permit due to its proximity to Shoestring Bay. Sincerely yours, Susan G. Ras�.S. Chairman Board of Health Town of Barnstable SGR/bcs poppones Town of Barnstable �FfHE Regulatory Services &MMSPABM ; Thomas F.Geiler,Director .NAM z639. �.� Building Division L prFD M°r a 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 DATE: JOB LOCATION: J�(� � �n E 5�?L/ number �/ ,/ street village "HOMEOWNER": S C�SSG�L�12C 1,-41016 Sy?_ -L/ZQ-06 S 5 66F —7Z.3•-4. name home phone# work phone# CURRENT MAILING ADDRESS: J `Z city/town state zip coSe 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 re ements. ignature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see 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 1 - r MIl_ l 1 J ox ram./� t�,-/�/ •,�!//�i%�t�. � �' _ %�//>/\/i FRONT ELEVATION . ............... ... . SCALE 3/16" _ w T� ---- - ----- - � I I FOUNDATION PLAN ` o SCALE 3/16" \l. i ==---- ---=-- --- I - -- - I 1- 2X12@16"O.C. I I I I 2X12@16"O.C. FRAME PLAN SCALE 3/16"= 1'-0" 13'_B" ........................... .....-- ................ _ ASPHALT SHINGLES -- - '� ASPHALTSHINGLES Ll I 5 t... LEFT ELEVATION RI ................._ _.................................................................. GHT ELEVATION SCALE3/161t_ 1, 0,t .... ........................ ...... .. . ..... ...... SCALE 3/16 1'-0" I I I I I I • I I I I I -- � /�J��r/li��r ram'�..%y Jrr T;is%r � r�i•,7� _ __ I HiiN_ I" I. 1 r q h, r• � � sy I . " - � F_ � f IIII �� �o � � I • .y. III - ` PLAN - _ SCALE:3/16"= 1'-0" �r IT-6" —_ I � I.. _........................._ -- — — ---- -- ----- ; d I \ I { -- --.-- I I ROOF PLAN SCALE 3/16 — 1,_ a // 4o+ _;rtiF ti'.i\iON 1F0I LIM ,ORM':.:, SIINI� �! .•,a..s. .ir•:. r aches ;State ailidin Co e< . SDI .` ., en echo The Massachusetts State Building Code(780 CAM) includes provisions to ensure that houses and house additions meet energy efficiency standards. This supplemental .CONSUMER INFORMATION FORM is to be filed as part of the building permit application when a builder/contractor or homeowner, constructinglinstalling a house addition with very large percentage of glass to opaque wall, seeks to utilize a special energy conservation exemption option for "sunroom" additions jo,an existing house (780 CMR; Appendix J, Section J1.123.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom"of any size, configuration,orientation, form of construction or percent glazing,but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a"sunroom"addition. The connection of "sunroom" structures to residential buildings may create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In the selection and construction/installation of"sunrooms", included below is a non-required, open-ended list of product and design donsiderations that .a homeowner may wish to consider before actually constructing/installing a"sunroom".It is recommended that consumers carefully review these options with their designer, builder, or contractor, in order to minimize potential-.energy consumption and/or house discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired are important considerations. PRODUCT AND DESIGN CONSIDERATIONS RELATED TO"SUNROOMS" • Solar Orientation and Natural Shading • Type of Glazing • Insulating value • Solar heat gain • Frame materials • Glazing to frame sealing and gasketing materials/.seal durability and/or weather tightness of the sunroom • Adequate ventilation Operable windows and fans • Applied Shading Systems • Insulation level in floors,walls,and ceilings • Possible Sunroom isolation from the main house via.a wall and/or door or slider • Heating and Cooling Methods: EMciency,Zoning and Controls Homeowner Acknowledgment The Massachusetts State Building Code, Section J1.1.23.1,..requires that the actual property owner(not the owner's agent or representative)acknowledge receipt of this CONSUMER INFORMATION FORM prior to issuance of a Building Permit for a project that includes "sunroom" additions to an existing residential building. In accordance with this requirement, the undersigned hereby acknowledges that she/he has read information in this document concerning sunroom comfort and energy conservation. ' IC rJ ;�4 ^- ignature of A d' Owner Date Print Name dre s o ermitted r 'ec, SUS- �L20 - O 8 S-�— Owner Address(if different than project location) Owner's telephone number L `G , °����G f GG�' P�,,,r�s r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# Health Division s -5 `�)5 IS— 3 Bl-,01 1_5 Date Issued 5 DS Conservation Division g /�/©-� ® `�VD/71&1-*v Fee 40wo ,ilG y.®0 hev S/A/� Tax Collector olk.t",*Iya ��•�� �a� Treasurer Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street Address ! _ _ Village Owner JO5&ig1)6: L,&oDCr Address 5 l_2 Poh6n£SSFZ Uv Telephone 5 D6—`2!O—D(0..37 5— Permit Request ' ' aL � Square feet: 1st floor: existing proposed ao 2nd floor: existing proposed Total new O�d ��p-D� Valuation f^fDe Zoning District Flood Plain Groundwater Overlay Construction Type tA46 CL A/L4 6-t-t-4 5 Lot Size 3t, S Grandfathered: ❑Yes XNo If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic Houser ❑Yes )"o On Old King's Highway: ❑Yes 'QNo Basement Type: AlFull F Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 6 Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing 3 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 XNo Detached garage:0 existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:Xexisting ❑new size Shed: ❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes �' No �.If;yes, site plan.review Current Use Proposed Use BUILDER INFORMATION f177 Name ,e,iq k//4 Telephone Number PLZ -Ogy� Address t'ZD 4i s ek4 A( 5 License# Home Improvement Contractor# 16f ew Worker's Compensation# ALL CONSTRUCTION DE?�(SRESUP3NG FROM THIS PROJECT WILL BE TAKEN TO Trk SIGNATURE DATE ✓F ---; FOR OFFICIAL USE ONLY v ti• ' PERMIT NO. ; ',DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: -� FOUNDATION cm � r FRAME ?C d'''Tr'J fy N INSULATION FIREPLACE " ELECTRICAL: ROUGH FINAL k PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 8 ��I��L� Lo-7 DATE CLOSED 8UT ASSOCIATIOMPLAN NO. J ' � .3 The Commonwealth of Massachusetts Department of Industrial Accidents A Office.of Investigations d 600 Washington Street Boston,MA 02111 `,M 5�•`' www mas&gov/dia , + Workers' Compensation Insurance Affidavit:`Builders/Contractors/Electiicians/Plunnbers ,�ylicant Information Please Print Leeibly Name (Business/Organization/Individual): S .y 5 a_ A'/I LxJ 4 1� Address: `lZ- Pe-2 d oU,'55F_'_f7` Rd City/State/Zip: 0-10 117 0,2 3 S Phone#: S 0 F- YZ, B—® 6 5 5- 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 Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ n g ship and have no employees These sub-contractors have 8: ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or.additions required.] 3. 1 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.E Roof repairs insurance required.] t t employees. [No workers' 13.[:] Other comp. insurance required.] *Any applicant that checks box#1 must`also fill out the section below showing their workers'compensation policy information.' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors 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 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby:Z:der the pains andpenafties of perjury that the information provid above is true and correct Si afore: Date: ®O.S^ Phone#: Oj icial 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." dual,,partnership,association,corporation or other legal entity,or any two or more An employer is defined aS"an?n 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 havingnot more than three apartments and who resides therein, or the occupant of the dwelling house r repair work-on such dwe g dwelling house of another who employs persons to do maintenance construction o ep dwe g . be deemed to be an employer. or on the grounds or building appurtenant thereto shall not because of such employment 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-contractor(s)name(s), address(es)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 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 fin in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in . (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for;future permits orlicenses..A new affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts . Department of Industrial.Accidents ,r ..Office of Investigations 600 Washingion Street Boston,MA 02111. Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia ��Her Town of Barnstalble Regulatory Services annNsrnai.E, ; Thomas F.Geiler,Director 0.19. a g `0� Buildin 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: Estimated Cost � 6, 0© Q �v ®1) ��� — Address of Work: 5 �� � � Yl) �SS' � /�� ��./ Owner's Name: a Er 4- &A-V-0 Z6- Date of Application: 6La 7� 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: 37 Date Contractor Name Registration No. O0' -R' A I Date Owner's Name Q:famis:hameaffidav f INSTALL ON COMPACTEP LEVEL,13ASE Cntuit NOTE: EXCAVATE TO-C=STRATUM IN C / REMOVE ALL =A=&=13= IMPERVIOUS M) .` t ...r!nl�, o `.` � :. . ' �' ' - WITHIN 5'OF THE SAS.:REPLACE WITH C .. `CMR 15.255 .CLAY-FREE SAND (31Q ] b ` t .` ••'�_' �L � ` e� :}fir/ �� � j "' a , - ., t ._`•' '-EDGE �L'� ��1, �•�, -, , fi= ,-% ., d. a� 4 :,• �� , F o ` . '`• � 404O�.C-PM1•w Dlw�le��RIM}we0a:0Ci ,_•y M.,SeY:1:11A>.I IM M1�fGfM .. - •' . GENERAL NOTES: 1.ELEVATIONS SHOWN ARE BASED ON ASSUMED • 2. ALL PIPES IN THE SYSTEM,MUST BE CAST IRON �•••.48-' TOP '' -ORSCHEDULE 40 PVC. 3. HEALTH AGENT/CAPE & ISLANDS ENGINEERING --••�-` .4• ��F MUST BE NOTIFIED WHEN CONSTRUCTION IS e •: COMPLETE PRIOR TO BACKFILLING.. N . •`"•.,�• 4.ANY CHANGES IN THIS PLAN MUST BE APPROVED BY CAPE & ISLANDS ENGINEERING AND THE BOARD ••. OF HEALTH. 26• •.• 5. MATERIALS AND INSTALLATION SHALL BE IN . FILL EXISTIl�IG CESSPOOLS ( •. STATE SANITARY CODE NOTE: 7�-- TH THE l v�- �t - .•• COMPLIANCE WI • ES AND AND LOCAL A PPLICABLE.RUL �' . w. [TITLE V]A INS..ALLER SgALZ ft• REGULATIONS.NS. t, Tl�'Y CAPE c 0 1�0 HSE-NO •.•• 6. NORTH ARROW IS FROM RECORD PL ANS AND IS T j NOT INTENDED FOR SOLAR ENERGY PURPOSES. FOR SOIL EVALUA 27.3 LOT 3-1 22.8'+ �••. 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. OFSEPTICEXCAV, - 36,950 SF. 24 9' � 8. FLOOD ZONE C [NON HAZARD] 23 5' _ - LY 9 9 FLOOD PANEL' 250009 0007 F DATED• JU 0 10.THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL . GROUND DISTURBANCE OR VEGETATION REMOVAL ' 1 25.51 26.T 2 25. 25 25.1' 3' ' 3.9'J ;. 24.1'i WITHIN 1 00' OF WETLANDS,INLAND OR COASTAL 2 25.2' BANKS OR FLOOD HAZARD ZONES. 25.2' 40 MIL PERVIOUS LINER 23.4' 310 CMR.15.405 LOCAL UPGRADE AI + BETWEEN SAS&FOUND LEGEND 26.7 i 61X36' ATION EXISTING SAS TO STREET LINE 5' [10' RE, 3 BEDROOM 52 PROPOSED CONTOUR 24 SAS TO CELLAF',WALL,1 T [20' RE 2 . ' .9, ?�5. GARAGE DWELLING 248' --- 52--- EXISTING CONTOUR % RELOCATE 24.9' WATER SERVICE 24.4' } 2 1T 10' OBSERVATION PIT fir= J0,H ARr) hG 4.7,. i 24.�� ��_ 24.2' 2 E+L-h�F;P•C�D �s�'' 7$F?� _ 000 � ❑ DISTRIBUTION BOX r SERVE 10, ----__ ___ 81 R$ oj7r�r�4a �� -r ;� o 0 o SEPTIC TANK `•�%0111 L + 1 23.L j.9'�_-- i 24.5/+/ 1 ` 5�--_-! o �° SOIL ABSORPTION SYSTEM ; 0' 24.71 i' 1 224.09' �ZH o q\ PLAN NO. 11 '�--._fit` \ i RESERVE >�``� Js�c _ FILE N0. 26: ' RESERVE AREA DAVID \ 82 5� .5_� 2 .1 � 4.T 24.1 • + CHARLES �� SEPTIC FILE 3' PIPE fNVERT ELEVATION sArncau C.BASIN - - - - -�_,--•-•---•_._._._._25.5' 22.26 28085 ..� POPPONESSET RO SjER�a � . o00 PLOT PLAN•. 7 3 592 N