HomeMy WebLinkAbout0476 PUTNAM AVENUE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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Map Parcel 0210 Application
Health Division Date Issued _
Conservation Division Application Fe
Planning Dept. Permit FeO
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis �Q
Project Street Address Z A-4A,
Village ' r 40-J
Owne �f 4CL lV Address n���� 1��',_M (WK VrT
Telephone
Permit Request 1� -� �- 4rJ
W i! W
A
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
CProjectValuationo''"120 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)
Name-, -'� � t �°`S�� Telepf onesNumber �� /'Z3�
A dressLicerise,# .� 2 L.
®AO°rt� 1A �� D � Z- 61� 1orn
"'e Improvement,Contractor.# J ZZ r6 1
Worker's Compensation #
ALL CONSTTRUUCTION EBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
,SIGNATURE ° DATE :`_Y 4
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
r MAP/PARCELNO.
R ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
V
FRAME �Q OIL to
5
INSULATION
: 4
1
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
t -
GAS: ROUGH ' FINAL
FINAL BUILDING � OtJLJlL. o�
f .
DATE CLOSED OUT
ASSOCIATION PLAN NO. '
;i 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 Le 'bl
Name(Business/Organization/IndMdual):
Address: N
City/State/Zip: 0 { Phone#: - s
Are you an employer?Check the appropriate box: Type of project(required);
1.❑ I am a employer with 4• 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,,Q Remodeling
shipand have no em to ees These sub-contractors have
P Y , 8. Demolition
working for me in any capacity. ` employees and have workers' .
comp. insurance.t 9• ❑Building addition
[No workers' comp.insurance i P• •
required.] 5. ❑ We are a corporation and its 10:®Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their 11.oPlumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL '
insurance required.]t c. 152,§1(4), and we have no
12.0 Roof repairs
employees. [No workers' 13.0 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.
$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 must provide their workers'comp:policy number.
I am an employer,that is providing orkers'compensation insurance for my employees. Below is the policy andjob site
information
Insurance Company Name: (/ .
Policy#or Self-ins.Lic.#: Expiration Date:_/
I�
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 IA for insurance coverage verification. -
I do hereby cer ' nde thepaitA and p aloes f perjury that the information provided aboy2e is ue and correc>7
Si ature: Date:
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):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector. S.Plumbing Inspector
6.Other
Centgct Person: Phone#:
THE ro Town of Barnstable
Regulatory Services
vERLARMN
QbUSS. g Thomas F.Geiler,Director .
-Op i639- ♦0
rFn,39. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,.MA 02601
www.toWn.barnstable.ma.us
Office: 508-862403 8 Fax: 508-790-623 0
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject Property .
C� LDS
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit.
&A H7
v M e
(Address of Job)
**Pool fences and alarms are the ibili ons resP applicant. Pools
�' of the
are not to be filled or utilized before fence is installed and all final
inspections are performed and.accepted.
X lok
Si e Ownecant
r
F. :ignalture
.,
�- W�/' YU '
Print Name Print Name
Dt
Q:FORMS:OWNERPERMISSIONPOOLS 6/2012
TKKE r Town of Barnstable
o Regulatory Services
sARivsrAsr E, « Thomas F.Geiler,Director
9 MAS&
059. A,� Building Division
rE0 MA't
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
"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 ownei'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 pemut: (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:fornis:homeexempt
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All dimensions_size designations Judy Keenan This is an original design and must Designed: 9/5/2012
given are subject to verification on Mid Cape Centers not be released or copied unless Printed: 9/6/2012
job site and adjustment to fit job Custom Design applicable fee has been paid or job .
conditions. Proprietary order placed. -
wilson All Drawing#: 1 No Scale.
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Town of Barnstable 3
P� 0 Expires 6 tnontltss ue date
Regulatory Services Fee
t M
* BARNSTABLE.
9� 163q. Thomas F. Geiler,Director
ArFD MA't A I�r
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X=Press Imprint
Map/parcel Number C)rZ0
Property Address 7(a km Cok6 c�
[Residential Value of Work a,Q00 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
� CKAA . 0),(D
Contractor's Name C w tin,✓ Telephone Number 13 —7S 6 7
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance E, I
Check one: XWPRESS
RM
❑ I am a sole proprietor ZO�C�
®, I am the Homeowner OCT:
❑ I have Worker's Compensation Insurance -oWN OF BARNSTABL
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
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
#of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License& Construction Supervisors License is
required.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 090809
r _
The Commonwealth of Massachusetts
� ., Department of Industrial Accidents
!,� F--i�� Office of Investigations
f_ 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print n Legibly
� ,n C
Name (Business/Organization/Individual): iN y t rl r`r \ Le-IkOA
Address: f 7 H-er,. eu 5 -
City/State/Zip: Mk 0a04 Phone #: 33A —.(o 3 -18 U7
Are you an employer? &heck 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.[:1I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
workingfor me in an capacity. employees and have workers'
y p �'• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions
3.WI 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.t&Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other -(ZOo�
employees. [No workers'
comp,insurance required.] C(4 KLc.0 A1,
*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 isproviding workers'compensation insurance for my employees. Below is the policy andjob 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and the ains anndd -enalties of perjury that the information provided above is trice and correct
Si nat ure: �` Date: �O — a - 6
Phone#: 3 3' - 613 -766-7
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 e�niployee 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
employer, or the
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased
g gJ p g
er or trustee of an individual partnership, association or other legal entity,employing employees. Howe
ver the
receiver , p p, g
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
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 pen-nit 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 p).-nnit 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.tnass.gov/dia
,. Town of Barnstable -
oFt�t�
o Regulatory Services
. . �
BARNSrABLE Thomas F. Geiler,Director
ntnss.
9�A 039. 06. Building Division
jED MA'1 �
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: 10— Z — Oct
JOB LOCATION: �( ?(& P uA,nSCkTA A\iR-, LO-V(3t'h
number Inn street village
"HOMEOWNER": D0.V t A 1•,�1 C�,ciy� Z 39 —(R 5--Le— —
name home phone# work phone#
CURRENT MAILING ADDRESS: f=1 ef�t//-l�� Sk /� �y --
hFr h"\& M ��lrA. 0AdLl3
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.
C
j
igna a of Honjeowner
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\FOPMS\bomeexempt.DOC
�YHE Town of Barnstable
yT
Regulatory Services
HAM STABLE, Thomas F. Geiler,Director
AS&
Mass.
039. 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 Usine A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O W N ERP E RM IS S I ON