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HomeMy WebLinkAbout0642 PUTNAM AVENUE ��. ��� l �, it BUILDING DEPT. Application Number.......B..��... �.23.8..............'................ �BAk.NBTABLE, v M1tr14$. Q AUG 17 2020 Permit Fee............S.ti f�Q...........Zoning District........................ 40-�.i6�9• ,0� TOWN OF BARNSTABLE . Total 1-ee Paid ............................................................... ...... lI l TOWN OF BARNSTABLE Permit Approval by.... .................on...9)J.0!.�...... BUILDING PERMIT qq QQ Map..........Q3...—..............Parcel......!.Q8............................... APPLICATION Section 1 — Owner's Information and Project Location Project Address 1P H a OTVUM �WE. ccftot -{ MA Village 0167-0 Owners Name Owners Legal Address (p p (Y� t-Yy�l(�U� City State Zip 0a(03,5 Owners Cell #t 50 g- 5(pO —13 b9 E-mail CS�SI,�E,F-+i�)8Q QhCD C-CM Section 2 — Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under35,000 cubic feet S ogle / amily Dwelling Section 3 — Type of Permit ❑ New Construction ❑ Move /Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment Sprinkler System ❑ Addition ❑ Retaining wal] ❑ Solar VReovation L7 Pool ❑ Foundation Only Other- Specify Section 4 - Work Description — — Cv��Jfi �''� Last updated:8/10/2020 i Application Number.................................................... j Section 5 — Detail Cost of Proposed Construction 0® Square Footage of.Project ,302 �rg Age of Structure 44r 'v Dig Safe Number_c—6 6330 2®R17 #t Of Bedrooms Existing Total## Of Bedrooms (proposed) y 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist [�esign Section 6 — Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression HeatingEl System ❑ Masonry y so 1 Chimney � Add/relocate bedroom Y Y 1 Water Supply ❑ Public' ©�p ivate Sewage Disposal ❑ Municipal L'n Site Historic District ❑ Hyarmis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes �=1 No Section 7 — Flood Zone Flood Zone Designation t Within or adjacent to a wetland, coastal batik? Yes ❑ No Section 8 - Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage ti 4of Dwelling Units (on site) ! Setbacks Front Yard Required Proposed Rear Yard Required _ Proposed_ �1 Side Yard Required Proposed N/C_ Has this property had relief from the Zoning Board in the past? ❑ Yes [ No Last updated:8/10/2020 Application Number........................................... Section 9 —Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell 4 1 understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Attach a copy of your license. Signature Date Section 10 — Home Improvement Contractor Name_ i j t Telephone Number ;2_�—�)-Z.�/�'y Address 2�r Gkc(G 194,,,j or, City State/"►a Zip Registration Number _ r _ Expiration Date understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and dOCUmentatl0n re . ed y 780 CMR A I e Town of Barnstable. Attach a copy of your FI.I.C... Date Signature Sig 20 � �( Section 11 — Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures;specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICAA- I SIGNATURE Signature _ _ Date Print NameY __ Telephone Number ,moo S�7 ZY�y E-mail permit to: Last updated:8/10/2020 Section42 — Department Sign-Offs Health Department 0 Zoning Board (if required) i Historic District 0 Site Plan Review (if required) [J Fire Department 1:1 ! Conservation 1:1 For commercial work,please take,your plans directly to the fire(lepartment for approval. Section 13 — Owner's Authorization I, Dn r as Owner of the subject property hereby 9 ��l J p p Y Y authorize,rf Q 4 to act on my behalf, in all matters relative to work authorized by this building permit application for: �Ia u+nam EuP C_0+o-I+, M4 a a1a35 (Address of job) Signature f Owner ate - pem\i M - a. (bury,�In� Print Name i . 1 Last updated:8/10/2020 1� r/J( U � �c d N Pee Ilei�G o Ho OkE IgmcT'S x .6 c r o .- ��p1 w/ 3/$ is L.,f C- $oe-s �'- 2-<lD rr /2 -7 �� N PC.`rs i k,vrrcnlvrtwCrcrrrc of tv1u"uucuacrc,3 r Department of•Industrial Accidents Office of 112vesttbatlons if 600 Washington Street 4� Boston, MA 02111 WVviv.mass.y ov1dla Workers' Compensation :Insurance Affidavit: :Builders/Contractors/:Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Vadt �c. (!`, Address: z5- (,.j e�,(C, A,J City/State/Zip: r�et'�.. .� /'1e- Phone H-: 5-0$�" 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' ❑ 13uildin<r 9. addition [No workers' comp. insurance comp. insurance.> 5. We are a corporation and its 10.❑ Electrical repairs or additions required..] ❑ I 3.❑ I am a homeowner doing all wort: officers have exercised their ► I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] ' c. 152, S](4),and we have no employees. [No workers' 13.❑ Other comp. insurance required] Any applicant fiat checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors nwst submit a new affidavit indicating such. 'Contractors Thal check This box nwsl attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. I f the sub-contractors have employees,they mist provide their workers'comp.policy number. I am an employer dent is providing workers'conil)eitsatioti irtsurcence•for•my employees. Below is the policy and.job site in f ormrdion. Insurance Company Name: �T7 �CihTeL �J�l Policy#or Self-ins. Lic.#: 1f� 3 1 7<p Expiration Date: /15172oZ Job Site Address: 7Z (�d�C1n&VA ( e-< City/State/Zip: C-0�dt h'Y`G, 02 6Yj 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 c, r ler lire painsnd a enalties of peJtt y Thal the information provided above is,true and correct. Signature: Date: Ifi Phone#: 577 X-j( Official trse only. Do not write in this area, to be completer)by cilt)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 i. Plumbing Inspector 6. Other Contact Person: Phone#: r 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, S25C(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, 525C(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 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 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 0211I Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 6,17-727-7749 www.mass.gov/dia -MA { IKE Town of Barnstable! *Permit# FrI / - tres 6 months from issue date Regulatory Services Fee • • szn nxry sr y utAss. Richard V.Scali,Director, 90 11 J 5 U Qjp 16.39. rED Wray'' Building Divisio ® � Paul Roma,Building Commissioner '� �;+]f�jj 200 Main Street,Hyannis,MA 02601 M yelp www.town.barnstable.igny�ys, AR 21 201, - - Office: 508-862-4038 ' �� Fax: 508 790 6230 EXPRESS PERMIT APPLICATION. - RE SIDE , ' A _ Not Valid without Red X-Press Impfint Map/parcel Number 0 Property Address f �Gt l ea�• fl2 �—y�`�c Q > s­ Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address AZ 16�x . leya lll Contractor's Name &142 TIC //V-c Telephone Number 7�y"2 22— Sri 2 Home Improvement Contractor License#(if applicable) 1_5­2 3 7 2- Email: l'y--�Pa a -cater Construction Supervisor's License#(if applicable) PWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance/Company Name Workman's Comp.Policy# W C S-- _�%S 3f,1 Copy of Insurance Compliance Certificate must accompany eacli permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane'nailed)(not stripping.. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of door's: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sip' Property Owner Letter of Permission. . A copy of the Home Improvement Contractors License&Construction Supervisors License is �reiced. . SIGNATURE: QAWPFILESTORMSUilding permit forms\EXPRESS.doc 01/25/17 r , ^ ne Com ornvealtle of Macssadinsetts Depar t7neut of cad-ush id AcddeFlis i - Office o .mwtr afiom. 606 Washington street -� Bastana 44 02111 ------- --.. — -._.—. .. _IVFVIII-filaS.rr. aPIdia 'Workers'-�ampensa��n Insti�x�c���avat+Smldez��niractai�ElecfricianslP�hers _ — Applican#Infarmafan Please Fret F,eaily Address—. Are IGu an employer?-Che'ckthe appropriate bot: T of project r 4 I am a general coufmctor and I Fib p 1 t equi I.❑ I am a employer uitb. Dave]zireti ffie sub-contractors;-contractors; 6- Ide1w construcFio'n employees(full mdfor part-time)-* 2.❑ I am a sale proprietor orparbrer listed on the attached sheet I- El Remodeling.. ship and have no employees Tlxese satb-ca�rac#ors have 8. Demolition working far me in any capacity. employees andhatre wo&ers' 9. .0 B.nildmg addition IN4 wodm& comp_fine ante Comp_insuranmi 5. We are a co oration and its 10-❑Electdcal repairs or adds,Eons 3.❑ regnired officers have exercised their 1L0 Plumbin airs of additions re I am a homeowner doing all work � F mysd f[N8 workers'comp- rtg�of exemption per MM 13_❑Roofrepaim +ncercanre required-]'a c.Lit,§IM andwe have no employees-[No wor]cess' 1-3-El other comp-Jnmwa m required-] *Any WHcsmtdatcheftbosF1most also faoutthesecionbetowslwingfhe¢wo&eecampen5sti upoIugiafomudan_ I Sameownerswbo submit this affidnif iauffrztiug they erertm'allwa t emdtineahire outside cout2cfars— submitanewaffidarit'mdicating ssuh_ ZCantnactoathst cberkthis box mmt sttarhedi as addifianal sheet showing the name of the sub-camtrw1on;sad stafe whether ornotthose eolitiesbam employees.If the sob-c=tmctorshxvzmoployees,fite},mnstpmcideaek workws'tamp.palicyaumber_ I atit ari etiiployer diaf"ir SeIoiv is fltff pvticy wdiab sAe information. InsurancecompanyNEame: .Poficy;A,or self-ins_uc,_,4,- WC -;3/,�- 3911 fZ I/-a 2 41-2 Job Site Addy =A2 Of. citylstafelt p:�, IVA' 0 Z 6 3'_- Attach a-copy of the workers°compensationpolicg declaration page(showing the poTicy number and expiration date). Failure to sew coverage as requiredunder Section 25A o€MGL c.1572 can lead to the imposition of criminA'penaltbes of a fine up to$1,50a.00 andfor on_e ye irimprism=nemt,as swag as-civil penalties in the foam of a STOP WORK ORDERand a lime of up to$2S0_00 a day against the-violator. Be,adidsed that a copy of this statement maybe forwarded to the Office of Irrves igatioms of the DIA for insurance coverage sMrfflc&ioa_ I du-fteroby ceet*h- ,raatdar tits prtirts andpsnaWes o:fyredWy.thaftfie irtfbrmadmi-prm-iiW abota it true and carrect Sitmature' 7JEate Phi e a- y 2 2 Z— -3 ZId'�Z afi%dtd um ardy. -a not mrtte in this area, be crrlupTeted by diy artann a;oidaT City or awn: Per>mtUcense if T Bsuing Authority(c rde one): L Board of lffwl fi 2.BmZding Department 3.City1Ibwn Clerk d.Electrical Inspector I Plhmbmg Inspector 6.Othr Contact Person Phone 9: -- --- -- - — - - 6 Information and 11s ol1S Massachusetts General Laws chVfra M requires all employers'fn pnMEIM wozkeas'compensation fix then-employees. f PtD fhis�,an�Iayee'is defined as"_every peasan in$ie seaYice of another under any contrarx of lie, express or implied,oral or w " E An wTkyer is defined as"an individual,ParfnersTi p,assoc:Bdon,corporation or other legal entry,or nap two or more of the:foregoing engages m a1oint mtsrpr se,and including fhe legal representatives of a deceased employer,or the receiver or trustee of an iadividnA partnership,associafion or otherlegal entity,emploYmg eu3:PIoyees. $owever the owner of a,dweIIing house having not more than three apartmeats and who resides the-* n,or the o=4xmt of the - dw Mug house of another who employs persons to do mafi tma ce,coushuction or repair worlc on such dwelling house or on the grotmds or buzfldmg appmtenanf thereto shall not because of such employment be deemed to be an employer_" Mfg chapter 152,§25C(6)also S`�S that:¢every state or local licensing agency shall withhold the issuance or renewal of a Iicease or permit to operate a business or to construct buildings In the commonwealth for any applicantwho has notprodnced acceptable evidence of complu=m with the insurance coverage r d.equire " Additionally,M(ff chapter 152,§25C(7)status¢Neither the co=oaweahh nor iii�y of its political subdivisions shall enter into any contract for the performance Of-Public walls until acceptable evidence of compliance with the ins¢r'�ce. regtm emm s of this chapter have been.presented to the cont-actiag azdhoaV-7 APp4catrts Please fill out the workers'.compensation affidavit completely,by check ag the boxes 1hat apply to your sitnation and,if necessary,supply gab-contractors)name(s), addresses)andphonemumbea(s) alongwiththeir=tdacat*) of insurance- Limited LiabU4 Companies(MC)or LimitedLiabr7ityPmtam hips(LIP)with no employees other than the merhbers or partners,are not mquirtd to cauy workers'compensation i amxmce If an LLC or LLP does have employees,a.policy is required. Be advised-ffid this affidayit may be submitb:�;d to the Departinmt of Industrial Accidents for confiimation of insurance coverage. Also be sure to sign and date the afudaYit The affidavit should be retumed to the city or town that the application for the pemrit or license is being regnested,not the Department of Twio A.cci demos. Should you have any questions regarding the law or if you ate required to obtain a workers' cormpensation policy,please call the Department at the ntrmbcr listed.below Self-ins�aed companies should enter their self-ia,sM ce license number on the appmpriato Ime. City or Town Ofdcia S Please be sm-e that the affidavit is complete and prmiedlegr�Iy. The Departmenthas provided a space at the:bottom of the affidavit for you in fiM'oTit is the event the Office of Investigations has to cozrfact You regarding the applicant Please be sure to fill in the pen zi cease number which will be used as a reference-a=ber. T .-addition,an applicant that must subn�m_ulfiple pe�llicrose aPplit atims in any given Year,need-only submit one affidavit indium ctment p olicy, infomation Cif necessary)and under`Job Site Address"the applicant should Ovate"all 10cat bns in (cuiy or. town):'A copy of the-affidavit that:has been officially stamped or marked by the city or town may be provided in the _ applicant as�proofthat a valid affidavit is on file for fc±m pem cen ity or Iises_ Anew affidavitmust be filled out each year.WheSe a home owner or citizen is obtaining a license or penult not related to.any business or commercial vent=. a dog license orpem-it to bum leaves etc_)saidperson is NOT reTii e o ccrmpletm this affidavit The OfficeoflnvcS gatianswouldlflMtothankyoumadvanceforyourcooperationandshouldyouhaveanygnesftons> please do not hesitate to give us a call The Department's address,telephone and fax number f-ffiE of MaSS a chu--&its Depa mt of Indnstdal Accident �itce 4f�e�g�tio� - Boffin,YA Elul 11 Fax 617`27 7M Revised4-24-07 WW 7 gpg1dia Town of Barnstable Regulatory Services MAS& ` Richard V. Scili,Director 6 ►�� Building Division. Paul Roma,Building Commissioner —200-Main Street,Hyannis,MA 02601 -Mtown.barnstable.maxs Office: 508-862-4038 Fax: 508-7.90-6230 Property Owner Must Complete and Sign This Section If Using 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) **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. t . Signature-of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMSIONPOOLS Town of Barnstable owl Regulatory Services ` drrSNKE r,� Richard V.Scali,Director Building Division sattxsTasre. Paul Roma,Building Commissioner Mass. 1639. �e 200 Main Street, Hyannis,MA 02601 CEO 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 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 u may care to amend and adopt such a form/certification for use in used b several towns. You p this issue is a form currently y y your community. Q:\WPFILES\FORMS\buildmg permit fo rms\EXPRESS.doc 06/20/16 Y ++ I c ��e rpana��aa�rwealC�o�Coac�ccaeCC� CD Office of Consumer Affairs&Business Regulation License or registration valid for individual use only before the expiration date. If found return to: t0 'O � N HOME IMPROVEMENT CONTRACTOR rx o Registration °152372 Type: Office of Consumer Affairs and Business Regulation r « r z u - p. �. a� 10 Park Plaza-Suite 5170 ` k w Ex iration 8/Z3/2g18 DBA a P �, r�u � r Boston,MA 02116 f° ,BALTIC COMPANY: `r c LINAS REVINSKA$` w f - 87 CAMP OPECHEE RDA ma '- CENTERVILLE,MA 02632 Undersecretary Not valid without signature A 0 cCL W �U � m JU Jw LU V a Contract # 717 CUSTOMER INFO: JOB LOCATION: Alex Bungener 642 Putnam Ave. 642 Putnam Ave. Cotuit, MA 02635 Cotuit, MA 02635 AGREEMENT BETWEEN Alex Bungener 03/09/2017. AND Baltic Company, Inc Linas Revinskas Baltic Company Inc,hereinafter referred to as General Contractor(GC),on the one hand and Homeowner Alex Bungener hereinafter referred to as Customer,on the other hand,, have concluded the present contract as follows: 1. THE SUBJECT OF THE CONTRACT 1.1 Contractor undertakes hereby to supply all labor and materials necessary to complete the Roofing Project as proposed in the job estimate#667(02/08/2017), said proposal being an integral part of the contract. 1.2 Customer undertakes to pay in the order and terms established by parties in the present contract. 1.3 All work is to be performed according-to the specifications submitted, in a substantial workmanlike manner, per standard practices. Any alteration of or deviation from the submitted specifications involving extra cost will become an extra charge over the estimate, but any extras must be submitted between parties of this contract. h e Rd Centerville MA 02632 Baltic Company 87 Camp Opec e Linas Revinskas 774-228-3462 M.C.S.Lic.#094476 HIC#152372 2. THE PRICE AND THE TOTAL SUM OF THE CONTRACT 2.1 Estimated price for the home improvement project is eight thousand eight hundred and eighty three dollars($ 8,883.00). This price includes the cost-of labor and materials. 3. DESCRIPTION OF THE PROJECT: Permitting performed Roofing materials and supplies supplied One Satellite dish permanently removed One Satellite dish temporarily removed Existing roofing removed Chimney lead flashing replaced Ice and Water Shield applied on the bottom edge of the roof line and on the sides of the roof line Synthetic underlayment applied on the rest of the roof Aluminum drip edge installed on the bottom edge of the roof line Architectural asphalt (Certainteed, Landmark, to match shingles on the garage section) roofing shingles installed Ridge vent and ridge capping installed One satellite dish reinstalled Damaged trim part removed New PVC (Azek or similar)trim part installed Roofing debris removed and disposed 4. TERMS OF PAYMENT 4.1 Customer undertakes to pay'in two payments schedule 4.2 30%deposit of the estimated Roofing amount($2,665.00) 4.3 The remaining amount for roofing($ 6,218.00) should be paid after project completion 5. OTHER CONDITIONS 5.1 All changes and additions under the given Contract are valid, if they are accomplished in writing and signed by both parties of the Contract.The present Contract is made in-duplicate of one for each of the parties. All copies have an equal validity. The contract inures from the date of its signing. After signing the Contract all previous negotiations and correspondence on it lose force. 5.2 GC may at its discretion engage subcontractors to perform work hereunder, provided GC shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 5.3 GC agrees to remove all debris and leave the premises in broom clean condition. 5.4 GC shall not be liable for any due to circumstances beyond its control including strikes, casualty,weather conditions or general unavailability of supplies and materials. Contractor Linas Revinskas Customer Alex Bungener Signatures: _LLv -/Zev' ,Y� Signatures: Date: 03/09/2017 Date: Baltic Company 87 Camp Opechee Rd,Centerville MA 02632. Linas Revinskas 774-228-3462 M.C.S.Lic.#094476 HIC#152372 i t7 r ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . E � � O ,��� �F �,.�Rs�STAB A lication # Ma Parcel .z � 1 p PP I Health Division 71. Date Issued, 31)115:� Conservation Division Application Fee Planning Dept. Permit Fee _>�� Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Project Street Address �-- )Du 4,n Q 41tl� Village n:2'ZZ4 I n Owner Qfj ESL./` Address S Telephone 7 fWooer Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 7 5 la4istoric House: ❑Yes No On Old King's Highway: ❑Yes JYNo Basement Type: )(Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) V Number of Baths: Full: existing_ new Half: existing 0 new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count 3 Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes X No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes/WNo Detached garage:(1 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 naer _ IIa nf, k Telephone Number 774 q 30 0303 Address v' License # na -77Q Home Improvement Contractor# C Email CAtA Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE l FOR OFFICIAL USE ONLY f . T APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS - ! VILLAGE OWNER y DATE OF INSPECTION: i 3 1 `i FOUNDATION >, FRAME INSULATION FIREPLACE " ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING DATE CLOSED OUT 4 . ` ASSOCIATION PLAN NO. N Tlie Cornrriorrrvealth of Udssaclrusetts D,epartrnerrt ofTndustrial Accidents O,ffr -e ofIrrn+rstigadons 600 Washington Street Baston,M,4 02111 itrwttaanass:govIdici Markers' Compensation Insurance Affidavit BmlderslContractorsJEIectricians/Plumbers Applicant Infamation — Please Print Legibly. Nam(Bus-mess,orgmiiadonifndi-iduai) Address: ,Cify/Statel2ip._ one 7 Are you an employer:'Cfied£the appropa-ia e, Type of project(required): 1.El I am a employer with �•JJ I am a general c.ontracGx and I * [ have lured the sub-contractors 6. ❑New construction employees(full andforyart-time). i :,. 2.❑ I am a sole proprietor orpartner- f' lasted an the attached sheet 7. Remodeling ship and have no employees These sob-contractors have g. Demolition 1 working far me in any capacity. employees and have workers' jNo workers' comp.insurance comp.insurance$ 9. ❑Building addition. 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 I Plumbing repairs or additions myself o workers' right of exemption per MGL �` co 12.❑R.00frepairs insurance required.]i c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.]' ',Airy applicant:dat checks box K mnsi also U out the section below sbmeing their wodme compensation policy information t liomevwaen rho submit This afEd--,w$iad{cadug they are doing all wort and then hire outside contrrrctorsnmst submit a new affidavit mdic=[6-such.' tCantractorsd at check this boar must attached au additional sheet shouting tha mmne of the sub-contactors and state whether ar notthose entities bzve employees.Ifthesub-contactors have employees,theymusrpmuide their workers'comp.policy nt®ber. I ain art employer that is prow jig,workers'compensation irmirance for my employees. Beioty is the poll cY and job site informatiOlL _ r Insurance Company Name: Policy,4*or Self-ins.Lic.k Expiration Date: Job Site Address: City/State/Zip: Aktach a ropy of the workers'compensation policy declaration page(showing the policy mrmber.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 51,500:00 and ror one-year imprisorunent,as we.11 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 cgenlifyl edeY the its al d penalties of`perjury that the information provided abm a.is true mud correct sitmature: lU Bate: 7,4 Phone :- 'O,fjiciai use only. Do not write in this area,to be colnpleted by r ty ortbirn ofciat City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health Building Department 3.CilylTown Clerk d.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6. Mformatzon and Mstruc-ions Massachusetts General Laws chapter 152 requii ms all employers to provide workers'compensation for their employees. PM-Sra„ to this st ute%an employee is deed as."-.every person m the service of another under any contract of hire, express or implied,oral or wrin=:' An employer is defined as"an individual,partnership,associati=o corporation or other legal entity,or any two or more Of the foregoing=,gaged in a Joint eut!rpnse,and including the legal representatives of a deceased emplayer,or the receiver or trustee of an mdividnal,partaerslzip,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 mother who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appuurtenantthereto 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 is the commonwealth for any applicant who has not:produced acceptable evidence of compliance with the LISuran_ce.coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor auy ofits poliiical'subdivisions shall enter into any contract for the performance ofpuiblic work until acceptable evidence of compliance with the ills rranc6. ru Tiremeats of this chapter have been presented to the contracting anihoatyy." ' Applicants' Please fa out the workers'compensation affidavit completely,by checIdag the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone numbers) 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 regnief. Be advised that this a$dayit maybe subm_ttted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date if-heaffidavit The affidavit should be retrsmed to the city or town that the application fur the permit or license is being requested,not the Department of Industrial al 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 t _ 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 pen .itllicense number which will be used as a reference number. In addition,an applicant that must submit multiple p=itllicense 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 ( 'err town)-"A copy of the affidavit that has been officially stamped or marked by the city or town may b e 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 permitnot related. any bumsiness or commercial venture (ie. a dog license or permit to bwn leaves etc.)said person is NOT xequued to complete this affidavit The Office of Investigations wouuld 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 niuniber. The CGmmaawean of MassachusttEs Department of hiclustdal Accidents Office of lvestiotia.� - Boston,MA Evil 11 T�.l.#617 '27-49QO cat 406 or 1-a77- A.SSAFF, Fax#617-727-7749 Revised 4-24-07 �rW mass-ga clta AFDC Guide to T-Prood Cons-traction is High Wnd Areas:IRO mph T-M&Zorie Massachusetts Checklist far Com'oan.Ce (780 ark 5301•7.f.1)' t C?1 Ch❑ck 1.1 .SCOPE - - complia,c= _ Wind Speed(3-sec, gust).................. ......................_....... :.._.._........................................._ ....110 mph Wind.Exposure Category...._................ -. _.._.._............... ------ ............ B Wind Exposure Category................En ineenn Re uired For Entire Project.......................................0 1.2 APPLICABILITY Number of Stories(a roof which exceeds 8!n 12 slope shall be'considered a story) ' stories s 2 stories RDof Pitch..._............... ....... ._... _........_..._...__ s 1212 ' (Fig 2) .............:....................__....._.. MeanRoof Height' --.-.--•--.----------.-••--•-•-•-------•------:. (Fig 2).................................................. 'ft 5'33' Building Width,W........... ..............:...:...........-...,--. -(Fig 3)._•--•--..._..----:.._....... :�.-.._-._ft 5 8�' .._.-- Building Length,L ........ ......... .........................................(Fig 3)-- -::....:.:_.. ....................... ft s BO' Building Aspect Ratio(L/W) .._............_.............................. F 4 "__... _<3:1 Nominal Height of Tallest OpeningZ _..............Fig g 4)'- '- --' 4).-..-.- .....---•--__.....__. 566" 1-3 FRAMING CONNECTIONS General compliance with framing c�nnecEibns__..:._._..._._.(Table 2}-____._..._..._..._. 2.1 FOUNDATION Foundation Walls meeting requirements of 78D CMR 5404.1 r Concrete..................:......:.........................:.....................:::.. ConcreteMasonry............................................. ....................... :._ _.. 22 ANCHORAGE TO FOUNDATION"' 5/8`Anchor Bolts4mbedded or 5/8"Proprietary Mechanical-Anchors as an,altematirve in concrete only - BDItSpacing-general.................... ........... - -........._: ---- " in. Bolt Spacing from end(oint of plate......._...................(Fig 5).---- ....---_--:--- -..--, in. 6 -12'. Bolt Embedment-Concrete--.--.-_---------------------_.------ ! 5)......_......... ............._ _in.>_ r Bolf Embedment-masonry..................::..............:_...__.(Fig 5)......----•._....-._ in.>15" ------.....•-•---- - P(ate Washer..:.._..............................---.....................(Fig 5)........................................'3'x 3`-x Y" 3.1 FLOORS Floorframing member spans checked' ........................-_(per 760 CMR Chapter 55)............ :._... Maximum F1oorOpening'D1mension......................._......__.(Fig 6 % . ft c 12' Full Height Wall Studs at Floor Openings less than 2'frDm Exterior Wall(Fig 6).................. ................. Maximum.Floor.Joist Setbacks SuppDtgng Loadbearing Wallis or Sheanvall----__-.----_(Fig 7).......................:.................... Maximum Cantilevered Floor Joists Supporting Loadbearing Walls'or Shearwall................(Fig B)..................... c-•-- _d • FfoorBracing at F�dwalls................................-..................(Fig 9)_..__:__._.___--- Floor Sheathing Type '.................. ----------------------------------(per 7B0 CMR•Chapter 55)........:....._..._....... Floor Sheathing Thickness ................... ..(per78d CMR-Chapter 55 . _ Floor Sheathing Fastening_....... ..........................:.......:..(Table 2).,_d Waifs at in ed a/' in field 4.1, WALLS s Wall Height Loadbearing walls--:.._..----.----._------_--_-.•_--_-...........(Fig 10 and Table 5) ft _c 1 Q1 Nan-Laadbearing walls...- .......................................(Fig 10 and Table 5)............:......_._..-. 11'S 20` Wan Stud Spacing ..........................._._..._......_...._...... F! 10 an)Table 5).... ..�..._ in.s 24'•o._ i Wall Story Offsets•• ......................._---•--.....................:..(Figs 7&8 ft c 42 EXTERIOR-WALLS3 , Wood Studs +' . Loadbearing walls ............................................. (Taf?le S}_..............................2x - •rn Non-Loadbearing•walls.-------:......................................(Table 5)..............................2x - ft - _ _ _ Gable End Wall Bracing _ — Full Height Endwal!Studs..._......... __:.............._......._.._.(Fig i D}..._..........._......_.._._:_..........,.: ..._.:_.... ..... . WSP-AriicFloorLength---------------:._...._._...._:_.?_(Fig 11)_:.._..__..._.......-................... itLW/3. Gypsum Ceifing Length(if WSP not used).....................(Fig 1 i)..._..._...........-__........ —ft>_0.9W and 2 x 4 Confrnuous Lateral Brace @ 6 ft o.c (Fig 11). ........................... ...._ _ or 1 x 3 ceding furring strips @ 16'spacing min.with 2 x 4 blocking @ 4 ft.spacing in end joist Double Top Pla or truss bays Ee Splice Length ---.._.._:,..:._....__...._....._....._..____(Fig 13 and Table B).............................. .. ft Splice Connection (no.of 16d common nails ' • _ ).__........(fable 6). .__....__...... ,............... - -•-• ._ 4Ff,C Guide to FYood Consfmcdou im High Ff qd ireas: 110 fnph hVir1d Z•of1e . Massachusetts Checklist for Conzglignce(7sa ci-1Rs301.7_i.r) Loadbearing Wall Connections Lateral(no.of 16d common nails).......................:........(fables 7)----.--._---.---.-..-_-------.................. . . Nan-Luadbearing Wall Connections Lateral(no-of 15d common nails)-•---------------------------(Fable 8).____:._.__..___..._.-.-•-•---._-•-------..-._..--- Load Bearing Wall-Openings(record largest opening Sut check all openings for compliance to Table 9) Header Spans ..........(Table 9).._..._.................... ft—in. 1 i' -- - _ SillPlate Spans ...............:.......................................(Table 9)..........4......................... Full Height Studs (no.of studs)..............................,-....(Fable 9).......................................__.._. .... Non-Load Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9) HeaderSpans................................ -------•........_.........(Table 9)................--------------• ft_in.5 IZ' . Sill Plate Spans........................_,......................._...._....(Table 9)-------------------------=------.— ft _< _in. 12' Full Height Studs(no.of studs).........................._.........(Table 9)...................................................... Exterior Wall Sheathing to Resist Uplift and Shear Sfmulfaneously4 Minimum Building Dimension, W Nominal Height of Tallest Opening2 .......•.........-•.•..--......••.:...........................----._....._.... 5&'Er Sheathing Type.............-..............................(note 4)_.__..................._.................. w.. -Edge Nail Spacing_-----.......... ----(Table 10 or note if less) in. Feld Nail Spacing able 10 in. Shear Connection(no. of 16d common nails)(fable 1D):............:......................................... _ Percent Full-Height Sheathin .. able lb - ° 5%Additional Sheathing for Wall with Opening>6'B`(Design Concepts).................... Maximum Building Dimension, L Nominal Height of Tallest Opening 7..................... ............ 5 6'B` SheathingType.....-..------------------------------------(note 4)....-....-....................---........-...... Edge Nail Spacing........................._..... -.-....(Table 11 or note 4 if less)-----.-_--..--.----.-- Feld Nai[Spacing.------.-.-•-----------------------------(Table'11}:_ -- •:...............-......._.._._. . in. Shear Connection(no.of 16d common nails)(fable 11)..........................-------------_............... Percent FulkHei ht Sheathing--------------------- able 11 ° 5%Additional Sheathing for Wall with*Opening>SW(Design.Concepts)-----------------L. ' Wall Cladding Ratedfor Wind Speed?-_.._...--•---------•--•-----_-_-_-..---------•--•----• -----------•-------------------•--•----•-•----•------------ 5.1 ROOFS Roof framing member spans checked?------__-_------------(For Rafters use AWC Span Toot,see B.BRS Website) Roof Overhang ----------------------------------------- Truss (Figure 19)............. ft 5 smaller of 2'or LF3 Truss or Rafter Connections at Loadbearing Walls Proprietary Connectors Uplift...........:.....................____-------(Table 12)-------------------...__.............---U= plf Lateral...........................------------------(Table 12)-----------------------------------------L= pff Shear..................................-----------(Table 12)................................... r.S= Plf- Ridge Strap Connections,if collar ties not used per page 21... (Table 13)..............................T= plf Gable Rake Outiooker.....................:.....................(Figure 20) .......:_...._ff_<smaller of 2'or U2 ' Truss or Rafter Connections at Non-Loadbearing Walls Proprietary Connectors Uplift_...................::....... - __._._..(fable 14)----------------------------------------U= lb. Lateral(no-of 16d common nafls)...(Table 14).......................................L= . lb. Roof Sheathing Type...._....._....:.--......................_.__...(per 7BD.CMR Chapters 5B and 59)............ Roof Sheathing Thickness...._..........__.._.--•-------=------------------- ------- in.?7116`WSP Roof Sheathing Fastening........................................._.(fable 2)--.......... _.........................._.....__.. - . NDteS: 1. This checklist shall be met in ils entirety, excluding the specific exception noted in 2, to compfy urrth the requirements of 78D CMR•53D1.2.1.1 Item 1. If the checklist is met in its entirety then the following metal straps and hold downs ara not required per the WFCM 110 mph Guide: a. Steel Straps per Figure 5 b. 2b Gage Straps per Figure 11 c- Uplift Straps per Figure 14 d_ All Straps per Figure 17 e. Comer Stud Hold Downs per Figure 1 Ba and Figure I9b Exception:Opening heights of up to 8 ft:shall be permitted when 5% is added to the percent fulkhelght sheathing requirements shown in Tables 10 and 11. The bottom sill plate in exterior walls shall be a minimum 2 in.nominal thickness pressure treated P-giade. flWC Guide fo Wood C.orrstructcorr zn Ri h 14, ndAreas_ I10 rrzph IY7xrdZon' Massachusetts Checidisf for Compliance (7so chtlts 4. a. From Tables-10 and 11 and location'of wall sheathing and Building Aspect Ratio,determine Percent Full-Height Sheathing and Dail Spacing requirements b. Wood Structural Panels shall be minimum thickness of711T and be installed as follows: 1. Panels shall be installed with strength aids parallel to studs. 11. All horkon al joints shall occur over and be nailed to framing. iii. On single story construction,panels shall be attached to bottom later d to. _ p an p member of the double top plate. iv. On two story construction, upper panels shall be attached to the top member of the upper double top plats and to band joist at bottom of panel. Upper attachmeht of lower panel shall be made to band joist and lower attachment made to lowest plate at first floor framing. . v. Horizontal nail spacing at'dDuble top plates, band joists,and girders shall be a double row of ad staggered at 3 inches on center per figures below:Vertical and Horizonlal'Nailfng for Panel Attachment 5. .Glazing protection: a)new house Dr horizontal addition—required if project is 1 mile or closer to shore(generally,south of Rte.28 or north of.Rte.6) b)vertical addition—not required unless there is extensive renovation to the first floor c)replacement iVuidows-needs energy conservation compliance only(chap 93)S.Wood Frame Construction Manual(WFCM)for i 1 D MPH,Exposure B.may be obtained from the American Wood Council (AWC)website. r •YMENThEIDGEF1E=DN Tz Fc�istmePdFv S AT5'a>= • t tl II 1 - - 11 it it 1 ' t1 11 ! I W 11 n a • tY H �• � ¢ � - 1 ' i 11 , t{ •.; l , L • i I[ Il D F T Il 11 H- t 1 1 t 1 c If / 'Q lI itC7 Ed - a lI 11 1 I�t ri u i i i �d I Il II 1. . 1, � _I 1 j� ' � I FRAid1�G.1.dF1,,S6g�g � •I� I i {t ED&E�TE ,I LI 1 ET ii I L u 1 IL Il 1.1 IC t 1 l 1 S It tl yJ �'t I I 14 \ t � 11 tI JI -x— 1 1�-.-.�-.- fit.-. •. _ ^_� ,___- _ _ _ DDUI�I E 1 STAB 3'M141 f�AlLs�kOkJG l Ti41LlsATiSiIJ PANEL EDGE RDum.EwiLmc,ESPAcvc;DETAL See Dafail on Next Page Vertical and HDrIZ01711ai Nailing Detall for Panel Attachment Verf Ml and HDtzantal Nailing for Panel Attachment . kl til, 1 . ory Town of Barnstable o� Regulatory Services E sxi�ty�aixrv, f 4 MMAM �, Richard P.Smli ]}rector Building Division Tom Perry,Building Commissioner 200 Main Street,Hy=iis,MA 02601 www.townlb arnstablema_us Office: 508-862-4038 % ax: 508-790-6230 r Property Owner Must Complete and Sigh This Section. If U in'A B-tAde-t r . as Owner of the subject property herebyauthorize 1 / jl�r �/1�b�c�ri; to act on' mybebA in all matters relati7d to work authorized bythis building permit application for. . t;�,4 0-435 (.Address of Job) 'Pool fences Poolfences and alarms are the responsibilityof the applicant.Pools- are are not to be filled or sized before fence is installed and all final inspections_are performed and accepted. , o Owner Signature of Applicant Print Name Print Name 10�15 Dare . QFORMS:O WNEUERMI5SI01e00IS Town of Rarwtable Regalatory Services rojy Richard V.Scali,Director � � ��',. B>uidimg Division II t Tom Ferry,Building Commissioner F Ms a 200 Main Street; Hyannis,MA 02601 =639• ti ����►' www towmbarnstable.ma us Office: 508-862-4038 Fax: 509-790-6230 • HOMEOWNErt LICgISE ERIIl2P7.TOId r Pl=se Print DATE.• JOE LO AnOR anmbcrst=t Z4 \ Froa�oWl name, bomcphonc# woiCpbonc# P® 5 cuRP-ENT'MAff- GADDR-SS: _ f ` city��n staff nP CO& The cuaent exemption for"homeowne&"was extcnded to include owner-occupied dwellings of six units or less and to allow- homeowners to engage an individual for hirewho does notpossess a license,provided thattTie owner acts as supervisor_ DEFfNMON OFHOMEOwNER person(s)who oyms 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, affached or detached sfrucf ww accessory to such use and/or farm structures- A person who contracts more than one . home in a two-year period shall not be considered,ahomeowner. Such`homeowner"shall sabmitto the Building Official on a form acceptable to the Building Official,thathelshe shall be reible for aIl sbrh workperfoffied umderthe bm7dingpe�it (Section '109.1.1) The undersigned`.`homeowner"assuages responsibility for compliance widLthe State Building Code,and o-d=applicable codes, bylaws,rules and regulations_ The undersigned`homeownm"rcmbfes thathehhe understands the Town ofBamsfable Building De m,parfinentminim inspection she comply with said rocednres and eats. e � nts andthathe/ wrll requirements. pro . s and r qni, mp y . P • Sign omcowncr _ • Appraval ofBuildmgOf&cial Note. Tbree family dwellings confa�35,000 cubic feet or larger WMbe regniredto comply with the State Building Code Section 1:27.0 Cons ction Control HOMEOWNE$'S E%EMP110AI- , The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt From the provisions of this section(Sect iou,109.11-Licensing of construction Supervisors);provided that if the homeowner engages a-person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assumiIIg the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Sipervisors,Section 2_I5) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,Our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor_ The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is f0y aware of his/her responsribrhtiies,many communities require,as part of the permit application,that the homeowner certify that he/she understands the re$powibiIities of a•.Supervisor. On the Iast page of this issue is a form currently wised by saieral towns. You may care t amend and adopt such a form/certification for use in your community. - Q1R'PF1ZFSlFOR�i,,,�dmgp�it�rmslF�PRFSS.doc Revised 061313 Town of Barnstable Geographic Information System December 10,2015 639133 #54 039117 039126 #172 039110 #175 #668 l 039118 #184 039125 039109 #189 #656 039135 �Q 4 039119 }� #196 vl 039108 A' #642 039124 066001 #203 #0 039120 Ipp #208 039107 #626 own 4 4 039123 #227 039121 #222 039106 #614 Eagle Pony. 0 40 F38015 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:039 Parcel:108 a boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:BUNGENER,E ALEX Total Assessed Value:$342200 are only graphic representations of Assessor's tax parcels. They are not true property Co-owner: Acreage:0.49 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:642 PUTNAM AVENUE such as building locations. Buffer / FEE a TOWN OF BARNSTABLE, MASS. eird°� 19 � 00 o�•� THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO U > O MU _.......................................................... ............................................................... .................._......................... «...........«.................................................._..............._......._._.....�_... O �•y (PROPERTY OWNER) (ADDRESS) TO .............._...................._........._.........................................._......................__ __..... .............. ep ............... .............................................................«..........«....___._....� (BUILD) (ALTKR) (REPAIR) d6L rn 1. ....... ..................................... y N 1 Pd OF ILDINW 1 ' (APPROXIMATE SIZE) 1 O 0 1 0 o ,OD LOCATION .............._._....................................................... «.._.._ «__ __........ ...... .................................................._.............................. (ST T A D NUMBER) (VILLAGE) S PO NAME OF BUILDER OR C N T R A C T O R .._«...... ..«.........._.«..._._................................................. .__...«._..__._........_. C D+ 00.0 APPROXIMATE COST �0 b 0 a0.be I HEREBY AGR E TO CONFORM TQ ALL THE RULES AND REGULATIONS OF THE TOWN y OF BARNSTABLE, REG RDING THE ABOVE CONSTRUCTION. om >A 0 a _......._..............._................._.._..........................._......................................... «....._........................._.................................._.............................................................................. e] d C y (OWNER) (CONTRACTOR) �roo _.....__............._.............._..._.........._........_.....«_.__............._.................................................................... �a BUILDING INSPECTOR Subject to Approval of Board of Health. 1774 -v.Y-...�:/'r ".^'. �'q. -��a._^�+vTy; tt^ ,ts�`s'�'.��'•'."c 'i ..:�,-:t'�..K,.�.-,f�..�.�:�.y.-�.-'.-,4.-.�y. ;:w..^T'. '; � �-`Y_``^^_!�-'�^f`I Assessor's map and lot number 39-7 ✓ .l / 13 Sewage Permit number .......................................................... QOF714ETD�y TOWN OF BARNSTABLE Z "H9SH9TAIiLE, i °0 �"6 BUILDING INSPECTOR �D O D'. APPLICATION FOR PERMIT TO See Pe-:init #16835 (January 15, 1974) r TYPE OF CONSTRUCTION r lea family d ..................................Sin........................................welling....................................................... ..... ................................................19....75.... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: • iot #6 Cotuit Pines, Cotuit Location ....................................................................................................................................................................................... ProposedUse ............................................................................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner William E. Dace y, Jr. Address West Main Street, Hyannis Name of Builder ..............Owner...........................................Address ........... .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exierior ....................................................................................Roofing .................................................................................... Floors ...................................... ...............................................Interior ....................................................:............................... . Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH C-� - t I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the,-above construction. `//./1,. .. ... f%7_... - Name %... ........................... . Dacey, William E. A=--39-=-7— ��1� See Permit #16835 1/15/74 No ................. Permi for .................... Z1,7 P ......... Location ............Co..t.......uit....Pines .. .......................... .. Cotuit ............................................................................... Owner William E. Dacey .................................................................. Type of Construction ............ .......................... .............................................. �............................. Plot ............................ Lot ....................#6 ............ Permit Granted ............./.......................19 75 Date of Inspection ........I...........................19 Date Completed .....................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... . ................ ................... .............. ................... Approed ........................................ ...... ............................................................................... ............................................................................... Cos 106J15 Town of Barnstable .*Permit#C 0o PERMIT Regulatory Services . Fe '"° ' �suekoe snraesTnazs, KABS. Richard V.Scali,Director To �� BARNSTABLE Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY _ ��,� t Not Valid without Red X-Press Imprint L`Map/parcel Number J 1 -Pr perry Address Residential Value of Work$ 00©-. CIOMinimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑,I am a sole proprietor LR-I am the Homeowner, I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.,Policy# a Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box)' ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �Re-side ❑ Replacement Windows/doors/sliders.U-Value (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. •, =fit ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE:-. . QAWPFILES\FORMS\building permit formsEXPRESS.doc " Revised 040215 „ I The Cominortweaiith�x,f-Maiyadmis t, Dqwawent ofIndustrid Acddim& Office afTm�€tigai�ons 600 Washutgton s&eet `- Boston,MA 02111 mpm- mmmgov1dia ""rockers' Calnpensairan Insurance affidavit Bmlders/C�anir-actars)UecbciciansdPlumbers AppEcaut Please Print L21' Azer7 JWC,� City/SWt Am te AW 020 5 Phone-.A-_224 2a Are you an employer?Check the appropriate ban: Type of project(required): contractor and I �. ❑�New � 1.El I am employer with 4. ❑I am a general emgSoyreez(full and/or part timed* have hired the mb-contractors 2.❑ I am a sole psopsietar orparta-er- listed onthe attached sheet. I ❑Remodeling . ship and have no employees These sub-contractars have S_ ❑Demolition warldng far me in any rapacity. employs and have wogs' [NO tb-l7�Ecs' comp.ixavxanre consp_inettranmi 9. ❑Building addition 1Q Electrical or 5. ❑ We are a corporafioa null its ❑ additions '3. am.a homeowner doing all work officers have exercised fhefr 1L❑Plumb agrepaim or'additions myself[No workers' right of exemption per MGL ❑ 17 re�airs irsurance require&]T c.1.52, §I(4),and we have no other employe [No 13.❑{?tfier es comp-insure inquired-] ;Any app&mtffnt cbeftbos ffl—st almiMouttbemcfl=belowshonizgdmkwode&a=pensafioupolicyinfinmmdmL &omemmen who submit ibis afiidava makr ng they mm&mg alf wal sat then bibs aatd&contm=rs=St submit anew affidavit mdicoin s eli ' fCa—cwn Sat chui<tics boa must a3tarhed au additional sheet sbaming the name of fim sub-cam and sleds whethef or mat$base ewes hsv aWluyees.I€tbesab-conntr ha-mmptayeer,dsey pmvide d e'v aatk—'a-p.palir-y number- lam an etspLayer dial is prat idizg irarkers'coa powalion in=rattce f'or ary entp4 e= BeTvw is Ile policy amd jobs srte inforraafian. _ - Insurance Company Name: P•oficy f or Self-its.Luc. ExpiEatiouDate Job Site Address CifylState� p: Attach a copy of the workers coaupensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL a 157 can lead to the imposition of criminal penahies of a fine up to$1, OD.GQ and/or one-year imprisonment,as well as civil penalties.in the form of a STOP WORK ORDEAand a f e of up to$250-00 a clay against the violator. Be advised runt a copy of this sbdement may be forwarded to the Office of Inves#ga#ions of the DIAr for insurance coverage verfficai= ldoherzbyc!!p aerdsr t#e and allies a�gegury thatflre infbrxza€ibaprm dedabm a is tram and correct Siffiatuue: '"] at Phone ik O, cial use txnty Dn Fiat errita iM tires area,trr be crrtnpleted by tdfp srtaan ar `icrat City or yawn: PermitUceime# Tech Anthority(ea cle one): 1.Board of Health —2 Building Department 3.Qtylrown Clerl;. 4.Electrical Inspector S.Plumbing lector 6.Other Contact Person: Phone#- - y 6 Information and Instrac ons mitssac;hnseft Ge=nl Laws chapter 152 requires all employers'in pMMCI-,worms'compensation fur their eoployees.' purmantto this statute,an.err pkgyne is deed as"every person in$ie service of another under any contract of hire, ass or implied,oral or wriffmn" Au.employer is defined as an individual,partnership,association,corporation or other legal entity,or may two or more of the foregoing engaged is a Joint enterprise,and including the legal represerdaiives of a deceased employer,or the receiver or trustee of an mdivirlrial,Pmta ship,association or otherlegal entity,employing employers- However the owner of a dwelling fuse having not more than three apart eofs and who resides therein,or the octet of the - dwelling house of anof=who employs persons to do mafitmance,construction or repair work on such dwelling house or on the grounds or buNing appurfenartthereto shall not because of sash employment be deemed to be an employer." MGL chapter 152,§25q.6)also sites that'everysiste or local licensing agency shall withhold the 2ssaance or renewal of a license or permit to operate a business or to construct bwldings in the commonwealth for any applicantwho has notproduced acceptable evidence of compiance with tbje iIIsuranre coverage required" AddhionaIly.MQ.chapter 152, §25CM sus Neither the cow onwwlth'nor imy of its political subdivisions shall enter into any contract for the performance ofpubho wank unfit acceptable evidence of compliance with the insmmnce.. reTnr=e f of this chapter have Been presented to the contracting authority_". Applicants ' Please fll oimt the workers'compensation affidavit completely,by checking the boxes that apply to your sitnafion and,if necessary,sopply sob-contractor(s)name(s), addresses)andPhone numbers)alongwiththeir cerifficate(s)of mmnance. Limited Liability Companies(LLC)or Limited Liability Part aeashTs(LIP)withno employees other than the members or partners,are not requaed to cant'workers'compensation insurance. If an LLC or LLP does have empIoyees,apolicy is required. Be advisedth dthmis affidayitmaybe submitted to the Depa-[meet of Industrial Accidents for confirmation of msnranoe coverage. Also be mare to sign and date the affidavit. The affidavit should , be ream ned to!he city or town that the application for the permit or license is being reques�not the Depmt nmf of Imfi,strial Accidents. Should you have any questions regarding the law or ifyou are reqcmred to obtain a workers' compensafion policy,please call thee,Depar rent at the numbed listed below, Self-insured companies should ffi s their self-jusmance license number on the appropriate line. City or Town Officials t _ Please be sure that the affidavit is complete and prhted.Iegmly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigatio s has to contact you regarding the applicant Please be sure to fill in the peunitllicense ntnnber which will be used as a refwmce number. In.addition, an applicant that must submit multiple peEmitfIicensa applit flons in any given year,need only submit one affidavit indicating current policy info=nation.(if necessary)and under'2ob Site.Address"the applicant should Waite"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 furore perms-or licenses A new affidavit must be filled out each year.-i here a home owner or citizen is obfairing a license or putt not related bo any business or comma:vial vertu (ie. a dog license or permit to bum leaves efn-)said person.is NOT regrmred.to complete this affidavit The Office of Investigations would h -to thank you in adv nm for your cooperation and should you have any questions, please do not hesitate to give us a call. The Departmeufs address,telephone and fax number: Tha • Itlr ofMassaChURC s . Depkrtn t C&II Estda AccZents y y am=@f 11tv gktLo= ' 2`f,-L:#617-727-4900=t 406 car I-977 MA SSA Fay#617 727 77D R.evised.4-24-07 g� 4 Town of Barnstable • Regulatory Services 'WE r Richard V.Scali,Director Building Division IMMST,+3314 Tom Perry,Building Commissioner i659. `0� 200 Main Street, Hyannis,MA 02601 >" s ED www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: jo 5 -JOB LOCATION: &/ a zn '4LIE lam/�Gl number street village "IOMEOWNER"'. J0 g 7 - -name pp omee phone //#•• - work phone# CURRENT MAILING ADDRESS: C� lZ I® (B 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 pro c ores and roquiremeigs and that he/she will comply with said procedures and requirements. 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 r 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 formlcertification for use in your community. Q:\WPFU-ES\FORMS\building permit forms\E3TRESS.doc Revised 040215 1 ; l �°Ftt1E tpyy� Town of Barnstable FD MA'S Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5.08-790-6230 ' 1 Property Owner Must Complete and Sign This Sectio If Using A Builder I Owner of the subject property hereby authorize to act on my behalf, t work authorized b application f in aIl matters relative o wo onz d this permttor: ( dress 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::,WPF=\FORMS\bUding permit forms\EXPRESS.doc Revised 040215 rr/ A Town of Barnstable *Permit .6/3®? FTNE Tp� _ Expires 6 months from is date Regulatory Services Fee • BARNSTABIE,1639. « Richard V.Scali,Interim Director Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY O 39 ,O oO Not Valid without Red X-Press Imprint Map/parcel Number c� Property Address 6W z [/<-' r k(Residential Value of Work$ `000. oo Minimum fee of$35.00 for work' under$6000.00 Owner's Name&Address P v.✓ �`� fGt�-1^-� �{,f/t� '774 23�3 —7172S— ((�� .. Contractor's Name �t;&y X 7-(16ctrr cr, Telephone Number 774 Home Improvement Contractor License#(if applicable) A 296 7_57 Email: Construction Supervisor's License#(if applicable) LO of 7 69 ❑Workman's Compensation Insurance X-P Q LESS PERMIT Check one: ❑ I am a sole proprietor NOV — 6 2013 am the Homeowner I have Worker's Compensation Insurance Insurance Company Name- /kf!g. TOWN OF BARNSTABLE Workman's Comp.Policy# 6�56'0 Y8 7L52P13 uZ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �bdlc�7 Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home I provement.,Contractors License&Construction Supervisors License is required SIGNATURE: u - Q:\WPFILES\FORMS\building SS.doc Revised 061313 . - - ---. .... 77ze CoTrx;<nanwealth of Vassachusetts Deparftnenf of l�irdustrial Accidents Office o f Investiga iens 600 Washuigton Street Boston,MA 02111 wtov.mass:govldia Workers' Compensation Insurance Affidavit:Builders/ContractorslFiectricians(P1umbers Applicant Information / Please Print LeggibIy Na=(Business orgmizaiionandividnal): /P ow VIE A61ress- City/State/Zip: V1Pi a1r et v`t�bb Phone A: 77 °—X6—t93G( Are au an employer"C'heckthe app.ropria a bGX: Type of o ect(required): a 1_ I m a employes with 4. ❑ I ant a general contractor and I 6- New oonsfruc# on employees(full and/or part-time).* have hired the sub-contractors. 2_❑ I am a sole proprietor or partner- listed on the attached sheet 2- ❑Remodeling ship and have no employees These:sub-contractors have 8_ ❑Demoliticn. working for me many capa.c.ity employees and have workers' 9- ❑Building addition [No workers' comp.insurance comp.irtsurauce 1 required-] 5. ❑ We area corporation and its 10..❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 E]Plumbing repairs-or additions myself. [No workers'comp- right:of exemption per MGL 12..❑Roof repairs insurance required-]F c. 152,§1(4),and we h Ve no employees [No workers' 13..❑Other comp.insurance required.]; "'Airy apphcwt that checks boa#I taast also fal out the section below showing Their wodkers'compensation policy inf,rnatinn I Homeowners who submit this affidavit indicating they are doing all wmk sad then hire outside contractors mn submit a near affidarit indicating srrcli LCout mcwrs that check this box must attached an additional sheet shooing the r mne of fhe salt-coniracton and state whether or not those entities have etoplvyees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy,number. .tam an employer Scat is pr"idfug workers'compensatton insurances for azy*enq£nyees Bebw is Ste policy and job site information. IR - Insurance Company Name: rl cjF✓� I�'1�_ Policy+#or Self-rus.lac 4: i��f �/"��"I�/� Exptzatl9II Date: 12- 14, Job Site Address: 64� /'ul tic 14— er - 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 mquired under Section.25A of MGL c. 152 can Lead to the imposition ofrriminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as ciiril penalties in the form of a STOP WORK ORDER and a fine. of up to S750.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Im=estigatrans of the DIA for insurance:coverage verification- I do herelq,certz;fy uniZ ns , `per ury that Ste information provided abm is hum and correct &- Date- Signature: �/ 06 j Phone#: ! 7 — 6 9 QUicial use ant,}. Da not sprite in fhis area,to be completed by city or town offr'ciaL City or Town: Perurit/Liceuse 9 Issuing Authority(circle one): 1.Board of Health. 2.Building Department 3.City/fown Clerk 4.Electrical Inspector S.Plumbing,Inspector 6.Other Contact Person: Phone#: 6 i 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 IocaI 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 auy applicant who has not produced acceptable evidence of compliance with the insurance.coverage requ.ired." 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,a necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their cez hificatc-(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. Uie 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. Seli 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 lice 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 Javestigations 600 Wasbangtou Street Boston,lvlA 02111 Tel.#617-727-4900 W 406 or 1-977-MASWE Revised 4-24-07 Fax# 617-727-7749 viww.rnass1gov1dia F. ' °FTHE r Town of Barnstable ti Regulatory Services ±�MASS Y.IE� Thomas F. Geiler,Director Eo;9.�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 13I, C N , as Owner of the subject property hereby authorize A y'c to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be fille solor utilized before fence is installed and all final eed and accepted. Signature of Applicant I� Print Name Print Name /%16/201-3 Date Q:FORM&OWNERPERMISSIONPOOLS 62012 FSNE h, Town of Barnstable Regulatory Services nAxa'sieIRM " Thomas F.Geiler,Director Mari Eo j,�.`0�' 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 village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityitown 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. DEFIIrTTION 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 Bamstable 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. C:\Users\decollikV,ppData\Localll4icrosol'\Windows\Temporry Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 Office of Consumer Affairs and Business Regulation r`o 10 Park Plaza - Suite 5170 Boston,:Massachusetts 02116 Home Improvement Ctntrctor Registration + Registration: 169875 Type: Individual srf t f a f t a1 Expiration: 8/16/2015 Tr# '243186 PAVEL ZYBAILA PAVEL ZYBAILA 'w M ' 145 CEDAR ST WEST BARNSTABLE, MA 02668 ` Update Address and return card.Mark reason for change. y` ❑ Address ❑ Renewal" Q Employment F1 Lost Card SCA 1 it 20M-05/11 - exe W("7M4oazc61ea&1Z'a11 a4jac1uae6 License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR egistration. <,169875 Type: Office of Consumer Affairs and Business Regulation Expiration 8/16/201'S Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 PAVEL ZYBAILA PAVEL ZYBAILA 145 CEDAR ST WEST BARNSTABLE, MA 02668 Undersecretary ou signature Massachusetts- Department of,Public Safety 1 Board of Buildin!- Reluulations and Standards Construction Supervisor License License: CS 104769 PAVEL ZYBAILA 10 AFT ROAD YARMOUTH, MA 02664 Expiration: 8/1/2014 ('ununissiuncr Tr#: 104769 J J NOTICE N NOTICE TO a TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6S6OUB-4752P13-1 -13) 07-12-13 TO 07-12-14 POLICY NUMBER EFFECTIVE DATES o� SCHLEGEL & SCHLEGEL INS 34 MAIN ST d' WEST YARMOUTH MA 02673 NAME OF INSURANCE AGENT ADDRESS PHONE# 0 ZYBAILA, PAVEL 10 AFT RD #10 SOUTH YARMOUTH MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE Uv— MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary,and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 007940 W20P1G02 TO BE POSTED BY EMPLOYER N ' �oF� ray own of_Barnstable *Permit Expires 6 months from issue date p ,R.egulatou Services Fee. > BARNSNBLFE atnss. $ "Thomas F. Geiler,Director 1639. plFD�y m Mj Building Division o'T Tom Perry;;CBO Building Commissioner,` 200 Main Street, Hyannis, MA 02601' www.town.barristable.ma.us Office: 508-862-4038 `Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL-ONLY Not.Yali,d without Red X-Press Imprint Map/parcel Number / �0 Property Address U t . <Residential Value of Work, �T W°00. Minimum fee of$ for work under 56000.00. . Owner's Name& Address Y h 17. ontract s Name. Y Telephone Number Ho mprovement Contractor License (if applicable):" C struction Supervisor's License# (if applicable) x• AARPRE Ss P ❑Workman's Compensation Insurance ". V EmMiT Check one: ❑ I am a sole proprietor JU� 201-0 I am the Homeowner I have Worker's Compensation Insurance T® � � 'BARNSTA� 1 E Insurance Company Name orkman's Comp.Policy opy of Insurance Compliance Certificate must accompany eachipermit. 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 *Vlhere 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; opy of the Home Improvement Contractors License& Construction Supervisors'License is, r uired. SIGNATURE: 1 The Commonwealth of Massachusetts r Department of lndustrialAccideWs 1 Office of Investigations 7 600 TYashington Street _ Boston; M, 02111 yy. wwmmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ccant_Information please Print Le ibl(Business/Organization/Individual):ss: Lle �G, Igan J k'eltate/Zip: .Phone # 4-5 Are you an employer?-Check the appropriate box: Type of project. (required): 4. I am a.general contractor and I 1.El I am a employer with ❑ 6 ❑ New construction employees(futl and/or part-time). * have hired the sub-contractors:. listed 2.❑ I am a sole proprietor.or partner- sted on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-con tractors have g„ ❑ Demolition working.for me in an ca act employees and have workers' Building addition y P ty. 9. ❑ g [No workers' COMP. insurance comp.insurance.1 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 11.0 Plumbing repairs or additions yself. [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' i 3.❑ Other COMP.insurance required.) *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit in they arc 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 entitics have employees. If the sub-contractors-have employees,they,mustprovide 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:. 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'MOL c. 152 can lead to the imposition of criminal penalties of z 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 S250.00 a day against the violator. Be advised that a.copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties ofPerjury that the information provided above is true and correct. Signature: Date: — 7 10 Phone# 50 D ` LZ Official use or.1y. Do not write in this area, to be completed by city or town official - i City or Town; Permit/License# -Issuing Autho'rity(circle one):. A s 1.Board of Health 2. Building Department 3, City/Town Clerk .4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone 4: information ation and hStruCtiO-Es their Massachusetts General Laws chapter 152 requires all employCrS Drop the�serviccekof anothCrr under any contract femp hyees. Pursuant to this statute, an Employee is defined as '.,.every Personw express or implied, oral or written:" her An e7n to er is defined as "an adividual, partnership, associore ation, ao'poieseontaliven or s of legal deceased employer, of Lhe, p Y of the foregoing engaged in a joint ente�pnse, and including the leg P employees. However the r -other legal entity, employ, eceiver or trustee of an Individual,not more hhanalh oeiapartm'enls and who rep des therrein, or the occupant of the owner of a dwelling hous grepairing house dwelling house of another who employs persons to do maintecanse of such employment be de moed to bedaneelmployer." or on the grounds or building appurtenant thereto shall not b ance Gp L cha ter 152, §2SC(6) also slates that "every state or local licensingla i;gencyri the comhmold the thsfor any r M renewal Of license or permit to operate a business or to construct applicant who has not produced acceptable evidence oche mpliance nwwith th nor any of its political the insurance subdi4vusioas shall Additionally,MGL chapter 152, §25C(7) states "Neither enter into any contract for theperformance ofpublicworontrac1,ac apthoretyv deuce of compliance with the msLuance. requirements of this chapter have been presented Io the b Applicants Please fill out th e workers' compOf ensation affidavit completely,by checking the boxes that applylo your sih�ation and, if along wmilli ir rt necessary,supply sub,contractors),name(s), addresses) and pbonb 1 to Parknersh)ps (LLP) with eno employeeificatrs)her than the insurance, Limited Liability Companies (LLC),or Limy Y members or partners, are not required to carry workers'fdavcomP may be submitted to the D parlment of cnsatiOD insurance. If an LLC or LLF Indust have should employees a policy is required. Be advised that this of Yit Accidents for confirmation of insurance coverage, Also be sure r sign is bnd eing requestcdvnot he D partment Of be,returned to the city or town that the application for the penn�t or 1I g Industrial Accidents. Should you have any questions regarding the law or if you arc s equired to yed companies should enter their compensation policy,please call the Department at the number listed below., 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 asdp,nCe�e applicant. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding In addition, an applicant Please be sure to fill in the.permiOlicense number which will beensedars need only submit affidavit indicating current that must,submitmultip]epermitflicense applications in any glv y (City necessary)and under"Job Site Address" the applicant should write"all locationsybe rovided to the or ation if n ry) r Town may p policy inform ( e or marked by the city o Y p en officially stamped out each at has be Y lled o davit that be f co of the affidavit affidavit must town). A PY • applicant as proof that a valid affidavit is on file for future permits or licenses, Anew to any siness or Y ear, Where a bome owner or citizen is obtaining a license or pe. uiredatodComplete this affidavommercial venture (i.e. a dog license or permit to bum leaves etc.) said person is N 9 y uestions, The Office of Investigations would like to thank you in advance for your cooperation and should you have an q 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 Fay fl 617-727-7749 F of�NF, 'Town of Barnstable Regulatory Services zwxxsras Thomas F. Ceiler, Director � ai.Ass. � `b i659 Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,lvlA 02601 wwty,t own.b arnstabl e.ma.us Fax: 508-790-6230 Office: 508-862-4038 ° �vvni r Must °i � roperty ection Complete arid' S1brl Ts S ig T '- 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.b building permit application for: r (Address of job) Date Signature of Owner Print Name If Pro e : O�wher is applying for pemut�please complete}tlie x Homeowners License ExemptionForn;orit-be.`reverse side. Town of Barnstable 0 f 3 HE Tpk o Regulatory Services r Thomas F. Geiler,Director TABLE, wilding DiyisiOD 1639• p�FDt A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 508-790-6230 Office; 508-862-4038 _ HOMEOWNER LICENSE EXEMPTION Please Print DATE: 7 — 42 V i1 {�1QL�1'1I/Da W `� JOB LOCATION: D �� village number sued "HOM EOwNER": h work phone}I name �rnephonc CURRENT MAILING ADDRESS: if 017��� ®� � city/town , state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellin 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/abdresides of intends to reside on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory Such 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, "homeowner"shall submit to the BuildingOfficial on a form acceptable to the Building Official,that be/sheshall 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,riles 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 requir MIS Sig attire of Homeowmcr 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]09.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Flomcowncr shall act as supervisor." Many homeowners who use this excerption art unaware that they arc assurrung the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) Thislicensed lack of awareness o8cn resuhs in serious problems,particularly e Board cannot proceed against the unlicensed person as it would with a when the homeowner hires unlicensed persons, in this case,oursde 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 hdshe understands the responsibilitics 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. Town of Barnstable a a Regulatory Services oFYt+e ram, P� ti Thomas F. Geiler,Director - Building. Buildin Division w BARNSTABLE, • - v MASS. g Tom Perry,Building Commissioner 039. �0 A t A fo►��t 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: — Permit#: HOME OCCUPATION REGISTRATION nate: h Name: ,sal•� Ace t? -p 'Pl ad— Phone #: 30(s 74� 335:p Address: t�,`� �U�)701�� �rQi Village: Name of Business:_ 1 ='�'�� —1/cQC 04VA Type of Business: Ce20804 Map/Lot INTENT: It is,the intent of this section to allow the residents of the Towu of Barnstable to operate a home occupation cNitlain single Family chvellings,subject to.the provisions of Sectioia i6-I A of the 7,cnliug ordivanc:e, provided that the activity shall not be discernible from outside the chvelling: there shall be no increase in noise or odor; uo Visual alteration to the premises Much hvould suggest anything other th, a resiclelitial use;no increase in traffic above nol1 al residential volumes; and no increase in air or groundwater pollution. After registration hVlch(lie Building Inspector,a customary home occupation shall be permittecl as of right subject to the follmi'lug coliclitioias: • The activity is carried on by the permanent resident of a single family residential dwelling unit, locatedwithiia that dwelling unit.. • Such use occupies no more than 400 square feet of space: - • : There are no external Alterations to the chvelling hdilcla are not customary in residential buildings,duel there is uo outside.evidence of such use.. • No traffic will be generated in excess of normal resiclelitial volunies. • . "File use does not.involve the production of offensive noise,Vibration,suaoke, (lust or other particular matter, odors,'elect rical disturbance,heat;glare,humidity or other objectionable effects; • There is no storage or use of toxic or hazardous inatenals, or flammable or exploslVe materials, in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing tile Custonaaly Home Occupation,and not crlthrra the required front yard. • "I'lim is no exterior storage or display of niaterials or equipment. - • Where are no commercial vehicles related to [lie Customary Home Occupation,other than one varl or one pick-up truck not to exceed one toll capacity,and one trailer not to exceed 20 feet in length and not to exceed if tires,parked on the same lot containing the Customary Home Occupation: • No sign shall be displayed indicating the Custoimary Home Occupation. • If the.Caastona.uy Home Occupation is listed or advertised as a business,the street address shall neat be included. • No person shall be employed in the Customary Home Occupation hvllo isxaota permancnt resident of the chvelling unit. 1, the undersign I, have read and agree mth the above restrictions for nay home'occupation I ana registering. Applicant: Date: 4�6 " f t-(omco .doc Rcv.01 3'0R YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 Town Hall and 200 Main Street Offices at the Licensing counter. DATE: kr^, Fill in please: ' APPLICANT'S YOUR NAME: %�l �'_7G2✓1e � BUSINESS YO R OME ADDRESS: - ` ' TELEPHONE # Home Telephone Number: NAME OF NEW BUSINESSZ TYPE OF BUSINESS ciu� IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS l" F� 0 6al' AP/PARCEL NER When starting a new business there are several things you m (st do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) -to make sure you have the appropriate permits and licenses'required to legally operate your business in this town. . 1. BUILDING CO ONER'S OFFICE This indivi ual•,ha ee in m a permit requirements that pertain to this;type of business. . Authorize ig re** MUST COMPLY WITH HOME OCCUPATION. COMMENTS RULES AND REGULATIONS. FAILURE TO D l 2. BOARD OF HEALTH This individual h informed he p it qureme that pertain to this type of business. Authorized nature** COMMENTS: 3. CONSUMER AFFAIRS (LIC LASING AUTHORITY) This individual ha ee i fq� ed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: t ,1. Town of Barnstable IUle *Permit# g� Expires 6 monthsfrom issue date �7 RegulatoryServices Fee • BARNSrnsre v� ass.1639. Thomas F.Geiler,Director. . �0 plED MA'I s R Building Division . C Tom Perry, CBO,_Building Comanissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maaas Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY. Not Kilid without Red X-Press Imprint Map/parcel Number Property Address C«►Z4- 6 M4 '0,2 6 35 -Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address / Contractor's Name Telephone Number Home Improvement Contractor License*#(if applicable) Construction Supervisor's License-4(if applicable) ❑Workman's Compensation Insurance PERMIT Check one: P" V❑ am a sole proprietor am the Homeowner 0EC` 4 Zad� ❑ I have Worker's.Compensation Insurance Insurance Company Name ``OWN OF BARNSTABLE P y Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Do Pf"Replacement Windows/doors/sliders.U-Value_ (maximum_44) ltil *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: G Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 14 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please-Print Legibly Name(Business/Organization/Individual): Address: 4Q Aiti2inf_"✓1 City/State/Zip: t/' C� j� ",35Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. EJ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. Lam a sole proprietor or partner- . listed on the attached sheet. . 7...[Remodeling ship and have no employees These sub-contractors have g• Q Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers'-comp. insurance comp. insurance.$ ,required.] 5.•[] We area corporation and its '10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their I LF]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.❑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 state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: 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 cent' u der the pain and penalties of perjury that the information provided above is true and correct~ Signature: 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 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 d __._..... ----- --�_-----' - - - - - "P -oI the of the--foregoing engaged in a joint enterprise,and including the legal representatives of a ecck Y— w5 y er, receiver or trustee of an individual,partnership,association or other legal entity,employing emptuy, However the owner of a dwelling house having not more than three apartments and who resides therein,or the o upaiit of the employs persons to do maintenance,construction or repair work on such dwelling house dwelling house.of another who 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 corrpiiance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),.address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation-insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that-the application for the permit or license is being requested,not the Department of Industrial Accidents.. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will.be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in^_(city or town)."..A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for 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 Fax# 617-727-7749 Revised 11-22-06 www.mass.gQv/dia Town of Barnstable THE Regulatory Services BAWSTABLe Thomas F.Geiler,Director MASS. .•� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02.6..01., www.to wn.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Qr Please Print DATE: V O LOCATION: ✓��JJ 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 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, 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 men Si rc 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 hues 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:fonns:homcexempt oFs Taff Town of Barnstable ` Regulatory Services �sexxesr.E$ Thomas F.Geiler,Director i639 �� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize 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. QTORMS:O WNERPERMISSION