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1761 SANTUIT-NEWTOWN ROAD
Ir161 s 'v&-New-owm Ri r i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel WLDW( Application Health Division Date Issued 3 0 1 6 Conservation Division µ Applicatio e ! Planning Dept. TOWN OF��g Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Pr servation 7 Hyannis Project Street Address 11LP I I�1WV��/V1'1 IL1XA/� Village I Ownerc I� �_ C��QV���. Address UO Telephones d� - ��g q q0q Permit Request Wela2ffiph ZW 03 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �(P Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number _ 7 y 1 1 c `i 0 Address 2. I,/� �-trejt License ��Sy Mk �2 Home Improvement Contractor# 7s LgrjA3 maim � � �� �✓m� I Worker's Compensation #09ggzs ALL CONSTRUCTION DEBRIS RESULTING FROM 1MpT�HIIS PROJECT WIL BE TAKEN TO �L 1�11�1/V SIGNATU E �� A DATE FOR OFFICIAL USE ONLY APPLICATION # x, DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 0% Town of Ua�rist�ble, Regulatory Services yi tYt t ' Richard I'V.!tLaii,Director % r Building Division Tom,Perryr,Building Commissioner. 200 Main Stieet;;Sfyaxaxris.NIA 01260I ; wwvw.town.barnsiabte.ma.us . Office: 508-862-4038 Fay 508-790-6230 Property Owner Must ' Complete=anti Sign.This Section; F ` uilder VI as 0 er of tlle subject Prot ru herebyaurhon*7e ,` 0ti:actou.My"behalf, in aU rtiatters Miative,to work authdxi=d by this building permit applicafiot-for; -LI -(A. dress,of Job) .k Pool fenw, and alanns are the responss hlLy of the applicant Nc}1s' are not to be fi11ed ter uti cl �L lr>re l�nL L is :nstall�cl azzr�a j'u�l inspectlons are perf6iTned and accepted. Signattuu of Ow ier w ,.Signature of Appkai�t Pp e--C- pint Nameriza I�Tz 1 J —r The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC. Address:2 LARK ST City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 16 employees(full and/or part-time).* 7. New construction 2.r_J I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 Q Building addition 4.EJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M.I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� p Roof repairs These sub-contractors have employees and have workers'comp.,insurance.$ 14.E]Other INSULATION 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:STAR INSURANCE COMPANY Policy#or Self-ins.Lic.#:0849257 00 Expiration Date:02/26/2017 11191 NnI) Loo 12C) City/State/Zip:p: Otu I Job Site Address: Ci /State/Zi Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex iration date. Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pain ra,d enal es of perjury that the information provided above is true and correct. Signature: Date: Phone#:508-56 ,= 2 0 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector • - 6.Other Contact Person: Phone#: f ALTEIMEA-M TRANAR Z A 0, DATE '' CERTIFICATE F. LIABILITY tll��NCE V17rn►-f6 TIiGR CERTIFICATE IS 1SSl1ED AS A MATTER TiQ)'1 ONLY AM CONFERS pt0 RICaHTS UPOAI"THE CERTI# ATEtf01131 TI#,S CERFfFICATE'DOES �KlT"AFIATIIGELY:OR-MEGA .; Y:AMEND; EXTEND OR ALTER THE GAGE ;BYPOLIGS BMW :THiS CERTIl=tCATE llil R E DOES A 3 CONSTiTUTE A SE31Atf TFtE;If, l A REP A OR".I ODtIC R,AND THE CERTIRCATE AIttT: ;of fhe= hotder; aA ADDI RED,the� Yf� l�.eniorsed. It.SLSROGA'fMIMPORT f3 FA�1lED;seb to the terraRs asiri:;cortds of the policy, ;poRcleB an e::dorseel: A.state�neot.oe ;does; €erglS o the certifie"Ifoer in.Iu sic# g)• PRot>ric 8,lgason.Irtlstlrance CONTACT Agency,Inc. °"E :(784.)447.6531 c78+I).447 7230. So�tr�1V8+ . COItI EaNB& YlRsltmam:11IA A2382. •' ADnREss. ,;.. . _ ... AFFIM tJGE:Oj� NAIL# INSURER A: INSURED INSURER 8 AifernB&q Wea#wizatlon,Inc. INSURER c 2,Lar9rStreef I► RER D Fall Rlvec,IItIA.02721 I E: . @tStamF: ". COVERAGES CERTI ICATE NUMBER: RE%qSIOK, R• THtS.'ES TO CEEtTIFY THAT THE.ROL1CiES:''OF'INStfRANCE; BELOW, HAVE SEEN ISSUED TO THE INSURED IAED A$QVFFOR;TNE ROLI,CY RERlOD.. MIDICATED." NO t1MTHSTAt�{DMIG Ai�6Y RECtLEBtEMENT, TERM COI�iDIT#ON:Of.AAiY COI,ITRACT OR OTHER DOG.kR�JENT lY6T#t R£SPEGT TO VM,0H.THIS CERTtF{CATE MAY-:BE fSSUED OR MAY'REft FRW: THE CE AFFORDED BY THE POL'TC1ES"DESCRISEl1 HEREI�t:t$StJB tECT;TO ALL "TERMS EXCLL 81(QNS ANtJ CONDfTWNS QF'SUCH POLICFES.LiiIMTS 8ki0 ;MAY HAVE BEEN REDUCED BY PAID CLIIBNS: LIMITSTYPE OF;ffAURANCE LTR . LJABtL" EACH:000tSRRENCE $ CLAIMS MADE OCCUR PREI�ttSES' 'axrare e s MED:EXP{At>aG=0PW=) $ PERSONAL.&ADV HNAM S GENERALAGGREGATE. $ GEML AGGREGATE OMIT APPLIES PER: PRODUCTS $ . POLICY a L� $ OTHER: SINGLE' $ AUTOMOBLEUABLITY I30DLLYtWURY(PerD�?�) $ ANY AUTO BODILY INJCiRY(Per a S SCHEDULED !�IREFUTOS ED AND AUTOS g UMBRELLA LIAR OCCUR EACH OCCURRENCE. S EXCESSLIAB CLAIMS-MADE AGGREGATE $ g, DED. RETENTION$ PER STATUTE ER A{�'�rPt.OYERS AlABL(Y YIN 00 0?J26=16 O=W6 47 E.L.EACH ACCIDENT $ SWIM A ANY PROPR(EYORJPARrNSi/FxECUTNE ❑ OFFICERtMHdBER EXCCUDFD7. N 1 A E.L'DISEASE-EA EMPLOY $ if b►; 1 H,yes resarietu>Qer EL DISEASE-POLICY LIMIT S DESCRFL�TION OP OPERATIONS bebw pESC TiON OF OPERAT10NSf LOCATX I UFSlICI.ES(ACORD I*,+ Rom°Schedul°+are"be ifP►ma spm is req�d) CERTMATE HOLDER CANCELLATION SHOULD ANY OF THE AB01 0ESCR •POL=S:BE cANCELLED IEE.ORE. THE EXPIRA bl DATE Nt3 SE' IN Nation2l Grid ACCORDANCE 1101M T�;POLICY 40� 01581 AUTHOR REPRESEfTATM • . �4.988-2I3+I4 ACQRD C012Q0l'AT�AI Atl crgttts ACOl3D 2li.{?A44�1:} The ACORD Pan a and logo are registered marks of ACORD 1a�y1 ... M Office of Consumer Affairs and Business Regulation 10 Park Plaza_Suite 5.170 N .�.� - . Boston Massachusetts 02116 Home Improvement Contractor Registration: :: . Registrafion: 175683.. ... Type: :Corporation Expiration: 5/29)2017 Tr#. 265489 ALTERNATIVE WEATHERIZATION,`1NC TIMOTHY CABRAL: : .. .. . .. 2:LARK ST FALL RIVER :MA 02721 _:___T,__ __ . . . .. . update Address and return card.Mark reason for change. 7 :Address 7 1 Renewal 7,;Employment v..Lo`it Card Office of Consumer Affairs&.Business Regulation License or registration valid for individul use only. '21TOME IMPROVEMENT CONTRACTOR before the expiration date. If found return.to: ... —� _ .. M )Registration: 175683 Type: Office of Consumer Affairs and Business Regulation Expiration 5/29f217 Corporation;:, 10 Park Plaza-Suite 5170 # ;. . . . . . n...... - Boston MA 02116 ALTERNATI:VE:V1lEATHf�R{7.AT�QN;1NC.:i TIMOTHY CABRAL ' 2 LARK ST FALL RIVER,MA 02721 Undersecretary / valid.witi utsignatu �' s�� lrYe"'�v. •yr ;.s '+4'Q '- NlassacE►use is Depattmenf bf UD110 Safe ` --J�@ ``•''' Fh4 - ' •'4 if` 1L _".aw+Y aa'Y' . . :: .. .. Regutattattsand�Stand d•s 'L11s'e CS-t05454„ .. ':. ::''::. �>S',`�-Jq il�C��S�.S� ,. rt'.f` "l"�tl• �'yr�' �' ... xFaIl River MA ;1` U 0�'121 .l..{•w.+ii EX(itflOD �. Gorl*d-ssioner, 7r [1 0 ti 05/08%Z01 o ' w p. r Town of Barnstable *Permit# Expires 6 monthsAom 4sye date r7 Regulatory Services Fee • anxxsrnaie, • 1 `� Richard V.Scali,Director EDA Building Division fit- PERMIT Tom Perry,CBO,Building Commissioner JUL 15 2015 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BARNSTABLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ,1�� Not Valid without Red X-Press Imprint Map/parcel Number U L Property Address [.Residential Value of Work$ �b too° ® 9 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address "l 745u12 Lo N 7 Contractor's Name lev 1— Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ` ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value 6 �maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\ ing permit formS\EXPRE$S.doC Revised 040215 Hof A A ,HA allT wmke& Fsrctrr�narag =fr�a+-gf � ( ar�ri ,��y lnfiF�III cityfs _Co Tu-ri PhD=;g- ��Z '9v-,vl :. . I ❑ 4.0 I=as mmmd �L rL N,:w Z❑ I ma a sole gragfie#or arpati2w- Bzted an fhe +e s 7- ❑R- sbig aid bare no=plcFj es _ Elg Ong for m-..im airy mpadLy aoahage wad=T' jNb- mmp. camp- $ 1 Q- ❑�ad3 on 1 5_ We ate a mTmxHamzoff its idEffiions �'_ I a daiug atI wmi-_ cffi=h&ve ems* i&ed f 1 ph=hmg=Fa:=or adffiii s we haste 12-$saampa"I ++�� ��INErwaffine =M3p-==MM ZaqMaj "gyp���r3edcsboral amst+�sa�outtb_�br7os�sbuain�r ti�eswadrr�s'm�aupeTs}- � ' rt �_w+tbL.bas mmst xa xMffi T14T sled thenmaeuf&e Z m3 a omat �wf�esEz-� �SScpe�s_IfYht Iuper,dzy P=7ZE9dr tom'—ng-pmEt}'m ' ;• �'rrnt•r�• �isgrrsaid�irg•trnrkers'cna mar,fa{-At$�ea�Sl�yass. �elatP is�egrr�artd�eb.u� , 7a�x;rr,r•n��NRr,iR. . IOIxcp:9 cr Sq4f-inrl Aiiaffi a copy af$e wutkers`mn:peussiirm goULT dwlm—a:nn pzge(sbavTbsg tha Puy7'mmmiser MME Ana }: • Fad�se�a¢c cav�ge xszetjuaedzszDder�ecfiiaQSA afl�ii3L.�I5�tin IEad to ire aupa�.trF�al of a fT�l YIP to S15D M anafcr i as Ven as ar7 genatiiS zn fie:ffixm of a STGF WDRK tlRDIM and a Huj-- czf 4P.to$250d)0 a day apfi3st ffie via} 13e a6vised Iltd a cagy t¢ffbs sib maybe frwarciod tv the Of am of Iare =oas of ffie I3TA€nr mstaanre coves v . I tea � urrdrx ilts � �paaff�+ar u�f fftat$sa�rnta#rr�u prate al2av�is hug rtad 6a� _ ..; _ Z��' �ik �U� �r�S 21 . 1? �. Z3 ' gss� .tarr rrr�t�rd�i��r��fa 5s �y rr�rxF tit u,�cwZ - tay W ToWa.: ;r ig E�gA�ariig tm�aun�: LBaard eflTcL-TfTT %Bm73r3ng I afPTawma=k 4-EIecEiczllasgec�ar 5_PfmmbmgFmpec€nr -6� . jtl� �aI LQ-ws 1$2 IeQDireS sII�ployeass tD�uvide�'���hies ezaplopees, . PrnmMit-fa$gs sEaf an Iaprz is damned as¢—carzY Pecan m e service of�n$ez mztisa�Y canfrar#gfbae, ex MCM oft implied, oral crwrittc� coLgoratrDn or o Icga1 Cmh:t7,or any two or mere of fie wing m aJO:i23t s and inda t kgal m of a deeed eiployq-cr the receiver c r trm'fee of an niEn±nL parbzzhip,ass=aton air afbet Iegal eut±y,employing employees- Elawcvm-the owner of a PTm r-.bare havingnDt mom f=f n-=ap atm=d 3 and who resides f=m,or fat Dccmpsnt of 111e - dwellmg hDu=of m3cfficrwbc mnp3o7s per=s to do on or repair woiik on such dwelling house or on fhe grooms m bmlding agpmtmarlt fberefn shaII nct becaase of such c=ployment be deemed to be-an employer." MC`rL c r I52, §25C(t7 also sfates.thk`every state or Inc2I§ceasing agency shaII wiEhhoId ffie iss¢ance or renewal of a license or permit to Dpetate a bn:6=ess or to ronst mct btadnings in the commonwealth for arty applicant Who has notpridgced accep#able evidce of caiap]iaace wi[$.� im e zarar_rc coverage regim ed Add ir„ aI y,MOL cbaptm L52, §25CM slates' mhb=-Ihe cammonwealthnor aay of iispDh ical svb� Shan e-Cr n3in may for penance Df pubfie tmi11 amt ptable evidence of=oplim=with the km.== regrrize MCMtS of ties djaptrr have bean prese3.ed to fbe coxdrartiug mthmity." A-Pplicaafs Please-MI out the wozlzem'compensation affida!a completely,by chmId g the boxes that apply to your sit ixa zOn and,if ne ,essajy, SPpl ML-confrectDr{s)name(s),ad ss(es)and phrme rnmmbea(s)along with they cPa�Ei ems)_of Tn m ranm- Limi Iz-ibllhy Conzpamts(LLC)or Limed Liab2*Pa:dne chips(LU)wiHi n o empl oyee s other ffim the members ar parfne2s,are nntreced to cant leas'competion Tncrrran�e If an LLC ar LLP does hate employees;EL policy is regviml Be advised fhat this affidavit map be submitted b the Department of Indvs'irial •Acr,ide=nts for confirmation ofm ce boverege_ Also be sane tb sign and date thm affidavit The affidavit should be reformed tD the city or trwz that the application f for the p=oit or licrose.is being reguestzd,not tl=Department of Indus ial'Accidents- Should you have any pension reg ding tc law m you are rued to obtain a-warlmrs, eompe�sationpoliey>please eaIlthe Deparlme�atthe masher dbelow. Self-insmzd companies should eat=their self-j„cr,ra„ce license number on the appupriate line. Y CYty or Town_Qffiri2Tr _ - • ' : . . . -_,. . Pleasemre�be s ihD a.ffidkYit is complete is legi5ly- The Department has provided a space atthe hot a of the affidavit for you to fill out in the e7mit tim Office of V=fi ii has in oontaot you r$gaFdmg the applicant ' Please be sm a to IHI in the perm't/T;=eF number which will be used as a mf�zmce number. In addition,an applicant that must submit muttipIe pen:dlicense app lit atons in arty given year,need only submit one affidavit indicting current policy information(if n y)and under'JDb Site Address"the applicant should write¢all locations in (city or town)-"A copy of the affidavit that has beet officially stamped or mked.by ie chy or town may be provided�the applicant as proof that a valid affidavit is an.file for future pcnnit or licenses. Anew affidavit must be Bled out c arh year-Where a home owner or citi=is obtaining a license or putt not related t o any business or cammcni aI Yegiure (i e.a dog license or pemut to bran I=Vcs etu.)said person is NOT r��i to complete this affidavit 'Ihe Office of Iuvmsdgatims would bike to thankyon m advance RTyour cooperation and should youhave any.qurs&ns, please do noth hMfr,to givens a caII. The Depa d m=f s address,t-1cpb one and fPxnumbCx: 'I$ arLV?,--s.I$i of Iassach Depaxf=at c,&YOmtdalAoDidntR _ • . - ���., Sizes - Bastm..IA G2III ww Ri�sed 4 z4-Q� . sARNSTABM Town of Barnstable 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 Faz: 508-790-6230 Property Owner'Must Complete and Sign This Section p g - If Using-A Builder as Owner of the subproperty, � , . J hereby authorize to act on my behalf, in all matters relative to work au%Aj y this building pe t application for: 1 �e T �� 7 (Address of Jo S' a e of ��Owner ate li A-• LA VIA/ Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:IWPHLESTORWbuilding permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services oFVE Syr Richard V.Scali,Director 'E Building Division BARNSrABLE. ` Tom Perry,Building Commissioner MAM 0.59. s��� 200 Main Street, Hyannis,MA 02601 ED MA't www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 _ HOMEOWNER LICENSE EXEMPTION I DATE: /Sl1 Please Print �,�,,,rr,•, /J _ JOB LOCATION: 1-7 � f �Vu v/vim Al R) nummb�berAA street village ...HOMEOWNER": �irt,y� 1+� �1 �Z / 7"� /11 b471 name home phone# work phone# . CURRENT MAILING ADDRESS: t 7 U f S f-N71t-i T.m,�Tu .,j Aj L.(7TI.tr rT yyl�1 672 & 5 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) t The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"h meowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection rote ores r ements and that he/she will comply with said procedures and requirements. S' afore of Homeowner Approval of Building Official . Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V�- Parcel Application# 45;;, 3a Health Division Conservation Division Permit# Tax Collector Date Issued Z �� Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address to I e46 Village Owner i_. Address Telephone Permit Request 1.vi 5 i c,.t ulJ 1A v 3 e_ - - i Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 D OCR Construction Type Lot Size a Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure' Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count � t Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coW hove: 1�ges ;11i No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑QFiAing ❑tt�w s c ` Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: 33" U �t 7v Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use -� BUILDER INFORMATION Name �y i y 5 d �4(0d � JS Telephone Number �Y 291 k!�ey Address/ License# UY cJ t S AAA c CCU 2 �� Home Improvement Contractor# / Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PRO CT WILL BETAKEN TO SIGNATURE .' DATES 017 t FOR OFFICIAL USE ONLY I PERMIT NO. 1 DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION r FRAME t INSULATION T FIREPLACE i i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL s FINAL BUILDING ACIAI(OK�,$��2�D� Gehl cl flc�ericr� ®Ar DATE CLOSED OUT - f ASSOCIATION PLAN NO. Department of Industrial Accidents Office of Investigations U 606 Washing mi Street Boston,MA 021II www jnm&gov/die Workers' Compensation Insurance Affidavit:Buddeis/ContractorsMectricians/Plumbers Auuhcant Information Please Print Leeibh Name pusine or Address: -a:.:_ P: City/3t itfaip: Cc Yu` r A o'�_C Phone#- S©i?� �} Z`v •- `t 2 4. ❑1 am a gmead contracOu.and I- Are ou an employer?Check the appropriate boa: Type of prq$ ct(re4�'�= 1_ I am a erii(i2oyer iwith-' ��`��•``� ti:❑New construction . �PIoY_ (falland/or pail tfrne).* have hired•he sub-c outwt zs = listed-on She attached sbeeG t- 7' II Remodeling 2.❑ I am=$-sale praprie6or orpartue .- - s have� pdoyees These sab--con'oac ors have l;. Q Demolition worlegg for me in any�Vacify- workers'comp.ms»ce. 9.. O[Noworkers' imp.ins�ance 5. Weare a corporationand its�l�'e-] officers have esemised EheirlU. rtrical le ens or additiaiis . 3.❑ I am.a homeowner doing aIl -work right of eaemptian per MGL il.n Phanbittg repairs or additions _r , myself [ATo workeas'.camp.. c. 15% 1`4) and we have no- 12,(3 goof repairs ms�ance ieq ed-hfi, ea ldyees-INo'wox ' i3.[]OSrer -• -- - ��-ice regnirea-1 - - - . =anyspp �ccluoa�i.m�ialsofn_oais�entieloW: -8�a• pokcymfr�a: _ • t sir xtIII ers who su�icth a�xmv m .g use alaing sII wad 6x a] amide t oRs c t a nee► vit u ug saw tcoonactirstiatA ftm.sc 4biadffi6oneiAlleecgbowing11--of*e.db-ooa�o =jtwkwafiw&cunp.-pofy on.•':: - I am an employer ig probing workers'c pEnsation'li"once.for.�w t Blow is the*ftcy irndjob site Insurance con Cc�&ti PA-A s Policy#or Self-ins.Lie:M Vd C 21 C — v 1 v 7$ F.apnation Date:t/3 G? t _ Job Site Address: City/S : Attach a copy ofthe:avorkcrs'camp ioap*.y dedaraflon page(showingthepolicy_namber and eapir$tiou date): Fame m secure coverage as required mkx Section 25A ofMGL c.152 can lead tioYthe imposition of arsmindpenawes.of a, Sue Up to$1,500 00 and/or one-year i prisamme - as wen as civil penalties in tihe f�of a STOP WORK ORDER.and aline of up to$250.00 a day against the violOx Be advised that a copy of this sMmMmaybe t wmled to the Offfce.of.= Invadgations of The DIA*r Rommee coverage verification I do hereby faf&under the aedpenaltiea0090)V'9 a W I e pr+wl&d old isvw,..mid.correa - signature, Date: LZ 0 9 phone# U O,#kW use only. Do not write in d*area,m be co offieiaL mpleted ly,chy or fawn City or Town: Permuf/Lioense# Issuing Authority(circle one): L Board of Health Z.Betiding Department 3.Cityrfown Clerk 4.F.leaUIW Inspector !L Plumbing Inspector 6.Other Contact Person- Phone#: ZNE p� 1 V rr 1L VA "Al AA1a L"iJia+ Regulatory Services sruvsTeet . '' Thomas F:Geiler,Director ' 3639• ,• Building]Division Tom-Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.towA,barnstable.ma.us Rce: 508-862-4038 Fax: 508-790-6230 Permit no. AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adjacent to \ such residence or building be done by registered contractors,with certain exceptions,along Rzth other requirements. Type of Work: �� st ® J l ,j� Es timated Co ��G .;yAddress of Work:. - _� Owner's Name: Ci !�t 1 �— Date of Application U I hereby certify that: Registration is not required for the following reason(s): ' QWork excluded by law FI7ob Under s1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is bereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNS UNDER PENALTIES OF PERMRY I hereb apply for a permit as the ent the own D to Contractor Signature Registration No. Date Owner's Signature Q wpMes.far=-.homeaffidav Rev: 060606 lbwn of BoMtable . Rejg i t :Services noes. Thomas R Ce4er Director B ,t�ffilY2SZaII. Tom Perry :Com oner ' 200 Main Street;;'$yMML MA 1]2601 ' wFew.to�larastable?nans . Cffim: 508-862-4038 Fax: 508-790-6234 Proper Owner Must Complete arid``)%n'This Section If Using A Builder j L as Owner of the subject property hereby authora, (��1'"7.t ��. � to act on behalf, my in d mattes relative to work authorized bythis building pemsit application for. l 7 � Sk ru Ir-iL&zumullo 10-ID (Address of Job) /z t� *oar=of owner Date V Prim Name ' Q:FORNiS:oWNERPIItM�SSION - ._ • Current Use rruputieu use - BURMER eve,rg reen :� � { Think Be ond.' f `� Y F SPRUCE LINE TM New 195W module y photovoltaic modules . Highest power and efficiency yet • Best available tolerance -0 / +2.5% i - - A range of high quality poly-crystalline solar a panels for on-grid markets offering exceptional i performance,extraordinary versatility and industry leading environmental credentials-based-on our, cutting-edge String Ribbon'"wafer technology: i 3 I E 1..,l r; Best-in-class performance ratings proven.by $ a field installations { _ • 98%of rated power guaranteed.for 1,80,`190W product; 1 s 100%guaranteed for 195W-pi6duct r. 5 year workmanship and 25-year power warranty t, for ultimate peace of mind ' More installation versatility with our extensive range of mounting options l H hher'strength with wind"and snow'ioads ' guaranteed up to 80 Ibs/ft2 r Qualified to all major industry certifications F' and regulatory standards e' + Smallest carbon foot-print leading t}ie fight i t against global warming Quickest,energy payback time-for the.maximum energy conservation Cardboard-free packaging for minimal on site waste and disposal cost } � C@ SCE *For full details see the'Evergreen Solar Limited Warranty available on request or online - This product is qualrfied3o UL 1703,UL Fire Safety Class C,IEC 61215 Ed.2,TI�V`Safety Class 2 and CE' String Ribbon andSpruce Line are trademarks'of Evergreen Solar Inc String Ribbon is also a patented technology of Evergreen Solar Inc ' v . J f V � � s - Electrical Characteristics Mechanical Specifications V. _ R a Standard Test Conditions(STC)t 37.5 ,. .-. I ", ES-180 - ES-190- ES-195 s; 0.16 4 GROUNDING HOLE' 7 RL,SL,TL wvl` -RL$L,71 crVL• RL,SL,71 or VL 3.5 Pmpz (V� . 180 190 195 Peoerance (%) .-2% -2% -0% P,np,ma. (W) 186.1 194.9 1:99.9 Pmp,min (W) '1`76.4 1186.2 195.0 m - Pptc3 (VV tOx 026) 1597 168.8 173.3 FOR 19-BOLT Vmp M. 25.9 26.7 27.T ` �1P5NM1CITION BOX 0 - imp (A) 6.95 7.12 7.2 u� CABLES(AWG12) r' V« M 32.6 32.8 32.9 Ix ` (A) N4.78:' - 8.053,.. . 8.15� ALUMIN uMODFR�am1°e Nominal Operating Cell I Temperature Conditions(NOCT)" ' P n p (W)y 129.0 136.7 140.1 i Vmp M- 23.3 23.8 23.9 I CP CONNECTORS Imp (A) 5.53 5.75' 5.86 (Types) V. M' 29.8 30.3 30.5 � t (A) ,6:20 h� � .,6,46,1, :6.59 .- - 7 5s x Vi.ts r GROUNDING HOLE TNocT, (°C) 45.9 45.9 , 45.9 �. I 0.76 (IF- .GROUNDING HOLE 1000 W/m°,25°G cell temperature,AM 1.5 spectrum; 1.6 35. Maximum power point or rated power At PV:USA Test Conditions:=1000 W/m2,20°C ambient All dimensions in inches;'module weight 40.1 lbs - temperature;1 rn w nd speed 9 °800 W/m7,20°C ambient temperature,1m/s wind,speed,AM 1.5 spectrum r RL model made in Germany without cell texturing;5L model made in USA% Product constructed with 108 poly-crystalline silicon solar cells, anti-reflective without cell texturing;TL model made in Germany with cell texturing;VL♦ , tempered solar glass;EVA encapsulant,Tedlar®back-skin and a double-walled model made in USA with cell texturing anodized aluminum frame.Product packaging tested to International Safe Transit Association OSTA)Standard 2B.All specifications in this product information sheet $ conform to EN50380.See the Evergreen Solar Safety,Installation and Opera- Low Irradiance tion.Manual and Mounting Design Guide for further information on approved _) The typical relative reduction of module efficiency at an installation and use of this product. irradiance of 200W/m?in.relation to 1000WIm2 both Due to continuous innovation,research and product improvement,the specifica- ° . . - o tions in this product information sheet are subject to change without notice.No at 25 C cell temperature and-spectrum AM'1 5 is 0/°- prights can be.derived from this product information sheet and Evergreen Solar assumes no liability.whatsoever connected to or resulting from the use of any Temperature Coefficients I P3 . -, " information contained herein. a Pmp (%/°C) -0.49 Partner: a Vmp (%/'C) -0.47 .. °•{ - - a Imp (%/°C) ' -0.02 a V. (%/°C), -0.34 System Design a- Series Fuse Rating' 15 A - ' t _ UL Rated System Voltage 600 V ( ' I - °Also known as Maximum Reverse Current - - QELECTRICAL EQUIPMENT CHECK WITH YOUR INSTALLER S195_US_010707;effective July 1st 2007 4 Worldwide Headquarters Customer Service-Americas and Asia 138 Bartlett Street,Marlboro, ,A 01752 USA _' A, 138 Bartlett Street,Marlboro,MA 01752 USA Evergreen Solar Inc.^ asr T:+1 508.357.2221 F:+1 508.229 0747 r T.+1 508.357.2221 F:+1 508.229,0747 www.evergreensolarcom Info®evergreensolaccom sales@e4ergreensolaccom Sac%R pP SOLA,R: T- t ao t Alt �� �\ S-rp ri 0 0�' L AC W Ct et Lq - ��� �e�•sv. 4 d�'Cy ..�--r-.�.,,...� ��,r".•' , � � _col 5IDL :fit i r.3 c fit: ��G� !y 10i1:0ecvll � € '' e1�/ ?: � �✓ yr s>%��4 Board of Building Reg, 'ons and Standards V One Ashburton Place - Room 1301 _ Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 146276 Type: DBA Expiration: 4/8/2009 Tr# 131107 COTUIT SOLAR CONRAD GEYSER P.O. BOX 89 COTUIT, MA 02635 Update Address and return card.Mark reason for change. SOM•05JOB-PC8490 Address Renewal F Employment Q Lost Card �jc (�orra»roierr.c�l�• r�...l��irt�icr./tuovka Board of Building Regulations and Standards License or registration valid for individul use only " HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 146276 One Ashburton Place Rm 1301 Expiration: 4/at2009 Trq 131107 Bo tpib Ma.02108 Type: DBA 4_' AT SOLAR 1 ZAD GEYSER FALMOUTH RD. ��G�..•�►.- "'•' STONS MILLS,MA 02648 Administrator Not valid without signature JUN-21-07 01 :34 PM TALANIAN BUNKER INS AGCY 781 659 2499 P. 01 JL v>s •.. -+r• �• •i a •pATI(MM/DO 6/05./071 THIS CERTIFICATE 1$ ISSUED AS A MA R INFORMA 03 Bunker Insurance Agency ONLY AND CONFERS NO RIGHTS UPON E CE�p�TlFIC ,( 2 Washington Street HOLDER THia CERTIFICATE DOES N07 ACME D> EXT1D. R;i ALTER THE COVERAGE AFFORDED BY E LICIES BELb Well y COMPANIES AFFO�jD�V_. E_ E MA -02061- 8�..659-0400 COMPANY S .__. t ) Scottsdale Ins.. " Co. ••__-_-- , o uit Solar h COMPANY Granite State Insurance C Ornpan: . BOX 89 COMPANY - ---- - ' 4 Old Share Rd. .; _Arbella Protection Ins: o 'uit MA 02635 C- 428-84421X2221— IB IS TO CERTIFY THAT THE POLiCiE8 Of INSURANCE LISTED BELOW HAVE BEEN 188UED TO THE IN7811k ED ABOVE FOR TH �1f0UCY PERT 1 DILATED.NOTWITHOYANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTNT WITH'RgSPE TO WHICH T� t E�{TIFICATE MAY BE*SUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCIN IS SUBJECT TO ALL THE tERhB LUSIONS AND CONDITIONS OF SUCH POLICIE9:LIMITS BROWN MAY HAVE BEEN III, UCED BY PAI TYPEcFtNSURAfiCE rOLIaYNUMBER � pDfM IDAR --yl1 LueK m ;o>:naRr►L 11t3GREGATE I ,0 tali COMMEMAL GENERAL UAMUTv CliS 13 8 4 0 5 6 '0 6/0.1/0 7 0 6/01/0 6 r PRODUCTS-wmppaw Am �2�01009, CLAIMS MADE ['X I OCCUR . PENBONAL a ADV INUH+r 81 O O:O Oi OWNERS rl CONTTiACTOR 9 PROT EACH OCCURRENCE' 1 0 0 0 0` lit I— - i FIRE OAMAOE(My aft figj b 5 Q MEO EKP Wry an peieon) 9 0 0: UIOMOSILE LIABILITY ' ANY AUTCI T/B/A COMBINED&NOLE LIMIT 6 04/30/07 04/30/08 1,00:0�0 ALL OWNED AUTOS 0€ ry 901EOULED AUT09 BODILY INJURY B tPe�tavtso�I I , KRED AUTOS NON-OWNEOAUTOS " NOILYI(YJURY 8 (F�ArcoidTnTl j PROPERTY DAMAGE 9 LIABILITY AUTO ONLY:EAACdOENT 1 i ANY AUTO OTHER THAN AUTO ONLY: AOOREOATE 6 I :I LMBIUTY .EAC_H000URRENGE I ;I UMBRELLA FORAd OTHER THAN UMBREWI FORM - !- —` -! Kvw COMMM9ATION AND X I• �LOYFRB'LIABILITY I �t/1�/a 06/05/07 06/05/08 EL�ACMaCpoEkT 1500 00 PROPRE UTIVE INCL ERSlEXECU EL DBME•POLICIIL NiTV 'B 5.0 01 0 0 cERB ARE: X TD(CL EL DISEASE-EA EPAOLOYEE $5 0 0 •0 0 0 ER E ON OF OPERATIONOfLMTRINaNEHICLESWECIAL ITEMS . BMOULD ANY OF THE MOVE oOMWO POLICIES 6E ELLED WORE' E EXPIRATION DATE THEREOF, THE NiBWNG COMPANY WILL ENDEAVOR TO t . DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLOM AMEO TO;THE BUT PARIM TO MAIL OUCH NOT=SNALI WPOOE NO OBL TION OR LIAEI Oi ANY KI O UPON TM COMPANY, ITS REPREMENTA AUTHOR EPRES AIM w.<. ttus.:oo x>e• wn•a:ou xx<x it ' xs•' <e< Engineering Dept. (3rd floor) Map � � Parcel 4�lf Permit# ( 7) House# 1p Date Issued 1-6 9 Board of Health(3rd floor)(8:15 =9:30/1:00-4:30) - 4 Fee _ Conservation Office(4th floor)(8:30-9:30/1:00'-2:00) I - 6r �c - ' /2 2 76 SEPTIC SYSTEM MUST DE ,TALL.ED IN � 19 WITH'T . ENVIR®NM6 ND TOWN OF BARNSTABL9 SWN ft1 Vi� 'jEOMA�a V" Building Permit Application . F7�1 Y.I�"WTD� t217 Project Street A ss Village COTO I I- Owner�f' 08GR 1 ZT, Y,0L-,4vp, Address 1� r l.DoL)T" 0 n11*TUS IV 0 Telephone Jl Permit Request K/ %L&-&j r First Floor square feet Second Floor 2 c2—D square feet Construction Type Q A ;Y� C— Estimated Project Cost $ 6 ;$8 3� 600 7 Zoning District Flood Plain N Water Protection Lot Size 3 Y A Grandfathered 56 Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Y-6 YAS Historic House ❑Yes 54No On Old King's Highway ❑Yes )4 No Basement Type: XFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 2 D Number of Baths: Full: Existing_/ New Half: Existing New No. of Bedrooms: Existing 3 New Total Room Count(not including baths): Existing New First Floor Room Count 3 Heat Type and Fuel: AGas ❑Oil ❑Electric ❑Other Central Air ❑Yes ANo Fireplaces: Existing New - - Existing wood/coal stove ❑Yes VNo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) Al 0 ❑Barn(size) �j None ❑Shed(size) / \ ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ANo If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE i BUILDING PERMIT DENIED R THE FOLLOWVRG REASON(S) FOR OFFICIAL USE ONLY t PERMIT NO. it DATE ISSUED MAP/PARCEL NO.-, ADDRESS P VILLAGE OWNER DATE OF INS ECTN: ` FOUNDATION t ✓' ` FRAME INSULATION FIREPLACE \ i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: '° Y. . .ROUGH FINAL FINAL BUILDI: IG = DATE CLOSED OUT ASSOCIATION PLAN NO. ° ✓j R - .. ... .. .. VE ri • astable The Town of Bar KAS& De artment of Health Safety and Environmental Services , 659. P Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commissioner Fax: 508-790-6230 J For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containingto or to such residence or building be done by registered contract ., with structures which are adjacent certain exceptions,along with other requirements. Type of Work: I�ITC �.: K � GO Est.Cost Address of Work: n (91 Owner's Name Date of Permit Application: " I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied __Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEE O HO PERMIT ME IMPROVEMENT OR G WORK D WITH UNREGISTERED NOT HAVE CONTRACTORS FOR APPLICABLE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Contractor Name Registration No. _Date • OR r The Commonwealth ol4fassachusetls • u;i , ' � _ =�,_.w Department of Industrial Accidents A I t - 1 Olf%CB 0110YeSM1911O/JS - `'^` l;I,._'-y_ h(/(l {{'ashitrrton Street •` i �' Boston, Mass. 02111 `- ' Workers' Compensation Insurance Affidavit �p�nlicant Information• Please PRINT leblbly s ', ( m c I(0 I�1 i-C)OLr �D ' J/ t� Cit% AN N A,�bU S M D � � �L U � nh<mc# �f ,�`7 57-3� I am a homeowner performing all work myself. I am a sole proprietor and have no one working to any capacity I am an employer providing workers' compensation for my employees working on this job. company name: i address: ' �.. phone#: incur•tnce co policy# - •: . . ..-.-- •- ..... .ter...._ ..,.,..-•--.�•;.�......... .,.Y,«.:.,.,�..,�,.,.a,,.�;.a.�,.q....�.--,,;,.,. _ 1 am a sole proprietor, general contracto or homeowner 'ircle one) and have hired the contractors listed below who have the following workers' compensation police . comIjAny name- address: city phone Of: tnsurince co nolicy# _ I _ .-. tt..1,r:.. ?1�Y!`.... :.- ;�'1•':.Y;n<• Rai+ ... •�4 I I..::i.L:..iiOriiYl''~t .LL�..+S company name: address: cih•• phone#• insur•tnce co policy# Attach additti' al sheet tf necessary,;_..� r: :s 1�+ •*, {?s,: r :_;_ . ':z:.`;.'�r�y�{ ?x`s�r; �� `� �eViut. =Yitiic�uC. �" ti+aa Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. t do hereby certi t under the pains and penalties ojperjurt•that the information provided above is true and correct. Si_nature Date // Print name 0 1��' z Phone# `rr 4 0 -757-312-9 i• a' r-- 71 �. otTiciai use only do not write in this area to be completed by city or town official city or town: permit/license# MBuilding Department ❑Licensing Board ❑check if immediate response is required ❑ Selectmen's Office . ❑Ilealth Department contact person: phone#: MOther (remised Pt.a) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted from the "law", an enrpl( ree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An emplurer 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 ONVIler 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 section 25 also states that even, state or local licensing agency shall withhold the issuance or rencival 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, 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 ha;"F been presented to the contracting authority. 77 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for 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. ,.� . 7777 i City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. t Tile Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents .-; . Office of Investigations .,:. 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 • TOWN OF BARNSTABLE r�3. BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION -Number Street address Section of town "HOMEOWNER" �06w V• AK D-?S�I�c3/o2 N .4:. : : Name Home phone Work hone - PRESENT MAILING ADDRESS R Duar j?2 IN�YP01Ws -740 City town State 1 Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures accessory to such use and/or farm structures.... x 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 Stat Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. F' HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person (s) for hire to do such work that such shall , ch Home Owner act as supervisor. . Many Home Owners who use. this exemption are ,unaware -that they are assuming the responsibilities of "a' supervisor '(see Appehafx' Q, Rules and Regulations for .licensing Construction Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In, this case our Board;-cannot`- proceedlagainst the inlicensed\ person as 'it 'would with licensed Supervisor. The Home "dwner- actin as supervisor is ultimately responsible. To ensure that the Home Ownert,' s fully`'aaware of his/her responsibilities, man communities require, as part of the permit application, that the:Tome Owner certify that he/she understands the responsibilities of a`supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. ' QNS VI AT co y ,X 4 V � e •.,f Y f � � _ � t tv,P ' 1 / • i ' � • t. _ �� � '• s � � .� � � III X � L � . r