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Building Division q as lEo.r,�r Cos) .III Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 1�a S DS Property Address Qt/[o Residential Value of Work 2 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address /�/¢�Iy- {/. C O.yL o 2I 6yfSrgRc 4. f7;�,EfT- VN/.T- Id 6j,- /Pl (�y. MV az %"y2. -,rG6T -- Contractor's Name �p 8 EK-r (/5 t"O Telephone Number 77 3 8 -2-93 Z• ��Z .rt Home Improvement Contractor License#(if applicable) /D S G 3 %1�' io�.e trlf s►s �i Iry(-d - d39693 ❑Workman's Compensation Insurance p � PERMIT Check one: 9-I am a sole proprietor ❑ I am the Homeowner AUG 14 2008 ❑ I have Worker's Compensation Insurance � TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy#Copy of of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. U-Value • 3 f (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission4,dl')l A 10 A copy of the Home Improvement Contractors License is-r bed--` -- �l V1 �i1d Luc SIGNATUR Q:\WPFILES\FORMS\building permit forms EXPRESS.doC Revise020108 The Commonwealth of Massachusetts. . Department of Industrial Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individud): Fa 13 -rot r T MV ST y Address: / v S $O N ti n• 6410*0 D2 City/State/Zip: t957 f2 r<«F, ZMA DtG SS Phone-#: S08 S3 0 Are you an employer? Check the appropriate box: Type of project(required): LEI I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction . employees(full and/or part time).* have hired the stab-contractors dd listed on the attached sheet 7. ❑Remodeling 2.,�`I am a•sole proprietor or partner- ship and have no employees These sub-contractors have g, 0 Demolition employees and have workers' working for me in any capacity. . t 9. 0 Building addition [No workers' comp.—insurance comp'insurance. rtquirtxi] 5. 0 We.are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions myself;[No workers' comp. right of exemption per MGL 12.0 goof repairs insurance required.]t c. 152, §1(4),and we have no /aeLIME.vr employees. [No workers' 13.�--Other �pP comp,insurance required.] . L(//N Do�+s Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating lhcy are doing all work and then Dire outside contactors must submit a new of davit indicating such. t-_Mtractors 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-conlractars have cmrployces,they must pmuvidt their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name: A/A — Policy#or Self-ins.Lie.#: /�'�id- Expiration Date: Job Site Address: ee A��a mom.i b r c Dt ��1�it vie¢ .0i Cty/StatelZip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to see coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy-of this statamei t may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I : ferjury that the information provided above Zr true and correctdo erfy 7ep p a p Si Date: �/9 d8 _ Phone#- J-d 8 —53 Vd- 774-Z98 • 2 93 z- Official use only. Do not write in this.area,to be completed by city or town officlaL City or Town: PermiMcense# 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 of the foregoing.cngaged 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the-contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(a)name(s),addresses)and phone number(s).along with their certificates)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding tiie 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 Deparhnent 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 ono 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 (Le. 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,telcphone•and fax number. The Commonwealth of Massachusetts Depart rent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02 111 TO. #617-727-4900 ext 4-06 or I477-MASSAFB Revised 11-22-06 Fax#617-727-7749 www.mass.gov4a oF�HEf . Town of Barnstable Regulatory Services BARN" AULK MASS. Thomas F.Geiler,Director rFnNu.�a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,.MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize ��Bi<2�C' T /KU S T-0 to act on my behalf, in all,matters relative to work authorized by this building permit application for: �/MPP-f qy! A I C d«G F �!/4 0 2 C 3 i (Address of Job) Signature of wrier Dat . M'q(Z.V 1.1- C 0 rj Lo AJ Print Name If Property Owner is applying for permit please-complete the Homeowners License " Exemption Form on the reverse side. Town, of Barnstable �pF THE 1p�� 0 Regulatory Services " Thomas F.Geiler,Director t BARNSTABLE, �. y, 'MASS. Building Division PrfD f"A�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Kvnv.town.barnstable.ma.us Office: S08-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB*LOCATION: number street village "HOMEOWNER': n me home.phone# work phone# CURRENT MAILING ADD S: /town state zip code The current exemption for"homeowners"w xtende o include owner-occupied dwellin&S of six units or less and to allow homeowners to engage an individual for ho does not possess a license,provided that the owner acts As supervisor. DEFIN ION OF OWNER Person(s)who owns a parcel of land on'which h she resides or i nds to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or tached structures acce ory to such use and/or farm structures. A person who constructs more than one home a two-year period shall not considered a homeowner. Such "homeowner"shall submit to the Build' Official on a form acceptable to the gilding Official, that he/she shall be responsible for all such work perfo under the building ermit. (Section 109. \\ 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 sai procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Jar will be.required to comp with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perforating work for which a building permit is required shall be exempt from the provisions of this section(Section iog.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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 caret amend and adopt such a form/certification for use in your community. Board of Building io"ns and Standards -�-.— -HOME IMPROVEMENT IMPROVEMENT CONTRACTOR License or registration valid for individul use only before the expiration date. If found return to: - - = Registration 108639 Expiration g Board of Building Regulations and.Standards g /20/2008 One Ashburton Place Rm 1301 ±Type -.I'diyidual Boston,Ma.02108 b Y ; ROBERT J. MUSTO Robert Musto 105 Bonnie Briar Drroe ;4, Osterville; MA 02655 •' Deputy Administrator Not valid without signature a. f - ,y ' e�PyoFTHE T TOWN OF BAR NSTABLE i • i BARESTADLS, i M6q0 y BUILDING INSPECTOR � pY�' APPLICATION FOR PERMIT TO .... ... .. ...................:.... ....�............ ...... .. ..............�........................... TYPE OF CONSTRUCTION ........ ..: > "'...... .....:Mq;......� 1; 4 ...............,...................19...... . TO THE INSPECTOR OF BUILDINGS: The undersigno her y applies fora permit acc- i to the following information: Location �........................... .. �. r "... ProposedUse .. ...................... .............................................. ............................................................................. Zoning District ........................................................................Fire District ..... .. ........... .o-� —`..................... ... ...................... Name of Owner ,;�.... . ... ... ..:.... . ... Address ....... .... ........................ Nameof Builder .................$,#................ .......................Address .................................................................................... Name of Architect ..................................................................Address . .................................................................................... Number of Roo s .......... .......................Foundation ....... ..,.<,,. ............`.... ............................................. Exterior .._ 0, � Roofing ................ t g . . .................... r� Floors ........Interior ....... .. . . ............................... Heating ...Plumbing ............................ Fireplace ...........--..... ... ..... ... . ::. .::. .........................Approximate Cost .... .. .6.... ...... .............. ..... Difinitive Plan Approved by Planning Board ________________________________19________. Diagram of Lot and Building with Dimensions THE PROPOSED METHOD 0 ICe SANITARY WAFER SUPPLY, SEWAGE DISPOSAL AND DRAINAGE 13 HEREBY AFji�'RoVED TOWN OF BARNSTABLE. A LICENSED INSTALLER BOARD OF HEALTH PERMIT, ANO 1NSTA MUST OBTAIN SEWAGE LL SYSTEiVI. dD I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regar i g the above construction. Name ...a ..... .. ..�.... „ . . ............................. . mall, Alan DEC 31 i No ....13639 permit for one , ...................story................. single family dwelling .......................................................... Locati n &.!h ppaquiddick Road ............................................ Centerville ............................................................................... Owner ......... lan Small ......................... Type of Construction ......frame ............................... ................................................................................ !! Plot ............................ Lot .......#31.................. t Permit Granted .....February 24 19 71 Date of Inspection + Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... Approved ................................................. 19 ............................................................................... 1 .................... ......................................................... r