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HomeMy WebLinkAbout0008 CHILDS STREET �y C���d S �'� � o 9 '�Y c. �.. _ � � O tl E ,. s .. o � a e e .1 , ,� {, I U ,� , v. _ �, c .. .,. , SS J a ,,.. .. .� ^�. - _� a a: . .. „ . n . s' . .. g -. o f :, ,; , ., p 4 �; � TOWN OF BARNSTABLE BUILIDING PERMIT APPLICATION Map O Parcel Application # C2 Health'Division Date Issued (3 Conservation Division Application Fee Planning Dept. Permit Fee Z Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 0 Ckl �T Village CftffA UGbf L Owner ' -4' M l- /Y A/ Address S74me Telephone 6 09- 7 3- " (o;P] D Permit Request �C`� i�� �l��T 1�d� G� icl/ �igS�l't /67*r1i1Qr9-fi. PY'Gf4WW( '/&6Y4 Ak� J. AL94ai4,n? 4i4A9t8 %� je)P , OA,40 Square feet: 1 st floor: existing13L6proposed JZ6 2nd floor: existing proposed � Total new Zoning District Flood Plain A/0 Groundwater Overlay Project Valuation a�f�C1Z�Construction Type -s � 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 Kings° ighway: fib Yeses No Basement Type: Full aCraWl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)' l3 " Number of Baths: Full: existing new Half: existing / nevi' Number of Bedrooms: existing 3 new Total Room Count (not including baths): existing - new First Floor Room Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ONO Fireplaces: Existing 0 New Existing wood/coal stove: ❑Yes VNo 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 _._ -- -- -(BUILIDERORHOMEOWNER) - - Name (O - Telephone Number Address 00 1 ' V l icense # efS f'96 �PA If t Home Improvement Contractor# d 2,5-6 01� Worker's Compensation # ®i- -1CC) ALL CONSTRUCTION DEBRIS RESULTING F OM THIS P OJE WILL BE TAKEN.;;O S� SIGNATUR DATE ��/ �"� � • } \ f FOR OFFICIAL USE ONLY } ` AOPLCATI N# \ . . DATE ISSUED - \ . MAP/PARCEL NO. - ! \ ADDRESS VILLAGE .OWNER DATE OF INSPECTION: ( . FO§ND TI pa - \ FRAME (tWnlll lee, . . % \ INSULATION, FIREPLACE ) FIREPLACE . \ ELECTRICAL: ROUGH FINAL . . . § PLUMBING: ROUGH F NAL y / \ . ASS ,,-2 ROUGH - rm FINAL »i . ) y l_ALBU&D|NG`, . it 7 .. , . g , . : DATE CLOSED pUƒ \ ASSOCIATION PAN NO. f . I{ � � } . s The Commonwealth of Massachusetts f Department of Industrial Accide" &>f- i Office of Investigations ;l e"-il; f 600 Washington Street i� Boston, M4 0.2111 e= www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information. Please Print Le>=ibly Name (Business/organization/Individual): w Address: , rQ City/State/Zip: U � � DL6/WPho 1 �f ne #: (17-0-6 U:r EEII an employer?Check the appropriate box: I oject(required): Are a employer with �� 4. ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors construction a sole proprietor or partner- listed on the attached sheet t odeling and have no employees These sub-contractors have olition ing for me in any capacity., workers"comp, insurance. ing addition workers' comp. insurance 5. ❑ We are a corporation and its red.] officers have exercised their rical repairs or additionsa homeownerdoingall work right of exemption per MGL bing repairs or additions lf. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs nce required.] t. employees. [No workers' comp. insurance required.] 13. Other *Any applicant that checks box#1 must also fill out the section below showing their workers'com cnsation ol p p icy 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 their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: ) _ Policy#or Self-ins. Lic. #: 0 c.og=�16-3181 d I " 0 f Expiration Date: Job.Site Address: ��/4b ; City/State/Zip: /l,�/ '`/Ae hli^0�✓Z- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required undler Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u r7the;' of perjury that the information provided above is true and correct Signature: -4111 Date: Phone#: `� 2� P C� Official use only. Do not write in this area,to be completed by city or town official City or Town:a Permit/License# Issuing use (circle one): I. Board of Health. 2. Building Department 3 City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector` 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who 'resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, 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-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 thattbe affidavit is complete and printed legibly. The D.epartment 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 proofthat 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 eom.monwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street B,Q.Ttoa,MA Q2111 Tel. # 617-727-4900 ext 406 or 1-877.-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass..gov/dia 08/23/2011 TOE 8:21 FAX 508 778 1218 DOWLING & O'NEIL INS R001/001 2/1,12011 8:13.13 AM PST (C-MT-8) FROM: i"urancevisions.com-TQ: 15087781216 Page: 2 of 2 CERTIFICATE csare¢nxcrnnnrr,vp THIS tUeRnFICATE 15 WSUED AS A!NATTER OF INFORMATION ONLY AND CONMRS NO RIGHTS UPON THE ClUt7lFiCATE HOL(JFJt THira CE MFICATE DOES NOR AF MMATIVMY OR IAEGATTVELY AMEND,WEND OR ALTER THE COVERAGE AFFORDED 13Y THE: POLICES BELOW. TINS CERTIFICATE OF INSURANCE DOES NOT CONSMU E A CONTPACT DMLEGN TN6 ISSUING INSUREe12(R),AUTHORIZED REPHES91WATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER- IMPOR7ANf: If the holdor is an ADDITIONAL 190RED,]be pollay(!e9)must he endue. E SUBROGA71018 IS WAIVED,cubjem to the tetans and conditions of the policy,min policies may require an enclorsenent.A state6Treert on aria certificate days Plot corals?rights to flee eerfificate holder in lieu of such endmwmw PROP'm DOWLING&O NFIL INS AGENCY INC COhM'ACY 973 IYANNOUGH RD E 20 HYANNIS,MA02601 . N:;U 8&PFORD@IC+CO7fEi>AG ._.. �vlaC9—_ F"URMA- Ube l a►suR® J J DELANEY INC MUMS:— 20 RASCALLY RABBIT ROAD UNIT 2 ROPFIR C MARSTON MILES MA 02M RO• MlSIAiER F COVERAGES CERTIFICATE NUMBER: 9663714 REVISION FIumse t THIS IS TO Carl IFY THATTHS POLICIES OF INSURAAICS Uf En SEL9W HAVE BEEN 189UED TO THE INSURED NAMM ABOVE FOR THE POLICY PERIOD INDICATED- NOTWCrHSTANOM ANY MQWREMENT,TERM OR CONDITION OF ANY CONrmer OR OTHER t]=MU NT WITH R,%r'ErT•T•C3 WHIC1,(Tf{IS CERTIFICATE MY BE MSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DEBOPE'FD HERMN IS SUD,IECT TO AM THE TEWS. 1 XcW8IOm AND CONDITIONS OF SUCH PCL1ma LIMrrs S OwN MAY HAVE[SEEN REDUmD BY PAID CLAM. TR c up Worm GMERALLAWtV EaCI10Cdf11it:N COFe M QMRM.LIAWJTY exaner o 5 zFt6edADE D OCCUR _ adEn ow �e elaOna $ FEMORAL 8AIN IHDJRY VENERALAOCOMOATF S 0@eLAgCrRE[iATpLWIrAPPLe P$t: PtI=CF8-00UPMPA.rsd 9 AuioR ong eL40LUY ANYAWO S M ILYIPLWRY(Parp-M) g ALLC IM 9CNm am &M - EODLY UQURY(IV na1J■nU ►eRElf AUTOS uomcvmmAURA - F rn Al!!59 OCG>R EACH OCCC NCE _ $ e11Hg CkALNB•MApE - A4'M"TE M Dim PETORmt S S A ?toRXM COMMOAT[aM WC2-183161 D7-010 11/20610 ITi=—lI AND 9Mft Y FX'UABOXY Y a N ANY�►+sa a�arrn� CFFIr1�RgIBA6rAFrrmerr. ® NIA @.L UCH ACCIDENr,_-- x QQ(} Ittfan'4inaeq EA,DISENE-VAEmpLa'E s ohmQw°�TIa�°e`�°°rooas+anaraeere■r e?.t.a)re�p14E_Ff}URYLtlWrr s 00 . oe a®mxoFo�Ra'ao1+s�LBCAT•oNS/VF�6taE6(!orate rmlo.AdnnlarmrRemanwace.mrrqurmn■pawNrequUa� W0rk9ft Compensation 4rsuar�.Part Onaof the VaCy applies Only to the Workers CotMOnsalion Laver of ttre State of IAA, L ERCANI SHOULD ANY OF THE AUVE DE8CM9M POLICIES BE CANCELLED BEFORE TOM OF 13ARNSTABLE THE EQe1RfAMN DATU 7"IDIEOF, KWCE WILD BE DELIVERED IN ATTN, BUILDING DEPARTMENT ACCORDANC�4NPiNYIdEPa3tIBYPFffi1r(pQNs, 200 MAIN STREW HYANNIS MA 02601 AaTHOta>�nRevRst�eraTrae Jeff FJ s (i�198&2010ACORDCORPORATION. All rlghtsmwrved. ACCRO 26(201 OAX) The ACORD Reaw and logo are rergWamd marts of ACORD CM NO-i 9369714 G°te1R COGS! L315596 wns tna■dies z/16/ib l: a:Itl•04 net e4ao 1 pe 1 L �SHerO�,y Town of Barnstable 0 - BL Regulatory Services - $ Thomas F.Geiler,Director 'Building Division Tom Perry,Building ConuTdssioner 200 Main Street,Hya=is,MA 0260I www-town-b arnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder , as Owner of the subject.property hereby authorize J B s (S'La 00� I Aj c to act on ray behalf, in ZU matters relative to work authorized by this building permit application for- (Address of Job) 4 of e Date 1 Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on -the reverse side. Q:F0 RMS:o W PZRP ERMISSI ON 04 cl•te r.� Town of Barnstable D Regulatory Services of � { i . � Thomas F. Geiler,Director rsAss. , . . ib3� g Building Division Leo {k Tom Perry, Building Commissioner 200 Mairi.Street,_Ayanms,MA_02601 www-to wn.b amstab l e-ma.us Dffice: 508-862-403 8 Fax: 508-790-6230 EEMMO WNER LICENSE EXEMPTION Pleare Print DATE: IOB LOCATION: number str=t village "HOMFA WNEIt': name home phone# work phone# CURRENT MAILING ADDRESS: cityho,%m state zip code TYie 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 constrgcts more than nne 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`4c undcrsigncd"homeowner"asstmies responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.t.Wshc understands the Town of Barnstable Building Department rrrinirrium inspection procedures and requirements and that he/she will comply with said procedures and ' requirements. Signature of Homeawn= Approval of Building Official Note: Three-family dwellings cunt dninmg 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 pm-forming work for which a building pant is required shall be exempt from the provisions of this section.(Sectirin 109.1.1 -Ucens-arg of amshvetion Supenisors);provided that if the homeowner engages a parson(s)for hire to do such work,that s-uCe h Homeowner shall ad as supervisor." Many homeowners who use this cxanption are unawars that they are assurmng the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Constuction Supervisors,Section 2.15) This lack of awareness bRan results in serious problems,particularly when the homeowner hires unlicensed persons, In.this case,our Board cannot proceed against the unlicensed person as it.A Duid with a licensed Supervisor. Thohorhrowncr acting as Super isoris ultirnatclyrtsponsibit. To eruuro that tbt h[3mc0wner is fully aware of his/her ztsponsibilities,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the responsibilities of a Supervisor. On the last 'a of this issue is a farm currsnU used b P � Y Y several towers. You may rare t amend and adopt such a form/certification for use in your community. Q:formes:h om ccx crop t ✓he Panvno-r�uealC� a�../f/faaaac�i,�� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR x Reg istratio t:4,--125529 Expirat, i15/2012 Tr# 291964 Type','ridividual JOHN J. DELANEYl JOHN DELANEY�� R� y J ,a 271 PLUM STW. BARNSTABLE,MN-020 Undersecretary — - massachr ettti-bcp:u-tment of Public Safetj Board of Building Rculations and Standards Construction Supervisor License License: CS 9961 Restricted to: 00 �' JOHN J DELANEY 271 PLUM ST _� . W BARNSTABLE, MA 02668 - Expiration: 4/14/2012 ('ununissiuncr Tr#: 20469 bef ehse or IO re lee of a expgrstrat/o4 0 a v Bo ParkPcohsh t�oh da a/idfor s / hie to . to a r �h h, 2a_ q p If dip �l S fai fo id 9 v, r v u 02 to s a hd /4s S r. h e II I� d et o 6 0 8psihes urh to. h/y. Reb'v/atioh Not l li h04tsghat4r e f ( IVlassach ctts :'Dcp: llment of Public Sufetl. Board of$uildin- Regulations , ulations and Standards Construction Supervisor License License: CS 9961 Restricted to: 00 sr ` JOHN J DELANEY 271 PLUM ST W BARNSTABLE, MA 02668 c-- �"�- �f Expiration: 4/1 4120 1 2 ('ummiSNi oil er Tf#: 20469 • t �� f Fl JOB 'v TAYLOR DESIGN ASSOC.,'INC. sHEEr^Na of P.O. Box 1313 ,. Forestdale, MA 02644 CALCULATED BY< `t Tel./Fax: (508) 790-4686 A _ .yCHECKED BY Q+ `f Vf�.A.ia SCALE ! ..... c 4n.iC.. . , ..... .. 3 .. . ... .... . :......... .. CD r : ; 3. ri V �. y D } ... 7777 ..: ...... �4 �� . . .... /.� . . ... ...... 7 .... ... u b ! .. s - .,.. .�� .a f. �y F:fir/��y t, ..:. .: k .... ..: '.. ... /! r- :. . cry— 3.3 PR.OJE _ pp JT ' ADDRESS Cam"/�IGI,3 �- ti„ - s. . PERMIT# --d PERMIT'DATE: 3. M/P: 01�> LARGE.-kOLLED.PLANS ARE Ts":., BOX SLOT Data entered: rn ,MAPS program on; t � _ _.'..ice TV ! �L1 zJ ..�,� `� - �; !i:" :,� Z. -:'1 S- t}, j '7 . ..[.'�,,...<L_<.. ; .rl.: ]. wii:.�DE �.t.;,� e �s .,�a. _:�l`r. `•_i r -A.y s,-r,'r'f:r T##'�ff - .. .._ .�.F... t: I ... ., .. : .tv '.}i.•tf }. Y4t�1.r.d.+. Ll a':I' ,. ,. ..... ,. :?..i e✓a. .. i.r.��} - . Department of Health Safety .._ ... _. .i.i. _'r... .. .. t ... ._. and Environmental Services ;.R a ✓ r! . INE . MSS. 0 9. ED MA'S BUI•I bIN-_7;MVISI6N! BY i THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED. FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. 1 BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL I PECTION APPROVALS 2 2 2 3 1 HEATIN NSPECTIO AP ROVALS ENGINEERING DEPARTMENT 2 BOARD OF HEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. . CIA „11 10 12 T' d.,. .� .s�....iY.f. .. .,�N 14 ? :. F tX. ...�S,/.,7 ti; `J. 4� i'�1�_. y �.-�r.:! ,.S _::1'.. 1_ li'i.{_t , , f': I i.�,_,)!F S .. :. I_E.�.v .(?��.l. Department of Health, Safety `T I and Environmental Services INE iABNSTABLE, MASS. ><639. BUILbIl4G bt.VI$10NI BY �,I�i• I' i 4,'s,{iyt'1": {': � {�%rt :_:dit-' �,r' r ! G 11 1 ad:'� - THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED . FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS. 4.FINAL INSPECTION BEFORE OCCUPANCY. 11 BUILDING INSPECTION APPROVALS �PPLUMBING INSPECTION APPROVALS ELECTRICAL ItJSPECTION.APPROVALS 2 2 2 /N!s'/� �j�v ri G r�✓f 3 1 HEATIN NSPECTIO AP ROVALS ENGINEERING DEPARTMENT 2 BOARD OF HEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVEDTHE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. Y y t Erig3' ap cP Parcel `�,V Permit# ' House# �� �`a Date Issued Board of Health Ord floor)(8:15 -9:30/1:00-4:30) Fee �• a.., �. c;? T Conservation Office(4th floor)(8:30- 9:30/1:00-'2:00) ©lam► live. MSS i Planning Dept. (1st floor/School Admin.Bldg.) �` �N�� ��[0A Definitive Plan Approv Board �- 19 ` BABNSTABLE, .^. . e MASS.' �/� :71anning TOWN OF BARNSTABLE, , Building Permit Application l Project"Street Address � �S6---�-», - �- f— � k�' S Village Owner n iX oh " Address e i,/n SOF �r1Lee /J,�ar�f�✓ Telephone apd/� Permit Request /9'D4 e o ��CiS�itfF �u-�/any ,liv iicy i�i7* /Y1A>Li do.0,. First Floor s o 1,b square feet Second Floor —F �i4 square feet Construction Type 6z&ME Estimated Project Cost $ t7"0,&& Zoning District jZ /. Flood Plain C7_ Water Protection Lot Size Rc w• Grandfathered ff/Yes ❑No Dwelling Type: Single Family UK Two Family ❑ Multi-Family(#units) Age of Existing Structure 6,6 Historic House ❑Yes 0�o On Old King's Highway ❑Yes pNo Basement Type: ❑Full @/rawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) oho - c&a 4y Number of Baths: Full: Existing / New / Half: Existing I < New —� No.of Bedrooms: Existing New / Total Room Count(not including baths): Existing 4� New 3 First Floor Room Count 7 Heat Type and Fuel: R'Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes 0'No Fireplaces: Existing New Existing wood/coal stove ❑Yes wlvo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) done ❑Shed(size) (,y1 ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use / //// Builder Information Name �' iFpi9 m/B/'ittG.( Telephone Number Address License# bdrJD�] Home Improvement Contractor# Worker's Compensation# �`' U� ,, 41-7 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 !�1t�— DATE L3��5� v BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) -.. mod v r FOR OFFICIAL USE ONLY PER IT NO: DATE ISSUED MAP/PARCEL NO. c ADDRESS VILLAGE' ': .' 1 OWNER •.,` ,i >° �. i+ • •� ..1� ` fir} DATE OF.INSPECTION: FOUNDATION ' FRAME INSULATION FIREPLACE + a ELECTRICAL: ROUGH FINAL - - PLUMBING: ROUGH ' FINAL GAS: '7 ROUGH s FINAL FINAL BUILAtfg j- - II • DATE CLOSE'b O�LTT F t s% 5 ' r , - ASSOCIATION-PLAN NO. • f i r *THE r, The Town of Barnstable • n�exsrnBi.E. • r 9� 1679. Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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 containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: Est.Cost �r Address of Work: 5 S1114l1� 4!5�Pr2y i//,0 /?�q, Owner's Name T 6f�X —T!0 Ae4LO� Date of Permit Application: a427 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law l' Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that:' OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: .�T •(or! `IZ Date Contractor Name Registration No. k OR Date Owner's Name The Commonwealth of Massachusetts 1r; Dc�prrrtntcnt of Industrial.9cciflc•�tts offl 60011'ashingtunStre�t J1. Bustoa.Alas. 02111 Workers' Compensation Insurance AMdavit apPiic•tnt informatitin� -� _ _Ple•fse PR1NTl=�j� name'. Vejr-� 14)e6.t . location L'h• S 57— city �i�rl� `!!,q• nhonc# 7� %� I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity . _'.'�::i.:-'--..��:.:'.���..�'�,�.....�n�c,_. L`,��'•-_- - - - --x- ----- ...yam..'_..."-....".....-----• p 'I am an entplover providing workers' compensation for my employees working on this job. enntnanv name: 9y/4 •tticlresc• �y f�iat!ah �7 . city. Adel nhonc N. �� ���• incur•tnce co Z—/ ;j� to� 1/206/gam M lama sole proprietor. general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comnam name: adttrese• r cit.•. nhonc#� insurancr rn. noiicr# I .• •'-r�� Yam...•.__.__ �.Y-.-......:_- � �r�•`S��1�1T"f yl.��. �.�.:.- - _ .f,.-`= _ comnnnv natnr* addresc- rin r nhonc#• insurance co nolict•# .Attach additional sheet if neceisary 1� i�' -�� �;,•y. <r •� �w++.• +w - � ���•� ��� Failure to secure coverat a as required under Section 25A of l%IGL 1S2 can lead to the imposition of criminal penalties of a tine up to 51.500.00 andiur unc�cars'imprisonment:is weil as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a COP)'of this statement may be forwarded to the Olrtce of Investigations of the DIA for coverage verification. 1 do herehv cerrijt•under the pants andpenallies ojperjuty that the information provided above is true and corrects Sinnature ,�1G� Date .20�267h" I Print name �?P®�il /�h� Phone# ' official use unly do not write in this area to be completed by city or town official ` city or town: permitilicense# MHuiiding Department ClUcensing Board C check if immediate response is required ❑Selectmen's Office F • �flealth Ucpartmcnt contact person• phone#• nUther information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for the employees. As quoted irom the "law an emplggee is defined as every person in the service of another under anv contract of hire, express or implied. oral or written. An enrhlorer is defined as an individual, partnership, association, corporation or other legal entity, or any two or mot the foregoing engaucd 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 th owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwcllin- house of another who employs persons to do maintenance , construction or repair work on such dwelling llc or oil the �_rou►lds or building appurtenant thereto shall not because of such employment be deemed to be an employe MGL chapter d 52 section 25 also states that every state or local licensing agency shall .withhold the issuance or rencival of 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 in coverage required. Additionally;. neither the commonwealth nor any of its political subdivisions shall enter into anv contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and suppiying 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. Tile 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 require- to obtain a Nvorkers" compensation policy, please call the Department at the number listed below. Citv or,rowns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questio please do not hesitate ro'give us a c:ll. I y..y,..,.�. -. _..._.� - .-�w....a.. ..� -.-ter..•. -._..-.T•r�..w��aew.+�wrP. ,..: --...+.re--..w•r•...v.tiJrir••rr.r�•orw_�_ Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 NVashington Street }� Boston,Ma. 02111 „ fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 I Table JSi1b(condnaed) hpleriptive Paekago for One and Two-Family Residential Buildings gated with Fad Fuda MAXIMUM MINIMUM Glazing Glazing Ceiling Wall Floor Baseman Slab HatinWCooling Ama'(•/I) U-value= R value' It value R valuel Wall piaimew S*dpmm EffcicI package Rvaluej R value? 3701 to 6300 Hadog Degree Dare' Q 12•/. 0.40 38 13 1 19 T10 6 NormalR 12iL IZ•/. 032 30 19 19 10 6 Normal S 030 38 13 19 10 6 85 AFUE T • I3% 036 38 13 23 WA WA N� U IVA 0.46 38 19 19 10 6 Normal V 13% 0.44 38 13 2S WA WA 8S AFUE W 15% 032 30 19 19 10 6 83 AFUE X 19% 032 38 13 23 WA WA Nornukl Y 19% 0.42 38 19 23 WA WA Nomml Z 18% 0.42 38 13 19 10 6 "AFUE AA 18•/. O.SO 30 19 19 1 10 6 90 AFUE 1. ADDRESS OF PROPERTY: g 644T : 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING:. 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. } BUILDING INSPECTOR APPROV YES: NO: q-forms•t980303a 780 CMR Appendix J Footnotes to Table J5.2.1b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall area,expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 W of glazing area. 'After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding,structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces, basements, or garages).Floors over outside air must meet the ceiling requirements. `The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. "Me R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3,4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a NOTES: T a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J 1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall, floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 ;•�/re 'aaa/bi o�✓�aeoi�uRtoed HOME,IMPROVEMENT: CONTRACTOR ' F} � r `Registration �103419' � . Type'- INDIUIDUAI EXpiration 01/08/98 ; �•STEPHEN M.HOI.MES r Stephen M. Holmes � 0 Box 2537 14.Bacon Rd 4?: ADMINISTRATOR - 3 :: Hya !nn]1 15 ti� eo ' O,EPARTMENT OF PUBIC SAFETY 1 CON'STRUiTION SUPERVISOR LICENSE Number Expires: — Rist tcted'To� 80 STEPHEN Mil HOiMES l�..r+..•ss�!f1'T� 19 6'4CON'RD { HYANNIS, MA 02RI LOT ?A f LO7' Ili 0o.po i \ ,oo �� \ to � ,�210 PC4�� � \\` o �e N \\ LOT IA � 1 Ao'g jo �` N' �32 d RE'S LONE- "RD-J" This MORTGAGE INSPECTIONPIan 1s For ROOD ZONE: "C Bank Use Only TOWN: _C _ � .__.. .... ._... .,. REGISTR.►' OWNER: .....�L18�' �A_I'C IA _ DEED REF: _z �2/1l9- _ BUYER. _JF.�hY?L,.}` I�� I�IX�AL � MARY- N.L'_�d3'I�DI>?,-1&lxox DATE: 1 1, /�1 _ PLAN REF: 2?9 5'6 _ _SCALE:1 20 FT. Y I HEREBY CERTIFY TO TL _.13MR-OWD --- I'OI? SA VINCS ____THAT THE BUILDING YA�V�� ''T!; SURVEY SHOWN UN THIS PLAN IS—LOCATED ON THE GROUND AS "��� �9� � �E SHOWN AND THAT' ITS POSITION DOES ____ CONFORM ��' ►'Al3L „ CONS�Il.,'.'ANI'S n TO ME ZONING LAW SETBACK REQUIREMENT'S OF THE ;` mr-A l-IJEW 143 ROUTE 149 TOWN OF BA1>?NSTA& ______.ti____ AR'D WHAT , r40 32098 YARSTONS MI1d3, MA. 02648 IT DOES__AR7 _ LIE WITHIN THE SPECIALTFLOOD HAZARD `fir, �£�1St., . @y� TEL: 428-0055 AREA AS SHOWN ON THE H.U,D, MAT I)AT1���5 <<%� �,�� ]FAX 420-5553 Co ,250001 0005 r __ (�� PLAN NOT MADE FROM AID' I STRUMF,NT AU1 A. lg!, T'I —)�I _—�-- Y N'OT 'TO 13F. USED FOR FENCES ETC 77f 6' KJN � llt I i o I I 6\ ED! 00 I d s �I a N. o i I D 2 o im � �q i ;Iyyp D fV o ih 1p Q i , s .I c i I ' i! ! ' i I � � i - --- I C I �� -- �\\ � I j �.;�.\ i � �� I .'.. ' �':\\ � �x ( � I i �� 1 \\ /� � �, I f i l l I I ,�/ O i �� .�'/ . �__ � o II �i L. . 11 ,� -- r �'r I 1;� 1 !C f/� I � 1 1r � f r �tl 9 � III 'l lli� r;r I 1 , ; i —:::' :. j,-.-... ...._ i _..:_: .' f —,_-_— ,.. r ,...._. ... I �. I 1 ._..._....._ i ----- i 1 ---„..._�=.f I t f 1 1 i I 1 i I I i .� I I ' I l 1 t c: I L4 4 !I i I , I e f j • i i j i t j i ` E iI - =NMI f i I s i I i i ? I I l i ; i � f � ! f i i { i ? i I ! I i i i j� 2 : k � ; f Ii _ f 44 4O Cn e���'LAO nit, 01 tt 1 i i r 4 l f -- -------- _-------- ----....__-._... r ------'--- t� i i od ny 2 �Of1HE r To_ wn .of._Barnstable *Permit;# Expires 6 months front ne date Regulatory Services . Pee + BARNSTABLE, + MASS. 9 Thomas F. Geiler,Director n Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www,town.barns table.ma.us Office: 508--862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not.Valid without Red X=Press Ihnprint Map/parcel Number f Property Address 1�,A ( eykC e-9-1-)kk�e ❑Residential Value of Work '—A4Z Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address !S c� Contractor's Name_ ;cl!,� S op,,(,� m Telephone Numbers �'E) Home Improvement Contractor License# if applicable)-_ 2. Construction Supervisor's License#(if applicable) f Q Q FEB ® 3 z0,0 ❑Workman's Compensation Insurance Check one: "TOWN OF IBARNST ABL . ❑ I am a sole proprietor ❑ I.am the Homeowner �] I have Worker's,Compensation Insurance Insurance Company Name ��aZ1a`� � -CAtt Workman's Comp.Policy# j 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 ( '455d(. ' ❑'Re-roof(not stripping.-Going over existing layers of roof)' ❑.Re-side /�nrSlF'Sc,�1 4b s2 e_5 #of doors _ a Replacement Windows/doors/sl'ders. U-Value (maximum .44)#of windows *Where required: Issuance of this pe does not ex pt compliance with other,town department regulations,i.e.Historic,Conservation,etc. ***Note: -prope caner m sign Property Owner Letter of Permission. A c f the e Improvement Contractors License & Construction Supervisors.License is re . e SIGNATURE: . Q:\WPFILES\FORMS\buil X-9perini f.,.s\EXPRESS.doc — - - Y The Cominonlvealtlr ofNlassachrisetts Department of industrial Accidents Office of1'nvestigations 600 Washington Street z� —f =� Boston, MA 02111 wwv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Name (Business/Organization/Individual): 1 (C . Address: `7 6L ke" ( v\ City/State/Zip: 01ae S N� Phone #; 40 3 Are you.an employer? Check the appropriate box: Type of project(required): 1A I am a employer with ZL 4. 0 1 am a general contractor and I 6: F1 New.construction employees (full and/or part-lime).* have hired the sub-contractors _ . 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 workingfor me in an capacity. employees and have workers' Y P y• 9. ❑.Building addition [No workers' comp: insurance comp. insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 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 Roof repairs insurance required.] t C. 152, §1(4),and we have no employees. [No workers' 13.�Other It�itvS comp,insurance required.) *Any applicant that checks box ff l 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. tContradiors 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: ('�2e�n e Aq G — Policy# or Self-ins.Lic.#: 0 6-5-1 Expiration Date: . 11 /d Job Site Address: 4�- c L• U5 SA City/State/Zip: Zlo 5 Attach a copy of the worke s' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage s/requiredrider Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 an r oprisonment, as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to$250.00 a da gainsor. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th IA for coverage verification. X do hereby cerl' rnd t e ai and res ofperjury that the information provided above is true and correct. Si nattiire; Date: 2 t A Phone#: Official use only. Do not>vrite in this area, to be completed by city or town official. City„or Town: Permit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6. Other Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees, Pursuant to this statute, an employee is defined as ".,.every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the , dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall.not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or 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 tvho has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their 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 pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below, Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact,you regarding the applicant: Please be sure to fill in the permit/license number which will.be used as a.reference number. In addition, an.applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for filture 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 pe rmit ermit to burn leaves etc.)said.person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.inass.gov/dia �YHEr°� Town of )Barnstable Regulatory Services i nmiNsrABL , ' Thomas F. Geiler,Director . rues. �+ � 1Fp i639. .m Railding Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �tDcSo,1 , 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) J � i Sig e of er Da e P" ame If PropejU Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. i .r r Town of Barnstable " Regulatory Services o� Thomas F. Geiler,Director 3AMSTABLE, 019; a,�� Building Division r�D '� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 vnvw.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 dwelling's 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 shall be exempt from the revisions uildin ' ermit is required p p The Code states that: "Any homeowner performing work for which a b g p �I of this i 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 fomi/certification for use in your community. n\WPFILF..S\FORMS\homeexempt.DOC From:Erica Barreh �i:0I6e Cape Cod insurance t'3r1L.i:OL.DE CAPE COD INSURA To:Meagher Cate 708/211,09 11:34 APA Page. 'of't 07®14-09 02 1lpm Fros-s#r ` +673 631 9566 T-443 P-0/40Z F-816 77 • it 1 ;•r C' �'b'f��(C ®^ 4ik 4 N � �- y*ri ' •. I � O!?UCEf#__-. .,,�.—_ ....�,.. -- m �t�•�'E't�'ia~i�i�o�;S �El..��°t�A,a A.V°,i""w,rt C t-d;�i'e~fJf?�A�Ti��- i..Y AND CONH;RS III r r• n c ENo �iiWc r�eU, :r W. G:d Capp vo6':��urmna: v n4y''te. r101 ,E-� ::'!�C .R F� �A,. 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TY?EQE94' PKRIJG1"t•,•dl°4� MD 61V�OYM'lwl-,-iy LIMITS r+AttLN�ibfCu'6ClTrIV2 ! 6 � � f ' 7 7FP'CE[r7 d L-rA1t1TQsp �_;,1�ca C7�Y.;,is ',..,,•:�:!Miff'�`i :...?-._..,. �1�?�t'i QU�1 ._ ;_r,.,a #r 5« _ .1 ,�...-.__.�r-..,..:�:.._ �.,., : t I M,THF_WORK?RS CoMn VNTRON PCLIC°f OCIFS NOT FE:iq`im G 4voAGIE F OR W VI AEA j fi Cr BARN STABLE ga.cnacra,�tvY i ?r AR V8 L7C8CRt{ A peg cit y reari9Ei A BEF61R�THE i �►_1�G�tEFT ! LIAP( Xrce�v Etatr� ,TMISOUNQCWPANYWIL ENDEW014new�sLy� �3C SOUTH n`�� A"!l tti i?E?(YG i N 2`'M TKs"-9rlPli:AA&P19LDER"en rQ THE LEFT,30 * ! t+AlEUR1i 1 Q AlAAf-S'JG1-0 rc6T'06 6 �1 1M14PL�9>�PiG p�.lt3A(10t6 OR I IA9I RY GF j NYAfVNtS,I+rA t7i.01 — _ # Pdd1�qr�DtfF'L'!3"NE,6Qtrr:*1y,rrSASONY3a�(teP11693tkTAT1V3S: ` � r,f.1�!OlY1Mi�f.�'t��PPtE53tit"A ff '�....�___.�._...�..�,.-__.�..-.-.�-�-�• s aoacras!u!wpd " 849ZO VVY'III11YSNO1S2dVVY l 07"MN3 L6 aru83WJV3w -13VHOIIN ?' NOI-LOnkIISNOO Sa3H1O88 a3HJd3W • t�•' b'8© atl�t j t3£b£8Z #Jl ftOZ/LZ/4 u6i;ejjdx3 $£6Z91 :woi;eJ;slBoa 21010VNIN03 1N3W3AO11d WI 3WOH sp-1epani5 PUB su01teln2ag Sa!PI!ng.lo Paeog Massachusetts -2epal-tmcnt of Public Safety Board of Building Ro,ulations and Standards Construction Supervisor License License: CS 102260 _ } Restricted to: 00 j MICHAEL MEAGHER JR 97 EMERALD LANE MARSTONS MILLS, MA 02648 .: Expiration: 11/5/2012 (t i�imi..i mra Tr#:'102260 License or registration valid for individul use only before the expiration da e. If found return to: Board of Building R lations an tandards r One Ashburton PI a Rm 130 t Boston,Ma.O�Za N alid withou si — — - Maloney Kathy From: Schlegel Frank To: Maloney Kathy Subject: Map 248 Pcl 014 Date: Wednesday, July 08, 1998 2:15PM Kath, Bob Burgmann told me that a property owner came in and asked to change their address on Map 248 Pcl 014 from#202 Pine Street, Centerville to#8 Childs Street, Centerville . I just did a field check on this building and determined it should be#8 Childs Street. I changed the address in Pentamation but I believe there might be a building permit open on this parcel for renovations. Therefore you would need to change your written files. THANX Page 1