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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map a� Parcel Permit# 78511
'Health Division f'� Date Issued J D
` Conservation Division AkG G Application Fee
4 Tax Collector o �C� 6� Permit Fee *3A•®0
Treasurer A` L— `�(� ' D • 0Lo rEe
Planning Dept. SEPTIC SYSTEM MUST BE
Date Definitive Plan Approved by Planning Board INSTALLED IN COMPLIANCE
WITH TITLE 5
Historic-OKH Preservation/Hyannis EWIRONMENTAL CODE AND
TOWN RECLil Annti$
Project Street Address ��� //��� •C./�n�
Village l ell Awdle, y
.Owner d1kPgeA) &k&DIAI Address
Telephone '7JQI-c 7S V3 yS CH ��' � �•� �/
Permit Request _ 4 RWJQce, 6,0S&r. z11��i c .� E,9/4 09a9diU1., 04 &4
Square feet: 1st floor: existing 100 proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
,Project Valuation 4 � I�t o Construction Type `
Lot Size ®./ Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family W/ Two Family ❑ Multi-Family(#units)
Age of Existing Structure?01/fi �9�� Historic House: ❑Yes * UK' On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑Full EY15—awl ❑.Walkout ❑Other
Basement Finished Area(sq.ft.) SV//�" Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing ® new Half: existing Al /3 new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing new. First Floor Room Count
Heat Type and Fuel: 0"Gias ❑Oil ❑Electric ❑Other•
Ventral Air: ❑Yes W<o Fireplaces: Existing New Existing wood/coal stove: ❑Yes Q-Nu
Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed: sting ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes _. ❑.No _. -If yes;-site plan-review#
Current Use Proposed Use
BUILDER INFORMATION
Name Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
I
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE ` DATE
T
FOR OFFICIAL USE ONLY ,.
PERMIT NO.
I DATE ISSUED -
MAP/PARCEL NO:
ADDRESS VILLAGE
OWNER ! I -
DATE OF�INSPECTION:
"• FOUNDATION
FRAME
INSULATION
FIREPLACE
S
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH fit'! FINAL _
m
FINAL BUILDING a!C IQd 0 ✓
om -
�; 3? 0 �- Mac
co x MJ
DATE CLOSED OUT m f s ram"- Q Rl
m
ASSOCIATION PLAN NO. ::> -, 'u Q
r m
;! .�'he Com�ru;neath of 1Vlussachusetts .
department of IndustriatAceidents
600'Washington Street
Boston;Mass. .02111 w
worlrers'..C m ensatio k Usurance AffidaQit-General Businesses
092,
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address: F•. .• hone#• ���� '7�� �'�
• date'
address '�-� {/ga�tEating Fstablisment
wor 'te locatioli d have no onA ' ${IsineSs x`YP e: (�Retail❑Restate an Antos etc.
Y sole proprietor an []pff ll Sales(includingReaYEst e, �
ca achy. L
yvoiking in anyP 'lo'ees dull&' art time: ❑Ocher
I am an em to er with ' em
n this ob.. . '
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ris'urst :~ a followin
" aud'have,hired the independent contractors listed below•who have th g
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insurance'•=`b+'t`:`' ooxoan or
e cpye overage as required under Section 25A of MGL 152 can lead to the imposition of crimin sl fleneYties of e,st i e, to de
Failure to aecur enaltiec Section
the foYm of a STOP WORK ORDER and a firla of�100.00 a'day againit me. I understand that):
one yearn'imprisonment as well as c} lp r ;
copy of this statement Ply
forwarded to the Office of Ynvrstigatiom of the DlAfor coverage verification•
er th airs and
I do hereby certi alti I jury that the information provided above is frue a4d 1CON"t
r
Date
Si�Iature hone
print name s .
;y efiioill use only do not write in this area to be completed by city or town offlcw
permit!llcense# []Building Department
. pLicensing$oard
city or town: ❑selectmmn's Office
•checkif immediate response is required [Health Department
[} ,
[]Other.
phone#;
contact pmrson:
qel Sept 2003) a
' inform afaon and Instruction
• ens forth
eral L'aws clz�pter 152 section 25 regiiires all employers to pYovid'c workers' comp exr.
Massachusetts Geu employ
; ,As quoted'fromthe `law",, an employee is.defined as every person in the service o another undo any contract
of hire; express or inapli~ed; oral of written.
oration or other legal enti' , or an two or nigre of
An e 'Tjoyer is defined as an individual,parhaership, association, core g t5' y ,
the foregoing gaged'ur a'iomt enf��e' and including the legal representatives of a deceased,employer, or the receiver or
association or other legal entity, employing employees. 'Howevei•.the owner of a
trustee of an iadivid�j Partriershi. p, •
dw ig house hapng,•nonnore than three apartments and-who resides therein, or the,occupant bf theAd yelling hoarse bf
another who emplbyspers;Ws to do maintenance, construction or repair work on such dwelling liouse.csr on the grounds or
burgling gppurtenant thereto shall not because of sucli.employmed.be deemed to be a:i employer,•,,.,
• • ;.
ct ' 25 also'states fhat'every ah
state local licensing•agency sh +Athhold the issuancb or renewal
MGT�chapter 152 se
too operate a business or to construct buildings in the.con=onwealth for any applicant who has
of a license or pernoit p
not Produced acceptable'evf dence•of coimpliant:e wl�enter into anthe Ce o3rtracgfor theeperforznan e of public work untT•
cozrm�onwbalthnor.any.of its political subdivisions shall y
acceptable evidence of compliar with the insurance requirernents•of this chapter have been pxesentetl to the contracting..
authority,
NO
A.Ppgcants
Please the ensa•Fiorr a€a&vit completely,by checking the box that applies to your situation:,Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be subnutted
to the Depent 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 perrnat or licens a is being
o'f l dustrial.A.ccideuts. Should you have any questions regards the'"IaV or if you are
requested, not the pepartment
btain a•workers•'•compensatjmpgEq,please call the Deparment at the nimrber liste�ck.belovsr.
required to,v.. , ,
City or Towns
Please be sure that the affidavit is cbmplete andprmted legibly. The Department has provided a space at the bottomm of the
affidavit for you to fill out in'the event the Office of Investigations has to contact you xegardu�g the applicant Please
be sure to fillip the penntt!license number which WM be used as a reference number. The.affidavits maybe returned tQ
maid ements have been made,
the Department by, or F AX unless other:ariang
e to thank you in advance for you cooperation and s`ioiild you have airy questions,
The Office of Investigations would lr�
please do not-hesitate to give us a
Now
The Department's address,tel
and fax number: . '
• The Commonwealth Of Massachusetts
Department of-Industrial Acddents
. • Bffice of!a>festi�s�ena .
600 Washington Street
Boston,Ma. 02111
fax#: (617)727-7749 .._.
E r 'down of Barnstable .
of °��. .
Regulatory Services i
f $ Thomas F.Geller,]director
9 s6gp• ,� Building Division
Tom ferry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Fax: 508-790-6230
Office: 508-862-4038
permit no.
Date
AF MAVIT
HOME ZMYROVF,MENT CONTRACTOR LACY
SPPLEMENT TO PERIYIIT APPLICATION
MGL c.142A requires that the"reconstruction, on of an addition to my p e— modernization,exi ting oowr�ez o conversion,
cc pied
•improvement,removal,demolition,or constru
bu>7ding cantainirig at Least one but not more than four dwelling snits or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements,
7- )G , tangy Estim4ted Cost
Type of Work: Ae-
ork•
Aadress of W
Owner's Name: �� ,
Date of Application:_ D
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
�]ob Under$1,000
ding not owner-occupied
Bbwner pulling own permit
Notice is hereby given that:
UT OR DEALING WITH UNREGISTERED
OWNERS puLLING TEMIR OWNLE ME IlYIPROYEMENT WORKDO N HA•YE
CONTRACTORS FOR APPIACAB
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A,
SIGNED UNDERPENALTMS OF PERJURY
Ihereby apply for&permit as the ageAt of the owner:
Contractor Name Registration hTo.
Date
Opla
Owner's Name
............... .........
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pro erne t So war Aut on
Phone: (816) 891-2800 e Fax: (816) 891.8018 o Internet: http://wwwsoftdesk.com
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Phone: (816) 891-2800 o Fax: (816) 891.8018 o Internet: http://wwwsoftdesk.com
152 Clifton Lane, Centerville
We plan to replace the existing 4' x 4' deck with railing on the front of the house due to
deterioration.
The assessor's plan of the house shows"FOP" on the front of the house as 4' x 19.'
There is an overhang, which is 19' across the front of the house. Under the overhang is
the 4' x4' deck. The rest of the area under the overhang, approximately 15', is a
walkway to the front door.
We have included a photo of the existing deck and a proposed drawing of the
replacement.
We plan to use the following materials to complete the project:
,All lumber will be pressure-treated.
2 - 4x4post
2 x 8 and 2 x 6 lumber for stringer, deck, railing and balusters
Concrete for deck sonatubes
Town of Barnstable
VE
„F o„ Regulatory Services
Thomas F.Geiler,Director
BARNSfABLE,
9 MASS.
1639. Building Division
rF0 MA'I A
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstabIe.ma.us
Office: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:� I
JOB LOCATION: ��.Z / �/ rC 9 �� /"0
number y� streets ,y ry,�- '/ village
„HOMEOWNER": qAPA-e-,) ! 1 E/'ZLc�/nI -70 l�Y 75-7�Cj S �B L -kpgfj •®-O%�D
name home phone# Q work phone#
CURRENT MAILING ADDRESS: � �EPE )0_-.JC,E
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
�qu"irements.,
P
/.
ignature o 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:forms:homeexempt
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' »-.- � .. rya•.-. p—.-r—• ��' '—,.—:—•.zr`-"-----'1^--`4�=—'—,i —•--•-- —_�—_
i
Town of Barnstable.'
. *Permit#
of
Expires 6 months from issue date
Regulatory Se �C Ss/y.�. Fee
lA MASS.
ABi.E,
`0$ Richard V.Scali,Director 105
�cAa
prED MA't A
Building Division BAR
Tom Perry,CBO,Buildin s oner 9 1�16
200 Main Street,Hyannis,MA 02 �1F 7
www.town.barnstable.ma.us 8A RIVSTABLE
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
ZVI _o Not Valid without Red X-Press
Map/parcel Number
Property Address a cj.�P,.n 14A
f�]Residential Value of Work$ ° Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address /
1 All
Contractor's Name )l (�-�—N1604 Telephone Number 1`t�Z��
Home Improvement Contractor License#(if applicable) Email: ns
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 NameA
Workman's Comp.Policy# WA-
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
[� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:_
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is-
required.
SIGNATURE: �f
Q:\WPFILES\FORMS\building permit fomis\EXPRESS.doC
Revised 040215
J
77te Comynoyrivealth of-Vassad iusetfs
D ewivfzmerzt of Industrial Accident
Qfrce a,f£rttigations .
600 Wasliington,S`tlreet
ti Boston,,.IA 02I1I
14'FmilmmgovId2a
'[TGrkers' Campensation Insuraaice Affidavit:Builders/C,nntradurs/Electricians/Plumbers
Applicant Iufm-m;tf Gn Please Print Leo'bly
Name(BusbaemK)rrgmizaation dy- �A C�l��t� AA00m
Address:.
City/Statel .>►( /�A D 4 6 Phone,4-- 77Lt
Are you an employer?ChLk the appropriate box: 'Type of project(required}:
1.❑ I am a employes with 4. ❑I am a general contractor and I
employees(full azldlor part�ime�.
* have lured.the sub conhactors 6. �New consimction
2. I am a sole proprietor orpartuer- fisted on the attached sheet. 7- ❑Remodeling
s p and have noemployees These cab-cmtractors have�P 8. El Demolition o
w4dung for me in any capacity. employees andhave wodcers'
[No workers'camp.insurance Comp.Fn¢nran�
9..El Building addition
reclnired_] 5_ ❑ We.are a corporation and its 110:[:1 Electrical repairs or additions
3_❑ I ama homeoumer doing all Mork 'officers have exercised their 11_E:]Plumbngrepairs or additions
my [No workers'czmp- right of Mempfion per MGL 1?[A Rflofrepairs
i„s�nce required-]i c.152,§l(4h andwe have no
employees-[No worms' 13_[6 Other
comp-insurance required.]
#Any SWKc &at cbecks box PI also fill ontth�secBoabeIotvshm4ag theirniorkexs'compeasaticapopcyinfnem�in�
HameMners who submit rhis afiidmft muNcadmg they sm domg all wat=—d&m hie autade roatrsctnrs mmst submit a new lmdavk;"a;f�satb
fCagtzscrors'fhat check thas bast must attached au addiliamal sheet sbatoiag the muse of the sub comttacmazs sad statewhether ormat those eruitksham
etaplayees. If the sub-cantn rmhave employees,tfie3'must'PmIR&&—it warkm'comp.policy number.
I am ara elrrplo�acrr t�Teatis prat arlirr �oarkers'corrrperesa(iarr i�tsurarrce for ar}*entpl gees Below is fthepaHcy and job srte
infarmalion .
Insurance Company Name: nn�
Policy 4,or Self--ins.Lic.;k. FoTiratian.Date: WA
Job Site Address._ L•I• CitylStatellsp: Ceniz-10IL AA o2L12
Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required.under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a
fine up to$1,500-00 anifor one-year imprisonment as well as CMI penalties Ju lhe form of a STOP j GRYL ORDERand a tine
of up to 0-00 a clay against the tiaolator. Be advised that a copy of this:statement maybe forwarded to the Office of
IuvesE gations of the DIA for insurance-coverage verifcation-
I do hemby cerlify sander thg pings and pBnabyes ofger,jury that the irrfbrnzadvn-prm ciedabzn a is bare and correct
Simature: Date
Phone ik 7711 —,5-2 ?/7!
Offidai use onl. Da atot tvrite in tl its area,to be coatnpL-ted by c4 ortenrn o,;f fiat
City or Tomm: PermitUcense;9 `
Issuing Author*(circle one):
1.Shard of Health I Building Department 3.City1rown Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#-
Information and lastructions
Massachusetts G&aeral Laws chapter 152 rcq=m all employers to provide workers'compensation for their employees. W'
Pm tto this fie,aa.errcployee is defined as."-.every person m the service of another under any contract of hire,
express or hnpliec�oral or writtur."
An errTIoyer is defined as"an mdividnal,partaerslip,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 employes,or the
receiver or tnstee of an individnal,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 mamteiiance,construction or repair work on such dweIImg house
or on the grounds or building appu rtonazrtthereto shOnotbecause of such employme-utbe deemedtn be an employer."
MGL cbapter 152,§25C(Q also sides that"every state or local licensing agency shall withhold the issuance or
to operate a business or to construct bindings in the commonwealth for ray
renewal of a license or permit
applicantwho has notproduced acceptable evidence of compliance with the msarance_coverage requ>z ed."
Additionally,MCrL chapter 152, §25C(7)states"Neither the commonwealth nor airy of its political subdivisions shalt
enter inter any confiact forthe performance ofpubho wodcuntil acceptable evidence of compliance-with the insurance..
re lLdremen s 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 snb�contractor(s)name(s), address(es)and phonenumber(s) along withtheir certificates)of
Tn,rurance. LimitedLiabilky Companies(LLC)or Limited Liabi yPartnerships(LLp)vvithn0 employees other thantbe
members or partners,are not required to carry woricers' compensation ins=ce If an LLC or LLP does have
employees,apolicy is required. Be advised that this affdaYrtmaybe submitted to the Department of Industrial
Accidents for confirmation of inmumce coverage. Also be sure to sign and date the affidavit. The affidavit should
be retimmed to the city or town that the application for the permit or license is being requested,not the Department of
hIaL stii al Accidents. Should you have aay questions regarding the law or if you are requited to obtain a workers'
compensation policy,please call the Department at the nrmtber listed below. Self-insin-ed companies should enter their
self-ir svr-aace license number on the appropriate line.
City or Town Officials .
please be sate that the affidavit is complete and priIIted le�y. 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
t
please be sure to fill in the pcn sit/license number which will be, u
used as a reference umber. In addition,an applicant
�mast submit multiple pe�itl e licens applications in any given year,need only submit one a ffidavit mdicatmg tPnt
p olicy ini rmation Cif necessary)and under"Job Site Ad-hers"the applicant rho*'ld write"all locations m or
town)-"A copy of the-affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for furore permits or Hceazses- A new affidavit must be filled.out each
year.Where a home owner or citizen is obtammg a license or permit not related to any business or commercial veuiase
(Le_ a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
'lire O ffice of Investigations would like to thank you i a advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparfinenfs address,telephone and fax number.
f�G.=jQn aj-ffiE of Massach-osttts
Ilepaliment of I ustdai AMUenta
Off jC�e Of f.Vesiigatio-=
- �Q4-�ashin�tan t -
Baston MA 0 111
Tf,-L 0 617 727-49QO Qxt 4€16 Or 1-977-MA-S `E
Fagg 617-727-7749
F-a ise�4-24--07
pk1HE 1p�
t SABNSfABLE, i _,
Town of Barnstable
ATED Mfg�
Regulatory Services
g rY
Richard V.Scali,Director -
Building Division
Thomas Petry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
z a
If Using A Builder
1 C i lP , as Owner of the P sub roe `
l P rty
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
I-V
Nionatute of Owner Date (40
JL\\-10(k � Le
�
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
QAWP=S\FORMS\building permit forms\EXPRESS.doC k
Revised 040215 ,
Town of Barnstable
Regulatory Services
TKE To Richard V.Scali,Director vj
Building Division
BARN 1A Tom Perry;Building Commissioner
1639. . � 200 Main Street, Hyannis,MA 02601
pTED" www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone# .
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was'extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
1. 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 ear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
res onsible .
an communities require,as art of the
his/her responsibilities,m , p
_ To ensure that the homeowner�fully aware of p Y q
' 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 formsVDMRESS.doc
Revised 040215
f
Massachusetts -Department of Public Safety.,
r ! Board of Building Regulations and Standards
- I�.ULJLI Ull1 V(I JLI��I YIJUI -
License: CS-096833
SAMUEL F NAOOM
76 VANDERMNg LM
Hyannis MA 02661 y
.I
Commissioner Expiration
11/10/2016
�e�dr�concue Q,
Office of Consumer Affairs&]Business Regulation�
II ME IMPROVEMENT CONTRACTOR e!istration: :.147624
xpiration:.;_- Type:
I, E_/z201=7= Individual
II SAM NAOOM
SAMUEL NAOOM ==ysi
76 V
ANDERMINT LN.
HYANNIS,MA 02601
Undersecretary
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991in )of
enclosed space.,
Failure to possess a current
edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing information visit: www.Mass.Gov/DPS
License or registration valid for.individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston;MA 02116
Not valid without signature
•
,f
p,
i
En r Map Y7 Parcel l S' Permit# ® � S
House# 'SoZ aJ Date Issued
,nely
Board of,Health(3rd floor)(8:15 -9:30/,1:00-AM)
.2. )
Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
SEPTIC SYSWN
USTE
,n � INSTALLEIR
GE
19 WI
' ENVIRONMAND
OWN OF..,BARNSTABLE TOWN
Cal/ Building Permit Application
Project Street Address (,L/ �„✓ Z_10 l/�
Village ,a
Owner Address 2S��i✓�£t'�rk7ts��<, n-0 734t isr� MY>
:Telephone 791 L-I
Permit Request 2qn&/LU S gy:?—,MIL - T z, L< b✓-ro Poh" 'U04 14100,1,
/ 'L- yc/Z Lv -/X CAMr.<4 L,,< /ZSROC)F /JPPO--
i I Q
r
,First Floor square feet Second Floor square feet
,-Construction Type
Estimated Project Cost $ A #7, 10 0
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
t
Dwelling Type: Single Family ,a Two Family ❑ Multi-Family(#units)
Age of Existing Structure 2 0 V g w Historic House ❑Yes ikNo On Old King's Highway ❑Yes CgNo
Basement Type: ®:Full ❑Crawl ❑Walkout ❑Other
V \� Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
N Number of Baths: Full: Existing New Half. Existing New
6 No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
122 Heat Type and Fuel:. ❑Gas ❑Oil ❑Electric ❑Other
y Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: p Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size)
� ❑Barn(size)
(- ❑None ❑Shed(size)
P
❑Other(size)
Gt Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name '1)4 d i�'_) /ul I�g?,B�Nl Telephone Number
Address (R.O. t3 try( bZ License#
Myt,/► V 1J`:;Y��L MA Home Improvement Contractor,#- //l!",? )9
Worker's Compensation# ti/,d
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
BUILDING PERMIT DENIED FOR THE.FOLLOW7REASON(S)
' - FOR OFFICIAL USE ONLY
PERMIT NO. » caLOT - _
DATE ISSUED'
MAP/PARCEL NO'
�.
Zil
ADDRESS ; VILLAGE'
OWNER z t i ± , L f ,'—�
DATiOF,INSPECTION:
FOUNDATION ;
FRAME
INSULAON4 - f.
FIREPLACE
ELECTRICAL: ; ROUGH r FINAL ;
PLUMBING: ROUQQ FINAL
t GAS: ( -R�OU� j FINAL I
rn
.�
FINAL BUILDII210 E 2m e
T.
` � m j
DATE CLOSED j& ➢'C)5,
10
-
ASSOCIATION]&I NQco
A
1�r 1
i
MIR-
MA
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FA
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IL
14
The Town ',of,Barnstable
9 "''M Department of Health Safety and Environmental Services
BuiIding Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227
BuiIding Commissiont
Fax: 508-790-6230
I
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: C`�zLt �- 1�bhLN Est.Cost
Address of Work:
Owner's Name 5`TL PI.1 A42 + SLC/J-%/
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
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 PROGZAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
M 101313W /l 37 9
Date Contractor Name Registration No.
OR
Date Owner`s Name
he Commonwealth of Massachusetts
Ti
t� , _ •-:"-�.��� Department of Industrial Accidents
office off ny95991 bons
600 Washington Street
Boston,Mass. 02111
" rr•"'
{ Workers' Compensation Insu/ra/rynrc�re Affidavit
name `n Q�/)h t�► 2 C�13 R t N�
location:
city W• phone#
❑ I am a homeowner performing all work myself.
® I am a sole proprietor and have no one working in any capacity121
❑ I am an employer providing workers' compensation for my employees working on this job.
come any name:
.
address:
city phone A-
insurance co. poficv#
❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who
have
the following workers' compensation polices:
company name:
address:
phone
dtvTIORT
#•
insurance co.
/ /
cam anv name: :;•;::._:. :
address:
dtv-
phone#:
o u
insurance co.
Failure to secure coverage as required under Section 15A of MGL 152 can lead to the im Q ositio n f criminal penalties of a fine P to 51,500.00 and/or
one years'imprisonment as well as civil Penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do herebv certify under the pains penalties of perjury that the information provided above is truo and coned
Date f g
Signature -
Print name �Ay1 r) YVI 'RU 7�I Phone#
official use only do not write in this area to be completed by city or town official
d permit/lkense# ❑Building Department
city or town: ❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person:
phone# ❑Other��
II (tevaea 9,95 P1A) .
Information and Instru.>_'
hors
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", 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 of
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 section 25 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,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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance 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.
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 io
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 questions.
please do not hesitate to give us a call.
The Department's EdreMssteleMphonMeandEx umber:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
office of lnvestlgauons
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749 'a
phone#: (617) 727-4900 eat. 406, 409 or 375
� r-h•-fir.-.,.,..-.,�---- � -. .; -.
1 r ? ✓fie �ommrnuuea a�✓�aaaac�euaeCta
OEPARTNENT OF PUBLIC SAFETY
.1A
CONSTRUCTIOlF'SUPERVISOR LICENSE
_.....:__.__....._.._
Nuober Expires:
V �_.�.___...... RestricfedTa BB
DAVID M R088INS
POBX 612.. .
YARMOUTHPORT, NA 02615
,�tl
1 5
t
Yt,
w ny�.�u ABM :R A�026I5
t
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
1
p I '� S
Map'.. Parcel li for #
Health Division Date Issued yr ZR !y
he—
Conservation Division Application Fee 4+ 9
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
Project Street Address
Village
Owner �G�PIQ/k -r'. � l Address Lam-��r6y
Telephone �`� S � /S✓�9 /O 7�
-Permit Request
L4v r r 3" rfilr J��erlo n Iq work ,
Square feet: 1 st floor: existing//oG proposed 2nd floor: existing proposed Total new
Zonind District Flood Plain Groundwater Overlay
Project Valuation S'06-00construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑, Multi-Family (# units)
C o
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King sr-Htighway: 1 Ye ❑ No
Basement Type: ❑ Full Crawl ❑Walkout ❑ Other '" ' o
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) f�
Number of Baths: Full: existing_ new Half: existing new
5_3
Number of Bedrooms: .J existing —new N
Total Room Count (not including baths): existing new First Floor Room Count°
Heat Type and Fue: U Gas ❑ Oil t&4ctric ❑Other
Central Air: es ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes dNo
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 �;�'1 f de( L4 Q a YQ Telephone Number 5�/Z w7
Address ��D 3 �i1 J�/�h ST License# la ;' 3
` ✓ 1 ) Home Improvement Contractor# Il Gf 7/D
Email Worker's Compensation #
ALL C�O/NSTRUCTION DEBRIS RESULTING FROM 1THIS PROJECT WILL BE TAKEN TO I
/ ��/it�l/i/I�� I'!x!� }�Jri°r TDi' /ll
SIGNATURE `� DATE
FOR OFFICIAL USE ONLY
APPLICATION#
DATE,ISSUED-
MAP-/PARCEL NO..
ADDRESS i VILLAGE
OWNER
�k
Y DATE OF INSPECTION:
FOUNDATION
FRAME b
INSULATION ,'Sljlg
FIREPLACE
t ELECTRICAL: ROUGH FINAL
t
'FPLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING raD� 612,ojjq
UA,4 -=CLOSED OUT
A ION PLAN NO.
.r
it
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
_www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ribly
'Name(Business/Organization/Individual): (;, }��t°j , ,•V
Address: v 03
City/State/Zip:_)� Od4)'hone#: ��� � �
Are you an employer?Check the appr priate box: Type of project(required);
1.El am a employer with 4. [] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ ew construction
2 jo I am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling
shipand have no employees These sub-contractors have
8. ❑Demolition
working for me in any capacity. employees and have workers'
insurance. 9. ❑Building addition
[No workers' comp.ins u*rance comp.P•
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
t C. 152 1 4 12.❑ Roof repairs
insurance required.] , § O,and we have no
employees. [No workers' 13.0 Other .
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:'
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u der thepains and penalties of perjury that the information provided above is true and correct.
Si ature: C r .�(�� �G� G
Date:
Phone#: 7 Ki �}
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 4
:..
6.Other
Contgct Person: '
Phone#:
�INET° Town of Barnstable
° Regulatory Services
* muss.IE� Richard V.Scali,Interim Director
ED;Ac��e Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
w ww.town.barnstable.ma.us
Office: 508-862-4038 i Fax: 508-790-6230
Property Owner Must
Complete. and Sign This Section
If Using A Builder
as Qwnet of the ro subject
l P Petty
hereby authorize_ ,Y l ACLU�(� to act on my behalf,
in all mattets relative to work authorized by this building permit
7
4'yV* A U 6 �
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled ot.utilized before fence is installed and all final
inspections are performed and accepted.
Sig r er Signature of AppkWut
Cr '�
Print Aame Print Name
Date
Town of Barnstable -.
Regulatory Services
oFz>u rokti Richard V.Scali,Interim Director
Building Division
a AA7�NR1`ARr,� �` Tom Perry,Building Commissioner '
MACg
r� 039, ��� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6250
HOMEOWNER LICENSE EXEMPTION ;
Please Print
DATE:
JOB-LOCATIQI+I:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Appioval 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); provide_d 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.
n•inrocrr vetrnv�rctx..aa:..e IF;—;t fi, q%PYPRR R Anc .
v/ae `pao��n�aaiaeuecr a�vUurooic�c�eCY�- ,
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
OMEOME IMPROV
ration: 14718 Type: Office of Consumer Affairs and Business Regulation
egist;'Expiration 10%1W2015 Individual 10 Park Plaza-Suite 5170
a Boston,MA 02116
CHARLES J.MAURO' "
CHARLES MAURO s
203 UNION ST j
YARMOUTHPORT, MA 02675' Undersecretary �Nta�wit
out signature
9 I
Massachusetts -Department of Public Safety
Board of Building 1kegufations and-Standarc$s
Construction Supervisor
License.: C"42539 ff
V.
I CHARLES J MAUO
203 UMON ST
Yarmouth Port MA 0 67.
0
,riti� Expiratibn
Commissioner
`
. 06/10/2014�.�
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