HomeMy WebLinkAbout0018 GINA COURT :
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Town of Barnstable
Regulatory Services
�1HE Thomas F.Geiler,Director
Building Division
BAMSTnsi.e. Tom,Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
�prFG MP'�A
Office: 508-862-4038 Fax: 508-790-6230
December 12, 2012
Robert O'Melia
18 Gina Court
Centerville,Ma. 02632
RE: 18 Gina Court, Centerville, Map: 2.10 Parcel: 191
Dear Mr. O'Melia:
A review of our records, including the permitting history of the property, indicates that
the above referenced address has an open building permit without the required
inspections. Permit application number 201000288 was issued on or about February 12,
2010 to finish the basement at the above referenced address and to date has not had the
required inspections (building and electric). Please contact this office immediately with
an explanation and to arrange the required inspections. Thank you for your immediate
attention in this matter.
Respectfully,
La
Local Inspector
jeffrey.lauzon@town.bamstable.ma.us
(508) 862-4034
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel V Application #
Health Division Date Issued Z'
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
�' f✓ �
Historic - OKH _ Preservation/ Hyannis o►c z/�2Jio
Project Street Address S� n, C�_ 7
Village.. C e n er-V A-, m c. o a6 Y1
Owner �()b,e 'T (�� fli Address (l enl ryrA 4 .
Telephone S� - -7?7 - `70 9 .7
Permit Request i " c psa= e -e Ivo r-
<�bceAc--X ('00 &.,o &A, ocs M
Square feet: 1 st floor: existing 40proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation —'-'-t000 -Construction Type Wbo& -4—t .
Lot Size ,��� Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 5r— Two Family ❑ Multi-Family(# units)
Age of Existing Structure �� Historic House: ❑Yes �No On Old King's Highway: ❑Yes Flo
Basement Type: U ull ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) 6 30 Basement Unfinished Area (sq.ft) 200
Number of Baths: Full: existing __ new �_ Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not
including baths): existing new First Floor Room Count
Heat Type and Fuel: & Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ®'Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:' ❑Yes a<o
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size — Barn: 0=existing 0 new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ L-J
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Y (C b er� 1' A'I c, Telephone Number ����' 7 3 /
Address �e Ci CV License #
C-,e v'tAl Home Improvement Contractor#
Worker's Compensation # `` � /
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TOQc,(',_S� L
SIGNATURE r DATE (�
t
b
r FOR OFFICIAL USE ONLY
t
APPLICATION#
i.
DATE ISSUED
MAP/PARCEL NO.
f
ADDRESS VILLAGE
OWNER
y
x
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION 1)31 Flo
FIREPLACE
ELECTRICAL: ROUGH FINAL = l`
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I' 600 Washington Street
- Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �o\��ecV
l '
Address: � `1 to C
c, �
- , l 0 3L �- 7� �- 709
City/State/Zip: �ev�\Qry ��1t. �� Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
[]. listed on the attached sheet. 7. emodeling
2. I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. in comp. insurance.$
required,]
5. (� We are a corporation and its 10.� Electrical repairs or additit
3.qam a homeowner doing all work officers have exercised their 1 LEJ Plumbing repairs or additit
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
'cmployees, if the sub-contractors have employees,they must provide their workers'comp,policy number.
1 am an employer that is providing workers'compensation inscrance for my employees. Below is the policy and jQb site
information.
Insurance Company Name:
Policy#or Self-ins. Lie.#: 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
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
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.
1 do hereby Gerd a er the pains an p na ies of perjury that the information provided a ove i true and correct
Si nature: �- Date:
Phone# V�� 7Z 7' /V l /
Official use only. Do not write in this area, to be completed by city or town offciaL
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
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 Linder any contract of hire,
express or implied, oral or written."
An employer is defined a:s"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, constniction 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 retumed to the city or town that the application for the pen-nit or license is being requested,not the Department of
workers'
Industrial Accidents. 'Should you have any questions regarding the law or if you are required to obtain a w
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
"the applicant should write"all locations in (city or
if necessary)and under"Job Site Address h a
policy informationPP
P Y ( rY).
r town may be provided to the
been officially stamped or marked b the city o y p
.town). A copy of the affidavit that has b n off y p Y tS'
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required.to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 '
www.mass.gov/dia
f
ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR
ONE; AND TWO-FAMILY DETACHED RESIDENTXAT, CONSTRUCTION (780 CMR 61.00)
A licant Name: tM Site Address:
grin! Town: l en ec v, A e MQ NUJ
Applicant Phone: )t�0�_- _7 77- 70T7
Applicant Signature: ! �`6 Date of Application: .
NEw CONSTRUCTION: choose ONE of the following two-options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE- AND TWO-FAMILY BTJMDINGS
MA"cIMVM 'M]NCMUM
Ceiling or Basement Slab.
Option I- Fenestration exposed- Wall Floor Wl Perimeter AFUE
U-factor floors R-Value R-Value Value R ValueSP
R.-Value and Depth
National.Appliancc•Encr
.35 R-3 8 R-14 R�14 R-10 R-10, ConscrYalion Act{NAR
,4 ft.- 1997 as amcndcd,minim
cater as a licab(c
Note: This form is not required if you c Dose either of the two versions of REScheck as listed below.
❑ Option 2: REScheck Version 4.1.2 or later variant software- analysis must be completed
780 CMR 6107.3.2
REScheck--Web which can be accessed at http•//www cnrrgyrDdes:Roy/rrscheck/
A DDXX' ONS OR AL`f:�"TXOZ4S.TO MaS` ZING B ILDSNGS.O VER 5 'EAES OLD' *
*puildings under 5 years old must use option#1 or#2 in New Construction section above.
Complete the following formula to determine the % of glazing:
(a) Gross Wall & Ceiling.Area equals Foanula: (100 x b= a) '
SF. 100 x — _ % of glazing
b a
(b) Glazing area equals SF
If glazing i-s<:40%.ii�D the"chart below. If glazing is.> 40 %pr6ceid to "SUNROOM" seetion
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING.
LOW-RISE RESIDENTUL BUILDRIGS
MAXIMUM �9r
Ceiling and Slab Perir
❑. Fenestration Wall Floor Basement Wall R-Valt
Exposed floors R-Value R-value R-Value
U-factor. R-Value and De
39 R-37 a R-13 • R-19 R-10 R. 4
a . R-30 ceiling insulation may be used in place of R-37 if the insulation acbieves the full R-Value over the entire ceiling
area i.e.not com ressed over exterior Walls, and including any access o enin s .
SUNROOM—An addition or alteration to an existing building/dwelling unit where the tot
glazing area of said'additioa exceeds 40% of the combined gross wall and ceiling area oft
addition.
Note: Owner to fill out Consumer 17 orrnation Form found in Appendix 120T
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
163q. ,� Building Division
Tom Perry,Building Commissioner
200 Maid-Street,.Hyannis,MA Q2601
Rrww.town.barnstable.ma.us
Office: SOE-862-4038 Fax:.508-790-6230
HOh7E6V,WER LICF-NSE EXEMPTiOiY
Please Print
DATE: C)
JOB LOCATION: C� ( e✓ r-V
number s tr mt village
_ '--.'HOMEOWNER": 9-�pbP��
name r. homep phone# wort- one#
CURRENT MARJNG ADDRESS: , a GJ 1'�c C-
city/tovM states np 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 ro
does not possess a license,pvidcd that the owner acts as
supervisor. -
DEFINMON.OF HO)YIEOWNER
Pergon(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 strictures. 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 sha11 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 Codc and other
applicable codes, bylaws,rules and regulations..
The undersigned"homeowner".certifies fl at.he/sbc understands the Town of Barnstable Building Dcpartrpcnt
rn;r,;rnum inspection procedures and requirements and that be/sbc will comply with said procedures and
. regTr �jts.
/ t
Signature of Hoincowncr
Approval of Building Official
Note: Thrce-family dwellings containing 35,000 cubic feet or larger will be required to c)mply with the
Sthtc Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Codc states that "Any homcownct performing work for which a building permit is required shall be cxcmpt from the provisions
of this scetion.(Sectian I DR.].I -Limnsing of cmutruetion Supervisors);providcd that if the homeowner engages a pason(s)for hire to do such
work, that such Homeowner shall act as supavisor."
Many horn cownas wh n o use this exemption arc unaware that they a assurrung the responsibilitics of a supervisor(sce Appendix Q,
Rules,&Regulations for L;ccnsing Constrvetion Supervisori,Scction 2.15) This lack of awareness bftar results in serious problems,particularly
when The homeowner hires unlicensed persons. In this ease,our Board cannot procccd against the unlicensed person.as it-ould with a liccirscd
Supervisor. The homcovmcr acting as Supervisor is ultimatc)y responsible.
To unsure that the homeowner is fully aware of his/her respcnnb0itics,many communities require,m part of the permit application,
that the homeowner certify that he/she understands the respannbilitics of a Superrisor. On the last page of this issue is a.form currcnQy used by
several towns. 'You may care t amend and adopt such a formlccrtification for use in your eon-ununity.
� r Town: of Barnstab-Ze
r �
Regulatory Services
` xHsrAsc Thomas F Geiler, Director
Building bivision
Torn Perry, Building Commissioner
200 Main Strcet, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 FaK: S08-79[
Property Owner Must
Complete and Sight This Section
If Using A Builder
as Owner of the subtect.property
hereby authorize to act on my 6eb_af,
in all matters relative to work auth .'by this building permit application for-
(Address of b)
Signature Of Owne Date
Print Name
If I'ropertY Owner is,applying for per ait please complete e
Homeowners License Exemption Form on the reverse s"ide.
I --
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TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION,
Map .�, _
Parcel Application
Health Division Date Issued 3
Conservation Division Application Fee
Planning Dept. Permit Fee ado
Date Definitive Plan Approved by Planning Board
Historic OKH Preservation/Hyannis
Project Street Address
Village .'
Owner RzAL � VOGOya: ,11 Address �i �7y �.S>aa�ta c� CIA Ck1 �1
Telephone ,S 0(R-a0 a-ct3eb
rmit_Request-,U,o\1E1Z cb S TV-s ATTACRE-4, GAtAroc Tb ROUSE .X'n10 A % k�, �UoM
L,1UDWRN•: Rm1k WAS ALEWIsY Ea If ;.
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
W.
Zoning District Flood Plain Groundwater Overlay
t
N)
�P oject Valuatio--_L� Construction Type
Lot Size AGES Grandfathered: ❑Yes No If yes, attach supporting documentation.
1 r3
Dwelling Type: Single Family Two:Family, ❑ Multi-Family(# units) - r,
Age of Existing Structure 19(3 Historic House: ❑Yes X No On Old King's Hi hway: ❑Yes �No
Basement Type: Full ❑ Crawl ❑Walkout ❑ Other'
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: (D existing .L new
Total Room Count (not including baths): existing 5 new First Floor Room Count
Heat Type and Fuel: Gas . ❑Oil ❑ Electric ❑ Other
Central Air: Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
OR HOMEOWNER)
Name 2=V3. �OC-,oJ_rf"A Telephone Number 5OR-319Q,g3BO
Ck�S37
Address LfiNF_1) E.Saaw c,A License# .
(�PiCL (I—VC) %CX 09q r✓-SIgk)VN ZO-A Home Improvement Contractor#
M11S'�'1 Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
1 4 r
SIGNATURE � � {� � DATE
i
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
I5 ADDRESS VILLAGE
i
OWNER
DATE OF INSPECTION:
FOUNDATION i ►
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL I
3 PLUMBING: ROUGH FINAL
t
1. GAS: ROUGH FINAL
FINAL BUILDING r i�lbg �� 413� �8-
'f DATE CLOSED.OUT
ASSOCIATION PLAN NO.
i
ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR
ONE-AND TWO-FAMILY"DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00)
Applicant Name: Site Address:
P''"' Town: \ERV$tLE KA QaL)a
Applicant Phone:
Applicant Signature: Date of Application:sr_� .
NEW CONSTRUCTION: choose ONE of the following two options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE- AND TWO-FAMILY BUILDINGS
MAXIMUM' MINIMUM
Ceiling or Basement Slab
❑. -Option 1: Fenestration exposed Wall Floor Perimeter
U-factor floors R-Value R-Value Wall R-Value AFUE HSPF SI L,R
R-Value R-Value and Depth
National Appliance Energy
R-10, Conservation Act(NAECA)of
.35 R-38 R-19 R-19 R-10 4 ft. 1987 as amended,minimums or
reater, applicable
Note: This form is not required if you choose either of the two versions of REScheck as.listed below.
Option 2: REScheck Version 4.1.2 or later variant software analysis must-be,completed
(780 CMR 6107.3.2
REScheck—Web which can be accessed at http://www.energycodes.gov/reschecld
:'ADp7TIONS�On"ALTER ATIONS :TO'.EXISTING.BUILDINGSbVER 5.'YEA.RS OLD*
*Buildings under 5 years old must use option#1 or#2 in New Construction section above.
Complete the following formula to determine the % of glazing:
(a) Gross Wall & Ceiling Area equals Formula: (100 x b=a)
SF
100 x — — % of glazing
(b) Glazing area equals. SF b a
If glazing is:<.40"%o use.the chart below. If.glaziri is>:40'.% proceed to "SUNROOM"section
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BUILDINGS
MAXIMUM MINIMUM
-Ceiling and Slab fDeth
Fenestration Wall Floor Basement Wall R
U-factor Eicposed floors. R-Value R-value R-Value
R-Value and
.39 R-37 a. R-13 R-19 R-10 R-10, 4 feet
a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling
area(i.e.not compressed over exterior walls, and including any access openings).
ElSU 'ROOM—An addition or alteration to an existing building/dwelling unit where the total
glazing area of said addition exceeds 40% of the combined gross wail and ceiling area of the
addition.
Note: Owner to fill out Consumer Information Form (found in Appendix 120T)
I
The Cor'nmonwealth of Massachusetts
Department oflndustrialAccidents`
Office of Investigations
600 Washington Street
ry Boston, MA 02111
lvww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letribly
Name(�usiness/Organization/Individual):29zfx>
Address:Q7 1..1.,a 0Q, C-isNa 0er CF atvTu.0
City/State/Zip: E— •SAt%UiD \A -Phone.#: 5t Q9o?-93g0
Are you an employer? Check the appropriate bog; Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.W Remodeling
ship and have no employees These sub=contractors have g,/11 Demolition
workingfor me in an capacity. employees and have workers'
Y P t5'• # 9. []Building addition �
[No workers' comp.-insurance comp. insurance.
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.El 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.
xContractors 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.
Iam an employer that isproviding workers'compensation insurance for,my employees. Below is thepolicy andjob 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 dv hereby certify under the pains-ands enaldes ofperjury that the information provided above is true and correct.
i ature- Date. _
Phon - 9380
FOther
only. Do not write in this.area,to be completed by city or town official
n: Permit/License# .
hority(circle one);
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son:
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 representative's 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 couapliarice with the insurance
requirements of,this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely, by checking the boxes that apply to your situation.and, if
necessary,supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of,
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
Self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in _(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e:a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The.Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,.
lease do not hesitate to give us a call.
P �
The Department's address, telephon e•and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents.
Office of Investigations
e
600 Washington t ,
Boston, MA 02111
Te1. #617-727-4900 ext 406 or 1-877-MAS.SAFE
Fax# 617-727-7749:
Revised 11-22-06 www-.mass.gov/dia
op�[t+erO Town of Barnstable
�
y�P Regulatory Services
BARNSTABLE, : Thomas F. Geiler,Director
p MASS.
4�, ib39• ,$� Building Division
TFD Mf+�A
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER 'LICENSE EXEMPTION
2 Please Print
DATE:
JOB LOCATION: T GTU11 0_0l)9T Ne 0-re T LL E r1'A
number street village
"HOMEOWNER":. lAN -SoB-a8�-y19 sod-arta-93$0
name home phone# rwaphone#
CURRENT MAILING ADDRESS:
t,SA�)uwTx_NA rnA Oa ,
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of sN 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 IIOAIEOWNER
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 .ffdmigned"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.
pp
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 r- 7
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,Sectiom2.15) 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 pen-nit 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..
. i
O:form.rhnmeeremnt
°pttterp�� Town of Barnstable
Regulatory Services
* sAMgLE' i
Mass. Thomas F. Geiler,Director
.� �,
Foy,:ca�� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, \J ICA , as Owner of the subject property
hereby authorize �Vnacr on my behalf,
in all'matters. relative to work aut' dthis build' permit application for:
- v—u—
(Addmss f%'ate—
r&—m.,
Signature of Own/C6-J0'/'T.
Print Name
l
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
IMPORTANT wE REQUIRED MOKE;—ElE'C TORS REViE1�lED6STATE BUILDING CODE REQUIRES THE UPGRADING OF' 19
SMOKE DETECTORS FOR THE ENTIRE DW�EWNG WIEPI — - _ 4ONEO MORESLE F 3 f S ', BUIi nw('.nF T nnrr
NOTE: -- R
INST TION OFiMOKE DETECTORS-�E4tECICpL FIRE DEPAR ME„�' All
PERMIT NOT SATISFY THIS REOUIREMENI LOTH S"G ATURES AF F REQUIRED FOR PERMITTING
CA
--�
T)
" l
to
-W39LL �•
� f•IRt,L �
XLQ
Of3
3 -c
X -4 co
l,
70
7i X rt/
7b
OZZ
O
CARBON MONOXIDE ALARMS s,
�1 ! MUST BE INSTALLED PER
MASSACHUSETTS BUILDIN
G CODE
0Lk� �fl.y--RG E LAu0ta�� �
LRu
/ q-r vtsv
� rvi
T
1
X) 0
LAuwWy
M KEW
s
ON
I�
ly8
\ I
CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT
d� DEPARTMENT OF FIRE-RESCUE&EMERGENCY SERVICES
1875 Route 28•Centerville, MA 02632-3117
1926 508-790-2375 x1. FAX: 508-790-2385
John M. Farrington,Chief Martin O'L MacNeely, Fire Prevention Officer
Craig E.Whiteley,Deputy Chief Francis M. Pulsifer, Fire Prevention Officer
March 25 2008
Mr. Thomas Perry- Building Commissioner
Town of Barnstable
200 Main Street
Hyannis, VIA 02601
Dear Commissioner Perry:
Pursuant to MGL Chapter 148 Section 28A, I am making you aware and request
your interpretation of an un-permitted bedroom without fire alarm upgrade at:
18 Gina Court
Centerville, MA
While on a sale and transfer inspection at.this address, I observed an attached
garage that has been converted to a bedroom. The fire alarm system has not been
upgraded and we have no ending fire
alarm permits for this address. The owner stated
that the work was done in February 2007 by contractor Scott Quilter. The real estate,
agent has been advised to contact your office for direction.
Please contact me with any questions you have relative to this situation at 508-
790-2375 Ext.1. Thank you for your attention to this issue.
c5n :
t
Sincerely, ;+ ,
Francis M. Pulsifer
Fire Prevention Officer
Cc: Robin Giagregorio
"Commitment to Our Community"
Assessor's map and' lot number��....................
...............
I
Sewage Permit number d�Q� ♦�
STAR
House number ' ........,fig/h?: ................................ SEPTIC SYSTbWl ,� L 0�
tph,� A B
!'VSTfy CC)
TOWN OF BARN:STA�BK�iHTITLE5-
- - � NTAL CODE AND
TOWN REGULATIONS.
BUILDING` : INSPECTOR r
s ., - �
APPLICATION FOR PERMIT TO .... �..... 5................. , ,,..,...r ; ........ ........ ....
Y
TYPE OF CONSTRUCTION .................... 51 SC r
a
•fin -3.`..................:19. .1.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby.applies for. a permit according to the following information:
Location ........� ......... '?.` 1.C!`:.................'..:� .. .... 4' .�� ..................................
Proposed Use ....... V.tV�...... t .
Zoning District ......,.1�.a.< .C\ .`.�^�........................Fire District .....\.�5!\ � �� v'.\`V
Name of Owner ... Gi= .....�......J.m..`..."...."........Address ............. CJ..s.:•:.....?....................................................
Name of Builder. ..:(.\cxw.r?'v...�.....v...........?... .....':`..........Address .......... C i..1.. .. .........................
Nameof Architect ............ .......................... .................................................:..................................
I Number of Rooms ... Foundation ....... .. U..... n.� ! ...
Exterior .��i .:'...4�...� 5. !n.a '� \.\ \ .Roofing �� r. ....... .........................................
U , v
Floors '................ ...... ... ..................... .................:.Interior
.........................................................
!�r
Heating ..... C�................. ...................................Plumbing .... ................ .w` C. ...L '
... .... ... .......................................
Fireplace .........� y....................................... . .. ........Approximate Cost .„. .... ..:�'S.> .v.V. ........... .n. ..
Definitive Plan Approved by Planning Board ________________________________19________. Area .............
Diagram of Lot and 'Building with Dimensions Fee �j 7SS
..........................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH +
h
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. (� ,/
Name . :.,?..�..� ....�`.. ...............................
U
S-111ITH, JAPIES KA
�-23252 One Stor
3.�j',No .............. Permit-%r .................... ..... .......
Single* Family Dwellin
0;�................................................................................
Lot #12 , 18 Gina Court
Location ................................................................... '--7
Centerville
...............................................................................
Owner ..... ....... ..James..... .K............. .....Smith..........................
ry
Frame
Type of Construction ..........................................
................................................................................
Plot ...................... Lot ................................
June 30, 81
Permit Granted
Date of Inspection ...........................:,t�.......19
Date Corn ......../,a:7 1,9-
PERMIT REFUSED
................................................................ =19
....................................................z..................
..................................... .......................................
x Fes
..................................... ......................
............................... .........................................
Approved ........ ........... 7:�...................... 19
::n
. Y
, uv G�r::��cF cr�1��z. � • . �1.� t`19 ."l$ �,fj'" yr
LA&I L.'4 FF ti0%� s 110 ,c �., t 330 G Pt�
�ttiFi1-1r c-1-'1�.iK L • 4,9c2 6.P.o.33a� i5c %
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t5o s s=. . T N.
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s t%Ef1Gt,l.Q1 1UtJ . TZATE t"tw 2.miO**o ' 1flop
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I►JS('�?J :t-_ .1; �+Uc:.il ;� T��r� uF ', =T�. ����wta APP't_1 0A,i-.tT
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LOT Ll w`lr � QiM:t✓�
- � 4 ��
„o'""'• TOWN OF BARNSTABLE Permlt No. --------_-
e
Building Inspector cash --____--
"YL
OCCUPANCY PERMIT Bond
"No building nor structure shall be erected, and no land, building or structure shall be
used for a new, different, changed, or enlarged use without a Building Permit therefor
first having been obtained from the Building Inspector. No building shall be occupied until a
certificate of occupancy has been issued by the Building Inspector.'.!
i n -
Issued to Jamie, ti Smith t''' Address I5r1rm1 w'rbl,:.
Lot 017� 13 Goa ;'curt Ce t4;cv le
J
Wiring Inspector �✓ y Inspection date
Plumbing Inspector.�A Inspection date
Gas Inspector � �� 1� %r �'� r� -, Inspection date
Engineering Department Inspection date {
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS.
.......... ........................_, 19 ........ � Building Inspector.......
y
r r .
Assessor's map and lot number ......... ...... ./.. `,/per. 612 ��
o/( �QyoF TH E Toy O
Sewage Permit number .... .............
a Z EARBSTADLE. i
House number . ......:................................................ 9 NAM
Op t639. \0�
''�1'p IIFY a•
TOWN OF BARNSTABLE
BUILDING INS;PEC--TOR
APPLICATION FOR PERMIT TO CA C°�:s.... Q................�. ...................... ... ...........................................
TYPE OF CONSTRUCTION ................. .... . QS MV.....................................................................
`....................19. .�..
TO THE INSPECTOR.OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ........ ........ .�........ n�^ ........ CJU T...............\ ..P,( ' .`\ ...................................
�.a , . ..............Proposed Use ....... ���1ct�.�-....... "..... ...............................................
Zoning District ...... ..................................:":"'.....................Fire District ....` -..o5.....U..`.``V....................
Name of Owner ....wkM.e!�......v......... ....... ......Address a�`-�........... ................................. .....................
Name of Builder ... ...... 7�11..........Address ........... ram++ <1.. .. .�. ..... ..................................
Nameof Architect ..................................................................Address ...............................\.......................................................
Number of Rooms ...............5...............................................Foundation CluJ1C.C�.....0 (�sz`ts--
Exterior �. �.V. n..0... ... .���......Roofin OY? �. cam✓
g .................. .............................................................
Floors ...... \'....................................................................Interior ........... ..............................................
` Heating 1 11Ct ....................................Plumbing � t" ..�
Fireplace ......... '.............................................................Approximate Cost ..............` .S.a.d. . ............................
Definitive Plan Approved by Planning Board _______________________________19--------. Area ..........................................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL -OF BOARD OF HEALTH
f�
N,
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..':.. ( 11f( ... ,.. . ...............................
U�
SMITH, JAMES K. A=210-191
No 2 3 2 5 2 Pdr''mit for ..One S ..........
Single Family Dwelling
...............................................................................
Location ..Lot #12 18 Gina Court
............................................
Centerville
...............................................................................
Owner'......James...K-...Smith.......................
Type of Construction ...Frame _
................................................................................
Plot Lot ................................
Permit .Granted .....June...3 Q.c..............19 81
Date of Inspection ....................................19
Date Completed ......................................19
PERMIT RE SED
..................................... ..................... 19
....
........................ ..........................................
00*0-
�•
Approved ................................................ 19
.....................................................................
...............................................................................