HomeMy WebLinkAbout0055 HARBOR HILLS ROAD �,
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �)Y 7 Parcel O-5OZ Application # .3
Health Division Date Issued l (
Conservation Division Application:Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board - -7 -11
Historic - OKH _ Preservation/ Hyannis
Project Street Address % �A OQ63.Z\
Village Car� n�l�1CQ
Owner MAjaco ;\. Address 5-5 &Ab i1�S & C, )t4V%\6 lf'Y�j
Telephone Soo -dg
Permit Request A oc� r CA 8
�U ' •• c� \5'1 u's �o kc tns-�,.� Al�� �rdorh. A&L✓ x
Square feet: 1 st floor: existing X\Aproposed %1a9l 2nd floor: existing L-.I p proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation .Soo•.v Construction Type
Lot Size d• Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure '50 Historic House: ❑Yes kNo On Old King's Highway: ❑Yes �No
Basement Type: AI Full XCrawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) �00 Basement Unfinished Area (sq.ft) qbO
Number of Baths: Full: existing_ new dJA Half: existing All A new MITI
Number of Bedrooms: a existing A-new
Total Room Count (not including baths): existing new 7 First Floor Room Count S
Heat Type and Fuel: V Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes 1 No Fireplaces: Existing 1 New Existing wood/coal stove,:_.❑Yes � No
M,
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑gx�sting knew :maize_
i F
CD
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#
Urrent Use V^41e Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name yQc.o )Ir eeky-oSc 0,1 k -me , Telephone Number ��o
Address 55 1acn WN; License'#
C2ny;1LQ 111(1A Q�(Il�u Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO �o.RnS�ob�c
SIGNATURE T DATE �� �'
�*s FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED -
MAP/PARCELNO.
ADDRESS - VILLAGE
OWNER i
I
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE .
` ELECTRICAL: ROUGH i" FINAL
PLUMBING: ROUGH - FINAL
' GAS: ROUGH FINAL
FINAL BUILDINGn
v
DATE CLOSED"OUT
ASSOCIATION ;PLAN NO.
r -
The Commonwealth of. Massachusetts. - -#
Department of Industrial Accidents
`' - `� , Office of Investigat66ns
' '600 Washington Street i j... �
Boston, MA 021I1
www.mass.gov/daa` '� a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIuiinnbers
Applicant Information _ Please Print Legibly
Name (Business/Organization/Individual):
i 1\5
Address: 55 Vi1�2. r
City/State/zip:
V�Lo O Phone #: 5 o
Are;you an employer? Check the appropriate box: ,
t- Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I
employees ful] and/ -time).'
( or part-time).* have hired the sub-contractors 6. ❑ New construction
2.0 I am a sole.proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no erployees , is, These'sub-contractors have g. 0 Demolition
working for me in any capacity employees and have workers'. '
[No workers' comp. insurance comp. insurance.$
9. ❑ Building addition
required.] 5. 0 We are a corporation,and its 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work officers have.exercised their l l.❑ Plumbing repairs or additions
right of exem tion, er MGL `
myself..[No workers' comJ.p. g p P 12.� Roof repairs
insurance required.] t c. 152,'§1(4),'and we have;no
x employees. [No workers':' 13. ] Other A
comp:insurance required.]; , i�+h -}�nrb,
Any applicant that checks box#1 must also fill out thc7section below showing their workers'compensation policy information; &A m�1�
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
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' compensatiA 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 irriposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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-yerification.
I do hereby certify under e pai and pen es of perjury thatihe infor ation provided above is true and correct_
Signature:
1��. Date: I
Phone#: 10(0 f
Official use only. Do not write in this area,to be completed hy'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
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'comp'liance wifh'tfie insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor,anytof its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),addresses) 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
'"`' 4 `` be returned to the'city'or town that the application for the'pemrit 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 periiridlicense 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(ifzlecessary) and under-" Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or masked 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 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'riot 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
Teh.9.617-727-4900 ext406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www.rnass.gov/dia
'
Town of Barnstab-lo
P� Regulatory Services
Thomas F. Geiler, Director
'6`.tti39- Building Division
���
��► � Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 "
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 509-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: f ,�p- ,/jf J/
JOB LOCATION: JS /1Gx)i' /��175 eVnhUt.11=� /''� � a
nnu�mb�efr- _ r street
village
.,HOMEOWNER": ////�I� Rom'�i�'Gdr1� • CJ�f7o `��V �J, Uk�Lo
name home phone## work phone#
CURRENT MAILMG ADDRESS: t3C) D ljot7 �e etc i
d9f/r� ell-
city/town state zip code
The current exemption for•"homeowners"was extended to include owner-occupied dwellings ofsix 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.
DEFCNI'TION OF HOMEOWNER r
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 d requirements and that he/she will comply with-said procedures and
requirements
O '
Signature of Homco ner
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.
i, 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.l -Licensing of construction Supervisors);provided thatif 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 ofa supervisor(see.Appcndix 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. to 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 helshc 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
of YHE T,
�P� tis
, f
f f
- � BARNSrA.HLF—
MASS, Town of Barnstable
Regulatory Services
Thomas F. eiler, Director G , Dir or
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.b arnstable.ma,us
Office: 508-862-4038 i Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
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)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.0utl0ok\DDV87Ap2\EXPRESS.doc
Revised 072110
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TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION,
Map s Parcel O y� t. Application #42o�
Health-Division Date Issued 'L
Conservation Division Application FeeV_
Planning Dept. t Permit Fee
Date Definitive Plan Approved by Planning Board ob'
Historic - OKH Preservation / Hyannis
Project Street Address $•� ��t��cT�'�//�t /,/ .' S�Zz�a s -
Village
Owner :�(l��e/ Address S� �i��rba��>✓��l/rW
Telephone 77 9-
Permit Request
r
Square feet: 1 st floor: existing/ 2nd floor: existing proposed ? Total new
Zoning District Flood Plain Groundwater Overlay '
7
y^I
Project Valuation Construction Type
Lot.Size . /-7 Grandfathered: ❑Yes ❑ No If yes, attach sup portin docuntation.
gcme
��s
Dwelling Type: Single Family ;Q Two Family ❑ Multi-Family (# units)
Age of Existing Structure 3 Historic House: ❑Yes )0 No On Old King's Highway: ❑Yes ❑ No
Basement Type: ® Full ❑ Crawl ❑Walkout ❑ Other.
Basement Finished Area (sq.ft.) 111a Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing� new Half: existing new
Number of Bedrooms: �Z existing d new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ®Gas ❑ Oil ❑ Electric ��❑ Other
Central Air: ❑Yes 13 No Fireplaces: Existin6&New - Existing wood/coal stove: ❑Yes X1 No
Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑existing ❑ new size _Shed:W 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 �� /C�/ /_�t/r� Telephone Number %7 1/-
Address .SS / 4Y 4,0o/ 14.4 �Gt License #
�e4 llL e _11.a a/ 61-7.2 Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO�1Gil'II �`
J/,1/7 j f le
SIGNATURE DATE
r
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
r ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
s
FOUNDATION
FRAME
•
INSULATION
FIREPLACE s
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL-'
GAS: ROUGH FINAL
FINAL BUILDING Iti 7 I
DATE CLOSED:OUT
� ASSOCIATION PLAN NO.
i
f
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 Le 'bl
Name(Business/Organizationandividuai): f
Address: SS �J0/d
City/State/Zip: 6P/I k_V/� p�.,,l-71—Phone.#:
Are you an employer? Check the appropriate bog: 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
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers'comp,insurance comp•insurance t
required.] 5. [] We are a corporation and its 10.E Electrical repairs or additions
3.W I am a homeowner doing all work officers have exercised their I Ln 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' 13.4Other �,C
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.
ZContractors 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 providt their workers'comp.policy number..
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: /� —
Policy#or Self-ins.Lic.M 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 rrimirial penalties of a
fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the MA for insurance coverage verification. - -
I do hereby certify under the a' sand penalties of perjury that the information provided above is true and correct
Signature: /�.�' ? Date:
Zzl,,if
Phone#• -7 D �b
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.BuiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions `
y
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 Towp 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
(Le. a dog license or permit to born 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
Departinent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass..gov/dia
f
Town of Barnstable
�Op1HE tp��
Regulatory Services
swxtvszwar Thomas F.Geiler,Director
MASS.
039. Building Division
lfn � Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
vtimv.town.b arnstabl e.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
Z'ZZ
DATE: 5 �
5S
JOBS LOCATION:
number L � street village
"HOMEOWNER!':/ /��/� //yJr�e/ 77�/—� SO4 M_ a 7_Y y
name C y home
phone# work phone#
CURRENT MAILING ADDRESS: ✓J lyo,, rr /�f�II� �V
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 ovens 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
resQonsible 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.
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.
oF1HE r Town of Barnstable
Regulatory Services
BAAPM.N` � Thomas F. Geiler,Director
lEnrrwr" 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
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)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on the reverse side.
(I-POP KAIZ•r)WNFR PPR KAPZRI IN
Map Page 1 of I
Town of Barnstable Geographic Information System New Search Home Help
Parcel Viewer Custom Map Abutters 7 Map Size ® E® Zoom Out J J J J J J J fl In
N ``,_ f El _]PG Map: 247 Parcel: 052 Property
/ Location: 55 HARBOR HILLS ROAD Info
i r p6B ea .Owner: BUTLER,MARK K
I
247053 Ir
247057063
N20
oomationit Y J
t Map&Parcel~ 247052
Location 55 HARBOR HILLS ROAD
`, Acreage 0.17 acres
_. 1-
a 2�58069 i a Current Owner
4
o Mailing Address BUTLER,MARK K
J 135 WEST MAIN ST UNIT 45
y
Wi 247052 f E' HYANNIS,MA 02601
I� r A aised Value FY 2008
p285a I �I Extra Features $4,200
1 � � Out Buildings $400
Land $157,600
Buildings $125,800
Total Appraised $288,000
0 52
27
--{ 247051 'Assessed Value(FY 2008)
aa7 ,' .•*---.F, E� - Extra Features $4,200
O 4 34 5g
37}}}Feet � { 1 Out Buildings $400
Land $157600
- 1 S �. _ Buildings $125:800 _
Total Assessed $288,000
Set Scale 1"= 37 I Aerial Photos
�\ � Copyright 2005-2007 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS
BarnstableMA v0.2.91[Production]
I
http://www.town.bamstable.ma.us/arcims/appgeoapp%map.aspx?propertyID=247052&mapp... 5/9/2008
f
Barnstable Assessing Search Results Page 1 of 2
. -
Home:Departments:Assessors Division:Property Assessment Search Results
New Search
`New Interactive Maps>>
Owner: 2008 Assessed Values:
BUTLER,MARK K
55 HARBOR HILLS ROAD Appraised Value Assessed.Value
Map/Parcel/Parcel Extension Building Value: $125,800 $125,800
247 /052/ Extra Features: $4.200 $4,200
Outbuildings: $400 $400
Mailing Address Land Value: $157,600 $157,600
BUTLER,MARK K
Totals $288,000 $288,000
135 WEST MAIN ST UNIT 45
HYANNIS,MA.02601
2008 REAL ESTATE Tax Information: Tax Rates:(per$1,000 of valuation)
Community Preservation Act Tax $56.85 Fire District Rates Town
Barnstable FD-All Classes $2.04 $6.58
C.O.M.M.-All Classes $1.03 Commercial
C.O.M.M.FD Tax(Residential) $296.64 Cotuit FD-All Classes $1.33 $5.80
Hyannis-Residential $1.53 Personal Property
Town Tax(Residential) $1,895.04 Hyannis-Commercial $2.35 $5.80
Hyannis-Personal $2.35 Other Rates
W Barnstable-Residential $1.86 Community Preservation Act 3%of Town Tax
W Barnstable-Commercial $1.86
i W Barnstable-Personal $1.86
Total: $2,248.53
Construction Details .
Building Property Sketch & ASBUILT Cards
Building value $125,800 Interior Floors Carpet Property Sketch Legend
Style Ranch Interior Walls Drywall
W V/ray x
Model Residential Heat Fuel. Gas.
Grade Average Heat Type: Hot Water
re 1,4o
PTO 1� WDK9
Stories 1 Story AC Type None 15 1-
Exterior Walls Wood Shingle Bedrooms 2 Bedrooms
-46> -
Roof Structure Gable/Hip Bathrooms 1 Full
Roof Cover Asph/F GIs/Cmp living area 1104 'dx OAS
M
Replacement Cost $151587 Year Built: 1961
Depreciation 17 Total Rooms 5 Rooms 33 f3
Land
CODE 1010
AsBuilt Card N/A
Lot Size(Acres) 0.17
Appraised Value $157,600
Assessed Value $157,600
http://www.town.bamstable.ma.us/assessing/assess/displayparcelO8 map.asp?mappar=247052 5/9/2008
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Assessor's map and lot number ..................... ................... E C .
SYSTEM MUST BE
Sewage Permit number ...!.2?4................................. STATE
SA ",Py CODE AND TOWN
QyOfTNEr�irO ®7 �� BA� ^' 11LB
roe" •n _
• • r
Z BAHBSTAI1LE, i
wa9. d DUILDINd INSPECTOR
APPLICATION FOR PERMIT TO .. ��f l`./�..:...a'l?..(.!�.......�'r:Jj....l.. ................................... ......
GvO � J�mL-
TYPE OF CONSTRUCTION .....................o................................................................................................................
................................................19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned heby applies for a permit according to the following information: ¢
Location ......... ... ....l...r c.s�... .��.. ... / ...............
ProposedUse ................ ......................................................................................................................................................
ZoningDistrict ................4..05........................................Fire District ....................................................................
� �� Ste/� ; ..............
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms ow-�� .. � G e'
/�, s .....................�.��..................................Foundation .... ..... ................. ...................................
Exlerior .4.11 ,(.......c ..a.� ...5/..... � ` ...Roofing �'� � . ....................
,o��t/ovQ� S1O��o� is7SIR o"r-[os1Y'QJoor-
Floors / T Interior d SG2�e��
Heating ...... y'42— ............................Plumbing
Fireplace ................................ ........................Approximate Cost
Definitive Plan Approved by Planning Board ________________________________19________. Area ..... ..............................
Diagram of Lot and Building with Dimensions Fee .f !9.
SUBJECT TO APPROVAL OF BOARD OF HEALTH
dY . ie£
% r 1 �b .��a.,,p
^ Z 9 fs��sa
�y9
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
lr� ..4`..`A,r�. ....................... ....
Victor Gentile
No �6917...... Permit for......... ....................... ...... ....
.. ........................:,�� .....................................
e
LocationHarbor... ....H...il.......Rd.........................
Oyvner .Victor.......................................................r Ge Atile
Type of Construction ........Frame.......................
................................................................................
Plot .......� P.. ..... Lot -5?...........................
Feb
/Permit Granted ........�27.. ...............1974
gate of Inspection .....................................19
Date Completed' J.i:Z/3- P17 4r
PERMIT REFUSED
...................................................................... 19
40
...............................................................................
...............................................................................
...............................................................................
...............................................................................
Approved ......................................I.........'.......... 19
...............................................................................
...............................................................................
I
Town of Barnstable *Permit# 1,67
3 p� Expires 6aioRths from issue date
• KAStsrt+�. •
Regulatory Services Fee �� ef0
%63 m�' Thomas F.Geiler,Director ®® �?
Bu�ld�ng Division
Tom Perry, Building Commissioner MAY 2 0 2005
200 Main Street,.Hyannis,MA 02601
Office: 5b8-862-4038 TOWN OF BARNS TABLE
Fax: 508-790-6230
EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY
Not Valid rvMout Red X-Press Imprint
Map/parcel Number :2 V 7 d S'A r
Property Address r J #SO
Residential Value of Work OB ' Minimum fee of"$25.00 for work under$6000.00
Owner's Name.&Address
Contractor's Name 4, �/� Telephone Number 77 Y 7o
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workmaes Compensation Insurance
Check one:
❑ I am a sole proprietor 1
91 am the Homeowner
❑ I have Worker's Compensation Insurance j�
Insurance Company Name
Workmaes Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
® Re-roof(stripping old shingles) All construction debris will be taken to A/i
❑Re-roof(not stripping. Going over existing layers of roof),.
❑ Re-side "
0. Y- �9
Replacement Windows. U Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e:Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.. ,
Home Improvement Contractors License is required.
Signature
,0of ns:expmtrg
Rmise063004
' i
Yr r •
The Commonwealth of Massachusetts
_ - Department of Industrial Accidents
_ Office of Investigations
600 Washington,street, 7`h Floor
Boston,Mass. 02111
�`,r.:, :, Workers',Compensation Insurance Affidavit:Buildin r/Plumbing/Electrical Contractors
��»nlAkVa ffi
name: / /C/�/C
address: 114011 /11 ljf /I
city 41e rl state: .�� zip• .®9, Dhone# 77 Y—",7 302�
work site location full address : G if kG ve
I am a homeowner performing all work myself. Project Type: ❑New Construction ORemodel
❑ I am a sole proprietor and have no one working in any capacity. -❑BuildingAddition
,,�4{t-t,-�k"`Yy-K•; + . c."`.rd:�^raC''r:55k;rd�, ,; ^r4:.:;�s%�a •A..r: rq•rro:
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c .. :+m...l>+%bid .. S ...>'%" Y' l..i• .!ti!'�:'.^':'F:...�.:;•7.:.. �..Y. G't l'S•.'=`-;::.�.h'�t°7"r'•:\.rr:yti�.i.W.•{:..."R,
❑ I am an employer providing workers'compensation for my employees working onthis job.
company name:
address-
city: Rhone#•
insurance co. Doliev#
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r C-rk L�::YiC!.. r(n`'l�i. d. P�'!�'i �iN'.1 ::Y'S•
�° rF`i::.> cy�au., •._N_:: .�. §:.• .rG"?:3:ar'S••:„�W..a}.u•i:...";.rC^.:n� :.,� `�yu.r`.&n:t'�'�S:
❑ I am a sole proprietor,general contractor, omeowne)(circle one) and have hired the contractors listed below who have
the following workers' compensation polices
company name
address
- F ,
city: phone#:
insurance co. Dolicv#
•A$�
V }..i.phr.. .d.V 1 - K^ ,F.•.� F Xk�li r+'x:? .-+•.D5 - -
n i3.;,..•.?7•. a��`<_..}a >•::A;r`:..r :y:.....,+e., haii
"company name `
address: i
city: phone# .
insurance co. policy#
r" U z. ✓�, s F�;Arr.. 4.�.s T ,L;�' r'j'. u t S- .y -
i r•- e... r s tra¢ dd i7o aF:sh�eta necessa qv 'fi? Sa �r T�: .a:«,�
�w� .�°rrar'x �2 a� `;' <a9',•''�'�i�. 'es ;�'.,.y r �a»` s^.- ,�` .:fir-, .�,�y
— & :��� r..� �.' � �e".r'�tl�;T:�i$k.�' ;�EL°1'$,�w������i:�
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 maybe forwarded to the Office of investigations of the DIA for coverage verification.
I do hereby certify under the pa' s ddlnalties of perjury that the information provided above is true and correct
Signature Date
Print name 742/K // : Phone# 77 J,7,,-
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑check if immediate response is required []Licensing Board
❑Selectmen s Office
❑Health Department
contact person: phone#; ❑Other
(rcviscd SepL 2003)
_ i�A°-df'r'.ay..werm�s+�me�.ra..s•.wa.rr..•asea�a+wa.. -
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an 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 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.
'£"yy��'tir' t_'s4.fi+$• ¢¢ t�{? £.yy. .Y. 2lP' y�.' ya5';C',.gp a� y, Jt? '�S'9�i:Y.+�•Aiq��Vhu,'�k�e�z:�...
' If�, � ;• .. ..tl'a,.,. awE'.T:. ." ra �f`� ^''!�$.F.+kfi"x<Y•,"+, ,•y�#r�jr°S" ;'y�. ,'�_.ilM�a'�'`C'.-�yS..::. !.'AQ,xS''�^'=X' ..:�'T p+-' Yi �'i'j.,;.'.'',.' ..� .A".-,ey;�
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t.�l:�. sY+ .�. 'a`�.Y'i.�?kF,.;. :ea tm'�+.'a ''.�"'�;..':N.air•. . ..�•-:n:S.
Applicants
Please fill in,the workers' compensation affidavit 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
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.
:•r, "I :?A. !w i`?F:+'"i.y '•�"r., =�'::ii!`:�P:`.'-;„.. r.r.;r-: {.;i:"cj"1;+3.'2+.' s'�' :4`/.,, Fjs f':sA pk •?,f.Ri�Yi. _ _ r-• ^u Y''#: ro;F!", y .., y�:,l�,t'.:.fi>�':,�'.,i�;r ��'+,
}} ,��. .+;�,,. .c a - S c;�f„a ��+4 '4.E�`EST:•.'+�3�,�"'1 `��d�ro��«N,`-'° ^o3A '-,5'+ ,,.,.n,r,_:;:Ct.3 +et � �'�rR,•�f.x.dt�` 'I t � .. .�'�.�.'s��+. !�
:".38wy h1' �Zy fl.-• iaY �' a'�as' �'2tkl�'+t:l5f� Ih'y S 4.iia;.: ::��} F $. _ 4`h'+ 1 4 � Yi &:p-I.is
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
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...i:� .,,..� -�'.�� ,:7;i�,�as�' '+�;:•�." ;'.-"ter' :.«..,�'•" - .=4= �.�!�" 5�• .,.,. a�.._.a�:��k., ..-?�.v�t�r'� ;ix.b:•. :k;�:
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•"N.r�%) ra+L• i:nw.. .y, ...o--_y.k... •a+�: „..'�x•: ,.F..;7. a, - F•c'w"3i: :,jr'I°ro''s=`v^if.k.c,;}':-- .;s,,,,��•..'=^�5,'.e.,.,ry aF;? =�5t3
a�'�'lt;,`'a xS•fr -`� +'" ro.A t 'r�r7�.rt'arr"�e2'���:r•r'r:��hl�x,.sd$'(4•.,a.� �`�:3 'rv:' �4�3+ .,r. ,. y.. ,r,,,�a..:a:' n �,, 4^"..'ck...._
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,7`h Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406