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0056 HI-ONA HILL ROAD
\ 56 NT- ou Fl Ni �� ���� Town of Barnstable Building Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept I mAS& Posted Until Final Inspection Has Been Made 1639. 9 Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. e i J Permit No. B-19-2297 Applicant Name: RetroFit Insulation Approvals Date Issued: 07/23/2019 Current Use: Structure Permit Type: Building- Insulation-Residential Expiration Date: 01/23/2020 Foundation: 0 0 1 Zoning District: RC Sheathing: Location: 56 HI-ONA HILL ROAD CENTERVILLE Map x/Lot: 207-090-00 y .. Owner on Record: BOYLE,JOHN C&SUSAN A Contractor Name:',1RETROFIT INSULATION INC. Framing: 1 Address: 56 HI-ONA HILL ROAD , Contractor License: 160461 2 CENTERVILLE, MA 02632 ~' Est: Project Cost: $4,091.00 Chimney: Description: 10" layer Cellulose open attic,damming, Install 2" rigid board to Permit Fee: $85.00 kneewall area,insulate attic hatch 2 thermax board,Sheathing Insulation: Fee Paid:," $85.00 Access, propa vents, Install 2" rigid board kneewall:rafter area,Air Final: Sealing, Install blown in cellulose exterior walls, Install 2 rigid„ Date: 7/23/2019 board to common wall area i � Plumbing/Gas Project Review Req: 'ti 7GG Rough Plumbing: Building Official final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.All work authorized by this permit shall conform to the approved application,and the'approved construction documents>for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: F work until the completion of the same. ` Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:[ Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r Application number.. .�.-�...s ..`...-/6YLo. O�TttE T ° oa C Fee .............��...?........................ ..................... MAS& ; MAY 20 g Building Inspectors Initials..... ... . i6g4. ♦0 ® Ql� CFO MAY ��� 1��. L) Date Issued.......... �. .Z(t�.�..U .. .......................... Map/Pa.rcel....CA"STABLF24�..�. 6.00.1.............. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project:5� Hi Ong W 1 Edad l Lt\` f- -\&, NUMBER STREET VILLAGE Owner's Name: '1BoLAP_ Phone Number Email Address: D Cell Phone Number Project cost$ 5� C)O Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMRC- Owner Signature: Date: 51 -4�/ !' TYPE OF WORK u Siding a Windows (no header change)# � Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to (,0 ti r 4 1� r•�t CONTRACTOR'S INFORMATION Contractor's name i Home Improvement Contractors Registration(if applicable)# C) I (attach copy) Construction Supervisor's License#I CI, S - /o_,/ $5- (attach copy) Email of Contractor MmE:o1 l0 @ Abe. (6M Phone number 5(j8 - ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. f APPLICATION NUMBER ............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am -9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date S aO 20/ All permit applications are subject to a building official's approval prior to issuance. rb a S tk d Nw Is r ' ®mod car Btldittva s Sty 3 Ml •2 ..jai pu` n f''' �t;�'. _ -+.R,,. �s #"'f roc. .a r WN vg x s z I 7 ��e�drn��ta�rraea�o��%l�aituc�uJell-3 h ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use odY TYPE:lrKWual . before the expiration dab. N found return to: RedsbvMan gairation Office of Consvmw Affairs and mess Regulation 1777b7 0ZWJ2020 1 .v One Ashburton Place-Suite 1301 KARLSPAIN Boston,MA 021 D/B/A K-T.sPkN INSTRUCTION KARL SPAIN - - 46 MAIN ST. Ot Wdhd Si9i18h/(S SANDWICH,MA 0256i UndwseaetW ��r;r - -,cl _JCL 01)C0-�� LAC� ;� f?�1��� Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement,Contractor Registration Type: Corporation . M.B.HOME IMPROVEMENT,INC. = Registration: 180881 53 CONGRESSIONAL DR „Expiration: 01/22/2021 YARMOUTHPORT,MA 02675 _ _ _•p'F s s .. Update Address and Return Card. SCA 1 0 20M-05/17 a Office of Consumer Affairs&Business Regulation ti ' HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE.Comoration before the expiration date. H found return to: . ReaigiWo Expiration Office of Consumer Affairs and Business Regulation 180881 01/22/2021 1000 Washington Street-Suite 710 M.B.HOME IMPRi Boston,MA 02118 s s MICHAEL BERN3TElN 53 CONGRESSIONAL.DR-_„_ YARMOUTHPORT,MA=02fi75 Undersecretary' Not valid without signature Y ' 4 NOTICE N NOTICE TO a TO EMPLOYEES EMPLOYEES O.qM S�6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO.• MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-0114N13-4-19) 02-08-19 TO 02-08-20 POLICY NUMBER EFFECTIVE DATES BRYDEN & SULLIVAN INS PO BOX 1497 SOUTH DENNIS MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# M.B. HOME IMPROVEMENTS, INC. . 53 CONGRESSIONAL DR o _. r YARMOUTHPORT MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named.insurer•is required'in cases of personal injuries arising out of and in the course of ' employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services X = provided by the treating physician,will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 001846 W20P1G15+ TO BE POSTED BY EMPLOYER Town of BarnstableBuilding : •. ... ad.. ' •" °' s ,.... ., a -, * is se`�\ei:. ^.�y".",,"\'.,: ri," Tm''." `a� a *.are;,Rw ;w BARDiSTABM is a' So�That it rsVis�ble,From:rthe=Street, ,A.pp;roved Plans,Musi be Retained ortJob and this Card,MuSt be;Kept ;\ MA$9. "`�k�* � �� "* -..a> r.,.'"��"c�,`�x.,� ."3''' �. \� ': F��•`�.`�` ,l, A �s '� x y��kz cc•'°�.k.. .r .�v. _� Permit ° Where a Cert�ficate,of Occu anc, his<.Re u�red such Bu�ldm shalLNot be Occu ied�until3a;'Final In'�s�ection has:been made��"' t � •:�< . �..a,�'..�\.e.,e,.. ��..;��p � y,�? ...4 �. ! ::� a.,.. �,«,....fig aa..�•�...�.�.,, »-..;,, .p\... ,��.�.:>_'��. .�: :�p: ;. ,w..,,._,:,.. ,. ��. .. .�,: Permit No:: B-18-1688 Applicant Name: BOYLE,JOHN C&SUSAN A Approvals Date Issued: 06/08/2018 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 12/08/2018 Foundation: 'Location: 56 HI-ONA HILL ROAD,CENTERVILLE Map/Lot 207 090 001 Zoning District: RC Sheathing: Owner on Record: BOYLE,JOHN C&SUSAN A ntractor Name' Framing: 1 Address: 56 HI-ONA HILL ROAD aContractor License 2 CENTERVILLE, MA 02632 Est Project Cost: $0.00 k ., Chimney: Description: Shed 8x12 Permit ee: $35.00 a Insulation: Fee Paid $35.00 Project Review Req: B 4� Date 6/8/2018 Final: 011 r - Plumbing/Gas e Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved applicat orrand the approved construction documents four which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open focpublic,mspection for the entire duration of the work until the completion of the same. v x l Electrical The Certificate of Occupancy will not be issued until all applicable signatures�tiythe Building andFire Off•igialsare provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: gO 1.Foundation or Footing £f Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable Regulatory Services I?U Richard V. Scali,Interim Director � � 7. B APNSTAI =RM ` BuildingDivision Mgy2 v� o a. Tom Perry,Building Commissioner )'00//V®_ 4 ?018 200 Main Street, Hyannis,MA 02601 '`N www.town.barnstable.ma.us � « Office: 508-862-4038 Fax: 508-790-6230 I;> PERMIT# 1 FEE: $ �� O SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less 96 K;-O► A cfhl4crylIli Location of shed(address) Village 'TOLN tSut.—, Property owner's name Telephone number w 207 29 ooal Size of Shed Map/Parcel# J23�/� Sign at 6de' Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) r% Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE 1 ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg ] REV:110413 of 41,60 02—,:512— Proposed Shed Addition Seabur Y Lane 12' 'a 1of roposed Shed 8ftx12ft cc 21 E I. Lot No. 207090001 John & Susan Boyle 56 Hi Ona Hill Road Centerville, MA n ,•��TO L°f yj 4t/ ��/�o�v� d. o sf���DGG Q ��/Io✓� lC� ' . y1 T Luy„1 S P vj �a.T� d- a I/Vt�z � � � 74e /mod y4� 741 4 1,2-f41w, o v Ka �c s Dle— SZ�-3�6U Plumbing/Gas Rough Plumbing: . ,Building Official Final Plumbing: nced within six,"months'after,issuance. Rough Gas: ion documents:forwhich this permit has been granted. h the local zoning by laws and codes. Final Gas: ed open for public'inspection for the entire duration of the r ^y, Electrical Y aals�re provided,on this permit. Service: a Rough: Final.• Low Voltage Rough: Low Voltage Final: Health Final: ty fund" (as set forth`in MGL c.142A). Fire Department e Final: SUED RECIPIENT +t * v+w ^ i\ a Qkll ni NL Wl ' , r„a It All , C• i. �07 - , �xr^~ �fi'ti+'r �. k'+'� J —`�',,,„�or`` --- _.. tr�P'` ..•� .�r, ,1 _ •�+�: v-= SS ) 4; UN. Y^ j Wes' .yp. iF � �"r 3� `• ,�"f '�S' ! � .vim` �.�'14 � a, T-4 _t•_ r � 1 f - T w of Barnstable *Permit# d I PROOFxp�l ,rrirsfromissuedat� ; q� ® atory Services Fee snaxmesr�. ��� OCT 18 KAM Z0R�chard V.Scali,Director 1"9. MAIN 0� 6011S i Ting Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION+ - RESIDENTIAL ONLY d — Not Valid without Red X-Press Imprint Map/parcel,Number Property Address � QI'T1 Residential Value of Work$a 5m+ l) ) . Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address I-)kn R u)e_ on' o re_o�ervd)e Ma Contractor's Name t C\aeA &f n n Telephone Number 5D(7 -a !H -q q IOIO Home Improvement Contractor License#(if applicable) ( ^ Email: 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 Name Workman's Comp.Policy# Ty U P)_ I 1 `-t l-1 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 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: Q MPFILESWORMS\building permit formsEXPRESS.doc Revised 040215 1� f a 'Rill cb-t It . 5 F C'� r L r { j 1!-a 5L J r _ L�iuc e LB-Lc 11 Massachusetts Department of Public Safety ® Board of Building Regulations and Standards License: CS-102185 Construction Supervisor - ^• haw - - KARL T SPAIN 46 MAIN STREET SANDWICH MA 02663 •..':crr�-- Expiration: Commissioner- 12/26/2018 * r..;'��r •f.r.w m,/rr/'IwIlli rI /1rr.1J/rl�rrdr irii t Office of Consumer Affairs&Business Regulation License or registration valid for individul use only Fa; HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:rE Registration: 177767 Type Office of Consumer Affairs and Business Regulation ;�• �-,?' Expiration: 2I3/2018 DBA 10 Park Plaza-Suite 5170, Boston,MA 02116 K.T.SPAIN CONSTRUCTION KARL SPAIN 46 MAIN ST. SANDWICH,MA 02563 Undersecretary. —.-----..- _..._....._..._.__..___.____�.... Potiva without ignature C6 oFTti Town of Barnstable Regulatory Services . ' E SiI tiTNCw•lRT4 f p assss$ Richard P.Sad4 Dirednr, DuRding Division Tom Perry,BuM3.,tr,Commissioner 200 Main gftee�Hyamis,MA 02601 • WWW DWXL'barnstablem�IIs Office: 50&9624-038 Fes: 508-790-6230 Property Owner Must Complete and Sign This Section: If Using A Builder I, �d . I►�o�.(� ,as Owner of the subject property y. hereby2L60IIT.f: P L i Z k a G I r e V A S e to act on mybebal� in all matters relative to.wank authorized by6.is building permit application for: , S-6 14 �i , Cl 2�1. eejcvl:,<<< /�'lA o-L431 r (Addiess of Job) -Pool fences and alarms are the responsibilkyof the applicant Pools are not to be filled or d before fence is installed and all final " inspection.are pe-do=d and accepted. ' o SS!eignat=of Applicant S' Pri„rName s Print Name Dam QFoxMs:awi��smrgoors ' Town•of Barnstable Regulatory Services Richard V.ScaH,Direc#or , Building biyisiort Tom Perry,Btflding Com-iccionex 200 Maier Street Hyannis,MA 122601 �Ep M� barncfafiT�r,+a� - �P•4PFY.t04Pn.. Office: 50 8-862 403 8 - - Fes: 508-790-5230 HOIMOWNM I u:: 1C'R R.XEB IION .rl=c Print JOB LC)I=C)K- n>�a, names h®Gphoao# :WOLTCphanc#r` CURRENT.MAMM-TG ADDRF_43: _ city/tea s� zip codc The cturent exemption for`$omeowners'was cxtended to include owner-occ�ied dweIIm2s of six twits or Less�d to allow homeowners to engage an individual for hirewho does notpossess a liccnsc,pi ovidad that the owner acts as stmeryisor_ DX•narrr0x OFHOMBOWNM P erson(s)who owns a parcel of land oa which helshe resides or hit rmds to reside,an which•mere is,or is intended to be,a one or two- family dwelling; attached or detarhed structures accessory to such,use and/or farm strnetums. A person who coast cts more than one home i a a two-year period shall ant be cauddrred,a homeownerr. Such"homeownet".shall submhto the BmI ing Official an a form acccpisble fn the Bm7amg Official,thathalshe shall be res�ansible for all such workperformed underihebm7dm�pczmit (Section 109.L 1) The,ffidersig r-d`.hDnaeov ner"as��responsr1iliiy for compliance Wif7lthe Sstafe Bmldmg Code and othet applicable codes, bylaws,rules and rm9m atiow- - T. bz vndmsi gnu—homeowner"*cerfrfies thathelshe imde stands the'Tower ofB=stable Building Depatimcnt min==inspection. procedures andregairements and that hrifshe will comp lywhh said Pro=A==and reggemeofs_ ' Sigaahaeof$nmeo�encr - ' Apprv -il QfBm7dmgOfFicial Note- Three fuZy dweIlings cont�35,000 cubic feet or larger Willbe requited to comply with the State Buz7div g Code Section 1'27.0 fiction ContmL The Code states that 'Any homeowner performing work for which a building permit is required shall be exempt Emm,the provisions of this section(Section 109—U-Liceusimg of consirac ion Sup.ervisors);provide$that if file homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this e=mpfion are uraware.thatthey are ass zarag the responsiibrades of a.supervisor (see Appendix Q,Rules&Regulations for Licensing Construcflon Sipervisors,Section T 15) This Lark of awareness often. results in serious problems,pardenlarly`when- ie homeowner hires unlicensed persons. In this case,our Board cannot prove d against the unlicensed person as it would with a Hceased Supervisor_ The homeowner acting as Supervisor is ultimately respoasible. To eum=e'that the homeowner is fulE,aware of his/her responsibrMes,many eommaurides reqm[re,as part of the permit application, that the homeowner caf y thathe(she understands flee responsibrTr(x'es of a Supervisor. On fhe Listpage of this issue is a form cmrrenfily used by several towns. You may rare t amend and adopt such a for-mlcertifr__ ion.for use in your cammuaity. .R,pF1IF�.•pE�,d:�14,,,��,,,gPeaz�f�s1F�HF5s.doc • Q� R.aviscd 061313 Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston, Massachusetts 02116 Home ImprovemenfContractor Registration Type Corporation R4ttstration: 18=1 M.B. HOME IMPROVEMENT, INO Eiration: 01/22j2019 53 Congressional Dr iy Yarmouthport, MA 02675 a ` - Update Address and return card. Mark ran for change. SCA1 0 20M-05MI D Address 11.Renewal 0 Emninvment O Cost Card �te�pa»a�rea�u��tl�o ��ir�tac�zresell3. OftrceofConsumerAHai�s�Bus[nessRegulation "- — -------------__--._. _-_-.-. HOME IMPROVEMENT CONTRACTOR Regibstretion valid far Individual use only TYPE.CorIm ation before the expiration date. It found return to: eaishrabian iration Office of Consumer Affairs and Business Regulation 181. 01/22019 10 Park Plaza-Suite 5170 Boston,MA 02116 M.B.HOME IMPROVEM -T INC. Michael Bemste�t - _ •yy, _ , 53 Congressional'13r __ ✓/c�sl` ���i —� . Yatmouthport,MA•O�f335 - ` UnderseamtW Not valid without signature V ?Tie Commomweakh ofMass diusd& DqAartment ltf 1IduYftd Accident 600 Washnigton,k&--et _ Baston,MA 02111 fvwmmm&g dw' Workers' Cmipens.af o n.Insurance Affidavit Buffders/ConftwftwsMectricianslPluinbers Applicant Inform.ai un Please Print Div Name _ m �mP_ ������P Z71G Addrew 53 Cow-e-s-,5 i nna� N-oje ph( 50�5' o�1 Are you Tyke of grnject(required -- L El am a employes with. 4_ UJI am a general confractor and I' ❑Netts construction employees(full Rumor parwime)* have lured the salt-ccrnlractaas 6. 2.❑ I am a sale proprietor orpartner- Tested o the attached sheet ?- ❑Remodeling ship and have no employees _ Them sub-co n rac-tom have 9- ❑Demolifion worldag forme in any capacity: eu4doyees andhave wa&=- [No wadoeas'comp-insurance comp-; surana l 9. ❑Euilc&ng athlitiom regaked-] 5. ❑ We are a cogxxxEm and its 10_❑Electrical repairs or additions 3_❑ I am a.bomeovmer doing all vt & officers leave exercised#heir 11-❑Plumbing repairs or-additicros myself[No worlamrs'comp Agbtafexemptiort per MGL 1?❑Roof repairs insmaace require&j c-i 152,§1(4�andwe have no emp (No wa&s' 11%0ther i " comp-msurance wed-) •sag app 61"Icbedksbas in masc also snouctt mci w ianbelowAaaimg dieirodce a compeasatkmp©Ew inrn� ?Ida �Imsubmitddsaibdash J they an=_doing atf rival&mlaseautd&canbxcMspac'submit anewaf&dava SudL rcantnactocsthatebedrthisboat i Stattachedassdditia�isb sbaarmgtbenameofthe mrssaristate otntetthoseeai bean employees.Iftbesab4antmctmh veempIayee%dLeg=Lsrpmuide&W WarkeWomp-poTicymumber. lain an snepLaFsr t7eat is provident;workers'catrrperesstir�n insrsrat3re jet empf gee Betrrsv is tits pu&cy abed job sits friformahbn. Insurance Compa:a ty Name: e S .Porley 41 or Self-ins_ Job Site Ad&n I_I a � _Cep �� I 6)cb�a Attach a copy of the workers'compensation policy declaration gage(shawing the go&y number and epgation date). Fafl=e to secure coverage as required.under Section 25A of MGL r- 152 can lead to the imposition of criminal penalffies of a fine up to$1,500 00 andtor one-year impdsonmeut,as well as civil penalties m 1he fan of a STOP WORK ORDER and a 11me of up to$250-00 a day against the violator. Be advised&t a copy of this statement may be fkwarded to 1 e Office of Investigations ofthe DIA.for fsarance coverage vet ion. Ida,Jteratty cBrh y under the pants and pertabiss rrfperjury that the b1forma€va prod ab a is(rare and correct �ia�tature Ott. �i---� rU �' -(- CS Phase A- 56 -a-7`I q q� D f T5( Officiad um only. Do not twits in fids area,to be cmapleted by city orhnm 4ffitaal City or Town: PerruibUcense:9 Issuing Authority(code one): L Bird of Real& iBuffiring Department I CUylrown(1wk 4.Electrical Inspector 5.Plambing Iuspecttar 6.Other Contact Person: phone#: 6 NOTICE W NOTICE TO TO w a EMPLOYEES - a EMPLOYEES 0,9M Sv8 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 - http://www.state.ma.us/dia. As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I q(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7POUB-0114N13-4-17) 02-08-17 TO 02-08-18 POLICY NUMBER EFFECTIVE DATES BRYDEN & SULLIVAN INS PO BOX 1497 SOUTH DENNIS MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# op M.B. HOME IMPROVEMENTS, INC. 53 CONGRESSIONAL DR o� YARMOUTHPORT MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS '. omag W20PIG15 TO BE POSTED BY EMPLOYER • i ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 6`i Parcel `l6'D Applicatidn # . Health Division "'.Date Issued Conservation Division ;Application Fee Planning:Dept. Permit Fee 1 '"�S• Date Definitive Plan Approved by Planning Board � ilZZlb9 Historic _ OKH Preservation / Hyannis Project Street Address 0, Village Owner 1-C) �)e Address ' �l 10 (j r:eeti to c�ar Telephone 6 ada Permit Request c� P �,,r eabi n�� TnS+k, ZAE no (Ja to roc(L Q14 r6`q,1(�-ire-, ,s U 4 ki ON Square feet: 1 st floor: existing - proposed 1 2nd floor: existing proposed Total new Zoning District. Flood Plain Groundwater Overlay Project Valuation ���'U0 Construction Type X s Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: A 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: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas S Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing es New Existing wood/co stove:..]Yes Ell No f Detached garage: ❑existing Li new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing L;Tew size_ Ci'i �. Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: R z "x O ex� o Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ CO Commercial ❑Yes ❑ No If yes, site plan review # ``•=' cn Current Use Proposed Use APPLICANT INFORMATION (BUILDEWOR HOMEOWNER) Name ( o 'm'� ��n Telephone Number Address Oy 17 License # S S-0 a Home Improvement Contractor# L/ 7 9,5�' Worker's Compensation # ALL CONSTRUCTION I-DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S os,=? SIGNATURE `i�/ 21'iy •Z DATE')'/2 F FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP/PARCEL NO. i i r . ADDRESS VILLAGE OWNER 4 .4 Ap. f F DATE OF INSPECTION: FOUNDATION ` FRAME Cv�) (IS9Lo9 INSULATION It S cws FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT . ASSOCIATION PLAN NO. s f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 wM =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): IN G 4\��1 Q �n 5����e r ��^C. �`Tb�7� 1 n 00A,� { Address: c, 12 o,� 17 G-7 4-ig, City/State/Zip: k� �w s �er f11 c� Phone.#: Q - �- y a Y Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-timel. * have hired the sub-contractors 6. ❑New construction .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• ❑Demolition working for me in any capacity. employees and have workers' 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.PO 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.❑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. tdontractors 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 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: --.%z7 ''y L/ �` Date: /o21s /f�9 Phone M '50 6e q — 0 aZ 41 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 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. ined as"...every person in the service of another under any contract of hire, Pursuant to this statute,an employee is def 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-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, 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 02.111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-774 Revised 11-22-06 www.mass.gov/dia ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: —t- O D Ae ,fin (� Site Address: S� K _ rw print Town: Applicant Phone: so 8 o oP 7 L[ Applicant Signature: ( �- ✓� Date of Application: ���b /0,;- 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 Slab QO tip on 1: Fenestration exposed Wall Floor Basement perimeter U-factor floors R-Value R-Value Wall R-Value R-Value AFUE HSPF SEER R-Value and Depth National Appliance Energy R-10, Conservation Act(NAECA)of 35 R-3 8 R-19 R=19 R-10 4 ft. 1987 as amended,minimums or eater as 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.energg cy odes.gov/rescheck/ ADDITIONS'.OR ALTERATIONS.TO EXISTING BUILDINGS OVER,5 YEARS 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%.use the chart below. If glazing 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 Perimeter Fenestration Wall Floor Basement Wall U-factor Exposed floors R-Value R-value R-Value R-Value R-Value and Depth .39 R-3 7 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 t ton achieves the full R-value over the entire ceiling area(i.e.not compressed over exterior walls, and including any access openings). SUNROOM-An addition or alteration to an existing building/dwelling unit where the total ❑ glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form (found in Appendix 120.P) Licensee Details 10/16108 11.05 1 Public Safety Mass.Gov Home State Agencies State Online Services Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License# 111795 Restriction Company Mac Donald Installer Inc. Name Todd Macdonald Address 26 Francis Rd City,State;Zip Harwich,MA,02645 Expiration Date 2l3/200 Status Cum Trent No complaints found for this Licensee. Back To Search Massachusetts- Department of Public SafetN 4 Board of Building Regul ations and Stand;u ds Construction Supervisor License License: CS 55029 Restricted to: 00 n4." TODD R MACDONALD PO BOX 1767 BREWSTER, MA 02631 --�- Expiration: 6/14/2010 (ununi�si drrr' Tr#: 5129 http://db.state.ma.us/dpsilicdetails,asp7txtSearchLN=HIC111795 Page °FtHE►°„�� Town of Barnstable Regulatory Services =A SrAABLE ` Thomas F. Geiler,Director Building Division . Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403.8 Fax: 508-790-6230 Property Pro er Owner Must . Complete and Sign This Section If Using A Builder I . ..�-4 ..1 Qc� , 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: O (Address of Job) Signs e of Owner Date Print Name If Property Owner is applying for permit please complete the Homeov ers License Exemption Form on the reverse side. Town of Barnstable Q�OctHE T�ti Regulatory Services Tbomas F.Geller,Director saaxsrwe 16.19 ��� Building Division ATED I�y a Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 vww.toyvn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current.exemption for"homeowners"was extended to include owner-occupied 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 resQonsible for all such work performed under the building permit. (Section 109.L 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 persons)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by,. several towns. You may care t amend and adopt such a form/eertifrcation for use in your community. Lewis and Weldon Custom Kitchens Susan &John Boyle r. 111 Airport Road 56 Hi-Ona-Hill Road annis, MA 02601 Centerville MA 02632 e phone 508-778-5757 508-775-2322 Fax 508-778-5111 check back pipe by pantry before production Cell 781-771-0464 #5 Room 1 #1 Not To Scaaie 124 1/4 159 3/4 - 84 3/4 Dining Room side 718 70 7/8 11 2 26-1 2 271/8 g�- �-_, 31 1/4 1/2 1 18 18.3 1/4 , 13 1/4 193 1/4 .24„g5 1/2 O 2F 24,14 ./8 1 19 1/16 24 1 22 36 11 2 18. 2711 16 1 2 #6 This layout is based on specific window and door placement.Drawings 84 may have been adjusted from architectural details in order to mabmize design.If you are ordering and Installing new windows or doors,please consult us to confirm correct size and placement.Communication is #4 important to assure that the design process does not adversely affect the #2 115 installation and construction process. 115 #7 62 51 _ - 36 1 2 r 8 .. 20 30 28 7 8 Sierra Madre Silestone 2e 1 z 25 ss 26 2e 26 Green Crackle Tile `, ' "" - 13 1/4 13 1/4 13 11'� 2 36 1 12-30 1 I%2 - Schaub730-26 Polished Chrome pulls 11 2—as7/a 3o z87ia Schaub 704-26 Polished Chrome knobs 3 3"stiles and rails #3 molding to match existing D/R-need match made 412 159 3/4 need extra for mud room 28 3/4 #8 127 35 #13 43 36 45 12; 12 12 12 12 "#10 3 3 3 3 36 #251/8- Stairs U 42 #14 116 i i OF THE j�� 1 o I.'I n Of Barnstable - T Expires I i nIh f onr sere dut Regulatory Services = Fee �� * BARNSTABLE, * _ v MASS. s6gq. Thomas F. Geiler, Director lj ,� ATFD MP't A Building Divisid"n Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY . Not Valid without Red X-Press Imprint Ivlapiparcel Number Property Address ��N"i t`et U �] Residential . Value of Work_� (� 600 C) Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address Su SCLK 1?0 I y� n Contractor's Name --Tj�-by) �_ �O�a�of _ Telephone Number Home Improvement Contractor License#(if applicable)❑ l -7 qJ Comstruction Supervisor's License'#(if applicable) S b 14� m n's Compensation Insurance❑Work a p _ e RE Ch ck one: +� 91 am.a sole proprietor I am the Homeowner t`a ❑ I have Worker's Compensation Insurance -VOWN OF Ir;surartce Company Name Workman's Comp. Policy'# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side . 7 S� . „ Replacement Windows/doors/sliders. U Value t _ (maximum .44) "'Where required: Issuance of this pennit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner.Letter of Permission. , A copy of the ITome Improvement Contractors License is required. SIGN/V['URE: Q: 4VPFI1.1.-S+FORMS\building pennit forms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street �< Boston,MA 02111 MI ww.w.mass.gov/dia Workers'- Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A Ucant Please Print Legibly PA Information �- Y Name (Business/Organizati on/Individual): -I Address: pQ-T'lam,c� gOK 1`7(p7 City/State/Zip: lb g w 54-vr, i q- u Phonet Are you an employer? Check the appropriate bog: :Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I * • have hired the sub-.contractors 6. El New construction . employees (full and/or part-time). 2.El am a'sole proprietor or partner- listed - on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' g ❑Building addition comp. insurance.$ [No workers comp.insurance 10.❑•Electrical repairs or additions required.] 5. We are a corporation and its 3.❑ I am a homeowner doing all work . officers have exercised their It.❑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 13.❑ Other employees. [No workers' 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, lContractors 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 provido 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 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 maybe forwarded to the Office of Investigations of the MA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided a ove is true an'd correct. Si afore: • Date: Phone#: 50 ^ 6 `o a-7 el 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 6. Other Contact Person: Phone#: 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 d including the legal representatives of a deceased employer, or the e foregoing engaged in a joint enterprise, an g g p of the g gJ rP receiver or trustee of an individual,partnership,association or other legal entity,employing m emP to ees, Ho ever 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 ehapter..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 coinpliaziee 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 caiy worriers' 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 towr_)."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 bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please'do not hesitate to give us a call. The Department's address,telephone-and fax number:. e Coz onwe, .th of M.Usavhusetts Deparfamot of kdu,�41 Accidents Office of Ituvestalg4ous 600 Washingtoxi Street • B.ostonz_I�iA ���11 TO. 617-72'-4�Q.4 ext 406 or 1-977RMASSAFE Revised - Fax#(517-727r7749 11-22-06 wwv.mass.gov/dia V Town of Barnstable Regulatory Services 9 ' s. Thomas F.Geiler,Director 'Orfply�p'la Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us d Office: S08-862-4038 Fax: S08-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, TO 1-t as Owner of the subject property hereby authorize ��, �/ a ��,, /� to act on my behalf, in all matters relative to work authorized by this building permit application for: Hi-Ot,, Will (Address of Job) Signpee of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Hof srte r�� Town of Barnstable ., Regulatory Services t sawvsrAar.e, Thomas F.Geiler,Director MAIM Building Division �rfD �n 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 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. 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 accessoy 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 Barns.table.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 homeowncm 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 fonn/certifi cation.for use in your comarunity. Q:fornrs:homeexempt Licensee Details 01=6f08 11.05 I Public Safe .rj0V Home Mass.Gov Home State Agencies State Online services Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License# 111795 Restriction Company Mac Donald Installer Inc. Name Todd Macdonald Address Francis City,State,Zip Harwich,MA,,02645 Expiration Date 2/3/2009 Status Current No comptaints found for this Licensee. S„k Tc SeaYch Massachusetts- Department of Public S:11'C:t) Boat A of Buildin- Re-ulations and Standai Construction.Supervisor License License: CS 55029 Restricted to: 00 . TODD R MACDONALD J PO BOX 1767 BREWSTER, MA 02631 �--�- —� Expiration: 6/14/2010 ( rnmii, ivsirr Tr#: 5129 E http://db.state.ma.us/dps/IicdetaiIs.asp?txtSearchLN=HICI 11795 page