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.r 1 J s•�- ai a5 �. .V 3n 1' iy jXf 4. m ' a , 3) �„S Town of Barnstable *Permit# ,6'13 " 7o z • "� Building Department E%6 hsfto date �Brian Florence CBO a a + 1AlN9TAsi�, • t9. 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 Map/parcel Number � � Ua� Property Address H.47 1 c ,G C f r,)i e V�4 A Ln'G,1 ;o,�, } Q Residential Value of Work$ 6&a4 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /,'> Q 6 e u !�/) ePC's Contractor's Name�p.� N+� (� Telephone Number Say•7 3 7— 3 7 ) 9 Home Improvement Contractor License#(if applicable)I�i s 1 Email: U/p GG JPe ti� Q ccl A%C. ,CC/A.% 'Construction Supervisor's License#(if applicable) QW)❑Workman's Compensation Insurance Check one: `l4►� 0 8 ❑ I am a sole proprietor 2018 (❑ I am the Homeowner BA 11[� [glbave Worker's Compensation Insurance ��� ��U NSTAB LE Insurance Company Name S So G 1 ti c,� r•, ,�...j i./��c Lv»�� Workman's Comp.Policy#Wu•—JOO— S Vl(o au! a 0 1 J-k Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Q,%S•)r— ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [g-ftplacement Windows/doors/sliders.U-Value • 3 U (maximum.32)#of windows f4'0'� 5 #of doors: / *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: .�' i� C:\Users\decollik\AppData\Local\Microsoft\Windows\lNetCache\Content.Outlook\9NNOKXYW\RESIDENTI LONLYEXPRESS.doc 09/26/17 i f Town of Barnstable *Permit Z— - 7()Z Building Department Services Expires 6mof,hsfrom issue date RUMSresr,E, : Brian Florence,CBO 1 0.19. Building Commissioner � i0reo�r 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number O` / / Property Address 9 3 i4,J /C.�L �.e^fUV 1lC G�f j4�— Residential Value of Work'$ GV clU Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address T—( ��ZG f�1 �C>U (a Contractor's Name o" �'�" Telephone Number SC'a —? 3 3 k 0 Home Improvement Contractor License#(if applicable) Email: p U Construction Supervisor's License#(if applicable) orkman's Compensation Insurance oRa C�.�he '°ne: n 0 1 am a sole proprietor 11 El ��I am the Homeowner AR 0 8 2018 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name S$'��( /� 7✓f -ic I 7 Workman's Comp.Policy# u/ �Gy Sy 6 :?C) Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to G 4w0 S ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re- side eplacement Windows/doors/sliders.U-Value G (maximum.32)#of windows S #of doors: *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 equired. SIGNATURE: QAWPFILESTORMSUiiding permit forms\EXPRESS.doe 08/16/17 swuvsTnu�, = r , 639. Town of Barnstable Building Department Brian Florence,CBO Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the sub' r sect property hereby authorize —Doti O u e" I to act on my behalf, in all matters relative to work authorized by this building permit application for: Address of Job) +S' ature of Owner Date 'v/.i A S Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. z C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc 09/26/17 The Commonwealth of/Massachusetts _ Department of In&soial Accidews Q,,Q`ice of investigations 600 Washington Sort Boston,MA 02111 i WWW.mfixLg0V1dia ` orlmrs' Compensation Lnsuranre.Affid2vit:Bu ders/C;ontracbw&W edricians/P'laumbers Applicant Informatimn Please Print Nmeam : I�Gn L. oP.C: Pe-n&3i Qty/StR&zip: -t/d,5 .A O•Z.GO r lPh,,,ne So - 3 - 3 9 ( k Are you an employer. Check the appropriate boss: Type of project(required): L❑ .I am a.employer with 4. ❑ I am a genend contractor and I 6. ❑New constuction e9ioyees{fall and/or part-time).* have.ihinA the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet 7- [ odeling ship and have no employees Tie sub-cofactors havve 8. E]Demolition working for mee in any capacity. employ=and have wo>lr n' [No worlaers'comp.insurance comp-ins I 9- ❑Building addition x-eqWred-] 5. ❑ We are a corporation and its 10•❑Elechical repairs or additions 3.❑ I am a homeowner doing all work ofoen have em ucised their I L❑Plumbing repairs or additions myself[No workers'omup. :right of esemption per MGL 12_❑Roof repairs insurance d.]g c_152,§1(4),and we have no employees.[No warm' 13-❑Ofitea comp-insurance regdued] *Any applict dw1 checks box#1 must also Moat the section below showing[heat workers'compensation policy isclatmadem i Homewnws who submit this affidevit nubmtiag they an doing all wo&aid ihen hire outside coa=mcirs nms,submit a new afdauh oudicatiug such kOntractan mat check this box mint amchad an additioad met showing the nsme of dte seb-cmin2 Pours and state whether ornot those enfifin,have employees. If the sobcoattactm ham employees,they pmmde t'hea waakers'comp.policy amber. I aam an emph yer that is prouang workers'ccongmusatton irasa mucefor any en*4vm Below is tine poSry and job sate inforinalion. _ Insluance.Company Name yw S So(.(,C. Fr.. Policy#or Self--ins.Lic.#: Sac) -5016 0.0(-.201 F-Xpiration➢ate: Job Site Address:a 3 I(y L Cstyistate/Zip: Cc-,fv y.�� Attach a copy of the workers'compmsation policy dedar+ation page(showing the policy icy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to$1,500.OD and/or one-year ingn isonment,as well as civil penalties in the form of a STOP WGIK ORDER and a tine 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 Investiga&=of the DIA for insurance coverage verification_ I Rdo hereby certi antler the pains,ar d;p poles ofpsditry f nt the informinion pro ded above is.trite and correct Date: '3 Phono Sob - � 3 � • 3 � / � OBk-W use only. Do not write in this mm,to be compWad by c*or 1ota officidL City or Town: Permit/License# Issuing Authority(cirele one): 1.Board of Health' 2.Bn1'fl&g Department 3.City/rowm Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 0: f NOTICE NOTICE TO TO v � 5 A EMPLOYEES y 4 EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5016201-2017A 07/12/2017 - 07/12/2018 POLICY NUMBER EFFECTIVE DATES 434 Route 134 Rogers & Gray Insurance Agency Inc South Dennis, MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE Daniel L. O'Neill Carpentry 351 Megan Road Hyannis, MA 02601 EMPLOYER ADDRESS 06/08/2017 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER _ Commonwealth of Massachusetts '1�ce�re:�,rn>,raea7l�c � lfr�,r��c�c�e{f� Division of Professional Licensure g Office of Consumer Affairs&Business Re ulat on Board of Building Regulations and Standards. r% HOME IMPROVEMENT CONTRACTOR TYPE:Individual Ccrostruction�S�t `e �1fs`car 1 & 2 Family Y1 Registration Expiration Y J 168722 05/14/2019 CSFA-105994 E-�pires: 10/23/2019 WWI DANIEL O NEILL';_ D/B/A DAN L.O'NEILL CARPENTRY DANIEL O'NEILL .361 MEGAN ROAD HYANNIS MA 02601 DANIEL ONEILL 351 MEGAN RD HYANNIS,MA 02601 Undersecreter n n Commissioner idp/A06'sseW-MMnn l!s!A Jo OOZE-LLL U1,9)IIeO asuaoil sitll lnoge uoilewJolui Job adn;eu61S Inot4pm p11eA ION _ 'asuaag s!yl to uolleoonaJ Jo;asnea si apo0 6uiplrn8 alelS suasntloesseW ayl;o uoippa luaJJno a ssassod of aJnl!ej. J 911Z0 VW`uolsog OLt9 al!nS-ezeld)IJed Ol uoileln6aLl ssauisne pue sJiellV Jawnsuo0 to aoiu0 :ol uJnlaJ punol 11 •alep uoileJidxa ayl aJo;aq Aluo asn!enpinlpul Jgl PIIeA uoileJlsi6a8 t AIIWRJ 7 w 1.JosmA`adnQ'uouonJisuo i r A TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION V NV A,I Map Parcel Application # �J� �3 Health Division Date Issued Conservation Division �'` Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address a 3 14c,/./z L c. Village G e h 4-el" LA Owner Vi zc,s4,fk rloc, (oc.e-r-- S Address 3 //y L4,� Ce., Y, ✓k,4 Telephone nn �' s00" �U " C3 S C Permit Request /i,Vrl27 rI. ., f'ep/cc9__ lc c_4 AdW 4 00 ri Qc laea//bu LA 14-e Cede! sAle ,fi, T4/•. G/G52t- -f-U Lr,_!!y /¢✓eC1 —Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation /g oo Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure IX-2e' Historic House: a'Yes ❑ No On Old King's Highway: ❑Yes 3-Mb Basement Type: 3-f-ull awl ❑ Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existAUILDING DEPnew Number of Bedrooms: � existing & new AUG 18 2016 Total Room Count (not including baths): existing new First Floo Room Count . TOWN �F iBARNSTABL Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name D be,l Telephone Number G " 3 7 3 7/ Address 3 S / A E Z , License # G S F,4 " l as /f,� o-L Cv l Home Improvement Contractor# /6 7a Z A Email ( w c l pe.-)&t2 0) ee ,,.�,( . c��, Worker's Compensation # wa-S°O "So I6 - "ct ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO v - mil,w r% P 51-, SIGNATURE �h- CJra`/�� DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. . . ' ; • .. De�art�rnentoflndurtrialAc�fs . Office o.flrn'estikafiomr 600 A'ashbVon.Sireet Bostory MA 02M - www.m=gov/&a Workers' Compensation Ins ance Affidavit:Bmlders/Contra ctors/IIectdcimLjplmubers Applicant information Please Print Legibly Name( viduai) L. be.,It Gc Irpe..Y ' Address: S l /j1 e� • R��� - • City/StatelZip: 1k,4 0.1 go I ' Phone#: so(3-737-3 7 1 F2.[�gfjfmm ou an employer?Check the appropriate bow ' Type of protect(required): ' am a employer wi$i 4. Q I am a general caofracfor andIazployees(fall and/or part tine)- have hired the sub-coahacfms 6. ❑Newcomstr actim a sole proprietor or partner- listed m the afta shed sheet 7. B-t modrling ship and have no employees 7h=ors bane 8. []Demolition wording fur ino in my capacity, =Ploys and have workers' [No workers'comp.insinanae MMP-inemM t 9. Q Building addition rogaurci_] 5. Q We are a corporation and its 10-0 Electrical repairs or additions 3.Q I am a hom eownea doing all work officers hm mareacised their 11.[]Phmrbing repairs or additions myself[No woaiocrs'corms. of motion pea'MGL 12.❑Roof repairs bsm=o required.]t a 1A§1(4),and we have no mPb)y=[No wodcrrs' 13.Q Oilier caalp.insurance required_] . *Airy opplicantthat ehcdm box#I=st zho f i onttbe section below showing t3Lcswod=&compcaw inn poIuy minm=fiQy t gomeownca who submit this efidavk indicating icy em doing sII wmk end then hire ore d&eoahaetoa mnst submit anew affidavit indicafnng such #Cmrhar1s du t eheckt b box nmst edmched en eddidc=l shed sbowingihe name afthe end staff whdba or nottbose ewes have employees.Ifthn soh-�cmxs have emP�s'�:�Y���wmdoa'camp-Po1u,Y a®obc I am an employer that is providing workers'compensmion ii=rMMcefor my employeeM Below it the poky and job.rite - information, _ Insuran Company Name: ASS a ,'�fKv( a�.,,�yv, h r�r►C. ce c. Policy#or Self-ins.Mr..#: WGC Soo Sot 6 a o( o l ich RXPhficmDaiz: 42` l- Job Site Address: /4^G Ciiy/State/Tp; C�-7&iVAL Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpkxtiou date). Facture to s=xm coverage as required under Section25A of MGL c.152 cam Iead to the impositiam of criminal penalties of a fine mp to$1,500.00 and/or one-•year imprisonment;as wen as cif penalties in the fmm 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 stat=mrt may be fDrpwm&d to the Office of Invcsdgud=of the DIA for insurance coverage vetcation. I do hereby certify under the paves and penal2fes ofpeJmY the dw h7fmma3ion provided above it&ue and correct Phone# G.✓ r 3 l.� FF,CU only. Do not write in this area;to be cotnpkted by city or town offidaL n: rer ff f.iceuse# one): Health 2.BuiildingDepartment 3.City/Town Clerk 4.EleetxicalInspector 5.Plumbfnglnspecinr on• Phone& Information and Instructions lv L%w.chr*setts G zaml Laws chapter 152 requires all employers to provide workers'compensation for fheeir employees. Pmmmantfn this statute,an WFIayre is defined as"_.every person is the service of another under any conhact ofhire, express or implied,oral or writtffi." An MWTayer is defmcd as'an individuaL partnership,associaficm,crnporation or other legal eQtity,or any two or mode Of a deceased employer,or the of the foregoing engaged in.a joint enierpIIse,and mclndmg the legal mp¢eseafatives f amp oy , receiver or trustee of an individual;'paitru;rsbip,'associafian or offierIegal enittl►,employing employees. However the owner of a house having not more than.f b ee apartments and who resides therein,'ar the occupant of the. dwelling . dwuMug house of another who employs persons to do maintenance,`c-r,istrac- on or repair works a a such dwelling horse or on the grounds or building°apprnrte nant thereto shaU not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states fad'every state or local rkensmg agency,shall withhoId 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 crimpliance with the insurance,coverage required." Additionally,MGL chapter 152,§25C(7)stir="Neither the commonwealth nor any of its political subdivisions shall _.__... enter into any contract for the perfomnance,ofp khc work mutt acceptable evidence of ca mpligmee oath the msuaance._ requirements of this chapter have been presented to the conUmcting auffiority." Applimi fs Please fill out the workers'compensation affidavit completely,by checking the burrs that apply to your situation and,if necessary,supply sub-confractor(s)name(s), address(es)and phone nnmber(s)along with their=tificate(s)of insurance. Lnnitzd Liability Companies(LLC)or Limited Liability Partnerships(LU)with no employees other than the members or partners,are not required to cauy workers'compensation insmmnce. If an LLC or LLP does have employees,apolicy is rapited. Be advisedthattius affidavitmaybe submitted to the Department of Industrial Accidents for confmnat4m ofmm►raTce coverage. Also be sure to sign and date the affidavit The affidavit should be rammed to the city or town that the application for the peunit or license is being requested,not the Departalcut of Industrial Accidents. Should you have any questions regardng the law or if you.ate requied 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 approprinfn lime. 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 n in the peimrt cemse number which will be used as a refere ace number.`Tn addition,an applicant that must submit multiple pennitlliceose applications in any given year,need only submit one affidavit indicating cmrmt policy information Cif necessary)and under"Job Site Address"the applicant should write"all locations in (coy or town)."A copy of the affidavit that has been.officially stamped or mm 3md,bythe city or town maybe provided to the applicant as proof that a valid affidavit is on fle fut for ore permits or licenses A new affidavit must be filled out each year.Vhexe a home at: or citizen is obtaining a license or permit not-related to any business or commercial vdat um (Le. a dog license or permit to bum leaves etc.)said person is NOT req h to complete this affidavit The Office of Invesdgaiions would Ike to thank you in.advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The DeRFf menfs address,telephone and Ax number-. e Comzan altlt of Mmsachusetks} , DepadmMt of Inds Aomdaaft Office of Xnvewgatio= 6w Wash nawn slMd Boston,MA 02111 TeL#617 727-4}Q4 oxt 4€16 or I,&77-MASSAFE Fax#617-727 7749 Revised 4-24-07 - g�dia • saxxsrnsis. 116A 9.. ,0� Town of Barnstable CEO MA'I A Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, /' ��'`'r �• U/4 AU4 ,as Owner of the subject property hereby authorize 4��"� ��-`��l to act on my behalf, in all matters relative to work authorized by this building permit application for: �3 A (Address of Job) f Sigffature of Owner Date A . 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.Outlook\2PIOIDMEXPRESS.doc Revised 040215 Vice W".maruaealCl a �ac/zccoeTJ a License or registration valid for individul use only., Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ;`165722 Type:' . Office of Consumer Affairs and Business Regulation Expiration:==5L5E2Q1 DBA 10 Park Plaza-Suite 5170 _ Boston,MA 02116 DAN L.O'NEILL CAPE1`1R ' '` - `-` - DANIEL O'NEILL 9 CAPTAIN ISIAH'S RQ:;.,,-^� COTUIT,MA 02635 "e Undersecretary I Not valid without signature t Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSFA-105994rt Construction Supervisor 1 & 2 `` Family �J- DANIEL O'NEILL 351 MEGAN ROAD t HYANNIS MA 0f601 = ^^� l Expiration:_ Commissioner 10/23/2017 li &2 Family Construction Supervisor 1 Restricted to: • y b . assachusetts possess a current edition of the Mf this Building Code is cause for revocati AIDPS license. Failure to State information visi DPS Licensing t: W. SS GOV f F to S c -le - IY I'3 v-Ff c� New C. New I G>XiSiM� w�(( � 'w1� 31d o GX(St( �� o �. D ►—• z N � Cl) Tu-- iS3/v m Ih„11�Sc.. •..,�� � .S,rx �� o s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map. Parcel ppli X 9 Health Division AUSS 21 At'! 10.. CiTate Issued Conservation Division Application Fee Planning Dept. Permit Fee 9l i DIVI: ;t Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Z 3 \A o Village Owner Ll`2_"AN \�at- ,o�\zj- S Address Lane-, Telephone - 3 8 — 6 c,2-0 -Permit Request RaT/Me\vAe- os '�� s b��lctsyon� y&4,\-,,A yokk" �pm\yxw v► ea S' and yas��\ Ise- �a�►� \cobs w a�ke.�t fir' w��s-��two. e.� cc� '����t�o ee.\� �1��t�c�c. � [� e.' ¢X�esr�r :Square feet: 1 st floor: existing 560 proposed 580 2nd floor: existing A/W proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation#\S 000.11% Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure d U r s, Historic House: ❑Yes O No On Old King's Highway: ❑Yes No Basement Type: ❑ Full Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing H new First Floor Room Count L Heat Type and Fuel: Gas ❑ Oil Electric ❑ Other Central Air: ❑Yes X No Fireplaces: Existing NO New Existing wood/coal stove: ❑Yes" 'No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn:.❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size_Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use - - APPLICANT INFORMATION --- --- - - -- - (BUILDER OR HOMEOWNER) Name t Z ct�C7h AT u k Aef ~Telephone Number -` �/" 36S ?aD 1Address- 0 6/U License # 6eN�Vej_ L`Q-- Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DA E FOR OFFICIAL USE ONLY AFFPLICATION# DAFE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' • FOUNDATION FRAME billy INSULATION ? > F FIREPLACE . ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH . FINAL FINAL BUILDING v/J u/1J DATE CLOSED OUT ASSOCIATION PLAN NO. --- ---- .... s � The Commai€nwalth of Vassachuse is Department aflidus&id Accidents OJT"Of Invest4wfians 600 fffshington&ree-t Bostarr,.HA 02111 YVF€'N?ma—mg 34 dia ' orlcers' CompensatianInsurance Affidavit $t-iilders/Contractnrs/ElertricianstNumbers Applicant Information. Please Print Legibly Dame(BusinesslOrganizadion&dividnal): Address: GiWstateJZip: &Ar-ru\�v , mA, o2oPhoneme/ Are you an_elaploFer?Check theapgrogriate oz: Type o#.project r ape prod (egnred): 4. I aril a. contractor and 1 ❑ 1._❑ I am a employer with ...TTTT���� � 6_ Neva cams�sc#iun i Io ees full mdlor time_* have hived the sub tors. emp y { pat-time)-* 7 2._ I am a sole or or partner- r listed on the attached sheet +- ❑Remodeling o ❑ proprietor ship and have no employees These sub-oontractors have S. ❑Demo-litiou w for me i a an capacity- employees and have workers' o�nng Y 9_ ❑Budding addition [No workers' comp:ammo, ance comp_insurance-I required I 5-❑ We are a corporation and its 10_.❑Electrical repairs or additions 3_❑ I am a homt3mtvner doing all work officers ha-m exercised dbwr 11_.❑Plumbing repairs or additions myself [No workers,comp_ right.of exemption per e 12_.❑Roof repaus i�n srrxnre repaired_]I c:1.52, §1(4},and we have no, employees-[No workess' 131❑Other comp-insurance required_' *Arty wplivat that checks boa 91 mast also fill out the section below sha i v tbea wocdceis'coatpensatiou policy'ufnrmattomt T Homeawners wbo submit this affidavit indicsting trey ate doing all uak and Bien bag outside contractors mmzt subffirt a new afbdsrit mdicafm smrb tCantrsctors thst cheek this box mast amr-hpd an additional sheet shawh3g the name of the sub-mmftscbots and state whether tx not those entities have anplayees. If the sub cantmctars bave employees,their must provide their workers'comp.policy number. I am an employer that is protid&tg ttrorliers'compensation irtsrtrarice for my e.mp7aryee-% BeIoir is the policy and job site information Insurance Company Piatme: Policy 9 or Self-ins-IBC 4: Expiration Date: Job Site Address: City/Statel - Af#ach at copy of the workers'compensation policy de-daration page(showing the policy number and expiration date). Failure to secure coverage as regniredunder Section 25A of MGL c 152 can lead to the imposition ofcriminal penalties of a fine up to$1,50G.fla andlor one-year imprisonment,as well as civil penalties m the farm of a STOP WbRS ORDER.and a fine of up.to$250.00 a.tray against the violator_ Be advised that a copy of this statement maybe forwarded to the Office of lin estigations of the DIA far incur r z coverage-verification_ I do herebJr certify u.rrder fhepairis anrt enaItt Dfpegury that the information provided abos�e is duo and correct Sianature: Date: A211Y Phone# `75'_3aS —® C c;?,0 Q,fjR&I use only. Do not write in This area,to be completed by city or town official City or Town: Permi'tUcense Issuin Authwity(circle oue): 1.Board,of Health 2.Building Department 3.Cityffown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other' Contact Person. Phone#= 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an ernployee 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,constriction 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 shaII withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for aay 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." r 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 ceri it cate(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 insur-ance coverage. Also be sure to sign and date the affidavit lire affida�rit 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 obt in 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 ad(L-don,an applicant that must submit multiple permitllicense applications is 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Cornmonwealth of Massachusetta Depattrneut of Industrial Accidents Qffice of lavestigati azzs 600 Washington Strut Boston Na 02111 Tel.9 617-727-4900 W 406 or 1-977 MASWE Revisers 4-24-07 Fax## 617-727-7 749 www.massgav/dia f 1 lrs Commonxsfxrlth of`Vassochuse e pwmmt offada.stl rrl Accidents - Office of S691mYons 600 WasT gton Street Boston,MA 02L11 tvniv 7nass gavAdia Workers' Compensation Insurance Affidavit:$mrtders/Contractors/E.lecfriciansMumbers Applicant cant Information Pleases Fr I,+ gihFy Name(llrtsine (OFganizalionlfndividnat�: � i�G Addrt I L) Sy-.rn M If i U City[Stat&Zip_ QU a FS rLLVllfi you an.employer?Ch ck the apprgpi iafe baz:_i-,_-- ---TYPCof o'ect ,r L.❑ I am a employer with 4. ❑'I a=ageneral contractor and I employees(full and/or pazt�ime)_ * have hued.the sub-ContraCc Dfs 6 []New ion I am a sole propritAar or partner- - listed on the attached sheet ?- Opemodeltag .ship aid have no employees These:mb-ooatractors have g- ❑Demolition w for me in an Capacity employeesand have workers' ot�ng y � � _ # 4_ El Building addition , [No workftrs'comp.ins'-mce comp-msarwme. 10 Electrical r or additions reTaired 5_ We are a corporation and its ❑ � I officers have exercised their I Plumbing airs or additions 3_❑ I am a homeowner doing all wtx� I-❑ 1;� myse f[No workers'gip- right of exemption per MGL 12-0 Roof repairs j s�e regnired-]€ c-152,§1(4),and we have no ' employees-[No workers' 13_❑Other comp_iusarance.reclui ed.-I *Airy applicant that cbedcs boa-91=ast also fill out the section beiaw showing ilea web'compensation policy infflto>si i Homwwrnffs who submit this affidavit in&6rg they aae'domg sA wA and then bire outside coatvacems nmst submit a aezr aSdacit mar *c smdi Enactors thst check this box mmt sttached ma additional sheet showh3tw the name of the s us and state uhethes anont t3xise eadries have employees Ifthe suk contnct�ushare emgTc s,t$e3�must giavide t zrork�s'comp.policy number lam art 8mglnyer That isFra► rig n�orkers'comlaRruation umsrmramrc�for rat}:R ny�c� ffelaty is thegoTicy and,}ob site information. Insurance Company Name: Policy#or Self-ins-Lie-;V Expiration Date: Job Site Address- CitylStatelZtp: Attach.a copy of the wGrkers'compensation policy declaration page(slrowkg the:policy number and expiration dale). Failure to seoxt:coverage as mquiredunder Section 25A of MGL c. 152 can lead to the imposition ofcaiminal penalties of a fine up to S 1,500.OD ant9lor one-year im pds as-well as civil penalties in 1he 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 Irrv,*gatiosrs of the DIA far ism:-Mce covuage veriEcation._ T do hereby certify tkspruns andpen ss of my that the information panidid abaue is true and correct S.ienat�e: Bate Phom 9: Qjfzdal use anly. Da not write in tiffs area,to be comgfe-W Iiy Gity�ar fawn official City or Town:. PermidUcense# Lssu Authority(circle one): L Board of Health 2.Bi9d'ng Department 3.CitylrGwn Clerk 4.Electrical Inspector 6.Plumbing Inspector 6.Other Contact Person.: Phone;k 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iegal 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to constract buildings in the commonwealth,`.or ally 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 certaficaie(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the 7 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 Departraent of Indus:'u al Accidents for confirmation of incrn-ance eoverage. 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 tine Department of the number listed below. Sell-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. Iu addition,an applicant that must submit multiple pemitlhcense 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 maybe 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. Fhe COmrmont�an of M&-saabmttts Degartramt of Industrial Accidee s office ce of kvestigatiorns 600 Washingtan Street B oston=IAA G21 I 1 TeL A 617 727-4900 ext 406 0r 1-977-MASSAFE . Revised 4-24-07 Fax 4 617-727-7-749 w .mass-gavldia I Town of Barnstable Regulatory Services ��o� roty,F Richard V_Scali,Director Building Division anaxsreiar Tom Perry,Building Commissioner 9� 1 �$� 200 Main Street, Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038 Fax: 508-790-6230 F HOMEOWNER LICENSE EXEMPTION DATE: 07� lV Pease Print JOB LOCATION: .3 //S/ 42 /G Wn L9 r 1 number /� sheet village "HOMEOWNER" L/i�a bdh //. name ss�� home phone# work phone# CURRENT MAIL NG ADDRFSS: 2 3 11c,& P city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requiremen and a 'he/she will comply with said procedures and requirements. Signa&e of Homeowner d 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 Constriction 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/certification for use in ;your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable - M. Regulatory Services M s�IE�` Richard V.Scali,Director $iOrEDMA��`� 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) *-*Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORMS:O WNERPERMISSIONPOOLS - �.sF �Qd$0fi6e17 1 ' S fi �' / i • ���' 's�'}'° Q T ® _® -- — — — x u „M ' .. { ! i it " � 'e'_r, i'iYl®fi3L� i ii� # 1. ` .f.-�. i ' �'-Y1 • !I ,`— - i j +a € 5.,.1 N .CO "�... E�jl �...' fti �P 5 ,1"� tf9 ' ' t'tiva.na terra O ; J � � �� ^ f, ., �d' 3 ' -- . -- rye 1' T . x y t •ri r ., 6�3Ret t to at_. {. i e } . } ,. P' "1 —i 1 � ary N 6ry�LW1�� I a f. t�IJ.k + ' � t• ;, ...#,. _t � �.+ t' + � j .. �_i �� L.i� t. �� •tl'g •L. iai � {. 1 j. , .i y._iw .# ,i (. i t F i... t •y`,. 4_. r~ i ', ,+. LL #... ,r {�f,� m , �� ��9'���t4W � .1� r i �{ r._+7{qf'�• "n�eG�r � i ' � ,SfdM c 30 ly l'S1A#t aa�•-' T= y �1 I' 71 3.Oco 4 00 r 61� ,�lG?•: #:�'1t,!! 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I. 1... �. . , D : YOU 1S'T1 G R_-O j - j ill Draw yourroom.on:tlie,gnd below Keep:=m,mind that each large.square equals one foot-and eachsmall�s equalsttes inches M I� - -e_: , - Be.sure to note the sure wiudows;;electncal=outlets„plumbing fixtures,vent 1a"' and°ma�or apPhances Onceyonrdes�gn.is . . - completed,it is strongly recommend'ed,that:yon:or your installer validate theI.dsffiensions on the design rendern 4 " _ - ,R, l START 0 Z " $� 10 1. l y l(o �+ Zo 2 Z I I ' I , i ! 1 I I k I l I .: -M It 0. .,�. t� i '1 I l I } �_�, if ............._� ..` I - - - a.o " � _ : .:.1. I I T ` .,,�a+� lei► . .....- I I �imtS►1&l8 ... 11' ... -t 1 ..f I i - t . I - ' � . p tk C' I I....; 1 e '�$, I . e . 6 t� j er1. I .. . . �� -...._.. ! I ... 4 - - - - 1 I i T 8- -y� * :: . I -1 i -a p[( tom, -.. -- I .: 4 I . � � _ - , - $, j I , ��a a ! 1 g%' �: tl - ..--- - �it�. _. �. r p, I .. .... ;-t -.--. +� ra �, . 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I T I 1 h- �; _ ou � . _� � _—�. _:- 1. 8efor�yoa� return.this gu7c9e to your dome_®ep®t.Kich�n D�sogr�er; remember to -F- t_. .-�. = ❑Answer all questions.and.provide all.measurements- ,. -. -_.._ ❑Double check all measurements myou fl°.T_ �a`N'ng" . .. - . . ❑Accurately measure the.room notm door and window locations ❑Include hotos ofthe exist_g - �� ` . _- - __.-. _ . - —11 g.. - - P �: r . — �.. `I. - ❑Check-off a fiances and rovide dimensions ❑Make-copies of e-+� fo-oucrecords _ _ ;,. PP . P _ _ _`_ x� t ', — i, '" = = y "`ate-9 -i 8 1'Ameacan.Woodmark Cabinetry.:Kitchen;P:.lanning Guide p.1 i ._. ... . .__.......az^,1K,- 'd._v^sw*:.�.•F..�,.�:�'�'. _e,.-�- ..r Town of Barnstable *Permit Expires 6 months from issu date 4 �1' ^ Regulatory Services Fee t BAMSTABM « v� MASS. Richard V.Scali,Director MASS ♦� Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY apt Valid without Red,X-Press Imprint Map/parcel Number / l Property Address 0,3 / 6c0-e_/'U� I/e /� "'44e, ❑ Residential L aloe of Work$-�' � '1'� ! Minimum fee of$35.00 for work under$6000.00 Owe_'s Name&Addresses �t�G�j C dt ) &alb Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) AF ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor AUG C _ _I•am lie Homeowner "z�d4 I have Worker's Compensation Insurance r Insurance Company Name I Tft"OFSA�7 p y MRMBLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) r / Re roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to yQ;/rrl(?taI'1 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: El 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. SIGNAT. JRE:�'" QAWPFILES\FORMS\buil mg permit formS\EXPRESS.doc Revised 061313 r Town of Barnstable Regulatory Services - �oF Taiyy Richard V.Scali,Director t Building Division • inxxsTns Tom Perry,Building Commissioner 'Q3 1639.9- ,�� 200 Main Street, Hyannis,MA 02601 ATFD MA't�' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION S //l Please Print DATE: 7 - 7013 LOCATION: � O - - uc// dumber----� "HOMEOWNER": ! aQ k ;�69-7T-057,5 7;zy-3,66 0 Z-210 .. • name- �,;�, �n�•� ^� ' �me phone!#fix.' �work,phone`#� - CURRENT hIAMING ADDRESS: p� J 1 �t�Y an e- r - ` c�>�tY��'n �`s�1.�ail".."�,..• fzip`code r,,�„7,,. The current exemption for"homeowners was extended to include owner-occupied dwellings of six unit`s`orless and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures_ A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and 1hp he/she will comply with said procedures and requirements. r'Si i=e of-Homeownera.� ' 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,RuIes &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. QAWPFII.ES\FORMS\building permit forms\EXPRESS.doc Revised 061313 ��E lti Town of Barnstable Regulatory ServicesIIAMSTAU `± 9 MASS.LEA Richard V.Scali,Director 1639- Building Division -C- T-o"Try,"Hingonumssi ner - _...-- --- ------ _ .- --- 200 Main Street,Hyannis,MA 02601 y 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 ,f r, as Owner of the subject property r hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Addfess of Job) Pool fences and alarrmsare the responsibility of the applicant. Pools are not to be filled orutilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name /% Print Name Date Q:FORMS:O1AWERPERMIS S IONPOO LS o� e�ort�;`ricr�rf€-�err��i a��assr�el�us Departinmt qfhuLusfr.&1 Accidents freet - .Brrsfon,,MA FJ2- 1TI ' WFC'17�.?'tiCIS��T,l3i3�1�11� Workers' Compensat an.Insurance .ffcdavit:BuilderslCanbli-a_ctors/E echiciansnurnbers PPIk-ant Infer ration Please Prnaf Le ibly ITame< rO nizatioull�ividnal): %'Z-. a lk,bi ,,,,, )5 herA S Ca q/Stat�l p= Ce nler .26 22 one 4: ,0 Are you an employer: Check the apprapr-iatebu= T , of.Pz o-ect :r d- E] I ai�2 agenen&contractor and I Y I e�}uarerl: L ElI am a ernp lover wit1; _❑New b oa enemployees(€u]1 andlor part-dime}*• Izare hirr�the sub�antEa�fors. 6- th listed o �_❑ I�a stile proprie�£or or partner- one a�ached shi✓et; 7_ ❑Remodeling , slay and h.2m e no employees Ilie�e sub contractors have g_ ❑Demralifioa working for mein any � �c ci r. employees and have workers' i �_ ❑Euilding atidifiort R0•Workers, Comp:in�e.." . comp_insurance_ . — 1 5_ -We,ar?a corgora6unwzd ifs 10_[]P-,ecfrical repairs a additions officers b ve exercised t3ieir 1$_. plumbs 3;rs or additions zbi a homeowner doinb all z�*orti ❑ ��� TTCC nrysel£ [No ivczS�rs'oontp_ rrght.afe�tndwerlvf L 12-01oofrepaim ir3_nance regaired_I i e_ 152,§1{ },and we ass no employees_[Na wmkem' 1�_.❑O.ther comp_insurance re qurred.1, any sggti sY e*ia[coed s bas rl fna also fill oiA th--section b9o-sh rainy ihm Wo-aers�Compensation Policy t Rmaecwnus tshn sobm t fns afidxnq m&cst_g they are 3oing ail zrc.3c rnd then hag outside cmtxacrors mnst smbm>Tt a nee.:aff d k in 6,cstni-such_ TC turt nrs fm�rt chxlc this box m=sttached an 33diannsI sheet:hvccm5 tlL�o*tiie sda-• �md sum�rhetts•ec acnoz terse�mties Ta�-ug Inygts_ Irthe sub coy i�ctcns lyre em�iay s,they s�rst goo ide t}� FrocS s'comp.policy n—bb-- f a arts FbO3'er that is prm idirz tvor.bars'c-orr>pgturlivn artsrtrruzcs f at ,e yse� HeLgw is fhe p.Oc}raid job situ ir;}`orgrtali8r� • Insmance CoMP any Name: Polky 44 er Self ias Lin ExpiratioaDate: Job Site Addresg: Citv[StatelT_rp: Attach A copy of the-xvorkers'compensation policy declaration page.(shoNviing the policy number sad expi-ation date). re Failu to srxuce coverage as required nnder Section 25A of MUL c. 152 can lead to the imposition ofcriminal penalties of a fima up to$1,50Q.OD andlor one-year imprint,as west as civil pem-Thes in Sae fatm of a STOP WORK ORDER and a fine of up to�250.00 a day against the violator_ Be advised that a cry of this stet maybe forwarded to tibe Office-of Im estigptions of file DIA far Tnsm nce cov4tr-age vedEcR ion_ I rIri F�ere �certi rtatd ttrspruns and snailiss l- ury b#atthe irt�farrantranprcn�dabave-is b-aa and correct �S:imataz�: `emu:.:I3aEe _� f v08= 7R©-D6 �,5 () test use only. Da not bring in this area,:a b3 compreted by cif}:or town o ciaL City-or Town: PeratitlLicense# L-,uixig Antharity(circle one): 1.Board of$exith 2.PuUding Department I CiWTown Clerk 4.Electrical fnspec#or S.Plumbing Inspector 6.E34her - Contact Person: Phone#_ 6 Information and Instructions Massachusetts General Laws,chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute, an enTloyee is defined as "every person in the service of another under any contract of hire, express or implied, oral or written_" fin 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 tht Iegal 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 thereirl�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 Iocal licensing agency shall withhold the issuance or renewal of a License or permit to operate a business or to construct baildiugs in the commonrrealt'h for an.y applicant who has not produced acceptable evidence of eompliauce,Peith`the insurance.coverage r quireu:" ` Additionally,MGL chapter 152, §25C(7)states "Neither the commonweal h nor any of its political subdivisions shall enter into any contract for the ptiaormance of public work until acceptable evidence of compliance,,vith the insu-ranc.e requirements of this chapter have been presented to the contracting authority_" Applicants Please fill out the workers' compensation aidavit completely,by checking the boxes that apply to yo'or situation and,i.f necessary,supply sub-contractor(s)name(s), address(es)and phone Lum-,be,-(s)along with their Cer b_Ecatt(s) of insurance. Limited Liability Companies(LLC)or Limited Liability PaT-tnershi s(_.LP) cvith no emric),ets other th an the members or partners, are not requ red to cagy workers' compensation ins>>-ante_ if;:n LT.0 or LLP does have employees, a policy is required_ fie advised hat this affidavit may be s?bmiiied to the Department of lndu_inal Accidents for confirmation of insm-arce,coverage. Also be sure to sign and date the zffd2 t. '112e aiLcl—"V7t sbo?ld be returned to the city or town that he application for the permit or license is being r quesed, riot the DepartL-nent of Industrial Accidents_ Should you have any questions regarding the law or if you are required to ob*_irn a workers' compensafioa policy,please call the Department at he number listed below. Serf—insured companies should enter their self-insurance license number on the a-ppropriate at. City or Town Officials Please be sure that the affidavit is 000mplete and printed legibly. The Depar'urent has provided a space at the bottom of the affidavit for you to all out im he event the Office of Investigations has to contact you regaarding the applicant Please be sure to BE in the p eroai'Al cease number which will be used as a reference number. In adctzcu,an applicant that must submit multiple perm Vhcense applications 'many given year,need only submit one ar1�vit indicating current policy information (ifnecessarty)and under"Job Site Address"the applicant should write"all locations in __(city or town)."A copy of the affidavit thaf has been officially stamped or marked by the city or town may be prow idcd to the applicant as proof that a valid a$idavdt is on file for futurt permits or licenses_ Anew affidavit mast be'Tilled out each year,Where a home owner or citi7en is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidw,7A. The Office of Investigations would I&e to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and hx,number. Thb�Conaianaw-n-an of Massachusetts Deparonent cif I6dustdal Ac-(_-idfnts Q-fc-e OJ VE1 St gatiuns 6600 Washingtan Sty Baston._M&02111 Dtl, 61 7-727-49-O W 406 or Fax : 6I7-`27-7 A19 Revised 4-24'-07 - ,mass-gavF d a Town of Barnstable *PermitV` Expires 6 months from isse dMe �7 Regulatory Services' Fee . 'j • eAtxsrnBLL MAS& Richard V.Scali,Interim Director 6 �.�' Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel N umber $ c� a f`s 0; (Q Not Valid without Red X-Press Imprint )r Property Address `l �^�- C�.�-t1 �01 A, VResidential . Value ofWork Minimum fee of$35.00 forrwrk under$6000.00 Owner's Name&Address /7�1a��� J • ��+�� �"S Contractor's Name D, t- 69 Telephone Number .C,"0- 73 7 3 71 . Home Improvement Contractor License#(ifapplicable)/6s?ate Exrrail: DZ m Construction Supervisor's License#(ifapplicable) '' IT R<orkman's Compensation Insurance Check one: MAR 2 7 2014 ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance r Insurance Company Name P&��l'� 6, 4G �+� � ® BAR 9 T��LE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping .Going over existing layers ofroof) ❑ Re-side ® Replacement Windows/doors/sliders.U-Value + t ,� (maximum.35)#ofwindows /D ..#ofdoors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&fire Permits required. •Where required: Issuance ofthis permit does not exempt compliance with other town department regulations,ie.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: TAKEVIN MuildingChanges\EXPRESS PERMIT MRESS.doc Revised 061313 dam + BARNSrABLF. 639. Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street; Hyannis,MA 02601 www town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I /i Qb�Cn U�`a �e^�S as Owner of the subject ro er 1 p p tY hereby authorize An O 'Ne i L l to act on my behalf, in all matters relative to work authorized by this building permit application for: 23 hA/ L e �4; /V, (Address of Job) 30Y / Signature of Owner Date Z tabekh I9• / 1cw1,Me^&s Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN_DBuild ngChanges\EXPRESS PERMMEXPRESS.doc Revised 061313 The Comrrmonlredth of Massrechusetfs - � fitdent otflriduslraal.Accio'erra t_ 0ffice o, ZjPFves#ga4,ords 6U(I Mashdazgtard of e Bosto d, 0211 . � iL'Wft�.ltlgtTf'fdrdd8 Workers' Compensation> ] sumnee Affidavit.-."Builders CoBtricto I rucian ujn era Applicant fi forffiationPlease Flint L blv. Name(BaismesslorgamationMidivadn j' Ga P1 Cr citstatztp63 5 . 'Phone... Are you an employer?Check the Appropriate baz: Type of project(eegunre ): 1_❑ I am a employer with 4..❑ I aan$:general"contractor and I loyees(fu11 audfor part-time)-* have hired the sub ontzwtors - 6: ❑hTevu r guctxon II°Jo I affi a sole proprietor or er-- listed'otn the a�ched'aheet 7. ❑It iadel g ship and hive no employees T Miss su contrac#ors have $: ❑Demolition w for me in c ci employees antl have rva�cers' ° III]', ` 9: ❑Building addition '[No wodom'comp_insurance cones_:insurance-$ required- 5. ❑ 'iVe area eorgcsration and its 1f1.❑Electescaltepaiss or additions ofBeees leave eat rctsed 3.❑;I affi a homeounei doing all work: ra t iif on per their 11_❑Piuuabing repairs or addataons sal€ o worlaers' n p r GL ffiY [IV caanp- 12_❑Roofnepans c_.152 1 4 and we: no inu�Ers�nre. ��f ( r 13_ lher i � emplOj�+ees=1.:`o vaork'en ', A► COffilf_mSLN3n£e fN1 red.] G4tyKM y •Anyapphrs®tthstctLedkibex#lmma also Loutfiresecbanbdwesha g thekwwkeW07vensstinp-v'.cy.infaar sob w 1 t$ameOVnWE who submit this a€fdavit indirsdng they axe doing all wcA and then hire eutd&conimaccus mast mtmit i new affldsw mdic=ng sash. 1Cantrac1Mrs that€beck then bin mast sttashed su addidnnal,Ave showh3g the name of&e Sub-dmtmt©as'md stele whethu or aOt these eatltim bag@ employees- If the smdamtractin haul employees,they must provide their wmrkws'coup.policy nupbim I am an empkyer that is providing workers'wmperlsalion IPrsrarrlrice for my let o s..'B1 dnt w is fhepofit y and job site .- f �l �p Insurance Company lJame: M� VC Sc r*^id. tr �d►�'O� Policy#of self-sus:Lic_ lam.t 1 . �.1 7L) • Job Site Ate: a vcc icy, tate� _ ce�,f�:v( r� ok eyk Attach.a copy of the"worke-rs'.ca pensotion polncy declaration page:(sh®wing the policy nuMbee and.egpurat 01 date).: Failure to secure coverage as required under Section 2.5A of MGL c_ 152 can lead to the imposition of crimin i penalties of a', Bee up to$1,SOQ-UO attdlor ane-year imprisonment;.as well as civil genslties in die,firma of a STOP OP WORK ORDI T#:sad a Elate of up to$250_t1U a day aga nut the viol itot_ Beadvised that a copy of this statement ffiay Ve foiwa ded to the,Of&6 of - Investigations of the DIA far ins mence coverage verification. I do herely c taPldar i0pains andpenabies.of pedwy that lien irtfohnadon provfdgd a beire 1i b we anddccorrcret Sagnahnre V �G C/ Date Phone : _ - O cim is se at![.::Ua not write an this area to ffr ,y U eauipleted by city arr down Vfficimt City or Town: ermitlLicense# Issuing Aatbarity(circle one): 1.Iiaard of Health 3.Btadirig I}epai-tifte.nt,3.ciwrown Clerk 4 Electrical Eo speetor 5.'Plumbing"Irupector d.Other Contact Person: Phase#: F 9LOZ/£Z/01, raUOis�siwuao�-O y o UoijeJIdxq ,t.ela.raasaapun � �, mZ0 b'W'iini00 . da S.HdISI NIVidVO 6 /,c£9Z0 t'I�i 1!YUoj 1113N,0 131N da ILSI XO9 'O'd s _-'I'II�N,O'I3INt�a 1�2l1N3d2id01113N.01 Nda Vec] 5LOZ/Sl/S ` :uop idx b6690L-b:lS3 :asua3ll +:ad7s Cllwr d Z ?t' [ adn4 1 ZZL8 L' :uope�;sl68 _ ) 21010t/2[1N001N3W3A021dW1 spiepuelS pue suoileln6a8'6ulpfing16 pleog u0geln2ag ssaulsng 7g sr1e„d aawnsa003o 33!i30 flfti S atjgtld f[s}uo�uikeda{j- s;Iasny:)esset,,j 8.ry71 971";i3 p 2 Ll�O7YG07/f.1G!9 no License or registration valid for individul use only before the expiration date. If found return to: I Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,+MA 02116 Not valid without signature License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116