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HomeMy WebLinkAbout0001 HUCKINS NECK ROAD / f-�u C 1� _, j�/,S /1�`Vic, k: ,- ,„. �, do ;: _ _. � - � � � � ,r .� a ,'. y .. .� .M1 a. f �. i .. .. .. .. p �. � - _ la ,. � - ,. y.. ,. _ ,. t:.. .. '� tlE Town of Barnstable *Permit#� p� Expires 6 mont from issue date r Regulatory Services- Fee i w 31' LE, i - - 9cb ��e j. n Richard V.Scali,Director ' glo boy 8 Building Division r0//�� 2017 Tom Perry;CBO,Building Commissioner r wfv Uk�H�I� 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us 5 rNgLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ' 1 oW Not Valid without Red X-Press Imprint Map/parcel Number {` , Property Address A a Residential Value of Work$ 3SOO Minimum fee of$35.00 for work under$6000.06 Owner's Name&Address QJ\ ` P 4�—��—TkC& Contractor's Name ��" @ Telephone Number Home Improvement Contractor License#(if applicable) \ �\�"��: Email: Construction Supervisor's License#(if applicable) s�3 [kworkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner - ®.I have Worker's Compensation Insurance Insurance Company Name fWorkman's Comp.Policy# '� Q �1 �j�,o� � t a �7--� Copy of Insurance Compliance Certificate must accompany each permit. 1 ' 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 a 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 Sand 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, • requir . • SIGNATURE: Q:\WPFILES\FORMS\building Permit forms\EXP .doc Revised 040215 .. 4 w .. .r :. • - • _ I .. , III 1 �VKWEtom, • TARNS"LE• • MASS. ,� Town of Barnstable ' Regulatory Services Richard V.Scali,Director Building Division 4 ` 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 - as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: _ , (Address of Job) Signature of Owner Date Print Name ,. 4 If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the r reverse side: F, QAWPFILESTORWbuilding permit forms\EXPRESS.doc - - Revised 040215 } Town of Barnstable Regulatory Services � Richard V.Scali,Director . Building Division &AMSTABLE. Tom Perry,Building Commissioner Mnss. $ 1639: 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 accessory to such use and/or farm structures. A person who constructs more than one . home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner c Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 r -'= Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR r - Type: Individual RegMration Exairation — Vv132149 12/07/2018 Dean F.Stanley, Dean Stanley - � ^ 359 Capt.Lgah Rd Centerville,MA 02632-.17T <` - undersecretary ;Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-035037 Construction Supervisor DEAN F STANLEY 359 CAPTAIN LIJAH ROAD ' { CENTERVILLE MA 02632 Commissioner 01119/2018 3 I MIS(I:K I II•I(:A It OF IN5UKANGt UUtS NU I GUNS[I I U It:A UUN I KAL:I tat 1 VVttN 1 lit ISSUING INSUKtK(S),AU I HUKILtU KtNKtStN I A I IV t OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT - NAME: NORTHWOOD ESHBAUGH INS PHONE FAX 540 MAIN ST A/C,No,Ext: A/C,No): E-MAIL ADDRESS: HYANNIS MA 02601 27JDD INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 236115 INSURED INSURER B: DEAN F STANLEY BUILDING INSURERC: CONTRACTOR INC 359 CAPT LIJAHS ROAD INSURERD: CENTERVILLE MA 02632 INSURER INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSH ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER. MM/DDIYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE ❑OCCUR PREMISES a occurrence S MED EXP(Any oneperson) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT a LOC PRODUCTS—COMP/OP AGG S $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY Perperson) S OWNED AUTOS SCHEDULED BODILY INJURY Per accident S ONLY AUTOS PROPERTY DAMAGE HIRED AUTOS NON-OWNED (Per accident S ONLY AUTOS ONLY S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDI IRETENTION S S WORKERS COMPENSATION - PER OTH- A AND EMPLOYERS'LIABILITY (7PJUB-2E49857-5-17) 10-08-17 10-08-18 X STATUTE ER ANY PROPRIEfOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N E.L.EACH ACCIDENT S 100,000 (Mandatory in NH) Y NIA N EL.DISEASE—EA EMPLOYEE S 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSWEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SG & D INSURANCE AGCY LL AUTHORIZED REPRESENTATIVE 540 MAIN ST STE 9 HYANNIS MA 02601 ©1.988-2016 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD -. ... .. .... ..... ... .. ... - ... .• .. IhL-Vai c�rr�veakh fMrrss�chuseds D)gwPi rrtent crf Industrid Accidents : : Off we of In tiggafions 600 W S&eett Boston,MA 02111 Yt'ft*�1�7liFls: giW(�lli Workers..Compensation Insnrance'Affidav BmdersfCoutractorslElectriciagsfPlumb rs Applicant.Information . Please Print Le 7i y �TIIe �¢ine- ahYCahi�t dtvitjl al}: ;: -e e Addr P C 1 A"you:an employer?:Check the appraprtate boz; I.T4 I am a: contractor and I:: I. I am a employer with `3... ❑ dal: 6 ❑ of project(required} . . * hati�e 1ii New.sub-coutratom.emFiay ful andcu )2_❑ I azu a sole proprie3or or parttirr: fisted;on the sttac ied sheet 7- [&Reri3,c&Ii3g ha ship alai have rto ! These sub-ccoiracta�s ve : 9 ❑Detnalatson woi anz for me m:aby arty. employees and havee worm [No warkeis't:vzup_insurance co®p.insurance I . ers ❑Butldmg addati an ❑ ate area coapc�rah and it. lt}❑Electt ical repairs additions retpared] _: 5 ❑ am a homeowner all vvorlc '. 11_ Plutiibm . airs or adshticns : afcers have exercised,their. ❑ g t of MGI .' myself.[No worloers'camp.: � per. .12❑Roofrepama iusivance J p c 152,;:§1(4},au+dwe:haven employee&( o.workess 1.;3-❑Oilier comp.insurance regiaired:] *Anyapplicaw thst checks box#1 must also fill out thesection below showingtheir wozkeW.cwmpenu onpolicyinfffmjrtioa :: Hannan aroets who snhmit this afTidavit i>edicating they ate doing a � akaihneWcaxtacrots mlu submit a nw affidavit indicating snch:d Icon. ttist chart this halal aasast ettacbed an additional dw4t ahmkg the nat>see btHie stib-CCZb dons and:state whether iWiw oio'eii.fi sham - -Vkyees:.It:the sub-coatrac nos hsse employees,they rust provide their workers'comp.policy number. I am an employer that is providing wvrkrsrs'coRWen=dvn insurance for my empkI wm Bdow is die pvdicy and job site informaliott. - Insurmce Com an Name: Pis cy#vr'Self urs Inc5-k Expirati�n Date i` JobSite Adds :� .� CAS 1 �CliL - \\C p� Ci *1State,±Zrp.. Q .Attach a ropy of the isorkers'coMpensation pdkT cle ration page(slzovvrng'the poiu}*number aatl rzpiration date) Failure to secure coverage as regi ired:under Sectiom 25A of MGL c 152 can lead to tale irtpcsitimi of criminal penalties of a fine up to$1,500 00 artdlor one�y impnsbmiienk as well as d.W- per�sl#tes in flie form of a STOP,WORD ORDER sad a fine of up to 50 00 a day ag last file iddUtdt. Be advised that a copy of this statement may tie f warde d to fe Office of` Iavestigatiams of DIAfor insurance ctivecage:won. - , 16 hereby. dpenaTtrasfperjury that tba sRforisadioaiP*m'i ahQue IS and correct Date. / Phone#- O cia[use ainZ�.:Do not write-h fhis area,to be'ccritpleted by caty or&ion.officLA Gam*or Town:: Per®/License Issuing Authority'(circle one):. L Board of Health 2.Buffing Department 3.Cityfr wn Clerk 4.Electrical inspector:S.Plumbing Fnspector 6.Other. Coiafact:Ferson _ '. ::: _: Phone#: _. 6 MELIA$OSOL,Attomeys 16 Harvard Street Worcester, MA 01609 Telephone: (508)753-5552 . Fax: (508)798-4040 PURCHASE AND SALE AGREEMENT 1. PARTIES This �� day of October, 2017, Albert Vezza, of Weston, Middlesex County, Massachusetts, hereinafter called the SELLER, agrees to SELL to Dean F.-Stanley, of Centerville, Barnstable County, Massachusetts, hereinafter called the BUYER or , PURCHASER, agrees to BUY, upon the terms hereinafter set forth, the property described. in Paragraph 2 of this Agreement. 2. DESCRIPTION The SELLER hereby agrees to sell and the BUYER agrees to purchase certain real estate situated at 1 Huckins Neck Road, Centerville, Barnstable County, Massachusetts as more particularly described in a deed recorded with the Worcester District Registry of Deeds . Book 21144, Page 28. f 3. BUILDINGS,STRUCTURES,IMPROVEMENTS,FIXTURES Included in the sale as a part of said premises are the buildings, structures, and improvements now thereon, and the fixtures belonging .to the SELLER and used in connection therewith including, if any,all wall-to-wall.carpeting,screens, screen doors, storm doors, awnings, shutters, furnaces, heaters, heating equipment, stoves, ranges, oil and/or gas burners and fixtures appurtenant thereto, plumbing and bathroom fixtures, electric and other lighting fixtures, mantels,fences,gates,trees, shrubs, plants. Specifically included are appliance per MLS. Specifically excluded are seller's personal belongings. 4. TITLE DEED f Said premises are to.be conveyed by a good and sufficient quitclaim deed running to the BUYER, or to the nominee designated by the BUYER by written notice to the SELLER at least seven (7) days before the deed is to be delivered as herein provided, and said deed shall convey a good and clear record.and marketable title thereto,free from encumbrances, except Facsimile: 508-775-6029 E-mail: michele aMwkesa.com loo 31. ADDITIONAL PROVISIONS a. Buyer states that they were provided with the opportunity to obtain a home inspection of the property and all of the systems servicing the property and has waived all rights to a home inspection and agrees to take the property in"AS IS" condition without any warranties and waives any claims relating to the condition of the property. b. 'Subject to the SELLER providing the BUYER with a passing Title V report NOTICE: This is a legal document that creates b' obligations. If n t understood, cons n attorney. Albert Ve , Se r Dean F. Stanley, Buyer I . 8 s . ivls Neck . J.acic say Was cU�� . �h yu� evrf�� r,�d �lo�c � _ ltivu�wfi ❑ Excavation ❑ Service Inspection ' ❑ Rough Inspection for ❑ Final Inspection for ❑ Other Owner or tenant Licensee's name, address, and phone License number i n Lice3� t This sectioa to be completed' 1 t Inspection date This work was not approved for violation of Electrical Code: Q-WPFilesf=&-e1wftquest Rev:04072014 °F,1E ,,ti TOWN OF�BARNSTABLE - -_N' ding ►j 7 Application Ref: 200902230" Permit EARNSTABLE, Issue Date: 06/15/09 �A s639 �0 Applicant: PROPERTY GWNFJt Permit Number: B 20090992 Proposed Use: SINGLE FAMILY HOME Expiration Date: 12/13/09 Location 1 HUCKINS NECK ROAD Zoning District RD-I Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 251064 Permit Fee$ 153.00 Contractor PROPERTY OWNER Village CENTERVILLE App Fee$" 50.00 LicewNum OWNER Est Construction Cost$ 30,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND REPAIR WATER DAMAGED AREAS OF HOUSE,INSULATE WALLS THIS CARD MUST BE KEPT POSTED UNTIL FINAL LCONVERT 1/2 BATH TO FULL BATH INSPECTION HAS BEEN MADE.WHERE A CERTIFICATE OF OCCUPANCY 1S REQUIRED,SUCH Owner on Record:VEZZA,ALBERT - BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Addre- 292 WINTER ST INSPECTION HAS BEEN MADE. WESTON,MA 02193 Application Entered by: JL Building Permit Issued By: J i THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY OR PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE 6UILDING CODE,MUST BE APPROVED BY THE JURISDICTION _ STREET OR ALLY.GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF.THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: " 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUC T rRAL MEMBERS(READY TO LA'ai). 5.INSULATION. 6.FINAL rN,PEC`r!0N BEFORE OCCIJ➢A.N': q, ` WHERE R f.I(7 4BT F SF^ARATE PI )In'.. I —ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. v.WORK SHLC(.V-�:'i..,.PLO UNTIL t.c.IN JR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMI;NV1 L.L 3;i:;,yl.F,NULL AND VOID T CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE TRI "'Er iVHT IS ISSUED AS NOTED Ai."VE. PERSONS CC nITp: _TL'7 7 WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 M Ae-i;-A?,Vn4 D k.: I 7fl3�i)5�� t lows 91e l �91 Azim 2 2 n l P�k 2 3 1 Heating Inspection Approvals Engineering Dept I Fire Dept 2 Board of Health z 1113 rJ LF C. O fL- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -5 ? Map . Parcel',`_ +` Application# � � ,0�0�30 Health Division V1. :Date Issued Conservation Division E ;Application Fee Planning'Dept: - `Permit Fees s . Date Definitive Plan Approved by Planning Board log Historic OKH Preservation/ Hyannis Project Street Address d/1 e A (yC_ 1 pl,! Ve C-K k a-vi Village 'G o 1// Ili :} Owner i Address t 'it ��''; e- Telephone 7� ��--� / - 3_ Permit Request 4 { r �`� < E v^ a.� ® �tu e 117�5 0Ids,je- 7L �tt l`S (aL er 16-m v' ::. 'l0/ A 'i�"`9 6 O = Square feet: 1 st floor: existing 1.171 proposed 2nd floor: existing VIP proposed Aogre Total new Zoning District Flood Plain Ground water.Overlay - Project Valuation V00 Construction Type Lot Size � r Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family -Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes -ZNo On Old King's Highway: ❑Yes ❑-No Basement Type: X Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) l�2— Number of Baths: Full: existing new _� Half: existing /. new — Number of Bedrooms: existing -4 new Total Room Count not including baths): existing b new First Floor Room Count -Heat Type and Fuel: X 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-Aexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes No If yes, site plan review# Current Use ;�. `` -`"Proposed Use - -- = APPLICANT INFORMATIONCLI (BUILDER OR HOMEOWNER) r`, p � � Name 4 L D T T V l; ? 2-� Telephone Number 2512�" V U ;9E�-33k)YJ(- Address _2FZ- -Vol, P Rt - License # Home Improvement Contractor# , Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE "� DATE , FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED x MAP/PARCEL NO. ADDRESS VILLAGE r OWNER DATE OF INSPECTION: FOUNDATION FRAME E ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ,5 GAS: ROUGH FINAL FINAL BUILDING z DATE CLOSED OUT ASSOCIATION PLAN NO. I �. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations- ' d 600 Washington Street Boston, MA 02111 w4 www.mass.gav/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeE01V Name(Business/Organizatiordfndividual): L. 13 t` /R ( 1_/�F�� Address: 77 �� ��! City/State/Zip: 1 95"., , Phone.#: $ 3 5� /'%/6- 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-tim.el.* have hired the sub-contractors 6. ❑ New construction .2.❑ I am a sole proprietor or partner- listed on the attached sheet. T. ❑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 11.0 Plumbing repairs or additions myself. [No workers' comp. right 6f exemption per MGL 12.❑Roof repairs insurance required] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this.affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 provide their workers'comp.policy number. lam 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: lob 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 crimirial 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 DIA for insurance coverage verification. I do hereby certify u the pains and penalties of perjury that the information provided above.is true and correct signature: Data: Phone#: J`3 '�C �_ ® 8—.3 33 ,P� L�f( 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 4: P Information and Insttuctions 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 o the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the f g l; J rP receiver or trustee of an individual,partnership, association or other legal entity, employing employees: However the h resides there' or the occupant of the ore than three apartments and who � uP e of a dwelling house havin not m p owner g g e ance construction or re air work on such dwelling house dwelling house of another who employs persons to do maim n, P 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 pontractor(s)name(s),addresses)and.phone numbers)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 .� '-I c___-...._. l— T_'.AX44— ��onnliranf Please be sure to fill in the permit/license number wnicn will oc used as a retbxeuue i1Li.11LI�... In uuWu�u,�-- - - that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy'infonDation(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.Whore'a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license of 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 nurnber: Tho Commonwealth of Massachusetts Department of I.ndustri-41 Accidents Office of Iaves igatlans- 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727=7749 Revised 11-22-06 s. www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C �Please Print Legibly Name (Business/Organization/Individual): <.S`640, � r Address: Jam" ;��Wxllele d/fG�c City/State/Zip: Phone#: Y" y� Are you an employer? Check the appropriate box: Type of project(required): 1.El am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑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' [No workers' comp. insurance comp. insurance. $ 9. ❑ Building addition 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 11.❑ 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#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t I do hereby certify der thepains an penalties ofperjury that the information provided above is true and correct Signafore: Date: v7 Phone#: 3or 4e, � Offcial 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. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised_4-24-07 Fax#617-727-7749 www.mass.gov/dia I r � Toti Town of Barnstable ` Regulatory Services . BAILIMABM M �, Thomas F.Geiler,Director 16196. 1&6 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 J I, as Owner of the subject property i hereby authorize �rl,�� j, — to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete*the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERFERMISSION r� E Town of Barnstable y���oF THE Tp�yT Regulatory Services s.«wsrF Thomas F.Geiler,Director Musa $ • 16.19. o.�.$ Building Division Tom Perry,Building Commissioner 200 Main-Street, Hyannis,MA 02601.. www.town.barnstable.ma.us Office: 508-962-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print a13 ' DATE: ,,/) �/}' r7� JOB CATION: I'f V C ( � ��C /C r( C�n I e Y' / �/� LOCATION: number street village "HOMF.OWNEW': �� �.�iC� /6 j —213S'4141 2 name G� /� home phone# work phone# CURRENT MAILING ADDRESS: / 2- �"�" / tl T el7 _3 1—pe zr e <�?/4 02-V.i3 cityhown 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 s_pervisor. DEF94MON 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 Budding 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 m;nimum inspection procedures and requirements and that he/she will comply with said procedures and qerments. of omeowner 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 perfomvng work for which a building pemvt 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 penon(s)for hire to do such work,that such Homeo Amcr shall ad as supervisor." Many homeowners who use this exerrrption are unaware that they are assuming the msponsibt'}ities of a supervisor(see Appendix Q. IZulcs&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness bftcn results in serious problems,particularly when the hDn=wner hirrs unlicensed persons. In this case,our Board cannpt 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 hDmeowner certify that hdshe understands the..responsibilities of a Supervisor. On the last page of this issue is a farm currently used by several towns. You may care t amend and adopt such a formkerofication for use in your community. Q:forrrss:homccxcmpt TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel = `A lication`# pp Health DivisionDate Issued Conservation Division "'Appltcation`Fee Planning':Dept.' ,Permit Fee : Date Definitive Plan Approved by Planning Board y v Historic - OKH: Preservation/Hyannis � 3�f Cl Project Street Address 9v(_KG,,,,(AJecK X (2C:,l1(A u It, Village t n�.c 1,&tU Owner ,� r3c„ � V "�Z {°► Address lill cl&Avs' Rd e c.X Telephone 7 a 3 LAO Permit Request c fit ealzac #,,VZP oqA4 �+ file Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay A ro�ect Valuatio �� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If es attach supporting documentation., Y pp 9 Dwelling Type: Single Family ;J Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ 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 new First Floor Roo Cough Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Im Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wocsd�coal stN, e: TYes ❑ No Detached garage: ❑ existing ❑ new size Pool: ❑existing ❑ new size _ Barn: I xisting❑ n&w size_ z � Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: M 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 L. l ll`` Telephone Number 3 6 Lt ( Z �t I Address License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# t DATE ISSUED y MAP/PARCEL NO. r ADDRESS VILLAGE j OWNER y}}{{ DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n :Please Print Legibly Name(B ess/Organization/Individual): r.:f-Address: C—_ity/_State%Z-1p: Phone.#: '�� 3 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-time). * have hired the sub-contractors6. New construction 2. I am a sole proprietor or partner-' listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors.have g. "Demolition workingfor:me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers'"comp. insurance +. comp.insurance.t required.] 5. F1 We are a corporation and its 10.❑ Electrical repairs or additions" 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.- [No workers' comp. right 6f 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. iContractors 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 subcontractors 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi ter the pains and penalties of perjury that the information provided above is true and correct CS_i a _ Date: 1z 12— Phone#:,50IF ^ �L114 75( Ij�^ 7s 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#: fa Information and Instructions p Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-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 fo 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 Commonwealth of Massachusetts Department of Industriol Accidents Office of InVestigatians- 6Q4 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727=7749 Revised 11-22-06 www.mass.gov/dia • Town of Barnstable y�P�pF THE Regulatory Services II Thomas F.Geiler,Director • sARNsMEM Prfo a. Building Division Tom Perry,Building Commissioner 200 Main_Street,.Hyannis,MA 0260_l- .-- --.--- vt'ww.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB IACATION: / (� C, i1 number street "HOMEOWNER':_ 6-,e_g 1 ��? 333— /yZ 4 name ~ home phone# work phone# CURRENT MAILING ADDRESS: 5'Z `�/,''/ /) . cityhown l state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to- be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requireme Signature Homo 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(Section109.1.1 -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 A Duld 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:for-ms:homeexempt zrti Town of Barnstable Regulatory Services . MAS& g, Thomas F.Geiler,Director 16.19. 16 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 Prop rty Owner Must Complete nd Sign This Section If in A Builder as er of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by uilding permit application for. (Addres of Job) Signature of Owner D to Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION --�.� _ -= � � a � • � . , ._a C B•j F2 �.�._�........r��_--•�-�-� •�•--_ -�a<— rs--t fie. `'���'�� ��i���`t�� �5 yG';.j�' -x ti. {.��'t` �--.:L�... - -�.",•.�F� rr`�b:"j f.��s �, t�� -t tT� . 11 1 "1 1 • Vert V-e l V l �� �� 5 "! P Y M vlt�-5tat�� ,� Restoration, Inc. 'Dapatca elea,rcay &�eusiduutCac$j6,eetu�iQt•, r 7-3333 orowindo " .' - Sept - f> .a- o 1 Huckins Neck Rd., Cent 2/23/2009 V` 4 ()V BAKNSTABLE IIEPAR'[AIY N I OF❑I.VI I II SAFETI'ANU . Y N,RFIG D"ISIµ NOE I DIN S STOP WORK I III)STRLI TL III AND:'OR PRITIISES HAS RF.EN INSPEL TF-D AND THE FOI.LON"1N(:V ZO NINI. OF PHE RCILDING(,DDE ANDVF BEEN pOUhU: NG . ORDINANCE HA I 2) YOL ARE HEREBY NOTIFIED 1'NA1 NO ADDITIONAL•1VORK SHALL BE.4NDERTAAEN L pON"ION", PREMISES,ORTHE PRF.V115ES OCCLP(Fp LI, EABOVE VIOI_ACIONS . ARE CORRI:CLY:D. - ANY PERSON REMOVING THIS NOTICE 1VITHOU'I PROPER AL-IHORILAI ION SHALL BE LIABLE iNt,OF 1 O ORE 1 H ANNONE HUNDRED DOI LIARS. 4.+. .k Aaarrs5 2 ,F!< RD :��: Date ' - a 1 Huckins Neck Rd., Cent 2/23/2009 oi IF J j• i 'moo' 1 Huckins Neck Rd., Cent 2/23/2009 M f f t rK i s s v, V $ !J { I t a7 r o ♦rs 1 Huckins Neck Rd., Cent 2/23/2009 oFt T Town of Barnstable Regulatory Services v�MASSS. Thomas F.Geiler,Director 'OTF 639. A,e Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 March 3, 2009 Albert Vezza 292 Winter St. Weston, Ma. 02193 RE: 1 Huckins Neck Rd., Centerville Map: 251 Parcel: 064 Dear Mr. Vezza: In accordance with 780 CMR 5118.6 you are hereby notified that a stop work order has been issued on the above property for violation of 780 CMR 5110.1 which states in part j "It shall be unlawful to construct, reconstruct, alter, repair, remove...without first filing a written application with the building official and obtaining the required building permit and.all other required permits therefore." As the owner of the above property, you are responsible to ensure compliance with all local and state codes. Please call (508) 862-4034 with any questions. Failure to comply may result in further action taken by this office. Thank you for your anticipated cooperation in this matter. By Order, &ey L. Lauzon , Local Inspector Q zoning5 oFt rq,,, Town of Barnstable Regulatory Services t s * BARNSrABLE, MAC, g, Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 March 3, 2009 41 Roy Ricci PO BOX 2210 Mashpee, Ma. 02649 RE: 1 Huckins Neck Rd., Centerville Map: 251 Parcel: 064 Dear Mr. Ricci: In accordance with 780 CMR 5118.6 you are hereby notified that a stop work order has been issued on the above property for violation of 780 CMR 5110.1 which states in part "It shall be unlawful to construct, reconstruct, alter, repair, remove...without first filing a written application with the building official and obtaining the required building permit and all other required permits therefore." Failure to obtain the proper permits by March 13, 2009 may result in this office filing a complaint with the Building Board of Regulations and Standards against your home improvement registration. Please call (508) 862-4034 with any questions. Thank you for your anticipated cooperation in this matter. By Order, rey L. Lauzon Local Inspector Q:zoning5 ' e i Town of Barnstable *Permit#0�2'co&a��- Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee Thomas F.Geiler,Director AUG - 4 2006 Building Division T01vVid OF EARNSTABLE 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 Not Valid without Red X-Press Imprint D �Map/parcel Number " Property Address !� ,p esidential Value of Work / [Jt Mini um fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name r / �i/ � / Telephone Number Home Improvement Contractor License#(if applicable)� � Construction Supervisor's License#(if applicable)_ ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance Insurance Company Name x2" A 9: r-I owl 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 ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pr pe wr must sign Property Owner Letter'of Permission. c y of Home provement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 1 ' �i STPAUL �i TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE POLICY NUMBER; (6KUB-8027AO5-1 -06) INSURER : THE TRAVELERS .INDEMNITY COMPANY INSURED'S NAME : DANFORTH, JAMES D. 11347-MA RATE BUREAU ID: 191379 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 042613108 ENTITY CD 001 DANFORTH, JAMES D. 1105 OLD POST ROAD COTUIT, MA 02635 CARPENTRY-DETACHED ONE- OR TWO FAMILY DWELLINGS 5645 IF ANY 9.03 CARPENTRY-DWELLINGS-THREE STORIES OR LESS 5651 IF ANY 9.03 ------------------------------------------------------------------------------------ MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ NONE LOSS CONSTANT (0032) 50 ADD FOR POLICY MINIMUM 308 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 358 EXPENSE CONSTANT(0900) 142 0.0300 FOREIGN TERRORISM / TRIA .(9740) NONE TOTAL ESTIMATED PREMIUM 500 DEPOSIT AMOUNT DUE 500 DATE OF ISSUE: 07-05-06 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST PREMIUM AUDIT TIPS Please take a moment to read the following audit tips, which will help you prepare for your Workers Compensation premium audits.With proper preparation, you could save time and possibly premium dollars. We are required to complete premium audits on your Assigned Risk Workers Compensation policy to determine your policy premium. Your cooperation in scheduling an appointment with our auditor, or completing and returning the Policyholder Report, is very important. Remember! An accurate audit depends on having your records prepared for review, and making sure that a person with detailed knowledge of your business is available to answer the auditor's questions. Become familiar with your state Workers Compensation requirements. Some of the following questions may apply to your state. QUESTIONS COMMONLY ANSWERS PREMIUM AUDIT TIPS ASKED BY CUSTOMERS What records will I need to We will look for payroll and Maintain your records up to date provide for a premium audit? disbursement journals, general ledger, during the policy term. cash receipt journal, and checkbooks. Will I need to provide my tax Yes, we will need to review your tax Keep copies of filed tax forms records? records, such as 941's, State applicable during the policy term. Unemployment Wage reports, 1099's, 1040c (Schedule C), 1120, 1065, etc. Are holiday, vacation, sick time Holidays, Vacation, Sick Time wages Severance and third-party wages, or housing allowances and housing allowances must be disability payments may be included in my Workers Comp included in your premium calculation. excluded. Maintain separate premium calculation? records for these payments. Are tips included in my Workers Tips are excluded, provided your For each employee earning tips, Compensation premium records separate tips from regular maintain records of tips and calculation? wages. wages paid. Are overtime payments included Wages paid for overtime are included For each employee paid in my Workers Compensation as payroll.at the employee's regular overtime, maintain record of premium calculation? Note: Not pay rate, provided that overtime wages regular wages and overtime applicable in the state of Nevada. are recorded separately. Overtime payments. wages that are recorded separately are included at two-thirds (2/3) of the total amount paid. (Contact your producer for your state specific guidelines.) When can an employee's payroll Employee payroll is assigned to the If the conditions are met, be split among more than one basic classification that best describes maintain records that reflect the classification code? the business of the employer. It is the employee's actual time working overall business that is classified, not within each job classification. each employee or duty. However,the Remember! Estimated or payroll for an employee can be split if percentage allocation of payroll is the classification can be applied to your not permitted. If records don't business (based on the Classification show the entire payroll applicable Rules), and you maintain a payroll to each classification,the entire breakdown for the employee by job payroll of the individual employee classification. Certain job classifications must be assigned to the highest cannot be split for one employee rated classification that (examples: 8810, 8742, 8871, 8748). represents any part of his/her work. WUNNKL05 Prepared by ST.PAUL TRAVELERS—Residua!Markets Division Rev.9/2005 WORKERS' COMPENSATION MASSACHUSETTS CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM APPLICATION DANFORTH, JAMES D. Insured: Federal Employers ID No.: Address City State Zip Policy No. (6KUB-8027A05-1 -06) Effective Date 08-28-06 Carrier THE TRAVELERS INSURANCE COMPANIES Issuing Office: Notice: Unless Code(s), total wages paid, total hours worked, calendar quarter reported are indicated and application is signed, it cannot be processed. Contact your agent if assistance is desired. : SSTCATSSSI lLN . . : . : . A CTHi�Siv :: .. ..... ..;: . . � .. ... ..5 :::::::..::;::::::: 1lG >"' 1 Excluding overtime premium pay. The foregoing is based on actual wages and hours worked, as reflected in our payroll records, for the complete calendar quarter ending Signature Position Date DATE OF ISSUE: 07-05-06 W20M 1 E01 i .. fie Y�oO1 IONS 6:O+ARQ ;BUIL©I�N `R ��4��t+Ai. �;icQns e: CONSTRUCTION SUPERVISOR t;?. NwmperrC�.� 008267 v �!►tt r 5f2g 946. Y r /20f048 Tr.na: 26087 JAMES D DANFO TM PO'Box 973 ` 'y -01 COTUIT, MA 02635 Commissioner —gale s c�anynuY�U sand Standard q $egulation Board of BU'ROVE MENT CONTRACTOR V O PR HOME IM ` n: RegiStratio 114 813 I '1.01-2712007 Exp�r It lug 0 'BA a rd,.Typ �. TI'1 JAMES D DANFPR _ t S DANFO RTHill f • JAME :'� _-:-•^,• �� ,. 1105 OLD POST RD:z`- i;>-' Administrator COTUIT,MA 02635 - ............ . ... r 1 ne uommunweatrn uj maz•mcnusettai Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 y www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectricians/Plum- bers Applicant Information Please Print Legibly Name (Business/organization/individual): Z12&Z ; Address: City/State/Zip: Phone#: �— Are owan employer? Check the-appropriate boa: Type of project(required): 1. I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- ted on the attached sheet. $ 71 ❑ Remodeling ship and have no employees se sub-contractors have 8. ❑ Demolition working for mein any capacity. orkers' comp.insurance. g, ❑ Building addition [No workers' comp. insurance 5• a are a corporation and its 10❑ Electrical repairs or additions required.] fficers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12,❑ Roof repairs insurance required.] t employees. [No workers' 13 ❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 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.Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition'of c?�:mi al penalties of a fine up to$1,50Q.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 ify and th p ns an enalties of perjury that the information provided abo a is t e a d correct Si afore: Date: �/ V/Phone#: Official Jse only. Do not wr'a in this area,to be completed b city or town official City or Town: Permit/License# Issuing Authority (circle one): 3' 1.Board of Health 2.Building Department 3.City/fowu Clierk. 4.Electrical Inspector 5.Plumbing Inspector 6. Otther Contact Person: - Phone#,: --- t Jul 21 06 01 : 26p p. 1 ESTIMATE James Danforth r P.O. BOX 973 Scl! COTUIT, MA. 02635 j, (506) 420-5131 Albert Vezza 292 Winter Street Weston MA. 02493 July 22, 2006 Work to be completed on house as follow. Remove the wood gutter and facia board from the front of the garage. Install primed facia board and aluminum gutter. Replace top U3 pine at the rear rake board over the garage roof. Remove wood shingles from the side and rear garage, also from the rear of main house. Install felt paper over sheathing. Install premium 1R&R white cedar shingles Extras. Removal of rubbish. Material and labor. $5,570.00 Acceptance of Proposal: re: Date of Acceptance: Signature; CA—e ._..� . <<i i . ri �o C) : LIZ IR L '` AL'-) Me " o J Ni' r , , e`! IQ� �a n al-'r7e tooR :S y, Tow �,r�..�c j •` `� i {� �' ro I i I i I i I 1 I �. �.. - � ��:. ... ._ - ,....: Wllll3�1NItlatlYHO NOEe NO A31NItld I10id'WtlOiOtld 3113tlUYN� }�� �i'