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Engineering Dept: (3rd floor) Map „ r Parcel /c rmit# j 0 92,
House# % � // �1' Date Issued ® '� 7 '�
Board of Health(300or)(8:15 -9:30/1:00-4:30) 9 If-7y eel 3
ve d' 19 '
BARNSTABLE.,p•
t619-
TOWN OF BARNSTABLE
Building Permit Application '
P J t St et Address v
Village '
Own Address ,6 • �
r t
Telephone
Permit Request,
First Floor v square feet Second Floor `s square feet
Construction Type
Estimated Project Cost $ -
Zoning Distri t Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure n(-� Historic House es &No Old King's Highway ❑Yes ❑No
Basement Type: ❑Full Crawl ❑Walkout Other
' NLn� : .�
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) LAC►
Number of Baths: Full: Existing_� New Half: Existing New
No. of Bedrooms: Existing 3 � New _
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: alas ❑Oil ❑Electric ❑Other
Central Air ❑Yes U(No Fireplaces: Existing New Existing wood/coal stove ❑Yes 4v
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
I None �ed size _
(Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name Telephone Number
Address License#
' Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL B TAKEN TO
SIGNATURE DATE--BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
/ St
FOR OFFICIAL USE ONLY `
PERMIT NO:.-
DATE ISSUED:
`MAP[PARCEL NO.
ADDRESS
VILLAGE x. r
� _
OWNER i '� �� 1• + � � 1 ;t '. ? � . , _. " - ;
_ t
DATE OF_INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE ..`
ELECTRICAL: ROUGH FINAL +
PLUMBING: ROUGH FINAL "
GAS:- t ROUGH + FINAL' -
FINAL BUILDING
t
DATE CLOSED OUT `
,
ASSOCIATION PLAN NO. t t !
, .
47
_ The.Town of Barnstable
NAB& Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commiss:
For office use only
Permit no.
Date AFFIDAVIT
: HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
A.
Type of Work: Est.Cost
/ Address of Work:. '
AOwner's Name
' � V
ate of Permit Application: _
1 hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME MWROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the age ea e
v Registration No.
Date
Tlrc• Cunrrrrurrlrcult/1 of atassachuscttr
Dc+pfrrtnzent of ludustrral.4cctdents
1 r
Office affIffestfgatfans
Bustort.Man. 03111
Workers' Compensation Insurance Afrid:t,%•it
i liiri f•rnt inn•- •-- ._._ . ...._ —PI ._._P . TNT._._.^. --..�..�...._..---•-•---..._-.......�--------
m e
iti ow
[j am a homeow performin_all work myself.
Lam a sole proprietor and have no one working in anv capacity -
71 1 am an emplover providing workers'— compensation for my employees working on this job.
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incttr•tnce rn nniic� #
1 am a sole proprietor, general contractor, or homeowner(circle oire) and have hired the contractors listed below who
the following workers compensation polices:
cmmmrnv n•rtnc•
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incur-nrr rn
cmmn.inv nnrnr.
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Attach additional sheet if necessary :.'_ ;�_ __Il..:.�....• _... .•...r..- .r. ••......�.. �.+_�..0 �....v: y' .'�..rv...�+L
_ _ _ a.r..._..��...
F:in secure
ure Iu cuverace as requtred under Section 2A of AIGL 152 can lead to the Imposition of cnminal penalties of a tine up to SI<SOU.UU andiur
uriccars• imprtannmcnt:is well as civic penalties in the form of a STOP IVORN ORDER and a fine of S100.00 a day against me. I understand th;t a
cope of this statement ma} be funvarded to the OtTce of investigation$of the DIA for coverage verification.
/do rent c ur the prriu� Id crra ojperj n•t/rar the information prorided above isNirued corrert.
Sianatur� Datc
... `' y 341�
Print name C Phone
oRciai use univ do not write in this area to be compacted by city or town oRciai
cit} or tn�vn, per•mitilicense it rliguilding Department
( QLicensinr.hoard L
t.•
Ll
check if imtnediatc response is required QScicetmen's Orrice
�• C211c2ith Department t
is contact perxun:
phone ft• r—rUthcr `
i
information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to pmvide workers" ctiiiipensaticm for
entnlmres. As quMcd loom the an emphuree is defined as every person in the sen'ice of antttlur undc: :ny
contract of hire, express or implied. oral or written.
An emplorcr is defined as an individual partnership. association. corporation or other legal entity. or an}, t%%-o or ,7
the foregoing enua`,cd in a joint enterprise. and including tite legal representatives of a deceased employer. or the
recciver or tnistee of an individual . partnership. association,or other legal entity, employing employees. Ho«Ve,.'e:
owner of a dwelling house haying not more than three apartments and who resides therein. or the occupant of the
divcllin�, house of another alto employs persons to do maintenance;construction or repair work on such dwellin:_
or oil the _,rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic:
MGL chapter 152 section 25 also states that even.state or local licensing agency shall withhold tilt• issu.Znce 01-
1:�11%111 of a license or permit to operate a business or to construct buildings in the commonwealth for any
icant Nvlto leas not produced acceptable evidence of compliance with the insurance coverage required.
AdL;.:iattall\•. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
periornt:.nce of public work until acceptable evidence of compliance with the insurance requirements of this chaptc.-
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an-z
suppiving company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial .-accidents for contirmation of insurance coverage. Also be sure to sign and date the affidavit. Tile
should be returned to the tiny or town that the application for the permit or license is being requested.
rn :he Department of Industrial .-accidents. Should you have anv questions regarding the "law" or if you are recui,
:o obtain a \\,orkers' compensation policy. please call the Department at the number listed below.
Cin• nr Towns
Plecre 7e sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottotr,
tite all"davit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P'.
be _ _'to fill in the perm it/license number which will be used as a reference number. The affidavits may be returner
ae Department by mail or FAX unless other arrangements have been made.
Tile Office of Itr\•estigztioils Nvould like to thank you in advance for you cooperation and should you have any quern(
pie--se do not hesitate to _ive us a cell.
Tile Department's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents -•
office of Investigations
600 Washington Street
Boston,Ma. 02111
fax R: (6I77) 727-7749
phone =. !617) '2--4900 exr. 406. 409 or 7
• TOL+1N OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
- Please print.
DATE
�•
JOB LOCATION . - .
Number S reet address Section Of town
"HOMEOWNER" 2 C C'� •a -:-
Name
Home phone Work phone - -
PRESENT MAILING ADDRESS
icity/toft State Zip code
The current exemption for "homeowners" was extended to include owner-odCUMie
dwellincrs of six units or less and to allow such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person (sj who owns a parcel of land on which he/she resides or intends to re
side, 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 Offic.
on a form acceptable to the Building Official, that he/she shall be responsi
for all such work performed under the building permit. (Section 109.1. 1)
s
The undersigned "homeowner" assumes . responsibility for compliance with the SDI
uilding Code and other applicable codes, by-laws, rules and regulations.
he undersigned "homeowner" certifies that he/she understands the Town of
arnstable Building Department minimum inspection procedures and requirements
nd that he/she will comp with ai pr cedures and requirements.
OMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICI
ote: Three family dwellings 35 , 000 cubic feet, or larger, will be re ired
0 comply with State Building Code Section 127. 01 Construction Control.
• s '
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner 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
Home Owner engages a persons) for hire to do such work, that such Home OwnE
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the responsibilities of a supervisor (see Appendix Q, Rules and Regulations
for licensing Construction' Supervisors, Section 2. 15) . This lack of awarene
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed. against the
' inlicensed person as it would with licensed Supervisor. The Home "Owner act-:
as supervisor is ultimately responsible.
To ensure that the Home• Owner is fully aware of his/her responsibilities, ma.-
communities require, as part of the permit application, that the Home Owner
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.
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.. SCALE't'y �:. APPROVED BY: DRAWN BYiY! '
' - DATE: REVISED
MAI
DRAWING NUMBER
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