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'o1E Application number......P....................�:�........�
BUILDINGD Fee .................. .:f`....................
BARNSTAOM
DEPT.
MAM
Building Inspectors Initials.. ::...............................
, 163¢ p eS OCT -7..2020 dDate Issue ..lo 10.........................
�CCTOWN OF BARN }� �STABLE �
SCANNED Map/Parcel......... ............ 1 .....................................jb7_/Q_,f_�T0WN0F BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY.INFORMATION
Address of Project: 0 g Le,�ic Cit. CI . t v,
'NUMBER. STREET VILLAGE IV
Owner's Name: c I I a S c ✓ Z_ Phone Number(?) 'j q 3 ® d O-1 6
Email Address: 2_ep �1V4E v mcfi5 Y1 Ctcell Phone Number
Project cost$ 104 CIO 0 Check one .Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application for uilding permit in accordance with 780 CMR
v{-caner-Signature: Date: 10
/,5
TYPE OF WORK
Siding Windows(no header change)# ID Insulation/Weatherization
Doors(no header change)# Commercial Doors require an inspector's review
Q Roof(not applying more than 1 layer of shingles)
Construction Debris will be going to
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY/S IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION NUMBER............................................................
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one:this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent
If food is being seined at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval
*WOOD/COAL/PELLET STOVES *
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
EHomeo_wnerlsName: L.�� s c_�n Z-
Telephone Number (� t 7 g q 3 —a O JL� Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures, specific inspections and documentation required by 780
CMR and the Town of Barnstable.
,SignatCae l�✓ Date /10 .Zo 2-0
APPLICANT'S SIGNATURE
Signature, Date to 2-0 Z
All permit applications are subject to a building official's approval prior to issuance.
Town of Barnstable
Building Department
Brian Florence CBO
• Building Commissioner
11,410xareeta.
200 Main Street, Hyannis,MA 02601
a499.
�p�,sptt www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION'
Please Print
DATE: I of/ 1
JOB LOCATION: "5 O
number f" street /� village "
"HOMEOWNER": -0ed-i SLhJft2 CS02) `775- 9338 (7) 9y3 o b
name home phone# work phone#
CURRENT MAILING ADDRESS: I e f r Ry
OQLG
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 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 i
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 buiWkgTermit. (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
uiretjents.
f
err
CSgnature-ofHomeowner_...,
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.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aonlicant Information p Please Print Legibly
Name(Business/Organization/Individual): L I! 'V, f C
Address:
Ci /State/Zi ® s Phone#: 5 o? 77 5 e f 3 3 40
Are you an employer?Check the appropriate bog: Type of project(required):
1. I am a employer with 4. I am a general contractor and I
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
workingfor me in an capacity. employees and have workers'
Y p n'• # 9. Building addition
[No workers'comp.insurance comp.insurance.
required.] 5• We area 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
.m self ' right of exemption per MGL
Y �o workers comp. � 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no tt
employees. [No workers' 13. Other ��,d b W S t S,d t
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 contractor;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?he 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofpedury that the,informadon provided above is true and correct
'24 1 Date: I® 5
P ne t: SOg 77 - VA ® G 9q3 a0
OfJ`Wal use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#
Application number .
..} ,. � Fee . .>
tIf aABAMMASM41
s e ;
Kosspec .....&L
Building Intors Initiaas
s [ 1019MY27 AH038
ba
te Issued..11.�...��..:�:..
Map/Parcel................ ......................................
qT-
WROF BARNSTABLE
EXPEDITED .PERMIT APPLICATION:
ROOF/SIDING/WLVDO WS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: L. q re- l;2e,6 e.T, 12r. Coo r 1/a le
NUMBER STREET VILLAGE.
Owner's Name: D 4, 1 hone Number
" SO$` 715 .
Email Address: Cell Phone Number '
oto
Project cost$ 5 P Check one Residential 'Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize W A L YYN C.
to make application for a •uilding permit in accordance with 780 CTVM, -
COrw_ni�C�, ature: 4 Date:
TYPE OF WORD
Siding Windows (no'header change) #__ff_❑ Insulation/Weatherization
❑ Doors (no header change) # Commercial Doors require an inspect®r's review .
❑ Roof(not applying more than 1 layer of shingles) r
Construction Debris will,'be„going to a ,E XC. O, /C
. - .. CONTRACTOR'S INFORMATION �
Contractor's name
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Superyisor'.s License# (attach copy) :;
Email iof Contractor Phone number
_ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF TIME SUBJECT PROPERTY IS;IN l
A HISTORIC DISTRICT. YOU MUST OETAIN'HISTORIC APPROVAL BEFORE A PERMIT CAN DE ISSUED. �
APPLICATION NUMBER ......:.
*For Tents Only
Date Tent (s) will be erected keanoved on number of tents total
Does the tent have sides? Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X
Additional tent dimensions can be attached on a separate piece of paper:
Purpose of Event
Check one: this event is a: for profit. non-profit event
Check one: Food served Yes ' No
Flame Spread Sheet of-each tent must be attached. Provide a site plan with,the location(s) of each tent
Fuel source being used LP tank 20 bs. or-> Yes No ,'.if yes, a gas permit is required.
Natural Gas Yes No ,°if yes,,a gas permit is required.
If food is being served at your event please obtain ca Health Department approval between the hours
of 8.00am-9:30 am or 3:30 pia-4.30pm Commercial events.may require Fire Departriaent appr®vat
*WOOD/COAL/PELLET STOVES
Manufacturer.# . Model/I.D.
Fuel Type Testing Lab
Offsets from-combustibles: front back . left side right side
HOMEOWNER'S LICENSE`EXEMPTION
Homeowner's.Name: C_ I r, ` C,
Telephone Number 1j g _775 S?j39 Cell or Mork number,
I understand mmny respousibilities,under the ruffles and regulations for'Licensed Construction.:
Supervisor in accordance with 780 CNM the Ma*ssachusetts State Building-Code. I understand
the construction inspection procedures, specific inspections and documentation required by 780
CAM and the'Town of Barnstable.
*rpture A_L4eA__1 Date Al, f
APPLICANT'S SIGNATURE
GSa e ��a Date l Zak
All permit.applications are subject to a building official's approval prior to issuance:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Inv&tigations
600 Washington.Street_
Boston,ALL 02111
www.mass.gov/did
Workers' Compensation Insurance Affidavit: ]3uilders/Contractors/Electricians/Plumbers
Applicant Information Please Print'Legibly
Name (Business/Organization/Individual):_�� �
Lake l 1 e �
Address: O
"City/State/Zip: Phone #: SOS — 7 7 9 — R33
Are you an employer?Check the appropriate box ""' Type of project(re quuired):
4 I am a general contractor and I
1.❑ I am a employer with
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 R
ship and have no employees 'These sub-contractors have g, 0 Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 11:Nye are a corporation and its . 10.013lectricahrepairs or additions
3. 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
�` myself. [No workers' comp. t right of exemption per MGL 12.0;Roof repairs
insurance required.]t c. 152, §1(4),and we have no a
employees. [No workers' 13.59_Other
`comp. insurance required.]
*Any applicant that checks box 41 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 e. 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage'verification. "
I do hereby certify under the pains and pen Ides of perjury that the information provided above is true/and correct
bi awe: Date: /G �lo 2
Plione 5 O
fir•, �
Official use only. Do not write in this area, to be completed by city or town official
City or Town:. - Permit/License
Issuing Authority(circle one): .
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.,Plumbing Inspector
6.Other
Contact Person:. Phone#:
P
Application numbe I
Fee ..............................................................................
Tp� Building Inspectors lnitials...... ...�
f ...............
el
Date Issued....,, ,.... �v [.1
............ ...
� l Map/Parcel... .... �............... ......................
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION Y .
PROPERTY INFORMATION
Address of Project: a L
c y.111,pz
NUMBER STREET VILLAGE
Owner's Name: v Phone Number 95 D, Z�,
Email Address: Cell Phone Number
Project cost$ ���� Check one Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application or a '1 ' g permit in .cordance with 780 CMIe
Owner Signature: C Date: _f 13 , ole /
TYPE OF WORK
❑ Siding ❑ Windows(no.header change)# ❑ Insulation/Weatherization
❑ Doors(no header change)# Commercial Doors require an inspector's review
RfRoof(not applying more than Llayer of shingles)
Construction Debris will.be going to e ur 0 t r.�.
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
,`. A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION.NUMBER............................................................
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan,with the location(s)of each tent
Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required.
Natural Gas Yes No ,if yes, a gas permit is required. k
If food is being served at your event please obtain a Health Department approval between the hours
of 8:00am-9.30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval.
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number 509 = 25 —5 3 0 Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnst ble.
Signature Date
APPLICANT'S SIGNATURE
Signature Date 1 ° , 3 1
All permit applications are subject to a building official's approval prior to issuance.
r � y
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InveAigations
600 Washington Street
Boston,MA 02111
www.mass.gov/du;
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information C Please Print Legibly
Name(Business/Organization/Individual): ��`� 7 c: V
Address: kt_ �,4 l'1
City/State/Zip: c,L v c✓a k Phone#: 50 8—77
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with I - 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, `❑Demolition '
working for me in any capacity. employees and have workers' ' 9. Building addition
[No workers'comp.insurance comp.msurance.t
❑ g
equired.] 5.❑ We are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per have
n 12.Z Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 11[i 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 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.
I do hereby certify u er the pains and enalties of perjury that the information provided above is true d correct.
Si ature: ?� —� Date: R o
Phone#
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#:
ti
f
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 maybe 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 permittlicense 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 021,11
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
i