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HomeMy WebLinkAbout0067 OLD FARM ROAD ,ram ... r / �T� y1, � \ 1' � 1� ,_ .� . , _ . et't. � .. ".. { 3. „ � - .. i �� O ., ' �5 �.... � .. �.. _ { J r' �$ .. � .. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel bob Application # Q6,3 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee J� Date Definitive Plan Approved by Planning Board ' • ' �6/71e Historic ,- OKH Preservation/ Hyannis — Y Project Street Address �j ,/� �� Rd Village C P 4-A ✓�/�� ' Owner Jrn zjP.5 )4 e et i Address Telephone 1 7 5A4 <,7 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay K Project Valuation A9 15&Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 51" Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes pl No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) C) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing / new Half: existing / new Number of Bedrooms: -3 existing —new Total Room Count (not including baths): existing 6- new First Floor Room Count Heat Type and Fuel: ❑ Gas P Oil ❑ Electric ❑ Other Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing 0 new size—Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: ..., Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name !, �.���.4A l W4--b> Telephone Number �gi 7,S'd 7 Address Z. d9/Q T License # D U, Home Improvement Contractor# /f:> Worker's Compensation # Al C- &// D 1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATEJle) FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED _ MAP/PARCEL NO. ADDRESS VILLAGE OWNER` DATE OF INSPECTION: t FOUNDATION FRAME D INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING K+ llb" 13 DATE CLOSED OUT ASSOCIATION PLAN NO. 'k ,t ' 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 Please Print Legibly Name(Business/Organization/Individual): [_' �����0 �. Address: City/State/Zip: Phone#: /f% ,ld% zz Are you an employer?Check the appropriate box: Type of project(required): _1.❑ I am a employer with t�i� 4. ❑ I am a general contractor and 1 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' 9. El Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions q ] 3.❑ I am a homeowner doing all work officers have exercised their 11.0_Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :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.#: � . �q /�� �� a Expiration Date: Job Site Address: �� 62 I!rl 4;tr4Akxd1A 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 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 ltie perjury that the information provided above is true and correct Si mature: Date: n 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#: L)DUtER M Assurance/Mason&Mason Ins 603 356 9290 05/27/2010 13:53 #214 P.001/002 M, CERTIFICATE OF LIABILITY INSURANCE o5/27/20101)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Whitman, MA 02382 Meaghan Walker INSURERS AFFORDING COVERAGE NAIC#. 'INSURED The. Sullivan Company Inc. INSURERA: National Grange Mutual 14788 PO Box 590247 INSURERS: Star Insurance 000204 Newton, MA 02459-0003 INSURER C: INSURER D: INSURER.E:' , COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR W TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY MPH S6792 12/31/2009 12/31/2010.. EACH OCCURRENCE - $ 1,000,000 X COMMERCIAL GENERAL LIABILITY _ - DAMAGE TO RENTED" - $ 500,000 CLAIMS MADE OCCUR MED F_XP(Any one person). $ 10,000 A PERSONAL&ADV INJURY - GENERAL AGGREGATE - $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - .. PRODUCTS-COMP/OP AGG $ -2,000,000 POLICY PRO- ECT LOC. J AUTOMOBILE LIABILITY M91-156792 MA 12/31/2009 12/31/2010- -COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ _ 500,000 ALL OWNED AUTOS - - BODILY INJURY _ - $ A X SCHEDULED AUTOS , (Per person) X HIREDAUTOS r BODILY INJURY $ X NON-OWNED AUTOS (Per accident) - - PROPERTY DAMAGE $ (Per accident). i GARAGE LIABILITY - - AUTO ONLY-EA ACCIDENT $ ANY AUTO - ;. OTHER THAN EA ACC -$'. - AUTO ONLY: AGG $ . EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ - OCCUR CLAIMS MADE AGGREGATE $ - DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND WC0110432 02/03/2010 02/03/2011. X -WCSTAORY TU X OTH- - EMPLOYERS'LIABILITY - - E.L.EACH ACCIDENT $ 500,000 TS - ER B ANY PROPRIETOR/PARTNER/FJ(ECUTIVE � - - � � - OFFICEWMEMBEREXCLUDED7 PAUL SULLIVAN 'IS E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below INCLUDED FOR -COVERAGE E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER B1H56792 NH 12/31/2009 12/31/2010 Combined Single Limit A Automobile Liability $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS perations: Maintenance & Remodeling CERTIFICATE HOLDER' CANCELLATION SHOULD.ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL t` 10. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, -Town of Barnstable , f BUT FAILURE TOM H NOTI E SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 Main St. i OF ANY KIND UPON T H IN l2ER,^AGENTS OR REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZED REPRESENT VE David H. Mason ACORD 25(2001/08) FAX: (508)790-6230 ©ACORD CORPORATION 1988 I �fxe 1�anvr�wruaea� �✓ Standards uaelta Board of Building Reeaiatiobs'and Standards License or registration valid for individul use only ' I HOME IMPROVEMENT CONTRACTOR I before the expiration date. 1f found return to: P ! Board of Building Regulations and Standards Registration� 102777 One Ashburton Place Rm 1301 Expiration .7/2/2010 Tr# 270637 1 Boston,Ma.02108 lug i � 'r' • r� ti , Type ate Corporation � I Priv r.l , in THE SULLIVAN COMPANYINC = s Paul Sullivan C — 50 Winchester St 1 , of valid without signature Newton,.MA 02461 Administrator -------------- lla�.aehu•ctt� - Dcpat-trrtcnt of Public afct." r$trtr't1,nf Building Rc�ulatinn. andiaritlard:. Construction Supervisor License License:,CS 45660 Restricted to: 00 ` PAUL L SULLIVAN PO BOX 81/73 W BRANCH RD L _ WATERVILLE VA LE, NH 03215 .: Expiration: 10/5/2010 5359 - .....�. : - •. - 4 a� ��70.�'.Y�lP/I72y/.C(JPQGC/. !K .-GGLCi7/.,C6E�6 - -. Board of Building Regu ations-a Standards — a i HOME IMPROVEMENT CONTRACTOR Registration: 102777 Expr -n 7/2/2010 Tr# 270637 'type Private Corporation: THE SULLIVAN COMPANY INC. ' Paul Sullivan - 50 Winchester St Newton,MA 02461 Administrator 05/26/2010 15:35 FAX 16175265000 W C. P H AND D LLP 0:002 � r � n�rzsraau, a a Town of Barnstable Regulatoq-Semites Thomas F.Geiler,Director Building Division Thomas Perry,C$O Building Commissioner 200 Main Street, Hyannis,MA.02601 www4own.barnstable ma.us Office: 508-862-4038 Fax: 508-790;.6230 Property Owner Must Complete and Sign'I b is Section If Using A Builder as Owner,of the subject:property hereby authorize_ 44-1 VA-4 , C-6m.04,1Y to act.on.my, behalf, in all matters relative to,work authorized by this building;permit application for: M (Address of'J4b) Signature of 0Wner late Print Name If Property Owner is applying;for permit,please complete the Homeowneral License Exemption Form on the reverse side. C:1Usersldecol iklApgDaffi1LocallMicrosoftNVm bws\Tempomy-latemet FiledContent.0u&Gkl45'rGusQQ1Fi)CPRESS.doe Revised 090909 05/26/2010 15:35 FAX 16175265000 W C P H AND D LLP Q 001 WILMERRu.li FACSIMILE +161.7 526 6223(1) Data May26, 201C7 t4&ra,r,2&. (.? monice.grewal@wilmerhale.cum To Paul Sullivan Fax (617) 527-8098 The Sullivan Company Tel From Monica Grewal Pages 2(including cover) Re lPer.Mit—67 Old Farm Road; Centerville,MA Wilmer Cuter Pickering Halc and 09rr LLr,60 Snare Screen,,Bosron, Massachuserts 021.09 Beijing Berlin Boston Brussels Prankfun London Los Angeles New York Oxford Palo Afio VValtham. fashington This facsimile halsmissim is modenm and mey be prMleged,lf you,ae not the intixtded=lpibnt,please lmmedlately cmtthe aender ar,it the sander is not avaBablk call+l 617 526 54113 and deghty an cepics of this transml"10n:If the transnAwion is Incomplete of inAgbbi picaso Cell Me SOW or,M the Seeder 19 mot availatile,.aell'+1617'52G'SA11 Thank yau. 0 o O Grewal Residence 67 Old Farm Rd Centerville . Existing conditions LIVING AREA 54 sq ft 01 Replace tub with new tiled shower Re-install exisitng sink and toilet New tile floor Insulate exposed walls Patch plaster ® O Grewal Residence 67 Old Farm Rd Centerville Proposed LIVING AREA 54 sq ft ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �\ Parcel v pp A lication# Health Division Conservation Division Permit# Tax Collector Date Issued' l8 _ Treasurer Application.Fee 56 Planning Dept. Permit Fee 3� • f Date Definitive Plan Approved by Planning Board GO `/I F-b' Historic-OKH Preservation/Hyannis Project Street Address`"\ Villager /''avl" yL.),� l� Owne7 ' 9444��`�� �xE,�l Address 97 Old rOYM gel Telephone l `- 3 P_ermitfRequ� 6 X ao, 2ak nQ 0 J� Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new e Zoning District Flood Plain Groundwater Overlay ProjecfValuatio Construction Type � . Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting d cumentati N �r ,Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) - f � I Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes O N ? 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 Room Count Heat Type and Fuel: El Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:0 existing ❑new size Pool:❑existing El new size Barn:0 existing ❑new size Attached garage:0 existing ❑new size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name �2 g✓4ly't` A2 45V fl117 Telephone Number* , Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE' DATE /����-:7 1, FOR OFFICIAL USE ONLY 60, PERMIT NO. DATE ISSUED MAP/PARCEL NO. i p ` ADDRESS VILLAGE OWNER e i DATE OF INSPECTION: FOUNDATION 1 FRAME a INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 0?ha, a Y DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations d 600 Washington Street Boston,MA 02II1' www.mass,govldia ' Workers'- Coanpensation Insurance.tffiddvit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LelziblY y Name(Business/Organization/Individual): . 8, .Address: 6-7 City/State/Zip: CL�4--MYV), 6- RA`r vZ phone.# -771 -6 00 05y;z" Are you an employer? Check the appropriate box: .'Type of pioject(required):. 1:ElI am a employer with 41 [] I am a general contractor and I employees (full and/or part time),* • have hired the sub-contractors 6, [1New 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• C]Demolition �vorkin for me in an capacity employees and have workers' g Y P t3' co insurance,$' 9; Building addition [No workers comp,m�� nce comp, re ed.] 5. We are a corporation and its CIO.❑Electrical repairs or additions officers have exercised their 3. am a homeowner doing ill-work . 11.❑Plumbing repairs or additions ' myself. o workers' co right bf exemption per MGL y [N �• • 12,❑Roofrepairs r insurance.required.]t c, 152, §1(4), and we have no •. employees, [No workers' 13,❑ Other comp,insurance required,] t *Any applicant that checks boi#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners,wbo 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 sbowing the name of the sub-contractors and state whether ornot 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.declarationpage'(showing the policy number and expiraticn date). 'Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of cr=inal penalties of a line up to$1,500,00 and/or one-year imprisonment,as well as ci,'ilpenalties in the form of a STOP 7"ORK,ORDER and a one ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the OfEce of XL Lvestigations of tha DLA for insurance covera>e yeri£catian. I do hereby certify under the pains and penalties of perjury that tke information provided above is true an'd correct. l S4Mature-: Date:����/ j F 2!T/ �� 6l -,V2_ Official use only. Do not write in this area; to,be completed by.city or town official, I j City or Town: Perm_t(License# Ii Issuing Authority(circle one): Board of Health 2,Building Department 3, Cityrown Clerk 4.Y Iectrical Inspector e Pli robing InspectGr 6,Other i Contact Person. Phone r: Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. P „ P�irsuant to+1;s statute, an employee is defined as"...every person in the service of another under any contract or hlie, express or implied, oral or written." An employer is defined as "an individmd,partnership,association,corporation or other legal entity,or any two or more of the foregoLmg engaged in a joint enterprise; and including the legal representatives of a deceased employer, or the receiver or trustee of an individ a,.tership,association or other legal entity,employing employees. However the owner of a d­xel ing house Navin;n\M�orehan three apartments and who resides therein,or the occupant of.the dwelling house of another who empons to do maintenance,construction or repair work on such dwelling house or onthe grounds orbuilding appurereto shallnotbecause of such employmentbe deem tobe an employer." MCM chapter 152, §25C(6) also staevery state or local licensing agency shall withhoI the issuance or renewal of a license or permit to'operate a usiness or to construct buildings in the commo ealth for any applicant who has not produced;acceptable idence of compliance with the insurance cov age required." AdditionaIly,MGL ohapter-152,§25C(7)states either the commonweal`rh nor any of its po ' cal subdivisions shall enter into any contract for.the performance of pub -work until acceptable evideuee-of•conzp afice with the vysurance- requirenments of this chapter have been presente&to e contracting authority." Applicants Please fill out the workers' compensation affidavit compl ly,by checking the boxes t apply to your situation and,if necessary, supply sub-conti;actor(s)name(s),address(es)an hone numbers) along their certificate(s)of insurance. Limited Liability'Companies(LLC)or Limited Li ility Partnerships(LLP with no employees other than the members or partners, are not required to carry workers' comp ation insurance. If LLC or LLP does have employees, a policy is required. Be advised that this affidavit ma be submitted to Department of Industrial Accidents for confirmation of insurance coverage. Also be sure t sign and date a affidavit. The affidavit should be returned to the city or town that the application for the permit.or ease is bein requested,not the Department of Industrial Accidents. Should you have any questions regarding the la or if you e required to obtain a workers.' compensation policy,please call the Department at the number listed be w, Se -insured companies should enter their self-insurance license number on the appropriate`line. City or 'Down Officials Please be sure that the affidavit is complete'and printed legibly. The Dep e t has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigation as to ntact you regarding the applicant. Please be sure to fill in the permit/license number which will be used a referent number. In addition, an applicant that must submit multiple permit1license applications in any given ye ,need only s mit one affidavit indicating current policy information (if necessary)and under"Job Site Address"the plicant should ite"all locations iu (city or town)."A copy of the affidavit that has been officially stamped o ked by the city o town maybe provided to the applicant.as proof that a valid affidavit is on file for future pe s or licenses. �A new davit must be filled out each Q c rmit not related fo an o ss or commercial venture year.Whore a home owner or citizen is obtaining a license or y (i.e.a dog license or permit to born leaves etc,)said person' OT required to complete affidavit The Office of Investigations would like to thank you m a ante for your cooperation and sho d you have any questions, please do not hesitate t6 give us a call. The Department's address,telephone-and fax numbe . Tb�CQ mweLa l of Mas huseds D.tp Lmt of kdutM A.eezdents •flee of In-festigadous 600 Waste toil Street Beta MA 02111 - Te.1.# 17-,77-27-000 ext 406 or 1-877-MASSAFE FaX#617--727-7749 Revised 11-22-06 L �pFTHETo�, Town of Barnstable Regulatory Services " BAMSTABM ` Thomas F.Geller Director 9 MASS. ��TEOM Biiildina Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-8624038 Fax: 508-790-6230 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. n y-�Ur L Type of Work: {/ 1 ,7) Estimated Cost Address of Work: 4-7 (}{Gi' ism &I Owner's Name: l Date of Application:_ t��/11 0 I hereby certify that: Registration is not required for the following reasou(s): []Work excluded by law ❑lob Under$1,000 E113 ng not owner-occupied weer.pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORD 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 agent of the owner; Date Contractor Name Registration No. 07 —� Date Owner's Name Q:formslameaffidav Town of Barnstable • r Pv�F SHE T��`v - Regulatory Services BARNSTABLE, : Thomas F. Geiler,Director. MASS. 1639• �,Q Building Division RFD Tom Perry,Building Commissioner 200 Alain Street, Hyannis;NIA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:----�;-� JOB LOCATION: -7 611 number street village J s� -7� / ,/�i "HOMEOWNER": �G�'t �Ih��J W` 1�� tr /P D %y 6��, 07 name home phone# work phone# CURRENT MAILING ADDRESS: city/to-,NM state zip code The current exemption for"homeowners"was extended to include otiAner-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 oVrner acts as supervisor. DEFINITION OF HOMMOWNER 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 r "homeowner" shall submit to the Building Official on a form acceptable to the Building Ofi cial, 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 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 EXEA'IPTION 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);proNrided that if the homeowner engages a person(s)for hire to-do such work,that such Homeowner.shall act as supervisor." Many homeovmers who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction-Supenrisors,Section 2.15) This lack of awareness often results in serious problems,particula-la , when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would v�th a 1icenseo Supevisor. 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 homeov,mer certify that he/she understands the responsibilities of a Supen-isor. On the last page of this issue is a form currently used by several tovrns. You may care t amend and adopt such a fotrn/certification for use in your community. Q:forms:homeexempt NEON��'4 INXIMMENN aria !�= al�l�lll��l°I1 �9�1�111��lilll 1111�I�IIGIl) 1119�I��iii 1011�1��1111�� Mill oil �� . :-. . : . - 1111�I��III Oil 01 4L ri' 1_P e K se. t AT rot4M vvnR o� NOTES: (t) Verifications of property line dimaislans,bui ding offsets,fences,or lot configuration may only- be accomplished by an accurate instrument survey (2) BThb plan was not mode for recording purposes, for use in preparing deed descriptions or for construction purposes. (3) This plan Is for mortgage purposes only. (4) Flood Hazard Zone has bean determined by scale and is not necessarily accurate. Until plans are Issued by H.U.D. and/or o vertical control surveyis accurate detem motion cannot be made. Performed, on I MORTGAGE INS"Xn0N PLOT PLAN Original Scale: 1 loch "�0 -Feet 400 Wadb8tan Shoe# &ftLL-9 Date:_C-�' Btafftq A!A 02184 . Looatton:/�3h�STAtZ-�+�- (�(�qV5. to skis LC4C�- Kr— that the existing dwelling�shown on. plan is located n the lot as 1 designated. It is my professional opinion that the dwelling was either. Reference` in compliance with the applicable horizontal_ dimensional requirements Of the municipality when Constructed, or is exempt from enforcementg action under GL Title VII, Chapter 40A, Section 7, unless otherwise S° atT9 as Deede on�this pd. laathe best of my knowledge and belief, the dweWag shown . Deed Hoolc,z Deed Pais: delineated. S 1�1 T located within a special Rood hazard area as P� Booms�� p ,_,S Map*.�J OOb 1 Dated: Z 2 _ SH DF yAg no fiN Domain n=Min rams toy ads fmm re a,p `o•�1� .G N*"4~t to No aeon roferw0g. o iAWRENCE oec UE.A ion- 5, Z4?53-ij�- s915ti ` ESS1d�P lob Prolessleaal toad 9uneyor