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HomeMy WebLinkAbout0068 OLD FARM ROAD �� .� �_�c� � a ., - , , o _ ,,. � p ' t.. ;i. ,, a �a �. .. ...... � .r n' � fin. � 1. � V ». .. ti r �, aG , ... a � G, n, d ++'.' :i�'. v t 1 � .S ., 4 .. - Y .. - i S �. :. .. - � .. k ` . R ,. f o r �. '� <, t� , L u 1,1 K� i o i i; a i — ,, o �; `>. `� , . r ,, .. � � ,.,. � i s s.. ' i '_ k � n e `; �•. � � 9 �. o t ,. __ Ir o N. Y � � ±. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION,,.,, Ma �s Parcel d O� C� A licati n # p pp o.., Health Division Date Issued ( 3 I Conservation Division Application Fee " Planning Dept: rr -Permit Fee F } Date Definitive Plan Approved by Planning Board ,Q/ ' / Historic - OKH Preservation/ H annis i Y � I Project Street Address Village Owner ckkou& -z L-cam Address _ ISG( IQ- Telephone :50 -2� J 3 1044 t� Permit Request kV,)0-•JCa_C1 , Vkp�!\ YL. \1` — 2 -� , 4V PrN aL = fl)!QJ30�, �UJ\N(,ow'5 ccy_ k1.7S `0. .oeil , ��C�� `tl�� n c�• �7�7 111��C Yt-�p Square feet: 1 st floor: existing proposed 0 2nd floor: existing O proposed TotalInew 0 Zoning District Flood Plain Q. Groundwater Overlay w Project Valuation 50`Oo0 Construction Type V300A „� • Ouo Lot Size o Grandfathered: ®'*Yes ❑ No If yes, attach supporT@g dO-c-umentation. Dwelling Type: Single Family �I( Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes No On Old King's Highway: ❑Yes '10"No Basement Type: CY'Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 560 Number of Baths: Full: existing new Half: existing 0 new 0 Number of Bedrooms: existing it new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: �i Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes N No Fireplaces: Existing a' New O Existing wood/coal stove: ❑Yes N No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes dNo If yes, site plan review# Current-Use 4Gt&ateT i A-L- = Proposed Use APPLICANT INFORMATION BUILDER OR HOMEOWNER) f( Name �Ic�AL` Telephone Number Address as QUt9_9 ' � License# Home Improvement Contractor# Worker's Compensation # , ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE 1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS - VILLAGE OWNER S ._DATE OF INSPECTION: FOUNDATION ��S �dl�d�l FRAME S OR)( ,Wlt . l!!;�: ' INSULATION (olo e K FIREPLACE , ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ,• GAS: ROUGH FINAL pp FINAL BUILDING 2 0 4c6_jl U l 0 r DATE CLOSED OUT ASSOCIATION PLAN NO. Town of Barnstable Building Department - 200 Main Street EARNSTABLE. * Hyannis, MA 02601 , 9 MASS. (508) s639. 862-4038 Certificate of Occupa'ncy Application Number- 201102339 CO Number: 20110107 Parcel ID: 251006 CO Issue Date: 08/01111 Location: 68 OLD FARM ROAD -: ..Zoning Classification RESIDENCE 0-1 DISTRICT Proposed Use: SINGLE FAMILY HOME Village: CENTERVILLE Gen Contractor: DEDECKO,MICHAEL Permit Type: RC00 CERTIFICATE.OF OCCUPANCY RES Comments: Building Department Signature Date Signed v Uilrding A� I fi-6ARNI -_;ZLk,, Issue Date: 06/13/11 Permit . MASS. �A i639� �� ��pplicant: r�0 .I A Permit Number: B 20111200 . Proposed Use: SINGLE FAMILY HOME Expiration Date: . 12/11/11 LLocation 68 OLD FARM ROAD Zoning District RD-1 Permit Type: RESIDENTIAL ADDITION/ALTERX ,MaP Parcel 251006 Permit Fee$ 510.58 Contractor DEDECKO,MICHAEL x Village CENTERVILLE App Fee$. .106.00 License Num 065891 Est Construction Cost$ '50,000 Remarks y APPROVED PLANS MUST BE RETAINED ON JOB AND RENOVATE,REPLACE SIDING,ROOF,WINDOWS,DECK,INSULATI�, N,THIS CARD MUST BE KEPT POSTED UNTIL FINAL : I SHEETROCK,AND INTERIOR TRIM I 'INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: DEDECKO,MICHAEL A `. BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: PO BOX 2384 INSPECTION HAS BEEN MADE. MASHPEE,MA 02649 Application Entered b : JL Building Permit ISSUed.B PP Y r g Y PHIS PERMIT'CONVEYS-NO RIGHT TO OCCUPY ANY STREET,ALLEY OR•SIDEWALK OR ANY PART TFIEREOF EI'r.HFR TEMPORARILY OR PERMANENTLY'.. ENCROACHMENTS ON PUBLIC PROP -Oil'- SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,'MUST�BE APPR, D BY THE JURISDICTION.-STREET OR ALI,EY'GRADES AS WELL AS DEPTH AND-LOCATION OF PUBLIC SEWERS'?d - OBTAINED FROM THE DEPARTMENT Oi PUBLIC WORKS THE ISSUANCE OF THIS PERMITDOES NO f RELEASE THE APPLICANT FROM THE CONDITIONS,OFANY APPUI CABLES UBDIVISION ti. RESTRICTIONS 711 MINIMUM OF FOUR C;1LL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OkFOOTINGS. -- 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE 1"7"7 FLUE LINING IS INSTALLED. ' 3. WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TOFRRArv!- iN PECTION. q 4.PRI.OR TO COVERIiti j S'I'RIJCTURAL MEMBERS(READ"Y T'O LAfIH).iZ 6 FINAL INSPECTION BEFORE OCCUPANCY. + , WHERE APPLICABLE;SEPARATE PERMITS ARE REQUIRED FOR El ECTkICAL' P.,I'x P IBING AND 1'4ECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE-VARIOUS STAGE'SOF CONSTRUCTION. '. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION'WORK IS NOT STARTER WITHIN SIX MONTHS OF 1 DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HA1117a A C CES',.-TO GUARANTY FUND(as set forth in MGL e.142A). h 110 MR, "!mm BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS l/ L 1. i eAj, ��j � 3 1 Heating I spection A ovals Engineering Dept cG �r"upI)e`.e'Ctk2aMtt'/1,Fipt 2 _ "`.. � �� 1� t" Bpoap' ' i1 .�( r The Commonwealth of Massachusetts 1 Department of Industrial A ccidents Office of I'll vestigations 600 Washington Street ' t t Boston, MA 02111 , ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMC (Business/Organization/Individual) A\ Address: oP 5 City/State/Zip: V�Sk/\ 'e-< A . D21#{ Phone #: O —Z2\ —So0a Are you an employer?•Check the appropriate box: Type of project (required): 4. ❑ I am a general cont7-actor and I- I. ❑ I am a employer with , ---'I oyees(full and/or part-time), have'hired the sub-contractors.. 6. ❑ New construction 2_� 1 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 h'• 9. ❑ Building addition [N.o workers' comp. insurance comp. insura.nce.1 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 of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §I(4), and we have no employees. [No workers' 13.❑ 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 arc 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. #: a, Expiration Date Job.Site Address: 606 Oka TpteW IlyRleol �M ity/State/Zip: �t ILv 62 b 1Z 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 MOL 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 eert�& under the pains and penalties ofperjury chat the information provided above is true and correct. Si re: 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: hformation and fnStructzons Massaehuse General Laws chapter 152 requires a)) employers to provide workers' compensation for their employees., Pursuant to thi tatule, an employee is defined as ".,.every person in the service of another under any contract of hire, express or irnplic oral or written." An employer is define as "an individual, partnership, association, corpor lion or other legal chtity, or n�iN poo�eore of the foregoing engage 'n a joint enterprise, and including the legal re resentatives of a deceased ernp to er, receiver or trustee of an in 'v'dual, partnership, association or other le al entity, employing employ ees: However the owner of a dwelling house h ing not more than three apartments and who resides therein, or the occupant of the dwelling house of another who mploys persons to do maintenance, onstniclion or repair work on such d`veJling house employment or on Lhe grounds or building ap rienant thereto shall not because,s f such . be deemed to be an employer."L MGL chapter 152, §25C(6)also stat that "every state or local 1' ensing agency shall withhold the issuance or renewal of a license or permit to op ate a business or to cons ruct buildings in the commonwealth for any applicant who has not produced acce able evidence of comp fiance with the insurance coverage required•" Additionally,MGL chapter 152, §25C(7) tales "Neither the cc onwealih nor any of its political subdivisions shall enier'into any contract for thepeiforuiance fpublic•4ork until acceptable evidence ofcompliance with the insurance requirements of this chapter have been prese tcd to the eontrac ing authority." Applicants Please fi11 out.Lb, workers' compensation affidavi complet y, by checking the boxes that apply to your si[Z12-tion and, if u necessary,spply sub-contraetor(s) name(s), addres es)an phone numbers)along with their cerlificate(s) of insurance, Lianiled Liability Companies (LLC)or L• ited iability Partnerships(LLP)with no employees other than the members or partners, are not required to carry Workers' o pensation insurance. if an LLC or LLP does have employees,-@ policy is required. Be advised that this a vit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also sure to sign and date th•e affidavit The affidavit should ested not the Department of be returned to the city or town Lbat•the application for the e it or license is,bring requ Industrial Accidents. Shouldyou have any questions reg.rdin the law or if you are required to obtain @,workers' compensation policy,please call the Department at the n ber 'sted below. Self-insured companies should en ter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed 1 gibly. The Daparfineni has provided a space at the bottom of the affiday.-il for you to fill out in the event the Office C f Investigationkas to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which ill be used as a•�ference number. In addition,an applicant that must submit multiple permiVl.icense applications in a y given year, nee only submit ona affidavit indicating current in __(city or policy information(if necessary)ay.d under"Job Site Ad ess" the applicants ouJd write"all ]ucatbensro town).—A copy of the affidavit that has been officially st ped or marked by th city or town Y p vide d ,t the applicant as proof that a valid affidavit is on file for futur permits or licenses. A new affidavit-.nust be filled o��t each year. Where a home owner or citizen is obtaining a licen e or permit not relaled to any businessor commercial venture (i,e. a dog license of permit to burn leaves etc.) said pers n is NOT required to corn let@ this afi`davit. The Off ce of Investigations wo i e o � �-� d should ouhave any questions, please do not hesitate to give us a call. The Deparlmenl's'address, telephone and fax number: The C0=0DWea th of Massachusetts Department of In usb-ial Accidents Office of InYestigattions 600 Washington Street Boston, MA 02111 Te). # 617-727-4900 ext 4D6'or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia Massachusetts- Department of Public SafetN . Board of Building Regulations and Standards Construction Supervisor License License: CS 65891 Restricted to 00, q ;MICHAELI A,fi DEDE}CKb ' PO BOX 23,84%CARLT0N DR F MASHPEE, MA 02649 'f` -- - f� Expiration: 11/9/2011 ('ommLcsiuner' Tr#: 8038 �k tO'm"ei- '��`� ju`�a License or registration valid Office o oosumer A airs smess egu shoo g for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: „4138653 Type: Office of Consumer Affairs and Business Regulation Expiration: ..51;1L 013 Private Corporatic 1 10 Park Plaza-Suite 5170 y Boston,MA 02116 WCASS REALTY�I) EOPME NTNT CORP 5 MICHAEL DEDECKO _ 25 CARLETON DR t , MASHPEE,MA 02649� Undersecretary Not valid without signature e 1 ,l 1 of THE Town of Barnstable Regulatory Services + 1AWSTASLE, r q MA-qQ Thomas F. Geiler,Director, PrEn µay a Building Division { Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-62: o 'Property Owner Must Complete and-Sign This Section If Usin' A Builder s. as Owner of the subject property hereby authorize �\, �� to act on my behalf, m all matters relative to work authotized by this building permit application for. .t (Address of Job) Signa -of Owner ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 4 ;Q:PORM,S:O WNERPERMISSION I_ „ Town of Barnstable Hof,fHE ropy 0 Regulatory Services Thomas F. Geiler, Director � BARNSTABLE, • � q, rbs9. Building Division Tom Perry,Building Commissi er 200 Main Street, Hyannis,MA 601 R-wrv.town.barnstable.m .us' Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE E MPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER”: name ho a phone# work phone# CURRENT MAFLCNG ADDRESS: city/town state zip code The current exemption for"homeowners"was e ded to include,owner-occupied dwellinl?s of,six units or less and to allow homeowners to engage an individual fo h' who does not possess a license,provided that the owner acts as supervisor. D ITIO OF HOMEOWNER ` Person(s)who owns a parcel of land on whit� he/she r ides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached o detached s ctures accessory to such use and/or farm structures. A person who constructs more than one borne a two-year nod shall not be considered a homeowner. Such "homeowner"shall submit to the Building fficial on a fo acceptable to the Building Official, that he/she shall be responsible for all such work=fOrmed der the build in t. (Section 109.1.1) The undersigned "homebwner"assume responsibility for comp 'ante with the State Building Code and other- applicable codes, bylaws, rules and re, lations, The undersigned "homeowner"ceiti es that he/she understands the wn of Barnstable Building Department minimum inspection procedures an .requirements and that he/she will mply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family wellings containing 35,000 cubic feet or larger will be,required to comply with the State Building Code Section 27.0 Construction Control. HOMEOWNER'S EXElt4PTION The Code states that: "Any homeowner performing work for which a building permit is required shag be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homcowncr 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 terrify 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 caret amend and adopt such a form/certification for use in your community. P.E. - Daniel 189 Harbor,Point PA gA 02637-0361 Ca> 4&► - t� 1115� STATE �5 4CJ J,Ls, c r1 ct CovL _ 1-©Ap o ok L r tA T S ��n., s�c• ,f. �, y; '+-titP. u Blvd Daniel E Braman,PE 189 Harbor Point Road Cummaquid,MA 02637-0361 Phone(508)362-0016 May 20, 2011 Mike Dedecko P.O. Box 2384 Mashpee, MA 02649 (508) 221-5003 Project: 4111 68 Old Farm Road,' Centerville, MA On this date, at your request and in your presence, I made a site visit to the above Project residence. The reason for the visit was to evaluate the skylight framing. As long as I was at the site, I expanded the structural evaluation to include.all framing in the roof, floor and deck as well as the basement area. In my professional opinion all of the construction is structurally sound and meets the requirements of the Massachusetts State Building Code. A Daniel E. Brame as �¢� • 2•�x,3b 3y x 56 IT- Ye �e c-� Uvkv�c r �2) 3LA x SM®KE DETECTORS REVIEWED B E BUILDIN DEPT. DATE FIRE DEPARTMENT DATE �2►JT��Jt! `R U� BOTH SIGNATURES ARE REQUIRED FOR PERMITTING oil 2tix �Z zA'4%Z w co tA N I is o j 0 r j i i aY X 2�1�tiZ 6A� alb c-ufr�.,�ee�1 Cexsrc�e,r.�l,. 'AA Y! I JI o Si . cr,� - - - . ---._ , I , IL �.lbr , o<< I i ✓ctLuk i zx L • t i tb I , V-t V- .0 k I I I � I 1 I Ce.�r<� I ' I I _ 1 i - i 0 I I � O � aT i 1 Ii I 1 e�e1�,,,5 1 o" t-4o�C ± PO'.STg t X\ 15r►�b��`e 1 _ J 14 �X � tJ 4 r L �:_ _I > � .. e... � �� .. 'YMsf• �1.��®.F}'4.',agYW'u'atY*••.Gar,..a.. ..r—>.,.. - 1. �• 'L- 1 - -- - LI Jz 41 ILI r DAYE: G DON�AL�D I. MERCER R�. Professional Building Designer DRAWINGN .. r j 1 0 So Ya_o}th.MA 02664 __�'t��ls:k� del o-- --•- _._ .. f� '- �.a. 8 .: i -- i- it M � N• I � ---'�- �- fib._ (� - I-- t -(1 CT" 2 �2 a Daniel E Braman,PE 189 Harbor Point Road Cummaquid,MA 02637-0361 Phone(508)362-6016 May 20, 2011 Mike Dedecko P.O. Box 2384 Mashpee, MA 02649 (508) 221-5003 Project: 4111 68 Old Farm Road, Centerville, MA On this date, at your request and in your presence, I made a site visit to the above Project residence. The reason for the visit was to evaluate the skylight framing. As longas I was at the site I expanded the structuralevaluation•p ura to include all framing in the roof, floor and deck as well as the basement area. In my professional opinion all of the construction is structurally sound and meets the requirements of the Massachusetts State Building Code. ► AA 4 Daniel E. Bram DA d • � g � t o R o Y 4. 6 Py �I8TE� ro"y'v'vy�`4 TOWN OF BARNSTABLE BUILDING PERMITAPPLICATION Map_ a 5'� Parcel 'COS Application # ��U�L / Health Division Date Issued Z Conservation Divisions E`" p , Application Fee Planning Dept. ti Permit Fee 3 �. 1 , Date Definitive Plan Approved by Planning Board Historic OKH Preservation/Hyannis ; Project Street Address 692 Village LZ.n:�T V )3 r,\ A Owner Address Telephone6 Permit Request 95�\e S-,S\ tail �o c.J�_ W^� �.S�cQ r' �'_ , 1 q�' ��•,_, \ c.�. 5'"L,r�le re C`���► C Square feet: 1.st floor: existing SW proposed 6D 2nd floor: existing proposed Total new Zoning District- \ Flood Plain G Groundwater Overlay Project Valuation 7 SO O Construction Type 4 e& Lot Size '` y Grandfathered: �s ❑'No If yes, attach supporting documentation. Dwelling Type: Single Family, Two Family ❑ Multi-Family (# units) Age of Existing Structure ti SO Historic House: ❑Yes U-No, On Old King's Highway: ❑Yes Ulo Basement Type: WFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Slob Number of Baths: Full: existing \ new CO Half: existing O new 0 Number of Bedrooms: existing Onew Total Room Count (not including baths): existing j- new n First Floor Room Count Heat Type and Fuel: ❑ Gas ail ❑ Electric ❑Other Central Air: ❑Yes YNo Fireplaces: Existing 0New 0 Existing wood/coal stove: ❑Yes YNo Detached garage: ❑existing ❑ new size_Pool: ❑existing ❑ new size — Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use ci +u —IY APPLICANT INFORMATION r (BUILDER OR HOMEOWNER) ' U3 Name i C)n C&L\ 1�� - Telephone Number 1502) 5wS z Address 2S GaVI _��� -� License# C_� tv AC Home Improvement Contractor# l Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S30 t?�2r3 C� �uy��r SIGNATU � d DATE l t ` ^ FOR OFFICIAL USE ONLY APPLICATION# 5 DATE ISSUED t t MAP/PARCEL NO. ,r ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION CO50afa3 ph G FRAME t k INSULATION 1 FIREPLACE :z ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts fy Departmentof Industrial Accidents �. Office of Investigations 600 Washington Street �,- t f Boston, MA 02111 " s`y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Legibly Name (Businessiorganization/Individual): Address: (aS Cz,rz 1�`�c� � --- ✓ City/State/Zip: '` Phone#: Q 7� ® Are you an employer?-Check the app�priatbox: 1 Type of project (required): I. I am a employer with 4. 0 I am a•general contractor and I 6. ❑ New construction have'hired the sub-contractors.. ----byres-(full and/or paft-time). -- -�---- -- g 2.MV I am a sole proprietor.or partner- listed on the attached sheet. 7. Remodelin ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition NO workers' comp. insurance comp. insurance.1 required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a bomeowner 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 employees. [No workers' 13.❑ Other 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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheek 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: (P-) 0\C9,T?N—vVN City/State/Zip:C T:NW a` 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 ofMOL c, 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 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 certl& urn r the pains and penalties ofperjury that the information provided above is true and correct. t 4 Si afar - 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: hformatzon and fnStructions Massachusetts General Laws chapter 152 requires all employers AD provide workers' Compensation for their errmployee.s' Pursuant to this s ule, an employee is defined as "...every pers n in the service of another under any contract of hire, express or implied, al or written." An employer is defined "an individual, partnership, associ tion, corporahDo or other legal edtity, or any two or more of the foregoing engaged i joint enterprise, and including e legal representatives of a deceased employer, or the receiver or trustee of an indi ua1 partnership, associalion or other legal entity, employing employees. Ho�Yevcr Lhe house aot more than three a a ments and who resides therein, or the occupant of the dwelling h P owner of a dw g air work on such dwelling house dwelling house of another who e toys persons to do ma' tenance, constniclton or repair or on the grounds or building appu ant thDreto shall n because of such employment be deemed to be an employer." MGL ebapter 152, §25C(6)also states °h "every stat or local licensing agency shall Withhold the issuance or renewal of a license or permit to operate business r to construct buildings in the commonwealth for any applicant who has not produced acceptable viden of compliance with the insurance coverage required." Additionally MGL chaplet 152, §25C(2) slates ei er the conunonweaIth nor any ofits political subdivisions shall ente into any contract for the performance of pub) ork until acczplablc evidence ofcompliancc with the ins�uance r requirements of this chapter have been presented to contracting authority." Applicants Please fill out.the, workers' compensation affdavi complete] by checking the boxes that apply to your situation and, if necessary,supply sub-conLraetor(s) narne(s), addr s(cs)and ph c number(s)along with their cerlificate(s) of insurance, Limited Liability Companies (LLC)or invited Liabili Partnerships(LLP) with no employers other than the rnembers or partners, are not required to Carry wo ers' eompensatio nsurance. if an LLC or LLP does have employees, e policy is required. Be advised that is affidaYit may be mitted to the Dcpartmcnt of Industrial Accidents for confumation of insurance coverage Also be sure to sign d date th•e affidavit, The affidavit should be returned to the city or town Lhat•the appliaatio for thepermit or license is Bing requested not the Department of Industrial Accidents. Should you have any questi ns regarding the law or if yo .are required to obtain a,workers' compensation policy,please call the Department U the number listed beloW. Se] scared companies should enter their self-insurance license number on the appropriate City Dr-Town Officials Please be sure that the affidavii is complete and •nted legibly, The Department has provi a space at the bottom of the afdavil for you to fill out in Lhe,event the ffice of Investigations has to contact you re arding the applicant. Please be sure to fill in the permikcense numbe which will be used as a.refcrence number. Ln dition,an applicant that must submit multiple permit/license applica ns in any given year, need only submit one aft vit indicating current policy information()f necessary)aad under "Job itc Address." the applicant should write"all loran s in _(c)'ty or town),--A copy of the affidavit that has been off Tally stamped or marked by the city or town rk be ovided Lo the applicant as proof that a valid affidavit is on file or fu turc permits or licenses. A new affidavi l-Fust be led nut each year. Where a home owner or citizen is obtaini a license or permitnof related to any business'orcomme ia] venture (i.e. a dog license of permit to bum leaves efc.) aid person is NOT required to complete this affidavit. Tbc Office of lnvesligahons wog i e o yot��sn^^Pratinn and Should y-0 have any questions, please do not bes,itate to give us a call. The Department's address, telephone and fax number: i The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInYestigations 600 Washington Street Boston, MA 02 111 M. # 617-727-4900 ext 406'or 1-877-MASSAFE Fax # 617427-7749 Revised 1-24-07 www.mass.gov/dia THE,, Town of Barnstable 0 Regulatory Services ' H/KTtbTASL.� f r�taa . Thomas F. Geiler,Director �p sb59- �a Building Division Tom Ferry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.b arnstab l e.maus 1 /. Office: 508-862 4038 «' Fax: 508-790-6230 . r \ Property Oder Must Complete and Sign.This Section If Using'A lBuilder h I, kA\�c� ��-2L � , as Owner of the subject property hereby authorize c act on my behalf, in aB rnatters relative to work authorized by this building permit application for. r t (Address of Job ignat= of Owner Date Print Name If Property Owner is applying for permit please complete. the .Homeowners License Exemption Form �n the reverse side. Q:FORMS:0 WNER.PERMISSl011 Town of Barnstable Regulatory Services Thomas F. Geiler, Dirctor � 6 �$� Building Dl "ion PrEa Ma't'` Tom Perry, Building C mmissioner 200 Main_•Sfreet_Hy , MA.02601 YFWW.town_barn fable-ma_us Office: 508-862-403 8 Fax: 508-790-5230 ErOn OWJ�R LT NEE EXEM TTION Plcar Print DATE: JOB LOCATION: number t village "HOMEOWNER": name o phone# work phone# CURRENT MA=G ADDRESS: city/town state rip code The current exemption for"homeowners"was exte d to include wner-occupied dwellin of six units or less and to allow homeowners to engage an individual for ' e who does not ossess a license,provided tba-t the owner acts as superyisor- AEFII�r ON OBHONlEOWh Persons) who owns a parcel of land on which he/ e resides or intends reside, on which there is, or is intended to be, a one or two-family dwelling, attached or deter ed stntctures accesso to such use and/or farts structures. A person who constrgcts more than one home in a o-year period shall not b onsidered a homeowner. Such "homeowner"shall submit to the Building.Offci on a form acceptable tqf th Building Official, that he/she shall be responsible for all such work erformed under th building ermit '(Section 1 L 1) 71�c undersigned"homeowner"assumes respons ility for compliance with the Eta Building Code and other applicable codes, bylaws, rules and regulations. The tmdtrsigned "homeowner"certifies tbat.he/ e understands the Town of Barnstable ding Dcpar#ment minimum inspection procedures and rcq i amen and that he/she will comply with said pro edures and requirements. Signature of Homcowncr Approval of Building Oftci;d Note: Three-family dwellings containin 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Frk l. HOME ER'S EXEMPTION .'Ih e Code states that -Any homeowner perfomring for which a building perrnit is rcquinmd sball be mairrpt from the provisions of this Seetlnn,(SCGtiOTt I D9.].1 -Licensing of construction Sup •sons);prorded that if the homeo-q mr mgages a person(s)for hire to do such wor-,that such Homeowner shall act as supervisor." )r-.any homeowners who use this exemption an una that they are assuming the responsibilities of a supervisor(sec Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Sec on 2.I5) This lack of awarcness born results in serious problema,particularly when the homeowner hires unlicenseders pons. In this case,our B cannot proceed against the unlicensed person as it would with a licrnscd Supervisar. The homeowner acting as Supervisor is ultimately resp nsuble. To ensure that the homeowner is fully aware of his cz-responsrbi]itics,many communities require, as part of the permit application., that the homeowner certify that hdahe understands the responsibilities of a Suprnisor. On the last page of this issue is a form currcnt]y used by scvcre.l tDwns. You may carp t amend and adopt sucb a fomrlccrtification for use in your corrrnunity. Q:fornu:homcczcmpt U�P. V!Of7Pd7t07tCCP,QA[I! O•/.. <'(GJJIll�!ldP��d Board of Building Regulatiods and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACT& before the expiration date. If found return to: Registration: 138653 Board of Building Regulations and Standards Expiration: One Ashburton Place Rm 1301 P b/1/2011 Tr# 283921 Type: Private Corporation Boston, Ma.02108 COMPASS REALTY DEVELOPMENT CORP MICHAEL DEDECKO " 25 CARLETON DR. �.t,. •` MASHPEE,MA 02649 Administrator Not valid without signature Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 65891 Restricted to: 00 MICHAEL A DEDECKO PO BOX 2384/CARLTON DR MASHPEE, MA 02649 c�7--G- ��>•�'` Expiration: 11/9/2011 ( numi.�inur Tr#: 8038 i s Town of Barnstable 116 , BABNSTABLE. Regulatory Services 9 MASS. i639. Building Division prED MPS a' 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection � �� Location 67- Q U) E R x �- Permit Number 11 Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: l 'J J�NIAPKAML No-r T!JS AU-Eb PER zb.F i ETY,47-�GKW Please call: 508-862-403.8•fQor re-inspection. Inspected by t1,hUm f-- v Date 727�� CENTERVILLE WEQUAQUET LAKE `o N • _ • _ s o� 0 F 0 N ii PARCEL ID: 251/005 LO o LOCUS MAP LO °°, LOCUS INFORMATION ' CB PLAN REF: 55/65 F-2 & 185/75 PARCEL ID: TITLE REF: 19329/161 PARCEL ID: MAP 251 LOT 006 251/006 ZONING: "RD-1" S AREA=8617 t S.F. s9e FLOOD ZONE: "C" COMMUNITY PANEL: 250001-5C DATED:08/19/85 EXISTING CONDITIONS PLAN LOCATED AT: O ss9e _ �68 ce 68 OLD FARM ROAD �0 'goo _.-_#$ _ CENTERVILLE, MA. A\ PREPARED FOR lb °•o. i•��F.�, 5`'� MIKE DeDECKO �0 ti,Q .9 NqN PARCEL ID: ��282 A ,A 251/007 8S/)S `3S6, � SCALE: 1»=20' of /mac ` SEPTEMBER 9, 2010 E . A . S. SURVEY, INC. GRAPHIC SCALE ZN OF"�Ssq� 141 ROUTE 6A 20 0 10 20 40 e0 EDWARD tiG�� SALT POND BUILDING A. STONE N P.O. BOX 1729 UPOLE C8 No.2 980 SANDWICH, MA. 02563 • ( IN FEET ) F 1 inch = 20 ft~ ®� �a® BUS:(508)888-3619 CELL:(508)527-3600 a �— SHEET 1 OF 1 J 1274