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HomeMy WebLinkAbout0148 STONEY CLIFF ROAD O FTHE T Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee .;g c * BARNSTABLE, * - 9� Thomas F. Geiler, Director " / I z63q. �0 • \,' 6 prfD�,tA Building Division Tom Perry,CBO, Building Commissioner, 200 Main Street, Hyannis, MA 02601 V www.town.barnstab le.ma.us Office: 508-862-4038 F Fax: 5W 790-6230 EXPRESS.PERMIT APPLICATION - -RESIDENTIAL ONLY' Not Valid without Red X-Press Imprint i. r Map/parcel Number 03 ProP r h'Address S . �^ g �G] Residential Value of Work -� &00 0` Minimum fee of$35.,00 for,work under$6000.00 G Owner's Name&.Address .i V 02-6.31 Contractor's Name �e✓ ��.�� �o� :Wl'. L`C Telephone Number(S68 3AS 73 83 Home Improvement*Contractor License#(if applicable)' (GL( ((( } Construction Supervisor's License#(if applicable) $ 7 y ❑Workman's Compensation Insurance;' C eck one: ; , I am a sole proprietor ❑ I am the Homeowner,, > t 4 A-PRESS (PERMIT ❑ I have Worker's Compensation Insurance ' JUL -1 2010 Insurance Company Name r Workman's Comp. Policy:#. _TOWN OF BARNSTABLE, Copy of Insurance Compliance Certificate must accompany each permit. } Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over. ' existing layers of roof) ❑ Re-side #of doors . Replacement Window's/doors/sliders,U-Value `7`'(maximum .44)#,of windows, *Where required: Issuance of this permit does not exempt compliance with other town'department regulations,i.e. Historic,Conservation;etc. ***Note: Property Owner must sign Property Owner'Letter of Permission. copy of the Home mprovement Contractors License & Construction Supervisors License is ed. SIGNATURE: QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 f ✓�ie i�anvmo�reusea�i ✓UGad6aclzuGelyd , Office of Consumer Affairs& usiness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of.Consumer Affairs and Business'Regulation Registration 164111 10 Park Plaza-Suite.5170 Expiration .--�8/3112011 Tr# 288114 Boston,MA 02116 J Type—!' WALL BUILDING PETER WALL } 57 LONGFELLONI/�DR '_ 'I ` YARMOUTHPORT MA 02675" Undersecretary Not valid witho t signature. f .._ Massachusetts- Department of Public Safet Board of Buildin!- Re-illations and Standards Construction Supervisor•License i License: CS 87194- Restricted to: 00 F PETER D WALL 57 LONGFELLOW RD . YARMOUTHPORT, MA 02675 Expiration: 8/18/2011 C:onnnissioura' Tr#: 19966 The Conimorrivenftlr of Massachusetts ---- -- epartnteiitofIndtsstraalAcciderris Office of Investrgahons t 600 Wasitington Street Bostwn M4 02111 V rr'rrw.rnass:gos ldiicr "Yorkers' Compensation Insurance AffidaN t:: Builders/Contracto'rs/Plectiici.•tns/Plumbers Applicant Information Please P"riut LeOb Name(BusinessDrgamzationdn&vidual)_ Address: �e iJ c City/State/Z.p / ,�r 0r ✓ e Are you an employer. heck the appropriate:boa Type:of project(re'' fired).. 1.❑ I am a y em toer with 4. ❑ I am a general contractor and 1 employer 6: ❑New construction employees(full andlof part-tinge).* have hired the sub-contractors 2..K I am a sole proprietor or partner listed on the attached sheet . ❑Remodeling slop and have no employees These mb-contractors have 8. ❑Demolition working for rTie in an ci employees and have ctrorlcers' 3'capacity. 9. Building addition [No workers' comp_insurance comp-insurariml d. 5. ❑ tJe:are.a corporation and its 10.❑.Electrical repairs or additions re e , officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a hameowntes-doing a:11 work. ❑ g � P No workers'co right of exemption per MGL . myself. f �• 12.0 Roof repairs y imsi>rmree required.[r c. 152, §1(4),and we have no employees.[No w-orl'`ws' . n.❑other comp.insurance:required.] *Any applicant thaechecks;box#1 MWt also h1l out the section below shomgg their workers'compensation policy information- ?Horneownm who submit this affio--n#t in&cating they are doing all:work and then hire outside contractors must suhn it a um a$idwit indicating sucl: lCantractors that check this box intw attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees. Ifthe sub-contactorshare employees,they tunst.provide their Workers'comp.policy number.. I airs are employer that is providing workers'corrrponsadon insurance.for iny eiployees. Be'loty,is the policy'and1ob site in,for�urrrtr`oPts - . � Insurance Company-Dame: Policy 4 or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: ; Attach-a copy of the workers'eompensa tion policy declaration page(showing she policy number and'expiration date). Failure to secure coverage,as required under Section.25.A of MGL c_ 1.:52 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andfor ane-)rear imprisonment,as well as civil penalties i> the form of a STOP WORK ORDER and a fare 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:DLk for insurance coverage verification_ I do h cerd ire ills pram es,of parry that the inforatatioai prcn'd eabo-w is trite and correcf rS trine: Date: ( .. � Phone 0: M re , • Official use only. Do not ivrite in this area,to be completed by city ar totavt nffic aL City or To,%m: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Gityfro-am Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other Contact Person: Phone#: i �pF THE Tp� BARN&rABLE, * - MASS. Town of Barnstable ArFD MA'S A ' Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner ,200 Main Street, Hyannis,MA 02601u www.town.barnstable.ma.us, Office: 508-862-4038 Fax: 50.8-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder` as Owner of the subject property hereby authorize le-TL�� �\ � to act on�my behalf, in all matters relative to work authorized by this building permit application for:. 1L qq CU C � esvi\fie 02 �2 .(Address of job)AQ- Signature o Owner ate Print Name . It Property Owner is applying for permit; please complete the Homeowners License Exemption Form on.the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Jq 0 Parcel 3 Application # 0 l Health Division Date Issued �: t o Conservation Division Application FA 1 Planning Dept.. Permit Fee Date Definitive Plan Approved by Planning Board NG 71 WIl0': Historic - OKH _Preservation/ Hyannis • Project Street Address 4. S�oKe ►M Villagee. e� �<«� i Owner e ' 0. d- ��b (S�V"Mwl Address Telephone(S©-,) 7�- Permit Request �e ���' �,�. Cove►�e� 0.11 K Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 4)_U,o6® Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 5 No On Old Kings Highway: ❑'.Y:es b-No Basement Type: A Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sqft) ` Number of Baths: Full: existing_ new Half: existing nbe v Number of Bedrooms: existingxnew Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing/__New,� Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:b•existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑' Appeal # Recorded ❑ Commercial ❑Yes O-No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number, /$Og 3 93 Address S License # 27- 1 7Z4 Home Improvement Contractor# 1441 l 11 02-a Worker's Compensation # L 1L'�,6 3 0 377 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE L 16 i w FOR OFFICIAL USE ONLY APPLICATION# - DATE ISSUED "> -ADDRESS_ ' VILLAGE OWNER . _. 5- DATE OF INSPECTION: Z .=FOUNDATION°: - FRAME t *INSULATION I. Y -- - - _.-._. FIREPLACE ; T '3 ELECTRICAL: ROUGH FINAL ? s - ' f r PLUMBING: ROUGH FINAL 3 GAS plNS--+ ROUGH FINAL -+ " - f FINAL BUILDING ',( DATE CLOSED,OUT .:.. ASSOCIATION PLAN NO. ,r t r' The Commonwealth-ofMassachusetts Y Department of Industrial Accidents I: Office of Investigations 600 Washington Street c� Boston, MA 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contracto`r..s/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/organization/Individual): `1 ' Address: City/State/Zip: V dQ. S Phone # <DS) 3 Are you ari emplo Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and I 6 El New construction employees(full and/oripart time).* have'hired the sub-contractors _ " . listed on the attached sheet. 7. Remodeling 2_[ I am a sole proprietor-or.partner- r ship and have no employees LLL, These sub-contractors have g• Demolition employees and have workers' working for me in any capacity: 9. [] Building addition ' [No workers' comp. insurance comp.insurance: 5. We are a corporation and its 10.❑ Electrical repairs or additions required:] 3.El I am a homeowner doing all work officers have exercised their 1 LF] Plumbing repairs or additions . right of exemption per MGL 12:[] Roof re t pairs myself. [No workers comp. insurance required] *I o. 152 §1(4), and we have no q ] employees. [No workers' 13.❑ Other comp.insurance required. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.- t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit anew 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$250.0 a against the violator. Bc-advised tbat a copy of this statement may be forwarded to the Office of Investi ations of e DI or ' sur ce coverage verification. I doh b c er e to nd y penalties of perjury that the information provided a ve is tr ce and correct. Signature: Date:— Phone Official use only, D.o notwrite in this area, to be completed by city or town offciaL City or Town; Permit/License#' Issuing Authority (circle one): L Board of IIealth.Z. Building Department tment 3. City/TownClerk 4. Electrical Inspector ector 5.Plumbing Inspector 6. Other Contact Person: Phone#: dions n for their' oes- CrS Massachusetts General Laws chapter 152 requires all emplo ersonoinrthe�sderwoce�of another underoany contrac of lhye, Pursuant to this statute, an employlee is defined as `.,.every p express or implied, oral or written." rahon or other lgal chtity, or any to or An employer is defined as "an individual, partnership, assoc) eolives of aedeceased employer,or theore of the foregoing engaged in ajoint enterprise, and including tai he legal p resenla 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 h employment bebe deemair work ed to be n Such anelmploy houseing uc ;" ' or on the grounds or building appurtenant thereto shall not because of s P Y or uance MGL chapter 152, §25C(6) also states that"every stater to 0 construct b ldgngs yin the commonwe lthsfor any r ' renewal of a license or permit to operate a business o applicant who has not produced accep#able evidence of compliance with the insurance coverage required. Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of'ts 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 [hatl?PPlcerlifiy to ocate(s)ur s �of on and, if along with r eses and hone numbers) g supply sub-contractors)name(s), addr s ( ) P s other than the necessary, PP Y 't Liability Companies (LLC)or Limited Liability Partnerships(LLP) With no employer insurance, LiDu ed tY p ton insurance. If an LLC or LLP does have members or partners, are not required to carry_workers compensation employees, e policy is required. Be advised that this affidavit may be submitted to the Department of IgdirstriaJ Accidents for confirmation of insurance coverage, Also be sure to sign andbdeane See uestedYnotthe Department Of be returned to the city or town that the application for the permit or license Is. g q. Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed beloW..Self-insured companies should enter their self-insurance license number on the appropriate line. City or-Town Officials Please be sure that the affidavit is.complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the.permit/license number which will bo used asneed only submit One affidavit indicater. In addition, an ing current that must submit multiple permit/license applications 'In any given y (city or policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in to the town)."-A copy of the affidavit that has been officially stamped1os oraliceoses Anew affidavi musy the city or towD may bt berflled out each applicant as proof that a valid affidavit is on file for future p . 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 Chmnnkyn-in-adva-ryee-# --Y ur so°pecatlnn and should you have any questions, Please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth.of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617427-7749 Revised 4-24-07 www.inass.gov/dia '� Tows. of Barn-stable ` Regulatory Services v� rM E AS& Thomas F. Geiler,Director 1 ,fig Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us. Office: 508-862-4038 Fax: 508=790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 0I, Aas Owner of the subject property hereby authorize �` ��' ��.�. to act on my behalf, in all matters relative to work authorized by this building permit application for (Ad ss of Job) Sig tur of Owner Date Print Name If Properly Owner is..applying for permit please complete.the it Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION T�r Town of Barnstable Oky Regulatory Services +` = Thomas F. Geiler,Director < BAxNsrwBt.e. Building Division prfD 's A Tom Perry, . g Buildin Commissioner 200 Mairi Street, Hyannis,MA__02601, www.town.barnstabie.ma.us Office: 508-862-4038 Fax: 508-790-6230 ITOMEOWNERLICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less.and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the.Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. w The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minir num 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 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 homcownm 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 curdy used by several towns. You may care t amend and adopt such a forrn/certification for use in your community. Q:fornZs:homccxcmpt . � �ILC V/O�JYIIEOIZLUCQL�L �L✓�/GQQ��LfldP�6 _ - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration ",164111 Office of Consumer Affairs and Business Regulation' Expiration'.'" 81/2011 Tr# 288114 10 Park Plaza-Suite 5170 Type DBAfi` Boston,MA 02116 WALL BUILDING ELU . _.? PETER WALL 57 LONGFELLOW�DR YARMOUTHPORT�MA02675`f Undersecretary. Not valid witho t signature 1 i ttis.rchusetts - DeIM1-tmcnt of Public Safht� Board of Buildin"r Regulations and Standards Construction Supervisor License License: CS 87194 Restricted to: 00 PETER D WALL 57 LONGFELLOW RD i YARMOLITHPORT, MA 02675 :Expiration: 8/18/2011. ('ummissiuner Tr#: 19966 NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, 8oston,.Massachusetts02111 617-727-4900 http://www.mass.gov/dia- As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: LIBERTY MUTUAL FIRE INSURANCE CO. NAME OF INSURANCE COMPANY 150 LIBERTY WAY, DOVER, NH 03820 ADDRESS OF INSURANCE COMPANY' WC2-31 S-377554-010 4/17/2010-4/17/2011 POLICY-NUMBER EFFECTIVE DATES. NAME OF INSURANCE AGENT . ADDRESS PHONE# WALL BUILDING LLC 57 LONFELLOW DR YARMOUTH PORT MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above-named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the.provisions of the Workers' Compensation Act.A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by'the insurer, if the treatment is necessary and reasonably connected'to the work related injury. Incases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER y J i 0 a Q. dt, I , i . Note:This drawing is an artistic 20 � , Designed:4/14/2010 interpretation ofthe general e.HNowcies+' Printed:5/28/2010 appearance of the design.It is not meant to be exact rendition. IJ ____ _ WALL BUILDING GRIMM KITCHEN JOB _ All _ Drawing 9: 1 � G2 k we nti T.p Q 126" �tstyl�SvQ t'.� c`3�DGi 37;"— 33" 3n 5" 25" 55 a 33" 2 2 9" 15" 12" " t`tii :W+:�'L. L..".a. ft soy$M P.V'. "i.'.•>. " M W3030LL 3330RR N - In I ,O ' O p m 24 DISHW FBF3-3 cO/2 Q M O 00 �IQ 3r m Ul Op r` 214 IN " _ IN m N co iflAM � a�• W t M W f" -IN N M M U') " 665811-1 c W tg 44 lzby—r All dimensions size designations �'+�� This is an original desi n and must Designed:4/14/2010 given are subject to verification on 20 a:t l y. g g TECHNOLOGIES not be released or copied unless Printed: 5/28/2010 job site and adjustment to fit job applicable fee has been paid or job., conditions. order placed. WALL BUILDING GRIMM KITCHEN JOB 04-14-10.kit All Drawing#: 1 of SHE Tpk, Town of Barnstable *Permit Q00Y63 ! S Expires 6 month rom issuate '3' s Regulatory Services Fee r r BLE Thomas F. Geiler,Director SS Building Division f0 MAC JUN a��Perry, CBO, Building Commissioner 16 2008 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us TOWN pFBARMSTABLE Fax: 508-790-6230 Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number / 90 0'112 Property Address c�( � OtU���j d t C c (Zo UResidential Value of Work (p ..(C-C (: Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addressr!I Contractor's Name Y"6 4, �,p/ (�a t�S r v c ta> > Telephone,Number So " `l a Home Improvement Contractor License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name .�= Workman's Comp. Policy# C C-, UU-s-(-1 I( Q f d o6 7 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) p I Re-roof(stripping old shingles) All construction debris will be taken to C qSS-e� lei ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. **.*Note: Property Owner must.sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, DMA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Lessibly Name(Business/Organizahon/individuan: LA,pQz Le, l p_o NIS t r V G 1-t U r\7 • Address• �� � ��r, ��seJt � ��-►.�-i�ry{ ��Y -- City/State/Zip: V A.e,- Phone*: Are ou an employer? Check the appropriate box: Type of project(required): 1, I am a employer with 4. I am v a general contractor and I 6. ❑New construction . employees(full and/or part-time).* have hired the sub-contactors listed on the attached sheet 7. ❑Remodeling 2.El I am a-sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑Demolition working far me in any capacity. employees and have workers' 9. Building addition [NO workers' comp.-insurance comp.insurance t required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowmnr doing all work officers have exercised their I I.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §10),and we have no, employees. [No workers' 13.❑Other comp,ina ranee required.] *Any applicant flat ehecim box 91 must also RU out the section blow showing then warkas'cotnpeoaalian policy infoanatiarr. t Homeowners who submit this affidavit indicating tbcy are doing all work and then hire outside contractors must submit a new affidavit indicating such. Tcontractars that check this box must attached an additional sheet showing the name of the subroaftwtora and state whether or not thosb entities have employem If the subcontractors have cmployms,they moat providt their wmkrss'corm.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /� Insuranco Company Name 11A.C— , . Policy#or Self-ins.Lie.#: Vim'CC 6-nOIS--q Lta D/ 00'7 Expiration Date: 3 d lob Site Address: l`l? 5-[ot\o-e J e,[<� l� City/Statelzip:ce►�4,eIv i It, V-,f q Od h-S . Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Fail=to sictse coverage as regttired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penaltits 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 statcmerit may be forwarded to the Office of _ Investigations of the WA for insurance coverage verification. I do hereby ceer�tify under the pains•and penalties of perjury that the information provided above is true and correct Signature:O Date: (c /0? Phone Official use only. Do not write in this area,to be completed by city or town offu iaL City or Town: Permit/Licens,e# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees: Pursuant to this Statute,an employee is defined as"...every person in the service of another under any conttAct 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 representative's 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-contractors)name(s),address(es)and phone number(s).along with their certificate(s)of inenran t. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pert 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 time Department at the mnnber listed below. Self insured companies should enter their self-insurance license number on the appropriate line. City or Tavrp Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple per33it4icense applications in any given year,need only submit on;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 of 5davit 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 firt ure 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 io any business or commercial venture (Le. a dog license or permit to brim 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 ti:give us a call The Department's address,telephone-and fax number. The Commonwealth of Massachusi�fts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TO. #617-727-4900 ext 4-06 or 1-977-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov/dia oF�HE ra,, Town of Barnstable Regulatory Services BARNMBt I'EMASS, Thomas F.Geiler,Director �FOMn'�s Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder l - T as Owner of the subject property hereby authorize �P����� CoiyS ' �� �`0'11 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date -z_ 6 y- Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 1. Town of Barnstable �oF SHt:rp . Regulatory Services t . Thomas F.Geiter,Director BARNSfABLE. Mess. ,bsq. Building Division PlfD k Tom Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862AO38 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION j Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. t DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner 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 perfomung work for which a building permit is required shall be exempt from the provisions of this section(Section i og.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 t amend and adopt such a forrn/certification for use in your community. Client#: 16665 U/ 2MEAGHERCO .�RDT. CERTIFICATE OF LIABILITY INSURANCE 0DATE 9106/07DIYYYY) dODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION low'ling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Igency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 173 lyanough Rd., PO Box 1990 lyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC# -ISURED INSURER A: Associated Employers Insurance Compa Timothy Meagher D/B/A INSURERB: Meagher Construction INSURERC: 49 Guildford Road - INSURER D: Centerville, MA 02632 - 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 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N R DO' POLICY EFFECTIVE POLICVEXPIRATION ITR TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ " j- COMMERCIAL GENERAL LIABILITY PREMI ES( RENTED $ CLAIMS MADE ❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ - GENERAL AGGREGATE $ 'GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PE 0T LOG AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT ANY AUTO - (Ea accident) $ ALL OWNED AUTOS ' BODILY INJURY $ SCHEDULED AUTOS - (Per person) HIRED AUTOS . BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) 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 $ $ A WORKERS COMPENSATION AND WCC5005442012007 06/23/07 06/23/08 X we sTATu- DFR TH- EMPLOYERS'LIABILITY - E.L.EACH ACCIDENT $1 OO OOO ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $1 OO 000 If yes,SPECIAL PROVISIONS below describe under SPEC E.L.DISEASE-POLICY LIMIT $500 000 SP OTHER .. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Insurance coverage is limited to the terms, conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION . ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN Building D.opt. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Hyannis, MA 02601 REPRESENTATIVES. AUTHORIZED R PRESENTATIVE -ACORD 25(2001/08) 1. of 3 948992 NS2' © ACORD CORPORATION 1988 i G,lfie "CJorvnw�zuea/,/! o�./�aaaacl+c�eetta " .. . "".r Board of Building Regulations and Standards I; License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registation:' 148111 Board of Building Regulations and Standards. Expiration __g%7�2009 Tr# 133618 I One Ashburton Place Rm 1301 Type DBA Boston,Ma.02108 MEAGHER CONSTR�JCTJON.._ TIMOTHY MEASHER -;.;: - 49 GUILDFORD CENTERVILLE,MA 02632' Administrator Not valid without signature is L I 1 . 4 r w g a„ W*�' e,. ` '5,•G`/. ' yf't i "r {h }:- ".J { S�.V ?"`f°*$y'�f' _+�;e' ''�Lyk^4 #� t }r✓ ?v�n''�'+z •.' V„ za "r} Zri � �` t i F,.v"'�s��.� °fS,� '�+F �'r \- - '.� '_ ,fit ``n.....ys"., "'�. y',s*,-• F ;>,•:'' y"S...r _ y�1'C�'t,.ti.. -.i''pr'�r '',x r '+' - " M .a`'` t � Ft` ' ?.... .. ,.t ,. ,... .. .a,«,M•r m€t§�.' , .;.�,x'... / ?" .'#<,' 01 '�" 'k+=, :z; a4 .d.,^ .a»+. ' ,..r'•na�an7u� .,�:._$'�,: t . �.Y iY e:�, spy+� i•4 � �- : ',p - t CONTRACTOR , 1 p .. .y .. � �4,x �q. -,.,i.,. .. •`'t 8�� y x y t t ` � I S �L f.�.,• -�:,;' ''-;_,-am�:ayy Nit k 1- r COMMONWEA�TN � DEPARTMENT OF PUBLI OF ° �1010 COMMONWEALTH Y MASSACHUSE 7-s fk BOSTON, i MA 02215 ' i a .EXPIRATION DATE a �.-4 t i.,Nw< ti,st- ' _ LICENSE -i. t . A,� s flMSTR SUP E Y#' � -' ry � CAUTION4 � w:t`�� �Ikc9ji � � , FECTIVEDA r �_ FOR PROTE+ - 3. af.-. <: :.;�i, ST;t 'tl I-IC-_ • , CTION°AGAIN F' -jib �9 „ {{; v �-fHE` �� R IGHTTHUMB�" �T� °. - /30/1992 P PPROPRIATE, r .r. t )r $ 2 FAMILY=� HarME ; ' }� ... s U�' r � o ° BOX:ON LICENSE z�, ag` T ti. � � •A_t•�'c"E,�'a.. ram'. ' r �t �?;`S� - � '�: Z sN�'.t71 52 TORS; , .i t•-,-«c9 Af.. ..,r.,.� ...•.,,:# ,.t .w--: ti xa -, fh,.. -d ,c..,.Yv:: --.. , '+ct-_"xs ,z�'s. „Z _;, Mt/S.TINCLUED y PHOTO. *3'.s - ,i a;. > w;5»S k:'r�°Y�,. �(BIAS NG APR ONL t /✓ � r.;: ,x �;,�;< .+,. �. t m�'¢ - •.a ° ..tia. rltt•` 9 `., �t" „..,_ ..•�y,,,,.�' ,,. ._.,'.- .. r :�.... � #�-.<.9,0•0�f �"NOr_YAL� - � ,.,1.._'.''4. .\ ..•+.-,et. .,.. . �' w*. _,r.,.,, .z... .1. SIGt�B_Y lJ 'CEN�E-`•- �a��"a.-� t I-�,t` _ � � �`�r �. # 7UFiE DF - •��' '.v �' ri GFiT- # a. � ac4 ,�,•.� ,�` �.�p :'-n.. '• .,,+a.,�^.,m i.�?�ti'`'� ysy„re�� .._ ot 3�-s£ i?n': .--::� s.. ,.. ..t._:1, s ;:a.,. +.,,.� ".�t��". - � X .:DOB: w' Kc� '�.e�3�'•y'S` �'�Wi`�F'LL;s+-,: .gat ���. '��}S"�'�t?�"Y'r';,s` - .?,y. I -. .... ,. „..,}�'t' ��� ,a• i � a�q`R:�f�` .' +.. .a- 1�::'.�••#.Fr, �',�q $�. "��' '<r .awr s�». '°�'� .Y..-. € vim..*aS` �F. 1.`'CIk Y„y�.' :... .,• ..':. � ....;,,: 'sxr`.�^ .7 4."'r; i � # !j .q ..�za 8scz" �A�� „�,^W�'< r ;.:'y'S. �":^<... ...a ....• , '.^.'<.'��- •:. + ,.(F! irF pw. 4Cu..*a ,'2;- ..: :�aa k q, -'-,',�• .- ....,. - '"7 THIS`DOCU �.�Y' � N.', r . r,zrd.7t" u• -1'. ` ter ? ��cw,' -. a' .. # 6 �.•: ..,CARRIED _-..i�.. .: .. , :•�. .. �,Ys:.c. :�r: :� k.:.. ONTHEPERSIN'1� g, qc 7l uCF,► , F�s ..... W FULL ABOVE SIGNATURE UNE "F;x - •4�' UMB Pft4T TGAGEDMiIiIS"w E ,,t 4 -' }�,3° ,a-.a.: -c ¢ y.•v k�^''. r�:: _ d f OCCL�ATIO�` '� f y 7.1 y_ T. ..Assessor's office(1st.,Floor): ��� Assessor's map and.lot number ✓ �Q�of THE>o`` Board of Health(3rd floor): _ Sewage Permit number d Z 21MUS AILL i Engineering Departm nt(3rd floor)., r.as House number /ll� •Z, 1r °o �a}q. Definitive Plan Approved by Plan 1 Board 19 ' �o MAI 6' APPLICATIONS PROCESSED :30-9:30 A.M.and 1:00-2:00 P.M.only AmmETOWN - OF BARNSTABLE I L D I N G INSPECTOR Aft—E.C TION FOR PERMIT TYPE OF CONSTRUCTION f /Pj�i�►Psi 19 TO THE INSPECTOR OF BUILDINGS: 16— The undersigned hereby applies for a permit according to the following information: Location Proposed Use (G/� /`� 4f"G�i' `�[�`�SO/�R� 17,X/ " Zoning District Fire District �© Name of Owner /� � '/�� Address Name of Builder Address A-5 SOW/s-re."- fe �� /✓+ �� Name of Architect Address Number of Rooms Foundation Exterior �'`�'�` �� �� Roofing Floors Interior Heating Plumbing { -3 Fireplace Approximate Cost i Area Diagram of Lot and Building with Dimensions Fee ` 0®i 9 9 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. F Name Construction Supervisor's License dcJ WALSH, EVELI,NE & MARIE 4 No 35417 Permit For?__ SC EEN IN PORCH - Single Famil we Location 1.48 Stoeel C1 f roadOi Cente> i le Owner Eve,l•ine Sri Walsh f ' Type of Construction F me .Plot` - j ^�% Lot -.� - r • � =1. Permit Granted - October 2 , 19 92 t . / Date of Inspection 19 Date Completed 19 i I S�/'FC/✓ 1 �1 �?1c1n7 u� �� q >_ ,11Jy 4 ' I SEE t�iir�i<r-fl _�LH. UATIN f ELEVA I�'IN Y• yl NI I.Ll . DIP ,REAR EL VATIC�N --`-