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HomeMy WebLinkAbout0459 STRAWBERRY HILL ROAD - r. , � x � �� � a o �Wks t��, x *`Irj. a ;W'r° rc v # � � �Y r •,�. a Y. s 1 , _ a s " 6 ..w.,..;,• t,h.w.v*an-•. ,.w..,..�,.. _.,-:.s..z.:t f' ° �w� ;�_fr r'»3'YT`.ie^V .+:r.'<.-,r+t:•.:,=wsri v-�`x?r�t�•.n..,-.+-,•s-'*.^cxw.'.s7'raa=�...•/w�#a+- _. . . fi - _ >. i .. ._ i Oi TN�ro TOWN OF BARNSTABLE z 33181...•.. Permit No. .. BUILDING DEPARTMENT aeaarr I Cash $4 0,0...0 0). /�( q TOWN OFFICE BUILDING ",your HYANNIS,MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to David Whalen Address Lot #2, . W- Strawberry Hill Road Centerville, MASS. USE GROUP, FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING' INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ` t December 7, 89 19 - - -*-�>����? fG�' ........................ ......... .. Building Inspector TQWN QF BARNSTABLE, MASSACHUSETTS a k. BUILDING PE R IVt 11 A�2�iU-1G6 t' Jcpt,�iwbur 1 u9 I f9 Q� DAT (9 . PERMITNO." /• 33.,.t:r1 APPLICANT Whalen GonLracting.', Sl • 'irGi yea-71-c.�e^, . .;llti t G� ADDRESS (NO.)I (STREET) (CONTR'S LICENSE) PERMIT TO build dWNlli'j.% i Slt'lp,le ii!,Mily NUMBER OF l (_) STORY DWELLING UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) , .LUL 1P4 Murry 1 l/r1 ',.t._i-t i.a.;.i:' AT (LOCATION) ZONING .. ., � ��- DISTRICT 1' {Rd.) BETWEEN AND ~ (CROSS STREET) (CROSS STREET) SUBDIVISION LOT LOT _BLOCK--SIZE s 1 BUILDING IS 10 BE FT. WIDE BY FT, LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCT). ` TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION f (TYPE) REMARKS: , Luc.) $400•OU i19Z it. AREA OR ,000 59.75 VOLUME ESTIMATED COST PERMIT Q (Cu Ic/ FEE .P R• BOUARE FEET) David { ► 441E OWNER 5� 'r , rl�. 1''i rr'I .i F' z •r !•� 4 4f1 7. - BUILDING DEPT.ADDRESS BY , (/ ) f THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART TIIFRICOF• EITHER TFMPORARILY ) PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE A PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINI, FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIOr OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHI:RG APPLICABLE SEPARATE. INSPECTIONS REQUIRED FOR ;."E:+MITG ARE REQUIRED FOR ALL CONSTRUCTION WORKi CARD KEPT POSTED UNTIL FINAL INSPUC T'ION HAS LIELN 1. FOUNDATIONS OR FOOTINGS. FL: !"(IrIC,AI., PLUMBING AND MADE, WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL.NOT BE OCCUPIED UNTIL FINAL INSPECTION TI TO LATHE FINAL INSPECTION HAS BEEN MADE, 3.-FINAL INSPECTION BEFORE OC.CUPANCY.- ii� POST THIS CARD SO IT IS VISIBLE FROM STREET 3 BUILDING I NSPECTI APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS Z 3 cc HEATING INSPECTION APPROVALS Dl_I,ARIMI'NI I d I N(;INI'I OTHER ---- —_. /a-7- ,P�. • ` O cIt O Ll d p BOARD OF HEALTH 1 WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION TOR HAS APPROVED THE VARIODUS STAGES OF 0 INSPPAIONS INDICATED ON THIS CARD CAD! WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE 1 CONSTRUCTION, PERMIT IS ISSUED AS NOTED ABOVE, nitltnNCLU Rn1 (1Y TELEPHONE Oil wHn l NUTIFICAI IUN.. I j} a r 103.62 • N (] C4 LOT 2 00 , 10380± 00 r IV cy 37.5 >-- z Q_ rn 40.2 V � N I Y� NOTES: I.THIS PLAN IS VALID ONLY IF IT IS STAMPED AND SIGNED IN RED. THIS OFFICE ASSUMES NO RESPONSIBILITY FOR INFORMATION CONTAINED ON COPIES WHICH DO NOT HAVE ORIGINAL STAMPS a AND SIGNATURES IN RED II,AS- 6UILT PLOT PLAN 2.THIS PLAN WAS NOT PREPARED TO THE STANDARDS THEREFORE THIST FORTH IN 250 PLAN S NOT TO BERUSEDTION FOR6.04 RA EA MASS. TITLE INSURANCE PURPOSES Lot _Z T eel 41 LCr !J I CERTIFY TO �i4pL6ti Ga�-ST2�►G?/cam LA.IVD USE TECHNOLOGY, INC. AND TO _ %,✓1,) o/- l3,g21x)Sr 134,C ( FORMERLY R. J. O'HEARN , INC.) THAT TO THE BEST OF MY INFORMATION , SWAN RIVER PLAZA , 35 ROUTE 134, UNIT 3 KNOWLEDGE , AND BELIEF , THE SOUTH DENNIS, MA. 02660 �o✓�.vy4CT�ov.� SHOWN ON THIS PLAN �, JOB NO. HAS BEEN LOCATED ON THE GROUND AS •`•'��5.1ECHN010C'•., �4/ INDICATED AND THA S LOCATED IN +1 .�' '•• ': DATE I FLOOD ZONE m `. D INSURANCE �;• : yc i RATE MAP DATE r``� _ q=' _ = CLIENT INC. 1977 • = L.J/H.pL L k) �, ,�C • `�:. PSCLE a 1 UT • -I rr if .� AT REG. DES 9. A LAND SURVEYOR I''•''�u�n�•N•'•� SHEET . 0F„�_ a y ` appG���IC'Q OLNOTE C A ES �All UMLE Building Inspection ®eparment +°�r'x .> 1 -.$+' r:' )ty '.i '•'t�y,t ,�""y x'� �Er M1'l,i�-. - 5"�ESp a — t lz ry — r' = 1--- - ............ ................ ....................... CT — t ���� Ir � I • --�---. ... .-----.—.__ .._... _. _ __�_ .._ ...:_._ is .I I: I Y 1 10 WWG . ea 1:aftepa ffi ing r i 1 naa aar o r,ee O ItlNp noyrav ^z€g xo� o m. 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AW- 144 >< 8.s Izzyvoly Y .'S�io ? X, ._x_9_.._.�..;.�,_... - ms• 3oKZ� 4-Z IC �o.�cl Co (aoK7o K( q"2 --= - P°� Z4 x i z.o -- p To .}IPt1G . brorzM o R L`r �JF}11+CfL6►S -Low ZX4 f R LA54e�i j. 1T1� r IxYi ryTzs PPI�+�y - �u�.T u INS p LOotz _ylp�me IM 9N TION ' �4 F, 1 p; lq lug GK 1 Itc) �OwQ�IQ' <Jo►xc�T� � ' 'S/z• t.l.t.LYS �, 914 aaop MIN ILA IG s, iQ/�G Q.L.r(3► �d0 R1 ,:. j N i-- r c,C7ST.� t` r1 �i -. COS 15 ISCALE DRAWN[V - ` I I � 1• � R[VI[HD } 'b ! ar A'►ql� O[Y DRAWING"USES i l o - out ._:;, , ONALD I. p.80 Cgrl.No.MA-+mP ' Asses sgr s' offVe (1st floor): , a 'YETEM �6, 132f Assessor's ma and, lot number THE T Board of Health ,(3rd floor)- �'.`".'."."...... ..... ......... ... .a.��E� �� �������C��� WITH TITLE 5 Sewage . Pesmit pumber ."..G�O�- . .................. qyvp� r v, ...... .......... �E�TAL CODE A...��d L Bafi�n9aTa LE, i Engineen�ig , alftmpt (3rd floor): �q House n.'r ryi r?' :."." .... y�...................... (� ylayb GULAMONS 9�0 26}9• \000 b ,,,.• 'FpYPYa' uf; ,tu;.a olve N APPLICATIO '*,.'R'OCESSED 8:30-9:30 A.M. and 1:00•2:00 P.M. only, TOWN OF - BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........................ &11 L� �• v( TYPEOF CONSTRUCTION .....................Frame..................................................................................................... ...........JulY ....' ....... ...19-.87 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ,..Lot••2.,, Plan•.Book...22 ,• ge••123.,...( C1..Stra�ab.er.xy...Hill... .,...MA..................... Proposed Use ..................TtrQ....(3)...be.d..7oo?n..s illagI.Q...fame.1.y........................................................................................ ZoningDistrict .........RD.................................. .......................Fire District .............................................................................. ? le Name of Owner .......na; � ��� . �.....................................Address 4R.."eye .":". ...,...eh'fLew_,4 Lwu ':.,..n "....ni 45...... Name of Builder .- ie�r e a � � T -�' TT_ - ................................................Address ................. .......r.�....aq ---- -P4�•—�lfa��-- P6 �.... Name of Architect ...L.N.....Branchard................................:Address -No.., .Dartmouth,...MAGJS # .. . Number of Rooms ...Six (6) ? Cement ..................................Foundation .............................................................................. Exterior ....................Wood......................................................Roofing ...................Asphalt/Shingle........................... Floors .......................Two ...............................................................Interior ...................Drywall Plaste.....r . . . .................................. Forced .dot Air. ..............` .......;... ...THP...;Q.de...(.c .r.e.:�,/rpr N Heating Plumbing �p^Te -..z: i................................. .................................................. Fireplace ...................XQs.........................................................Approximate Cost ........-$#.5.9•n6 '-.i......� j ......:. Definitive Plan Approved by Planning Board __-- 19 69___ . Are ....... Diagram of Lot and Building with Dimensions Fee � � SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules-and Regulations of the Town of arnstab in the a e construction. Name .. .. .. :. .... . .. .. . . . . .............. Construction Supervisor's License ...... WHALEN, DAVID Q 33181.. Permit for .....One..:S. oxy......... ~� ..Single Famil Location t..Lot.:.#.�.�....:� ...S.t a.wber.ry...Hill Road `tee. Centervil.1.e..:'..:........................ , Owner Da" l - ......vid................ en ..Wha....................................... , Type of•Construction ...........ZraIAe:................. %..... .......................................... f ~� Plot ..... ` ......... . .. . Lot ................................ .f , Permit Granted .....Se te.m.b...x..►1.,.....1989.. .... .. y _ f wDbte of Inspection ... .. .....r' �.�.. ....T.E{L^d�.:.......19 Date Completed ...I.........l q ^ , i i 1 ' n f r . Assessor's offioe .(1st floor); *TMEr Assessor's map and, lot numb ` �:: �6...........��.`I!8 "�� Quo o�♦ Board of He'alth (3rd floor): Sewage,..P,e " * dumber --...�5. ...��o�......................... 2 Baaa9TODLE, i .... g' p brit (3rd•floor): �o rhea En meed,K , a tm Oq�i679 6� House n' , l; ii,,:. .................................y`�1...................:... Y a` r: ..... 'f0 YP APPLICATIONt'*.'R CESSED 8:30-9:30 A.M, and�1:00-2:00 P.M. only !' t r TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .................. it R01mWTo..............:........... L L.� �:................... � TYPE OF CONSTRUCTION .....................bra^?....................................................................................................... July22, 19- $7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...Lot.•2.,. Plan..Book..228.,Page..,1,23g,.( d_,Strawberry..ff:*�.. pad,.,,C ntery 11 .t..MA,,,,,,,,,,,,, Proposed Use Three„ bedroom..sing]:e.Ja><ily............................ Zoning District .........RB. ..................................... >. ....... ......................................Fire .District ... . /well1> C'/,?c LC= cr OEn-tics /�l� F3-t-h--Rsataaa- -Name of Owner ..... A.................................................................Address .-7.4.-i�4�1.k'.-Aifi'..a-�:��C-e;�l��.-b�;�;3.',::.I?1�1,--0��4�-.-.. �. C!//,�/�CGi1/• C'oN!/f/�eT/NE' /l✓G � _ Q /�/lvD� .G��?rLe-' �� j>G-tii.i s • Name of Builder .. erg- T- 4" Address...—.i v3z3 'ov�strer ---0].bD9— — ....... f Name of Architect ...L.N. Branchard Address .No, Dartmouth,r._NA ......... Number of Rooms ...Six...(6)..........................................:. ..Foundation .............Cement .................................................... Exterior .....................Wood......................................................Roofing ...................Asphalt/Shingle.......................... Floors Two.......................................................:In Interior ................... .. l...Plaster HeatingForced Hot..,fir Plumbing Two•.code. .................................................. g ..�cop.P.er/1 Y0................................ Fireplace ...................Ye ........................................................Approximate Cost -- 6 -000-©fl d '�"'.................n......... .......... ....4, ..... . .... ...... Definitive Plan Approved by Planning Board __ 19_69___ , Area z-66 .. Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of arnstab.le .Wgarcling.._-the above construction. Name .. .. .. . .0 . .�. ......... ..ter. . .....�1 � Construction Supervisor's License `3i 137+77 WHALEN, DAV,Ivi-� A=,-4t---l-&6 No ... Permit for ....One Stork........ S.i.ng.je 7amilv Dwel i !.......................... Location'. ....bPt.... ..Hill Road ...................Q.en1.e-r.v.i.1.1e................................ Owner ......David—W-....ha-..1-en............................. .. .... Type of Construction -Fr.....ame........................ ........... ............................................................................... Plot ............................ Lot ................................ Permit Granted ......Septembex... 19 89 Date of Inspection ....................................19 Date Completed ..................... ................19 - Town of Barnstable ,•_ Regulatory Serrvices Richard V.Scali,Director Building Division * nnxxsrasra, � ` 9 MASS. Tom Perry,Building Commissioner i639 QED N►p`�a 200 Main Street,Hyannis,MA.02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee- Permit#: HOME OCCUPATION REGISTRATION Date: Name;c � V iJ\�\U U� ��Phone#: Address:(-\So� �� �� Y �\:� �� Village: �'l� egVQ ASL Name of Business: V � � � � P, \ N Type of Business: N�� �� c::) Map[Lot: 0AS .16:. INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the ,. following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. . • Such use occupies no more than 400 square feet of space. - • - There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal,household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I) the undersigned,haverea d agree with the above restrictio or my home occupation I am registering. APPlicantve Date — 7 A \ Rnmmr.dn.Rev.10,1113 YOU WISH TO OPEN A BUSINESS? For,Your Information: business certificates [cost$40.00 For 4 ye a:i,s;. A business certificate ONLY REGISTERS YOUR NAME. in town tvahich you must do by M.G.L. -it does not give you permission to operate: Yot.i must first obtain the necessary signatures on this forrn at 200 r-lain St., Hyannis Takes the completed form to the Town-Clerk's Office, '.i tit FI., :367 NAain St.; Hyanriis, titre 02601 (Town Hall) and get the BUSiM`6 Certificate that is, required by law. DATE: 0-�-. 'Fill_in'please: gwf APPLICANT'S YOUR NAME/S: A i O �'1 12-1 L f _ BUSINESS �2Z� YOUR HOME ADDRESS: 5 a �`r0AVi f�E_L i~k ` x o�8f5 Z . 0.2Co32- 2 06. f >' Home TPlPnhone NTELEPHONE # umber S NAME OF CORPORATION: N L► AME OF NEW BUSINESS M y 0-; -t-O L DS c�Pe N TYPE OF BUSINESS Imo+ s Ga ,ti IS THIS A HOME OCCUPATION? YES. . NO QQ ADDRESS OF BUSINESS. Lt `� S5- 2 � FlU+l�o2Q AP/PARCEL NUMBER ��'O [Assessing] When starting a new business there are.several things you must do in order to be in compliance with the rules and regulations of the Town`of . 1,2 Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST .G0 TO 200 Main St. (corner of Yarmouth. Rd. & Main Street] to make sure you have the appropriate permits and licenses required to legally operate your business in this town.. 1. BUILDING COM IER'S OFFICE MUST.COMPLY WITH HOME OCCUPATION -This individ al hn ia#or e an pe mit requirements that pertain to this type of busine��ES ANp REGULATIONS. FAILURE TO COMPLY MAY RESULT:IN FINES. g�6SqAuhriz ig atur COMMENT ; f c- 2. BOARD 04 EALTH This individual has been informed of the permit requirements that pertain to'this type of business. t Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business: Authorized Signature* COMMENTS: r� t GL o�z Town of:Barnstable • *Permit# Expires 6 months from issue date Regulatory Services Fee _ + tUarrsrest;e, y nsass 1639. ��� Thoma's F. Geiler,Director pJEn Mpt a r Building Division_` Tom Perry,CBO, Building Commissioner 200 Main.Street, Hyannis, MA 02601 wwW.town.barnstable'.ma.us Office: 508-862-403 8 Fax: 5087790-6230 EXPRESS PERMIT APPLICATION - ' RESIDENTIAL ONLY Not Vii id without Red X-Press imprint Map/parcel Number p?7, - /6 Property AddressOX- esidential Value of Work &C;? _ Minimum fee of S35.00 for work under S6000.00 Owner's Name&Address , f3 /� ' ( ��,�-( C�v s. Contracto_r's Name f G R t� � 0ejJeppho,ne,Number_,5V���� V7?0 Home Improvement Contractor License#(if applicable) 0 tj A j IS�. `J Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance -R S PERMIT Check one: I a sole'proprietor-' . AY am the Homeowner ❑' I have Worker's Compensation Insurance TOWN CIF 3ARNSTABLE Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit., Pernirt Request check box) Re-roof(stripping old shingles) All construction debris will be taken to U r'1� ❑ Re-roof(not stripping. Going.over existing layers of roof) ❑ Re-side #of doors, ❑. Replacement Windows/doors/sliders. U-Value (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. e Home Im ement Contractors License& Construction Supervisors License is require SIGNA URE: 2AWMLEST0 Slbuilding permit'forrnAEXPRESS.doc tevised 070110 Town of Barnstable o Regulatory Services.. Thomas F. Geiler,Director Building Division PrED {k Tom Perry,Building Commissioner 200 Main-Stract,_Hyannis, MA_02601 wwsv.town.b arristable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LIMSE EXEMPTION Please Print DATE: JOB LOCATION: number street village 'HOMEOWNER": z name home phone# � phone! UADDRESS:- w^' t CURRENT A NT MAILING DDRESS: ((3 o -� - Al- NJ , 4 cityhown state ap code T c current exemption for"homeowners"was extended to include owner-occupied dwellin S 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. DEFINIIZON OF HOMEOWI<l;R Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which_thrre is, or is intruded to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constMas more than one home in a two-year period sha11 not be considered a botneowner, Such "homeowner"shall submit to the Building Official on a form acceptable to the Building,Official, that h'e/she shall be responsible for all such work performt:d 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"homeowne es that,he/she understands the Town of Barnstable Building Department min;rnum' t cdures requirements and that he/she will comply with said procedures and rc cnts. i a - Approval of Building,OtTicial 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 EXEMMON The Code states.that: "Any homcovmcr performing work for which a building permit is required shaD be exempt from the provisions of this scction_(Scetion 109.1.1-Licamsing of construction Supervisors);provided that if the homeowner engages a pcgson(s)for hire to do such work,that such Homcownc r shall act as supervisor." Many homeowners who use this exemption are unaware that they art assuring the responsibilities of a supervisor(see Appendix Q, Rulcs&Regulations for Licensing Construction Supervisors,Scctioa 2.15) This lack of awarrncss 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'ultimatdy responsible. To ensure that the homeowner is fully aware of hislhcrrzsponsibilitics,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the respansibilitics of a Supervisor. On the Iasi page of this issue is a.form cur=Oy used by several towns. You may care t amend and adopt such a fom>lcertifieation for use in your corrmmunity. ro VEr, Town of Barn-stable o Regulatory Services Thornas F. Geiler,Director 619.. µ9 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 as Owner of the sui ject•property- hereby authorize to act oa my behalf, all matters.relative to rk authorized Y b 'this buildin permit a r. � w� g P PPEcation for-. (Address of Job Signature of Owner Date Print Name Y If Property Owneris applying for permit please cornplete. the Homeowners License Exemption Form on the reverse side. { The Commonwealth ofMassachuseits ' ( ^f I 1 Department of Industrial Accidents Office oflnvestigations. ' 1 li►"�� J 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant lifforinatigm Please,Print Le 'bl Name (Business/Organ' �o n ivydual): l �Sae,-�C- Address: 3 � City/State/Zip: �a'`1�tPhone #: Are you an employer?Check the appropriate box: Type of project(required): 1. ❑ I am a employer with 4. ❑'I am a general contractor and.1 6.. ❑.New construction employees(full and/or part-time).* have hired the sub-contractors ' 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # �• ❑ Remodeling ship and have no employees These sub-contractors have 8. []'Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its_ officers;have exercised their 10.❑ Electrical repairs or additions required.] of 3.U>i<a homeowner doing all work right of exemption per MGL I L Plumbing.repairs or additions myself. [No workers' comp. c.152, §](4); and we have no 12..❑ Roof repairs . insurance required.] t employees. [No workers' 1311 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 are doing all work and then hire outside contractors must submit anew affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepplicy and job site + information. Insurance Company Name: Policy#or Self-ins. Lic.#` - Expiration Date: Job Site Address: : ,Ciy/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing-the policy number and expiration date). Failure to secure coverage.as required under,Section 25A of MGL c. 152,can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of�a STOP WORK ORDER and a fine of up to$250.00 a day.against the violator. 'Be advised that a copy of this statement may be forwarded_ to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u ins a zes o erjury that t e inform Lion ARrovided above tru'7annd,correct -sign --.,� 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.TPlumbing Inspector 6. Other r.......a n­ .. Phnne#- yi i N ' b Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or'trustee of an individual, partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides,therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repaii work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed,to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal'of a license or permit to operate a business or.to'construct.buildings'in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is Tequired. 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 permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavip on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog.license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address;telephone and fax number '* r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,.MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www_rrrass.gov/dia .