HomeMy WebLinkAbout0017 WHITES LANE i
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C
mot , Town.of Barnstable Permit#
Expires 6 months from issue date
�7 ^ Regulatory Services Fee �—
* snaxsTABM
v� MASS. Richard V. Scali,Director
1639. �0
ArFD��p
Building Division..
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL_ ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number ����"
Property Address / /
(Residential Value of Wor $ ,(9 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 10 011_k G f w l/ WU
y
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
Ott > ,
❑Workman's Compensation Insurance ` °�MI T
Check one:
❑ I am a sole proprietor MAY ]( 5 2014
am the Homeowner
❑ I have Worker's Compensation Insurance
TOWN OF SA�R�WST�3LE .
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑�e-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
[Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. -
Separate Electrical&Fire Permits required.
*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 copyof the Home Improvement Contractors License&Construction Supervisors License is
requii ed.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
The Commomveafth of Massackasetts
De arbnent of Indrestriat Accidents
Office of l'mmtigations
600 Washington Street
r Boston,MIA 02111
rvmv masxgovfdia
Workers' Compensation Insurance Affidsivit BuiI rsicontracbnrslElectrkians/Plambers
App
licant Information Please Print
Name(BuimenKhganizationthulividnsl): v
Address
city/StatdZip-- 3 Phone:#_ ��`•c2(36• ����
Are you an employer?Check t e appropriate bo - Type of project(required):
1..❑ I am a employer with 4' am-a general contractor and I
employees(full aa��dfor part-time)-* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or parer-- listed on the attached sheet, 7- ❑Remodeling
ship and have no employees These sub-contracturs have S. ❑Demolition
w for me in an c employees and have wonicers'
working y'�Pa capacity g. ❑Building addition.
[No workers' comp.insurance comp-insurance.Y
required-] 5. ❑ We are a corporation and its 14.❑Electrical repairs or additions
3.❑ I am homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself:[No workers'comp. right of exemption per MGL 12.❑hoof repairs
instuance required.]T c. 1.52,§1(4�and we have no
employees-[No workers' 13.❑Other
' comp.insurance required-]
'Any applicant that checks has#1 must also fill out the section below showing their worker'compeusation.policy informatian-
t Homeowners Who submit this af5daint indicating they are doing all work and then hire outside contractors nmst submit a new affidavit indicating,such
lContractors that check this box mast attached wt additional sheet showing the name of the sub-caws and state whether or not those entities have.
emp"es. If the sub.-contractors have employees,dxy must provide their workers'comp.policy number.
Iam an employer that is prorating workers'cougmisation insnranee for my employees. Below is fiepolicy and job site
it for radon
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Bate_
Job Site Address: CitylsStawzip:
Attach a copy of the workers'compensation policy duration 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 chit penalties in the form of a STOP WORK ORDER and a fine
of up to MOM 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 cet ft,u d its and penalties of perjury that the information pm ded above` trnre and correct
Si tune: Date:
[�' r
Phone#_
Ofcial use only. Do not write in this area,to be completed by city or totim o;(iciat
City or Town: PermitUcense#
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 9:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lnvestigafions
' .600 Washington Street
Boston,MA 02111
www.mass govA a
Workers' Compensation Insurance Affdavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): 1 "
Address: .3 C1`14111-
City/State/Zip: 64pJ:DS Phone#: Z6� l w
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a -lover with 4. I am a general contractor and I
e oyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.V I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These subcontractors have 8. E]Demolition
working for me in any capacity. employees and have workers'
[No workers'comp,insurance comp.insurance J 9. Building addition
required-] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repass or additions
l£m se ' right of exemption per MGL
y �o workers comp. 12.0 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
employees. [No workers' 13.❑ offer
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-oontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c under a pains and enalfies of perjury that the information provided above is true and correct
Signature: Date:/
Phone#: 7 � ' (� iL
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter-152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the msurarice.
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
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit 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 affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massarhusetts
Department of Industrial Accidents
Office of west gations
600 washivon Street
Boston.,MA 02111
Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07
vvviw.To s.govfdia
Town of Barnstable '
Regulatory Services
Ft T�,yti Richard V.Scali,Director
Building Division
BARNSrABLE. ' Tom Perry,Building Commissioner
Mass.
1639. ��� 200 Main Street, Hyannis,MA 02601 >
ArEo �a www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: �
JOB LOCATION: , 112
n ber I street village
••HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS: I
` U
T ,
city own state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides.or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A 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 un ersi ed"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
proce d r quirements and that he/she will,comply with said procedures and requirements.
ftn1t&e'6fHAkwner
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."
tit t'.
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 la'ckof 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 form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit formS\EXPRESS.doc
Revised 061313
OF THE 1p�
* BARNSrABLK
6 9. ,m� Town of Barnstable
A?FD Mp2l A
Regulatory Services
Richard V. Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us'
Office: 508-862-4038 ' F. Fak:.508-790-6230
. Property Owner M-us i y
Complete and Sign Thi ection
If Using A B ' der
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized this b g permit application for:
-17
0 ,�
( dress,of Job)
11-5
ignattzr f Owner Date
inn 14
tint Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
QAWHILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
QL
�g�'oFTME�a,�o Town of Barnstable *Permit# ;;'9/2 3
Fxpires 6 months om issue d
R4PYMAEM : Regulatory ServicesHAM Fee
0.19. 10� Thomas F.Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 XsPRS PER a
Office: 508-862-4038 $EP 7
Fax: 508-790-6230 2004
EXPRESS PERMIT APPLICATION - RESIDENTIA-1—M MF BARNS'TA L
Not Valid without Red X-Press Imprint
dap/parcel Number OO, `L
?roperty Address FJ,T
"sidential Value of Work Minimum fee of$25.00 for work under$6000.00
)wner's Name&Address
C_ �
contractor's Name Seo es) �� in Lk-, Telephone NumbePT Xf a 9-I G
Some Improvement Contractor License#(if applicable) I '3ri-7 14
_"onstiuction Supervisor's License#(if applicable) ►° .,... .
7%rkman's Compensation Insurance j
Check one:
❑ I am a sole proprietor
❑ Jamthe Homeowner
I have Worker's Compensation Insurance
nsurance Company Name l r� f✓ u i n C e
Workman's Comp.Policy#
:opy of Insurance Compliance Certificate must be on file.
'emit 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
R lacement W' -�ep endow . U Value (maximum.44
*Where required: Issuance s permit d not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: erty ust sign Property Owner Letter of Permission.
r ent Contractors License is required.
Ignature
All Cape Aluminum Estimate
192 Iyannough Road t Date Estimate#
Hyannis,MA 02601
508-775-4299 ` 6/24/2004 01-635
b.
Name/Address
01
Cathy Lavedlero os ,
�
17 Whites Ln.
Cotuit MA 02635 � '
i
P.O. No. Terms Project
Farlev window/Farle...
Description Qty Rate Total
Farley 1000 series white patio door 6068.Includes low-e argon 1 650.00 650.00T
glass,full sliding screen
Farley 300 series white vinyl replacement window.fixed picture 1 245.00 245.00T
style.includes low-e,argon,double strength glass,24 square flat
white grids
Farley 300 series white vinyl replacement window.double hung 2 250.00 500.007`
style.includes low-e,argon,double strength glass,4 over 4 flat
white grids
Perm 0.00
Pen-nits&Dump Fees 85.00 8
Any additional wood needed to re-trim interior or exterior of door .U07
and window will be charged at cost.Additional labor to repair
rotted will be billed at$65.per hour
Labor to install door and window 665.00 665.(�0
i
Subtotal $2,145.0t)
A 50%deposit is required to bind this estimate. Sales Tax (5.0%) $69.75
This estimate is valid for 30 days.
Total $2,214.75
Signature
syiW�<'2p ,, s Y to {. { y -1.
�ie �
Board of Building Regul• tions and Standards
One Ashburton Place -.Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
-t Registration:: 135174
Type: DBA
�._ Expiration: .3/11/2006,
ALL CAPE ALUMINUM
SCOTT PRESTON
192 IYANOUGH RD.
HYANNIS, MA 02601
Update Address and return card.Nlark reason forchang
Q.Address Renewal Employment Lost Card
_ ------
��T7- p �/ ----
✓lie T�o�wrizaruuea c ,-ivGczaaac�ucoe —
Board of Building Regulations and Standards
'License or registration valid.for individul use only
HOME IMPROVEMENT CONTRACTOR ' before the expiration date. If found return to: s
Registration: 135174 - Board of Building Regulations and,Standards
Expiration:-'3/11/2006
One Ashburton Place Rm 1301 '
TYpe•:'DBA Boston,Ma.02108.
ALL CAPE ALUMINUM
SCOTT PRESTON : •« z
192 1YANOUGH RD.:
HYANNIS,MA 02601 �� f
Administrator Not valid without signature -
{:
t
c
Town of Barnstable
. °f TME rOj`3�
Regulatory Services
tom .
Thomas F.Geiler,Diiector
. Building Division
ED Tom Perry,Building Commfssioner,
200 Main Street; Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-623 0
TgRlIbT# 7S7)Z FEE: ZS-i�o
$
--------------
SEED REGISTRATION .
120 square feet or less
Location of shed(address)
Village
Property owner's name Telephone number
Size•of Shed
Map/Parcel#
Signa
Date
Hyannis Main Street Waterfront Historic District?
Old Kiz;g's Highway Historic District Commission jurisdiction?
Conservation Commission(signature required 3 .� 0
PLEASE NOTE: IF YOU ARE WITmN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSION$,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.PLEASE SEE.THE-APPROPRIATE CON3USSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLA
N
MAP 027 --
MAP
003-- Q0 6
# 31
i
MA ' 7 j
002
# 17 0 7
MAP 027 �\ 1
142 - 001
#
AP 0 7 ...:.:..:.:.:.:
0
# 57
o :.
MAP 027
\Desktop\Conservation.dgn 3/1/2004 2:33:40 PM
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Assessor's office(1st Floor):: ?
Assessor's map and:lot number �! Prof twe To`♦
Board of Health(3rdrfloor). d�
Sewage'Permit number �— y-9/ 1�. •
Engineering Department(3rd floor):
ae a number 17 g oo t639
Definitive Plan Approved by Planning Board 19
PLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABL- E
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO got d Lid cal eC rGdGl y�
TYPE OF CONSTRUCTION W00,41' f'2✓�syr
. I
/ 19 �a
f
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location
Proposed Use S� 'J CL ec..le�
Zoning District i~ Fire District Cp ( j '
Name of Owner) bb\ E ' C1t `)4 f1 �(Ylt Address
� I
Name of Builder Address r��T n. c �*,; t��
� v
Name of Architect Address
Number of Rooms Foundation S'DaJD f U r,S
Exterior ®e"J Roofing iU 0 xj4 ;
Floors
X 1JIF Interior A�
Heating Plumbing
Fireplace- Approximate Cost
Area
Diagram of Lot and Building with Dimensions Fee
i
f
f I
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.
J t
- E
L
Name 44, , tsf
Y Construction Supervisor's License
SMITH, DEBBIE & MARVIN air
A=027-002
No 34374 Permit For Build Deck Addition
f
Single Family Dwelling _
Location. 17 Whites Lane
Cotuit
Owner Debbie & Marvin Smith
Type of Construction Frame
i_
s
Plot Lot
Permit Granted June 4 19 91
Date of Inspection 19
Date Completed 19