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HomeMy WebLinkAbout0049 WHITMAR ROAD !4r; I /h 6/7-Y 9 1�� k ®-7111 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION .n� Map y- �! Parcel l 1.U 7L9 Pitt Application o Health Division Date Issued Conservation Division Application Fee Planning Dept. e Permit Feb Date Definitive Plan Approved by Planning Board r_ Historic - OKH _ Preservation / Hyannis l� �P_roject=Str eet Address VINe-► mod/ �vvvner,�,_M y �.AV6Y4A /-Address 9 �?�9/ fCl�• Telephones V.P4 /-2 7/ iPermit Request j0202C' -Square feet: 1 st floor: existing - proposed 2nd floor: existing proposed Total new: Zoning District Flood Plain Groundwater Overlay EProjecttValuat _?C0O,a�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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ 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: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name'"'�� �b TeIep no eh 'Number_6W-4��—/-.2?1 Address,_4V License # Home Improvement Contractor# Worker's Compensation # ALL—GONSTRUCTION`D€BRIS-RESULTING-FROM THIS-P—ROJECT WIL'L BE TAKEN TO f_� N OF SIGNATURE FOR OFFICIAL USE ONLY APPLICATION# DATE,ISSUED MAP/PARCEL N0. ` - ADDRESS VILLAGE t OWNER , t DATE OF INSPECTION: ' DAFOUNDA--TION 9t k 13 ft..ju A;'si, r FRAME jNSULATIONxr,frjwts, s 4 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH -FINAL k GAS: _ ROUGH 'FINAL FINAL BUILDING Z3 DATE CLOSED OUT ASSOCIATION PLAN NO. I p • i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 4F www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 9T 1VVV �ss:. City/State/Zip• /[L6 - hone#:�S" '" Zl� ^ d12�r Ar-e�youyan`employer?Check the appropriate box: %I— Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).. * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working,forme in any capacity. employees and have workers' � .[No workers' comp. insurance comp. insurance. t 9. ❑Building addition t '' 5. We are a corporation and its 10.❑Electrical repairs or additions required:] ❑ rP ,,3" 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions m e right of exemption per MGL myself.lf. [No workers comp. 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' d3TOthe comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 certify under the pains and penalti of perjury that the information provided above-is-true and correct .` Date: & Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 4an,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 ' 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 erriployees,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 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,4elephone and fax number: 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-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mm.gov/dia Town of Barnstable Regulatory Services AB& ' Thomas F.Geiler,Director 1639. ia,�ss. � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ` Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION (DA1t---� l- /-T Please Print �►�ry�� JOB_LOC-ATION: nu�mber,L ,,�n ,'�. / street village (� village �/ Q p (, 4 "HOME_ OWNER":_)�(/V C•///��N//`� J(/a f I,'7I 4,/7 1-a/—/dQ ! name home phone# work phone# CURRENT MAiLING-ADDRESS:Y9 W t 0��Ns' lL1.S' L1f�. O�G 7 city/town state zip code The current exemption for"homeowners"was extended to include owner-occulted 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 undersigned"homeo 'certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedur and requirerrWqjs and that he/she will comply with said procedures and requirements. G Signature of H eo 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 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 form/certification for use in your community. C:\Users\decollik\AppData\Local\MicrosoR\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBN\EXPRESS.doc Revised 053012 'ME l Town of Barnstable Regulatory Services Bnxxs& Thomas F.Geiler,Director 1639. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862403 8 Fax: 508-790-6230 Property Owner Must �. Complete and Sign,This Section' If Using A Builder ` i > I, er of the subject property hereby authorize to act on my behalf, in all matters relative to work auth ed by this building permit (Address of J ) **Pool fences6andalarms are the response ' 'ty of the applicant. Pools are not to be fitilized before fence is in tailed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012 i 0 STRUCTURE IS SHOHN ON THE PUN L ON THE GROUND. a PROFE ONAL LAND SURVEYOR / NOT UE IN A FLOOD HAZARD ZONE 0 d SIC w�qi c e4y �Q .r �o �`Z,— l— �— ` 43,923 sq.R. _ yam. 1 � ,�•,,,,.;� PLOT PLAN OF LAND ~`rfLA51. ` IN B , + BARNSTABLE, MA. OO ' "LT �•j/.n.,., t DEPICTING 11iE EFOR NC FOUNDATION �A�D suo R O A D GRAPHIC SCALE LOT 26 WI-.{ITMAR w I SCALE: 1' , 20- DATE; SETEMBER 2, 1995 A Da"AMD A/SOOIA710 MA.025M u DAHtomenrrDa-t .i' (IX►SIR) " 1 InoL••• C0 K . �� � , �� �/��l�Ei�S .__�,_ ✓P�./�--000/2oP�i✓lavC�T;...h;D�D_,�-� x 5�. �_,���� �r��,� G�/oS�.I _ I p . er` �-- ► '` .I -- 1 ,Rep'< - 3 6 77 f, _ _ z x.o• _s h W 1 u f �I G . ! I 1P _ _ e IU f 1 < �. ► = r i%V i V Q �7j , /1-w air�3 �,> Town of Barnstable *Permit# Expires 6 montlu from issue date Regulatory Services Fee 3 S • BARNSTABM MAC' Thomas F.Geiler,Director Building Division X-PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 JUN 12 2013 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790- 230 EXPRESS PERMIT APPLICATION - RESII R&n9 NSTABI. O 5, 71/7C 0D Not valid without Red X-Press Imprint Map/parcel Number Property Address41 Residential Value of Work 3 ePO �� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address y14-16y4& J, Contractor's Name M4 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman'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# 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ 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 copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNAT C:\Users\decollik\AppData\Local\Microsoft\ dows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 The C'ommonwealth of Massachusetts Department of Industrial Accidents -- -- Office of Investigations 600 Washington.,Street Boston,. 4 02111 waentt mass.gnv/daa Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print 1,mbI� Name(Busmess/orgud ationdrAviduaq: if wollL/ Address: y9 Wi tiy,ek �o6}-D �G►-ry�r� City/Sta&Z.2p: /W /l ieGS O Phone 9- .�b�-�•�f�— / 7/ Are you an employer?Check the appropriate boa: T of project r 4_ I an a era/contractor and I }'Pe P ] ( e4��= 1_❑ I am a employer with 6- ❑New consttuctioa employees(full and/or part-time)_* have hired the sub-conhwtaas 2_❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling scrip and have no employees 'These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have worms' 9 ❑Building addition [No workers'comp.insurance comp-instrance J required-1 5. ❑ We are a corporation and its 10-❑metrical repairs or additions 3AI am a homeownu doing all work officers have exercised their 11_❑Plumbing repairs or additions myself [No workers'eotmp. right of exemption per MGL 12_❑Roof repairs insurance required.]I c.152,§1(4),and we have no employees-[No workers' 13.X OtherRfg!46E As : comp_insurance required.] I I boo"? - *Any applied that checks box N mast also fill out the section below showing their®makers'compensation policy information- T Homeowners who submit this affidavti iacdi =g they ace doing all waft and then hire cumde contractors must submit a new affidavit indicatigg such. =Canusctors that check this box must attached an addin oat sheet showing the mane of&e sob-eoa�ra M0 and state whether or not those entittin have employees. If the soh-ccntnctors have employees,they must ptuvide their warkers'comp.policy number. I ant an etnpZV er that is prm*hWg worike s'compensarti®n insurance for my enrplgpmm Below is thepolicpy raid ja.6.sate inforntahon. Insurance.Company Nam: — Policy#or S ins.Lie.#: Fatpuai on Date: Job Site Address: City/Statrle ip: 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$1,506.00 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 iusuracce:coverage verification. I do hereby curd&under the pains and "es of pedury that the information prmaded above is trjw and correct Date: Phone# ��' 7� - / 7/ Official use only. Do not write in this area,to be completed by city or tottal of cgat � City or Town: Permit/License Inning Authority(tdrele one): 1.Board of Health 2.Bundling Department 3.City/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#- - -- - -- 6 t � °F Town of Barnstable Regulatory Services RMWETABM ` Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / ? Please Print DATE: JOB LOCATION: 40 64:71 J/7 number street village "HOMEOWNER":-1O/(N 4e /V0VGA7J ::;rx• ��•�aON�'7� L�7'Ya9 9o8P name home phone# work phone# CURRENT MAILING ADDRESS: �� a/'tlm,*2 xo" /lJARsf�lj *1144 S �IJI� O�4�,18 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 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 require9lws and that he/she will comply with said procedures and requirements. Signature of Homeo er 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 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 form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 : 25 ! I Pol I i ... 7 I e-!-�4, : { AF — h ,.. . � ce:r�.r�cr r,Rt�n� � � I � ' _ i i ��P � � ' • �It I I I 5 I !� 1 W (c oil I : l 2- D L f I I , : I _ , ! I I I i I n .. � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 1C, 6D� fO `f! j - Application # 1 F., Health Division ,;. Date Issued Z- Conservation Division Application Fee Planning Dept. Permit Fee '- Date Definitive Plan Approved by Planning Board V D _ Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner .�U h RO bl � Cl Mb�ianAddress �� w h t�WIEt �fiwS 0 1 Telephone 606 420 12-11 Permit Request > 1 to 1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay P-rojiect-Valuation t 6/()Ob 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ 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: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ _ Y T Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed`Use y - -=- - - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ��b 1 � M o y Lan Telephone Number 450� 1-20 � W�'� License # U 1 4-( M GY S�Un S Mt 1 S) M/� Home Improvement Contractor# j Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FR HIS PROJECT WILL BE TAKEN TO Y A SIGNATURE DATE r FOR OFFICIAL USE ONLY , r APPLICATION# DATE ISSUED MAP/PARCEL NO. t F r' ADDRESS VILLAGE r OWNER DATE OF INSPECTION: _ I , FOUNDATION FRAME r INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL C GAS: ROUGH FINAL i FINAL BUILDING 4I�'�`t3Aft DATE CLOSED OUT ,F ASSOCIATION PLAN NO. - i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - ' 600 Washington Street t, Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Lezibly . f- Name(Busme� z horgmi n/Individud):. y6 V l y, C-1- Mo y Lan Address:` 4q W h�i t Y Co-T•U I T Aclu Gtl City St�/Zip: Mar�fiu ais,n 1 l S MA.Pho�#� Goo A2.0 121 i EAre you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-.time). have hired the sub-contractors 6. ❑New constriction . ., 2.❑ I am a sole proprietor or partner- listed on the'attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition ,#,working for me in any capacity: employees and have workers' co insurance. ` 9. ❑Building addition [No workers' comp.insurance. comp. quired.] 5. ❑ .We are a corporation and its 100 Electrical repairs or additions 3.[ I am a homeowner doing all work officers have exercised their 11:❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below.showing their workers'compensation policy infomnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 'I am an employer that isproviding workers'compensation insurance far my employees. Below is thepolicy 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 ed that a copy of this statement may be forwarded to the Office of Investi lions e DIA for insmmlEe cover e v rification I do hereby a unde th ains en Ide of perjury that the information provided above is true and correct Signature: Date: Phone#: 595 Zo k 2-q 1 Official use only. Do not write in this area,to be completed by city or town offrciEaL City or Town: Permit/License# Issuing Authority(circle or - 1.Board of Health 2.Building Department 3.Ci /Town Clerk 4.Electr'ty icallumbin Ins ecto6.Other . g Inspector Contact.Pejrson• 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 the i required." . . ance w insurance coverage 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 uvidence 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 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 permitgicense 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 Sile 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 vand: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 io 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 youf have any questions, please do not hesitate to give us a call. The Department's address,telephone.and fax number: The;CommunwWth of Massachusetts Dgparkmemt of hadustriai Accidents Office of Investigations 600 Washingtc6 Streett B.ostQm, MA 02111 Tel. #617-.727-4900 ext 406 or 1-977 MASSAFE Revised 11-22-06 Fax#617-727-7749 www.nms.gov/dia �'THE Town of Barnstable Regulatory Services. m - + Thomas F.Geller Director snarvs�rnus, 9W,y 3F9. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 . HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 1 Y�l I Q 1 01 Wu l number D� street . village 'IHOMBOWNER": V ID �I M 0� a Yl rjo Q� q 2�D 127 name ." `-I home phone# work phone# CURRENT MAILING ADDRESS: 4-9 VV In 1 YV)CA f P—cI Marti�-oy1 S MOV S MAI. yZt t g, 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 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. e un ersigne o owner"c t he/she understands the Town of Barn table Building Deparhnent insp tion oced es d q ' ements and that he/she will comply with said procedures and re�ntsn. Shp- ature`of Homeowner " Approval of Building Official Note: Three-family dwellings containing 35,000zubic feet or larger will be required to comply with the State Building Code Section 12.7.0 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 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 fomJcertification for use in your community. Q:forms:homeexempt 1own ofBarsfit Regulatory Services 16y ` Thomas F. Geiler,Director 16 Building D' ivision 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 . y Complete and Sign This Section If Using A Builder , as Owner of the subject ptopetty hereby.authorize to act on ray behal� in O'rnattets to dve to work authorized by this building pe=ait (Address of Job) **Pool fences and alarms are the ons res ibili p ty of the applicant. Pools are not to be Ued,before fence is installed and pools are not to be- utilized until all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS I Y. G ..�" LlXY �S �. l . a i 1 1z-0 l l iFt'�M`aMp.. 15 .�h:•NY'�+.�a.cs@btiwM�a^Em'ri*n1lMMWNM+� - �/' }, Moylan 49 Whitmar Road Marstons Mills,MA 02645 s . s THE F,IOSTING STRUCTURE IS SHOMN ON THE PUN AS IT EMSTS ON THE GROUND. _ OATS PR�ONAL UND SURKYOR Ad LOT 26 DOES NOT LIE IN A FLOOD HAZARD ZONE - 1� �eeAdli O ii - td y}\/ O \� A 43,923 6q.R. wd P� o 7 (' PLOT PLAN OF LAND IN - IBARNSTABLE. MA. Nn 1 1 usrr% DEPICTING THE EFL NG FOUNDATION a,0;uar:. GRAPHIC SCALE LOT 26 WHITMAR ROAD .o • w a .o .• y �ty SCALE: 1' - 20' DATE SETEMBER 2, 1995 ( d fLEE) 919 Di A DMU AND Af60QATO 1 moe'. PO rL 42 CAM"MW LAN[.rALMOUIM—MATCHM"MA.omx .?. T IL P"aft e06/610—mm Town of Barnstable BARE. Regulatory Services 9 MASS. MP'�.6M" Building Division prFO a 200 Main Street,Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection �� Location ��� � � T- Permit Number 7- o Z O 3 2 Z� Owner 40 Builder �1 One notice to remain on job site, one notice on file in Building Department. The following items need correcting: /3 M t Please call: 508-862-4 for re-inspection. Inspected by Date Al //Z— .,N Parcel Detail Page 1 of 3 w B. TPYti,L'E, w Logged In As: Pa rCC I Detail Monday,June 4 2012 Parcel Lookup Parcel Info Parcel ID C00 Developer L(057-117- OT 26 I I Lot�..............�._____.__. _ I Location 49 WHITMAR ROAD I Pri Frontage�y I Sec Road Sec Frontage Village COTUIT I. Fire District[CO—TUIT Town sewer exists at this address i No _ I Road Index 2142 Asbuilt Septic Scan: Interactive 057117C00_1 Map 1 - - Owner Info Owner IMOYLAN,JOHN E JR&ROBIN G I Co-owner j Streetl 149 WHITMAR RD ~I Street2 City LMARSTONS MILLS `) State 1MA zip02648 Country - Land Info _ Acres 1038 Use(Single Fam MDL-01I zoning RF rvghbd[0107 Topography Level I Road[,,Paved Utilities I Public Water,Gas,Septic ( Location - Construction Info Building 1 of 1 Year Roof Roof Gable/Hip I Ext Wood Shingle Built Struct Wall Living E3075 Roof(Wood Shingle J AC Central I - Area Cover I g Type I Style j Colonial I Int 1 P astered I Bed�4 Bedrooms I Wall. Rooms Model Residential I Floor(Carpet Bath 2 Fu11+ 1 H_J Rooms, Grade Average Plus I Type Hot Air Total�� Rooms f7 Rooms er + Stories�2 Stories. I Fuel Heat�"d$ Found-ation(Poured Conc. Gross 5802 I Area Permit History http://issgl2/intranet/propdata/PatcelDetail.aspx?ID=3838 6/4/2012 Parcel Detail Page 2 of 3 Issue Date Purpose Permit# Amount Insp Date Comments 01/10/2007 Remodel&Addi 20065457 $10,000 10/17/2007 00:00:00 08/01/1995 9821 $175,000 01/15/1996 00:00:00 CT 2 STOR Visit History Date Who Purpose 10/17/2007 00:00:00 Paul Talbot Cyclical Inspection 10/04/2005 00:00:00 Paul Talbot Meas/Est 111/21/2000 00:00:00 John Greene Cycl Insp Completed-Update 03/15/1996 00:00:00 Lloyd Kurtz Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 04/27/2001 MOYLAN,JOHN E JR&ROBIN G C161299 $469,500 2 06/01/1999 HANEFELD, KIRK C&KAREN L C153389 $390,000 3 02/10/1997 BAIRD, RICHARD A&CATHERINE M C143536 $325,000 4 08/15/1995 FARRINGTON, LUCILLE C TR C137958 $66,000 5 02/15/1992 BISPLINGHOFF, ROSS L C125862 $110,000 6 12/15/1985 HALLETT, D C&SHIELDS, R M C104674 $130,000 7 12/15/1985 CALLAHAN,JOHN R TRS C104651 $1 8 12/15/1985 CALLAHAN,JOHN R TRS C104650 $1 9 04/15/1985 1 CALLAHAN,JOHN R TRS IC100995 1 $0 Assessment History_ Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2012 $278,400 $54,200 $0 $188,000 $520,600 2 2011 $326,900 $3,900 $0 $188,000 $518,800 3 2010 $327,500 $3,900 $0 $181,900 $513,300 4 2009 $465,900 $2,900 $0 $173,000 $641,800 5 2008 $455,300 $2,900 $0 $185,200 $643,400 7 2007 $452,900 $2,900 $0 $185,200 $641,000 8 2006 $417,100 $2,900 $0 $202,400 $622,400 9 2005 $377,800 $2,900 $0 $186,200 $566,900 10 2004 $293,700 $2,900 $0 $202,400 $499,000 11 2003 $267,100 $2,900 $0 $99,100 $369,100 12 2002 $267,100 $2,900 $0 $99,100 $369,100 13 2001 $267,100 $3,000 $0 $99,100 $369,200 14 2000 $218,200 $3,100 $0 $77,200 $298,500 15 1999 $218,200 $3,100 $0 $91,300 $312,600 16 1998 $218,200 $3,100 $0 $91,300 $312,600 17 1997 $179,600 $0 $0 $47,700 $227,300 18 1996 $0 $0 $0 $47,700 $47,700 19 1995 $0 $0 $0 $47,700 $47,700 20. 1994 $0 $0 $0 $59,700 $59,700 21 1993 $0 $0 $0 $59,700 $59,700 22 1992 $0 $0 $0 $66,300 $66,300 23 1991 $0 $0 $0 .$66,300 $66,300 24 1990 $0 $0 $0 $66,300 $66,300 http.:Hissgl2/intranet/propdata/ParcelDetail.aspx?ID=3838 6/4/2012 Parcel Detail Page 3 of 3 25 1989 $0 $0 $0 $66,300 $66,300 26 1988 $0 $0 $0 $21,500 $21,500 27 1987 $0 $0 $0 $21,500 $21,500 Photos 4 air a� i c , f L ' http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=3 83 8 6/4/2012 Town of Barnstable Geographic Information System lung 4,2012 r t DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:057 Parcel:117C00 Selected Parcel Owner:MOYLAN,JOHN E JR�ROBIN G Total Assessed Value:$520600 boundary determination or regulatory interpretation. Enlargements beyond a scale of 1"=100'may not meet established map accuracy standards. The parcel lines on this map t F- are only graphic representations of Assessor's tax parcels. They are not true property - Co-owner: Acreage:0.78 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:49 WHITMAR ROAD such as building locations. Buffer Aerial Photos Taken April 19,2008 k TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION - Map Parcel �� Co Application# Health Division Conservation Division Permit# Tax Collector Date Issued ° IZ69 k 7 Treasurer Application:Fee — Planning Dept. - Permit Fee o Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner Address Telephone Permit Request E00 Ott M W6111 Of N 12 vvg CO✓K4fc19 ZZzTe-J Vb?�Jn fi Y 0) v42 i 1 ex i 1 1 �b i ►� - nv Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total Zoning District Flood Plain Groundwater Overlay Project Valuatio .110 s 000 Construction Type VI/0001 rrfi Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family M/ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑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:❑existin19 ❑new„ size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: t ' c:f z �W Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ � Commercial ❑Yes ❑No If yes, site plan review# -Proposed-Use — -= -' �YvBUILDER INFORMATIONName9I 1 411 Telephone Number Address2 License# WC211PO:2 1Q 1A K; �1�7- c/ Home Improvement Contractor# t1 I 0 L o Worker's Compensation# WC mq-01 —01 1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO l Af2P 1 kz Wit t, SIGNATURE 1 h DATE l LP .f jY FOR OFFICIAL USE ONLY ' PERMIT NO. DATE ISSUED t MAP/PARCEL NO. ; ADDRESS VILLAGE , OWNER '-bATE OF INSPECTION: FOUNDATION_ FRAME b` INSULATION t .� ®moo ��- �C-sPaed.. FIREPLACE ELECTRICAL: ROUGH FINAL f � PLUMBING: ROUGH FINAL GAS: ROUGH FINAL , FINAL BUILDING GF/� O j< 9/0/0-7 /?htC-k-- DATE CLOSED OUT ASSOCIATION PLAN NO. f 1 1 4 The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information --.Please Print Le ibl Name(Business/Organization/Individual): Address: ^(� ®)(VIT ' City/State/Zip: �2 Phone.#: Areeyy u.an employer? Check th appropriate bog: .Type of project(required):. 1.[ I am a employer with 4• ❑ I am a general contractor and I * , have hired the sub-contractors 6. New construction . employees(full and/or part-time). t Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• '❑ _ g ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. ' right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑ Other " employees. [No workers' comp.insurance required.] *Any applicant that checks box K must also fill out the section below showing their workers'compensation policy information. ' t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. a Insurance Company Name: 4 — Policy#or Self-ins.Lic.#:���G CT ��� ^� 1 Expiration Date: 1"f Job Site Address: /V �� Lin ' City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number Lnd 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 Investi ations of the DIA for insurance covers a verification. I do here a under the pains and penalties erjury that the information provided above is true and correct ' `L Date: 2 V Si afore: � y Phone# �c6 `�� i 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#: int®rmation anct 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 produce&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 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 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:- The Commonwealth of Massachusetts DepartmQnt of Industrial Accidents Office of Investigations 644 W ashington Street Bostan,MA 02111 Tel. #617-727-4500 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 � - www.mass.gov/dia 1 ` �TFIE 1 V YY li vi LLLa JLL0 LLi1Jt1L5 Regulatory Services snu,sTssiJe. '' Thomas F.Geiler,Director . 9�plEc► `1��. Building Division Tom-Perry,Building Commissioner 200 Main Street, Hyamis,MA 02601 www.towA.barnstable.ma.us face: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement;removal, demolition,or construction of an addition'to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adjacent to \ such residence or building be done by registered contractors,with certain Exceptions,along w. other requirements. ��� Type of Work: U Y�/� ,�M tunated Cost o �o o Address of Work,. V�J'Y )1ft W1a✓ owner's Name: Date of Application I hereby certify that: Registratign is not required for the following reason(s); []Work excluded by law []Job Under$1,000 []Building not owner-occupied • []Owner pulling own permit Notice is hereby given that: OyMERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTYFUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner; (2,11—) IOU 11;A All/ Date COntr ctor Signature Registration No. OR Date Owner's Signature Q:wpfiles.fom�s:homeaffiday . Rev: 060606 •.4 t r .�, 'a�off' '�k'? Y I3f7#IRD; � $ ELDeN.G:REGLE,LATEt3�S C4�N:STR�C iO t SLFP>='R-V' R P�dumbe.v::.La' G4?'993 R� $ayt71(�y�tE: l� f�41 t9.57 Tr. 18t72 :��� S�_h�,L,�7i'1O'f�':s�. L�� � i'!Jrr„'•,i:+�.r�rr� IY�F1 Sl' u^f s ^f f ui'i`dia :Re u;1 ,on's au A$tA'm&.r'd s Bya rd;o.. . r HOME IfVIF OVE6111ENT CQ'RT.RA.CTCR y e Cacporation CENTRAL CAPE CQ, kS`fRU:C.��ONCQ. iNC. STEPHE N IDEVl,JN,' 261 StAQKTHCRNR Ct.Fc..'.. MARSTON.MLLS., MA 0264.8 Ueputy'Admiltistretor r Zd Wd90:20 LOW Sa 'upt ov2T OEV BOS: 'ON Xb-- NOIiondiSNOD -lb iUN99: WONJ • e A� Town•of Barnstable Regulatory Services RAMN iF Oe19er,DuecQor uildi�ag.Y3 vis on, . Tom Perry, )Building Commissioner 1V1ain Stzee4 HykU'Wid'ivlA:026QI ;t > Office: 508'862-4038 Fax: 508490-6230 Property Owner Must Complete and. Sign This Section If Using A Builder YaN Ownet of the subject property hereby authorize ��� _to act on my behalf,, in all matters relative to workauthoi izecl by-tbss'l it itng:per nit applicatim for: (Address of Job) ..� ignature of Owner Date Vb100 Print Name • u,., s "° a •. -=x.- t�` <�,, ,. Y ., Q:FORMS:O WNERPFRMM SIGN i UP KE - ONsuly MO o SUr 001 sn :- n aches State wldin Co e• The Massachusetts State Building Code (780 CAM includes provisions to ensure that houses and house additions meet energy efficiency standards. This supplemental .CONSUMER INFORMATION FORM is to be filed as part of the building permit application when a builder/contractor or homeowner, constructing/installing a house addition with very large percentage of glass to opaque wall, seeks to utilize a special energy conservation exemption option for "sunroom" additions to,an existing house (780 CMR Appendix J, Section J1.1.23.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom"of any size, configuration, orientation,form bf construction or percent glazing,but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a"sunroom"addition. The connection of "sunroom" structures to residential buildings may create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In the selection and construction/installation of"sunrooms", included below is a non-required, open-ended list of product and design considerations that .a homeowner may, wish to consider before actually constructing/installing a"sunroom".It is recommended that consumers carefully review these options with their designer, builder, or contractor, in order to minimize potential- energy consumption and/or house discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired are important considerations. PRODUCT AND DESIGN CONSIDERATIONS RELATED TO"SUNROOMS" • Solar Orientation and Natural Shading - • Type of Glazing • Insulating value • Solar heat gain • Frame materials • Glazing to frame sealing and gasketing materials/.seal durability and/or weather tightness of the sunroom • Adequate ventilation Operable windows and fans • Applied Shading Systems • Insulation level in floors,walls,and ceilings • Possible Sunroom isolation from the main house via a wall and/or door or slider • Heating and Cooling Methods: Efficiency,Zoning and Controls Homeowner Acknowledgment The Massachusetts State Building Code, Section J1.123.1,..requires that the actual property owner(not the owner's agent or representative)acknowledge receipt of this CONSUMER INFORMATION FORM prior to issu of a Building Permit for a project that includes "sunroom" additions to an existing residential bui ding In co 'th this requirement, the undersigned hereby acknowledges that she/he has read th inf ati n ' is o e concerning sunroom comfort and energy conservation. Signature of Actual Buildindbwiier Date wkl"tw-OK 0 Print Name Address of Permitted Project 90 20 Owner Address(if different than project location) Owner's telephone number . . § �2\. � , � � ��c�( . � � � \ ����� � / . _ ,, . . . { �� � ; � . � : ` S . . � � � . � � . \ `pF1NEfp�� The Town of Barnstable - BA MASS. Department of Health Safety and Environmental Services 7 MASS. 1639. �0 plEDMA+a Building Division 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection Location X&O-0 Permit Number 2-006 Owner /Ro q G & ✓ Builder / One notice to remain on job site,one notice on file in Building Department. The following items need correcting: / `7�w o L(J fYj )s 7-,o 2 AA u Sr d s - ��� 4217-0 /iV J-1i G a 7-1"O�f� . D Please call: 508-862- for re-inspection. Inspected by ✓Cu.� %c��i�L Date��l A sh©!<E To S jcs st floor Map 125 Lot /• �96 . Permit# g� Conservation ffice 4V . th floor C1,� �y- Date Issued Board of Health 3rd floor 5 _ n+E Engineering Dept. Ord floor House# °R � Planning Dept. (Ist floor/School Admin.Bldg.): _ MAW .. Definitive Plan Approved by Planning Board 19 A lica s roc sed 8:30-9:30 a.m.& 1:00-2:00 .m. f•� 1 `C/l��� �b ,i�l • Uv TOWN OF BARNSTABLE TITLE 5 Building Permit Application EN VI MENTAL CODE AND TOWN REGULA11ONS Project Street Address 4cz 1'kl N-T r 1l A-p -4-0 40 L®7 24 Village (� � Fire District ' >>T L-�z,(hvner uL e-Rwv- 77-02.vSr Address' /3S5 A-vv►4114 Sr C-07-0=7' Telephone +26- Permit Request: Alm/ S-46t!6 F " �-7 Zoning District Flood Plain Water Protection Lot Size 43%23 Alt Grandfathered Zoning Board of Appeals Authorization Recorded Current Use Proposed Use t+ Construction Type kuA9v A hY Eaistini!Information Dwelling Type: Single Familv Two family Multi*family Age of structure Basement type Historic House Finished Old King's Highway Unfinished Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Tyne and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information � o �Name . ✓T�le hone number ��� — a z /Address License# /1`Iome Im rovement Contractor# /Worker's Compensation # NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Project Cost S _ Fee SIGNA DATE f BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) BPERM T I #9821 FOR OFFICE USE ONLY 057. 117.T00 RESS 49 Whitmar Road �p '� VILLAGE Ceettr�t, MA 02635 R Ros Bisplinghoff N DATE OF INSPECTION: r '. FOUNDATION 6 , FRAME < INSULATION / !/ r VA2 _ FIREPLACE ELECTRICAL:, . ROUGH FINAL ;t PLUMBING: ROUGH FINAL " GAS: ROUGH `1 FINAL r ' FINAL BUILDING: DATE CLOSED OUT: t ' r ASSOCIATE PLAN NO. ' ' ```' g^'• ' ,' , r, - "L P4 i+ An TOWN OF BARNSTABLE Y PARCEL ID 057-117 T00 GEOBASE ID 35752 ADDRESS 49 WHITMAR ,ROAD PHONE (508)420-3085 t It mi�. �� i €i ZIP 02648- yxa- LOT PT 26 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CO i PERMIT 13340 DESCRIPTION SINGLE FAMILY DWELLING PERMIT TYPE BTCOO TITLE 'HEMP. OCCUPANCY PERMIT CONTRACTORS: Department of Health, Safety i ARCHITECTS: and Environmental Services i TOTAL FEES: THE BONS $.DO 7, CONSTRUCTION COSTS $.00 C r 756 CERTIFICATE OF OCCUPANC ; H!►RN3PABLE, MASS. OWNER LUCILLE CRAVE FARRINGTON T ST, 039. A ADDRESS 1355 MAIN STREET ED MA'S BUILDING �VISIO COTUIT MA BY DATE SS"'ORD 02/20/1996 EXPIRATION DATE DIVISION APMNALS FOR CERTIFICATE OF�OC�PUPANCY ! TO BE SIG BY EACH DI ISION HEAD UPON COMPLETION ' BUILDING: t DATE-4z COMMENTS t� tt DATE: T t;� �OMMEN S. - » ELECTRICAL: DATE•i 4- COMMENTS: GAS:���aQs" DATE: COMMENTS CONSERVATION: a SATE: COMMENTS: OKH: _DATE: k' COMMENTS: HISTORIC: t- DATE: COMMENTS: FIRE DEPT.: — DATE: ' COMMENTS: - I. - - OTHER: DATE: COMMENTS: TURN THIS IN TO THE BUILDING COMMISSIONER'AP&_R ALL SIGN-OFFS ARE COMPLETED.A CERTIFICATE OF OCCUPANCY WILL BE-ISSUED AT THAT TIME. 11.1 02'94 1;:02 V0177277122 CoIjUnanwPAL o/ MaWadzudelb `�epartnatl o�.�",:�wtriaL✓®eei�afs 600 lNaaknjtoa strwl dames J.Cam L7�fson, Mji i" 02f f 1 pbeff COmmissionet Workers' Compensation ftmnance Affidavit taera:edpamiaee► with a principal place of business at:24 - c�►isrmrzb� do hereby certify under the pains and penalties of perjury, that: () I am an mployer provid'mg workers' compensation coverage for my enipfoyees wo: this job. Insurance Company Policy Number () I am a sole proprietor and have no one working for me aWY capedty. I am a sole proprietor, general contractor or(Cmeowner �drde one) and have hire: contractors ilsced below who have the following workers' aon:pensadon policier. ;�o�r•.r q'�r1Z� PAurFo Stet �a� n1v•sr.r-. lUYZ � Contractor Insurance CompaIIY�od . , Contractor Insurance Company/Policy N �v �+g4..e je -574S:fty Contractor lnsuranoe Company/Policy N' O I am a homeowner performing ail the work myself. i und-M-ane�.0 copy of&tos=cmm wtU be fo.'vrarded to tre OMM of Invesdpdons of d%n OTA ror a nWM vff5nti°o end tfsat f: cove.Se as rcmired under Section 2SA of MGL 152 can lead m the irnpoaition of crko nai peeaitles one of a ON of up to S 1,SOC Yews, impt>:o:r..ant 'el!as civil penaides in the fom:of a STOP WORK ORDER and a Me of 5100.00 a dal►apinU me. S igned this , day of v � Gcenle permittee Building Department Ucensing Board Selectntens Office Health Department TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. . DATE •6'fG- JOB LOCATION 7 W•l Ga)v). Number Street address Section of town "HOMEOWNER" L u�i��pr C,p-,rev 1474--4E,;d-4 79.jSr Name Some phone . Work phone-- PRESENT MAILING ADDRESS 13 �►^�N �s; '' '- Co7v,T n44 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 such homeowners to engage an in- dividual-for hire who does not possess a license, provided that the owner acts as su ervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which .there is, or is intended to be, a one to six gamily 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 0fficii on a form acGQptable to the Building Official, that he/she shall be responsib: for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the Stz. Building Code -and other applicable codes, by-laws, 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. HOMEOWNER'S SIGNATURE 44��,-- APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, . Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q. Rules and Regulations for .licensing Construction Supervisors, Section 2.15) . This lack of awarenes often results in serious .problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would .with licensed Supervisor. The Home Owner actin as supervisor is ultimately responsible. �. To ensure that the Home Owner is 'fully aware of his/her responsibilities,. man communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. 47.79 LOT 26 DOES NOT LIE IN A FL-.,OD HAZAHO _'ONE J0.4 �047.28 EXIST. • I ';CATCH BASINS't v 47.53 ' l• 49.2 / N. 47.65 PROPOSED •' DRIVEWAY 1; T.M.EL 50.0 N 06 A�Zt•�' 49.3g'i O. i.•47.92 0 H � \ {9.J '•, 1500 GALLON TANK O SE��t 6'UTA.x 4�EFT/DEPTH LEACH PIT(TYP.) -� 7'1 nED - EXISTING •48.2 1LLA'� MATH 1.0'STORE ALL AROUND \ o �XX/ �. PAVEMENT. '. 10 iG 1d,� .49.4 S1 46.51 . . .�1 IN�OX B.M.B MAIL SO 0 TREE 49.1 100%RESERVE .... •IB j - •49.9 - 50.2 50.2 PROPOSED 1{'x 1!' DECK / .49.3 49.5 / DENOTES EXISTING SPOT ELEVATIONS(TYP.) . _ 43,923 9q.ft. .Ad . 100 48.7 48.4 .49.1 1E 5 ASSESSORS MAP OS .. . � �BLGfJ(_LOT�.C�m SHEETL OF Z . SITE PLAN OF LAND •48.41 IN 16.4 BARNSTABLE. MA. . - 1 DEPICTING THE PROPOSED DWELLING FOR _ TEPHEN' �P 37b hft o W11J.1R i LOT 26 WHITMAR ROAD. 37S lE9CR4-R SCALE: 1' 20'. DATE: 3/19/95 .. STEPHEN'J.DOYLE AND ASSOCIATES . .. _ .. - w '�. „`• 1,y4I 4$CARTERBURY LANE.FALMOUTH�HATCHIALlE;MA.025M . AJ� TMEPNONE: 50E/540-2631 THE EXISTING STRUCTURE IS SHOWN ON THE PLAN AS IT EMSTS ON T�HEI GROUND. DATE PROFESSIONAL LAND SURVEYOR Lg0 AO LOT 26 DOES NOT LIE IN A FLOOD HAZARD ZONE. Irt 6Ae �O vNDE zd c A L_ O - 43,923 sq.n. . .Ad A� �t m� `mod L N� +�'"""• PLOT PLAN OF LAND • S:EWn,r. IN n:r BARNSTABLE, MA. m {: FSy�,�,. DEPICTING THE EFL NC FOUNDATION e . .ISO nUYV:. GRAPHIC SCALE LOT 26 WHITMAR ROAD SCALE: 1' 20' DATE SETEMBER 2, 1995 Di�T) 9n)` 1 A DMU NO A860QATE! P ! f. \ RED CEdgR� SN...I $ L DE,rPL moLCC•Nf. ________ __.._ ..- -.__..___._ _- _ ��/��\�J/�\ - _ - ___ __ --- ___— _ QEU _GA ."DOw cRa _-_ /` ' ,___.-- —__ .. __.,.•. -MPce voaD dsts.t.a 30 LDI%¢ T4rM -__ I i_ - �� ____ _- — -- I_ T TI�1 _ I I .y-...�c._£Nf'- r•wOM$ � r _ L! L�Ilu I� .w -` � ess •rE FAkAi11C,TON RESrafA/CE LOi 16 WN/JMAQ RO COTV�T $'!S-95 REV G; r2c5Sr Fr-,—G—F CREc,•vF DES,ev AwG -.7 mp I D A m m - n I 1 t i 1 1 ' I I , i S i ? o p C 0 1 m +ia H �Z 8 n a IS G i " 8-l6-vs + .. BOSS [, BdRrN6NOFF CQEA'fivE OE�$/6.J 9�r0C�3TQ�cT/On/•«r✓�.E♦Q,� IYS RED CEDA2 CAP OVf4 REo LFOAQ SW GLES OVER CEOARBQEAr FQ - CoNrr.a 4 2xr0 0.'06E S"COx RooF SMFAT1146' .✓ - L x8 ROor= RAFTER$_16-O.C. . 10 I JS1a-ATrd.j (R-30,---_ ---- - I 2x4 Sru05 lb"O.C. 2x10 SEC-0 «ooR DECK y2"Con El 2x10 G.RST FLW4 pECK 19 2.6 P.T. S,,/ —� __—— ______ .�_J--� J`�"J_U V V!J.__J_'✓if ✓_Y'. -�`f���!!!.v-v'✓_!_�:l L` ji i _ 1 ID" Qo✓REO COdGFErE A..,o aJ - N, SECTrorJ Tr1Ru FOYER ,..E - ' x• Z 2'x::' \ MASTE4 64TV ! CIos L- ,x lo'x9' i� G't 7• !1 I 1� 6 .I OW i 1 i I 7 _ _ j 54 OW ! I i ' 19'x la' I I - • P. •4'. i OPSC ' +.. 1 - _ r _J 1 }q TV/VCR , + ` .. bbo Ij uARAGE ro . L igpAM17/DEN I, I I I O O a. r I r ! . a .': - - ' •. � � � � . r- V;_ }Y, 1 a_�. ice_ _� `� ... .4a - y� �C ---Q�2 + F,43T poop P - FARR+NG Tord RESIDE"CE R c 44 f .. LOT 16 IVN+TMAR QO COTVlT j •' SCALE i, _ QDS!L_g15PLIN6NniF•GtE.1TVE DEs+4N AEU LwyTRKTON•Cm•.T• 4 i i I N x p OD - .. L CA L K L A , � g r. �m • J � a 3 y a � ti r a g a #. - r n m T c y f PROJECT .TITLE i 1 eG� Srr y r ---— ---- E . r .��—._ ,r� '? r- �i. `y� r'r;t�y�}Yy` ,- .} r a � ' ! i ;• . 1= � : - , . kvt , PR ED R EPAR FO C6ntral Construdion company, n . r Steve Devlin President i / } I 2b]:Bladdhorn Drive•Marston Mil,MA 02648 508420-1340 . ------------------------ SCALE DATE t DWG O. I DESIGN � ;J _t i _ . CHECK DRAWN - , irli: Ain C1aFFT OF _ . . _.,. PROJECT TITLE ,, L F. 6 \' I r , E F F• PREPARED FOR �r I by - ! CSC I I . Central Construction Company, Ins Steve Devlin •President. 261 Blackthorn Drive•Marstons.Milh,MA 02648.508420-1340 SCALE /X1 F ��Y • !/�'__ DATE MG,NO. DESIGN CHECK DRAWN JOB NO SHEET OF PROJECT TITLE NOW ,r I sr zz G _ ---s— aS Yt" VSI+s` ' T7. ay CSce} � C s;J .. y i 1 :z / - —IWIC i—�•+'{ ��� - ;1 ��� �1!-.fly. @aJSr f-, C�CtST±;t 't- 1,440 o, T3 o so j< T� p•GJtsCJ PREPARED FOR : a _ Central Construction.-,Company, Inc. Steve DevUn President 261.Blackthorn Drive•Marston Milh,MA 02648.508420-1340 SCALE ` O DATE DWG NO. 4 � . . DESrGN CHECK . DRAWN JOB NO. SHEET' ;`OF f _ PROJECT JE TITLE DZ i S I ��;51'iJ�; �L-� iC-C1C�� - Sfl�^ . __ �I, ,y• G,c -;. , 9 PREPARED FOR cgs a �� c y �; 1 U4 � C �— L , - x otr Construction _ ®Ip ny, Ins Company, Steve Devlin President. 261 Blackthom Drk Marston Mills MA 02648.508-420-1346 _ ZZ �t - ! _ SCALE - — _. L DATE DWG NO. DESIGN CHECK / DRAWN - JOB NO. a SHEET. ' OF