HomeMy WebLinkAbout0031 SIMPSON AVENUE �arMou:l-Pc) CroOnd
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3'9 7 Parcel 6 0 1 Application# pW)610 11 Leo
Health Division 09''',c9 I
Conservation Division T Permit#
Tax Collector Date Issued L J (51
Treasurer Application Fee 4,
Planning Dept. Permit Fee , 1) S. 00
Date Definitive PI Approve• , 'tanning Board or. , / 03
Historic-OKH 0 : d�"''/Preservation/Hyannis
Project Street Address 3-I S t;"‘Qs o n) v e • CCCON\10C r Jh� e l'` 1
Village ,k R-Ns f-/�-rsl,C �1
Owner 12.-o L66 al i -C-6 k-rS A dress 31 5 r Pt Pc ua/ A Ur V/C.6,1-
Telephone 5'ti r- 740 -32.R Co b'li4.7 i",4 We-Sr Y tz� ✓it•L) f"id-� ' @ CP.13
Permit Request A Dip S G a ems iv (ci c-t 04ats I yc_.-
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
'Project Valuation . , o"To" Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family A Two Family ❑ Multi-Family(#units)
Age of Existing Structure 3"7 Historic House: ❑Yes ►-"No On Old King's Highway: ❑Yes gNo
Basement Type: ❑Full atCrawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing I new Half:existing l new
Number of Bedrooms: existing a new
Total Room Count(not including baths):existing 5— new First Floor Room Count 3
Heat Type and Fuel: 'biGas ❑Oil O Electric ❑Other
Central Air: ❑Yes CT-No Fireplaces: Existing New Existing wood/coal stove: igi,Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:ittexisting ❑new size `7a So F -Other: 7
0
ui N
k
Zoning Board of Appeals Authorization ❑ Appea # Recorded❑ - -.)
i _
Commercial ❑Yes ❑No If yes, site plan review# :]
c.)
Current Use Proposed Use
BUILDER INFORMATION, `G-0$l-7- co ® 1 cog 4-6
Name (56L F, (v 1E 2 l i0L(Sc-i-LiS Telephone Number(6 0 0 7'Qa -3 2-A.6 ei° fe 4
- Address 3 t $`tvti4.'S 0$^' Avc"j License#
44/L VA-19- "a, 6'2. 0 I ) Home Improvement Contractor#
•
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE (/24( CC DATE ii/11 d 7
s. •
FOR OFFICIAL USE ONLY
4
}
PERMIT NO.
DATE ISSUED
y ..
I. MAP/PARCEL NO.
•
'ADDRESS VILLAGE
OWNER
r 1
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE .I
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
i I
GAS: ROUGH FINAL
FINAL BUILDING
k
DATE CLOSED OUT
ASSOCIATION PLAN NO. •
f
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
_Ti = t Office of Investigations •
_win • • 600 Washington Street •
,�e�= Boston, MA 02111
_
.. �'�¢ www.mass.gov/dia
' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):V 0 baii.l • AL ben- .
Address: 7 I S / ere. ALAI' . ' .
-let-ILrwl0i4oOna-rS yl4�'L
t,.). uroo a2(o`7 3 .
g, City/State/Zip: f74-na S ra- - h A. e 24,0 I Phone.#:( 0 r) 7 90 -32--q
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 I 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. 7. ❑Remodeling
ship and have no employees These sub-contractors have 3. ❑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 10.0 Electrical repairs or additions
3.''I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
• insurance required.]t c. 152,§1(4),and we have no
q ] employees. [No workers' 13.v Other S�.mg:G.A/L�
comp.insurance required.] !,n 0a et-,
*My 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pain/ss.andpenalties of perjury that the information provided above is true and correct.
• L C&ii Date: Pfii'�°G /2 —2.a0 `7
Signature:/ — .
Phone#( 0k) 7 ° -;2 4 c
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_ttustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
•
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
- applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
•
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-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
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 Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-$77-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.govldia
•J.V T T J.+ la r...Os=.....'r..—......
/ TIE okti • •
"• • Regulatory Services
y ;�
Thomas R.Geller,Director. •
sAF�''�' Building Division •
•
kat::°9.
• Tom.Perry,Building Commissioner -
200 Main Street, Hyamsis,MA 02601 .
•
•
w w ww.tow ,barnstable,ma.us •
Fax; 508-790-6230
fice; 508-862-4038 .
•
Permit no. . ' . •
Date • •
AFFIDAVIT .
• HOME IMPROVEMENT CONTRACTOR LAW - .
SUPPLEMENT TO PERMIT APPLICATION .
MGL c, 142Arequsres that the"reconstruction,alterations,renovation,repair,modernization, conversion,
improvement;removal, demolition,or construction of an addition to any pre-existing owner-occupied -
bu1ding 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 with other
•
requirements. . •
_
fly SG/2LZ • Estimated Cost .b,��
Type of Work: �' •.- ` d 2-6-1 3
Address of Work:. 3 i 5/ a� v r t1s l R Ub•', •1't14-1.1 pPI S W• /4 0�`
Qyrner's Name: cp 4 wirppr
. •
L- U4L-11.t5
•
Date of App
lication: /1-1 a 7 -
I hereby certify that • . ,
Registration is hot required for the following reason(s): • •
❑Work excluded by law .
• [ Job Under$1,000 • • •
[]Building not owner-occupied 0
r2lOwner pulling ownpennit . .
Notice is hereby given that:
•
OWNERS p ;LING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
coNTRACTORS TO THE
FOR�ATIO PROGRAM OR UARANTYFUND UNDER AVEE HOME IMPROVEMENT WORK DO NOT 142A.
ACCESS TO'I'HE ARB
• SIGNED UNDER PENALTIES OF PERJURY '
I hereby apply for a permit as the agent of the owner; - •
•
Contractor Signature. Registration.N o•
Date
•
i201/oief"44----- OR
Date • Owner's Signature
Q;wpfu'es.forms,homeafndav .
gzv; 060606
•
RESIDENTIAL BUILDING PERMIT FEES •
APPLICATION FEE
•
New Buildings $100.00 •
Residential Addition . $50.00 ' • _
Alterations/Renovations $ 50.00
Building Peunit Amendment $25.00 •
.i.... ... ._-3 �.`4-v,A,.,E�Yh .. - r, s. � iia.�Y ✓� ...:y. _. .?nsi��.. � n A.o g+•k ?z.:�
FEE VALUE WO-RKSAFET
NEW LIVING SPACE
square feet x$96/sq.foot= x.0041= •
plus from below(if applicable) . •
•
ALTERATIONS/RENOYATIONS,OF EX[STING SPACE •
square feet x$64/.sq.foot= x.0041=
plus from below(if applicable) •
•
GARAGES(attached&detached) .
square feet x$32/sq.ft.= x,0041= .
• ACCESSORY STRUCTURE>120 sq.ft. - ' •
>120sf-500sf $35.00
>500 sf-750 sf 50.00 • • . •u SU ,-. Pe kce,C^,..,Sc26r4SrAiS
>750 sf- 1000 sf 75.00
• >1000 sf- 1500 sf • 100.00
>1500 sf-Same as new building permit:
square feet x$96/sq.foot= x.0041= •
STAND ALONE PERMITS
Open Porch i x S30.00=
•
(number) , •
•
Deck x$30.00= •
(number)
Fireplace/Chimney x$25.00=' •
(number) •
Inground Swimming Pool $60.00
•
Above Ground Swimming Pool $25,00
Relocation/Moving $150.00
(plus above if applicable)
Projoost Permit Fee
Rev:063004
Town of Barnstable
cF THE 1p� O
s�\"��„ Regulatory Services
t BARNSTABLE, : Thomas F.Geiler,Director
MASS.
9q,,,T fD 3� � • 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: el V O/ r'UI'GL ADO c " W.*kit
0 '13
JOB LOCATION: 31 Si 14(9soiV AULs' 15/41.IvS 114'14U='
number /� street village
"HOMEOWNER": 9.0 Ia -i-( L . AL.kncrz-rir
name home phone# work phone#
CURRENT AILING ADDRES 3 1 S t AiPco>J /4-l,C 1.✓•41/411 a-1 ocf rk/ MA G
t diti iv,AA- 62-613
city/* n 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 requirements and that he/she will comply with said procedures and
re irements.
Signature of Homeowner
•
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many 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.
Q:forms:homeexempt
)3irmottth Camp ground association, Jnc.
West -Yarmouth, L714.2 02673
•
December 4, 2006
M/M Robert E. Alberts
24 Evergreen Lane
Middlebury VT 05753
RE: Renovation
Dear Bob and Lois,
At their October 14, 2006 meeting,the Board of Directors of the Yarmouth Camp
Ground Association, Inc., approved your plans for renovation to your cottage#32,
located at 31 Simpson Avenue. This approval was contingent upon receiving letters from
each of your abutters expressing no objections to the renovation and less any foundation
work. Should foundation work be necessary,you must bring the plans back before the
board for reconsideration.
I have received all the necessary letters and therefore you may proceed with the plans as
submitted with the exception of anything pertaining to foundation work.
This work requires permits and it is the responsibility of you or your agent to obtain
proper ones from the Town of Barnstable. Additionally,all codes and rules must be
adhered to. Any debris resulting from the project is your responsibility and must be
removed from the grounds at your expense. You also must respect Standing Rule of the
YCGA, Section I, item 11, "no excavation or major construction or reconstruction shall
be started between July 1 and Labor Day"and"all excavation shall be filled and
foundations capped, and heavy construction equipment removed from the Camp Ground
before July 1."
Upon receipt of your building permit,you are required to"present a photo copy of the
permit to the clerk BEFORE beginning the project".
i !3
I am enclosing three signed copies of your approved plans and copies of this letter for
you,your agent and the town.
•
Established in.1863,as a place to conduct religious Camp%Meetings.
Reorganized 1946, as a Cottage community, cooperatively owned by the Cottage Owners.
P.
Good luck with the project and thank you for your patience while I struggled with
computer problems.
Very truly yours,
FOR THE DIRECTORS,
oid
(Mrs.)L. E. Barley, Clerk
LEB/db
Enc. 3
cc: pers.
corres.
renov.
YCGA Board of Directors October 4, 2006
Re: Renovation of 31 Simpson Ave.
Enclosed is a plan for renovating our cottage.
1. The rear deck will be replaced by a screened-in porch measuring 8' x 20'
2. The boiler and water heater may be relocated to a cellar and bulkhead in
one of two possible locations.
3. The original cottage floor will be raised approximately one foot to even it
with that of the "new" portion. (Possibly with crawl space below)
4. The original front porch (demolished years ago) will be recreated on a
smaller scale, approximately 5' deep x 8' wide, (like Calkin's)
5. The entrance and stoop will be replaced with one on the south side.
6. The siding on the original cottage will be replaced by vertical boards.
7. The entire roof will have new shingles and the cottage freshly painted.
9. There are several trees that should be removed. We will identify them the
next time we are on-cape, probably early November, and seek approval.
We need to sell our present home before beginning the project. It may be
possible to at least get a start February or March. Our neighbors are
submitting letters to you regarding their opinions about the project.
Thank you for your consideration.
Lois and Bob Alberts
26 Evergreen Lane
Middlebury, Vt. 05753
(802) 388-4010
enclosures: 4 copies of diagram and letter
/ , 3 4 �•te 7 0 /< )( 12�3 i� f s /6 '? /�' ig ( / °�� � �,� " �2 ah1 l 3 ,, -J `0 ::'7
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1_1Gi her 1 or a. toe(( r'eplacc o (bulkhead!)
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• erring Dept.Ord floor) Map 3 1477 Parcel 00 / 'ei
6.6.
- �aouse# 3/
a f4- 9 /7
`hoard of He (3rdfloor)(8:15 -9:30/1:00-4:30)
Conservation Office(4t floor)(8:30-9:30/1:00-2:00) -�
I Planning Dept.(1st floor/School Admin. Bldg.)
Definitive Plan • • raved Planning Board 19 IN:
n. ndeiing Dept. 3rd floor) Map 3 `j 7 Parcel 00/ J$.- Vermit# a.3S" 4
House# 3/ ate Issued ,
Board of HeaYif'i(3rd floor)(8:15 -9:30/1:00-4:30) `•• 025.o a
)Conservation Office(4thfloor)(8:30- 9:30/1:00-2:00) 6/J1-/'i?-_
...✓✓✓%%% PlanningDept.(1st floor/School Admin. Bldg.) SEPTIC SY - UST BE
P g) �sY?jSANC
INSTALLED . ,►``
Definitive Plan • s rovedp by Planning Boar 19 wl ,� �,.,� ;�
0,„„1,4 •
OF BARNSTABLE T®wN R�,P IONS
DE AND
Building Perm' pplication
Prol- t ddress JP/9✓L-?
Village
Owner Address
Telephone 79 �029 C
Permit Request aloe
First Floor square feet Second Floor square feet
Construction Type 2.
Estimated Project Cost $ 9,e2C9, az)
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
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
No. 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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review# -
Current Use Proposed Use
Builder Information
Name Telephone Number
Address License#
Home Improvement 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
SIGNATURE In-Yn• ATE 1 --Q
B I P T.D FO THE FOLLOWING REASON(S) //
FOR OFFICIAL USE ONLY
PERMIT NO. - 2 3 8L
,))/
DATE ISSUED
M4P/PARCEL NO. .,
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION •
c
•
FRAME • .
INSULATION '
FIREPLACE
I.LECTRICAL: ROUGH FINAL
-'PLUMBING: ''ROUGH r, FINAL
ti GAS: `JRDJGH 3 FINAL
•
FINAL BUILDINGS
C„+ to
k ru ply P
DATE CLOSED QVTI z4
ASSOCIATION NO .i
•
oFTME ra, _
s, The Town of I::arnstable
• BARNSTABLEI
•
9� 1659. Department of Health Safety and Environmental Services
1°PeoMo Building Division
367 Main Street,Hyannis MA 02601
•
Office: 508-790-6227 • Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
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 with other requirements. p
Type of Work: X/o1 i 16 0l Est.Cost Of%470 -d?)
Address of Work: /
44.4-et )12j4c7f--x-e-..--
Owner's Name
Date of Permit Application:
I hereby certify that:
Registration 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:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR
-/ 7 17 / . -
Date Owner's ame
- '�`�' • The Commonwealth ofAlarsachusctts
-•rcil --•=•1:=•
.- Department of Industrial ACCitle,:ts
t --II*- Office of Investigations
4.
••••\_,::.t.:.:_ r N_ • 600 ashin„
\ r ton Street
.-• ,
:;., '� Boston. Mass. 02111
Workers' Compensation Insurance Affidavit
i-I i an information: — r Pleise PRINT leni.ibly
•
name:
aix..e.
location' ...% J
city nhonc#
75?Gr —_3.:279/
XI am a h eowner performin` all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
contnanv name:
•
address:
city: nhnne#:
insurance en. policy#
0 I am a sole proprietor, general contractor, or homeowner(circle are) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
•
city: Shane 0:
insurance ro. policy 0
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... .__ ....._. _I.� iY.r._ .:►V-.r...J�:._a - - Il.-.- _- L•" - .-_ - L r:Y...Y.-.. .i.-
company' name:
address:
city: phone 0:
insurance co. noiicv 0
Attach additional sheet if necciiiii. =•.— 77 - -i --Ji• -•• _ .1• ice 4.•.—•%v:7}:•t,i...:- -�"'" _. '�
w:.w:'. _r `'�.:.�:Iiv�_.,,.a.+,- - r �,yis ....—.—.--� _ _..�,.,___�.:yi`e�.t._.ir•,w.�_:n.
Failure to secure coverage:ts required under Section 25A of 1M1GL 152 can lead to the imposition of criminal penalties of a line up to 51.500.00 andior
unc wears' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify a;der the pains and penalties of perjury that the inform�a-tlio• rovided above is true mi/d correct.
y
Signature � /^/G%eibizz- ( _ f�—Date ,/ // -7 7
Print name Phone#
..
' official use only do not write in this area to be completed by city or town official
city or town: permit license# f't13ui ding Department
Licensing Board L
rt ❑ check if immediate response is required Selectmen's Office t
• °11calth Department
contact person: phone#: fOther g,
i. .
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Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation forth(
employees. As quoted from the "law". 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 mo
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 tl
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 he
or on the `_rounds or building appurtenant thereto shall not because of such employment be deemed to be an employ(
MGL chapter 152 section 25 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. 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
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names. address and phone numbers as all affidavits 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 require
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns •
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom (
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ph
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned
the Department by mail or FAX unless other arrangements have been made. •
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questio
please do not hesitate to `give us a call.
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•
The Department's address. telephone and fax number:
The Commonwealth Of Massachusetts �,:...
Department of Industrial Accidents
Office of investigations•
600 Washington Street
• Boston, Ma. 02111
. fax #: (617) 727-7749 •
phone #: (617) 727-4900 ext. 406, 409 or 375
-Yarmouth Camp ground 2ssociation, Jnc.
9Lyanni.s, c ,2 02601
May 26,1997 /
Mr. &Mrs.Robert Alberts
22 Kent Road
Barnstable MA 02632
RE:4'X 12'addition to deck at cottage#32,located at 31 Simpson Avenue.
Dear Friends,
At their meeting last evening,the Board of Directors of the Yarmouth Camp Ground,Inc.,approved your
request to increase the size of your deck by an additional 4'X 12'section.
I have attached two copies of your approved plans along with this letter for your use in obtaining proper
permits from the town of Barnstable. All local building codes must be adhered to. It is your responsibility
to remove and dispose of all waste building materials and debris necessitated by the project. Just as a
reminder,"any EXTERNAL construction or reconstruction be completed by July 1 and no new
construction be started between July and August for the comfort of all members of the Association." This
is one of our standing rules and must be adhered to.
Good luck.
Very truly yours,
FOR THE DIRECTORS,
74}dy,
L. E.Barley,Clerk
LEB/db
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corns.
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Established in 1863,as a place to conducf religious Camp J'leetings.
99eorganized 1946,as a Cottage Community,cooperatively owned by the Cottage Owners.
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