HomeMy WebLinkAbout0436 BEARSE'S WAY � �
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0F1HE r Town of Barnstable *Permit#20 110131
Expires 6 montks from issue date
Regulatory Services Fee
• BAarvsrAst.E,
9cb 63� $ Thomas F. Geiler,Director`
'°len�wrs Building Division . n. �` .,E, :y e �.
.t�vf)
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.rria.us -r �VN 0 ➢1 �,��€
Office; 508-862-4038 Fax: 508-790 6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number —00-7
t
Property Address V36 &—A t.S t`\?(4Y r ��y oy)n)- '
Residential Value of work qeo Minimum fee of$35.00 for work under$6006.00
Owner's Name & Address L7c1,1 jG/�'�i, -Leyj�) 67S- SOU)} ►ram, /4rez—,, 6,ji icy , Mn- N-10
z} ontractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ 1 am a sole proprietor
2I 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(stripping old shingles) All construction debris'will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
e-side
#of doors
Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows J�
*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.
SIGNATURE:
Q:IWPHLESTORMSIbuilding permit fbrmslEXPRESS.doc
Revised 070110
i
J .Ji
XN The Commonwealth of Massachusetts
( I Department of Industrial Accidents
Office of Investigations
li Jr-'
W i /J1 600 Washington Street
Boston, Al- 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �Gr) /hlI tlel-%A�
Address:
City/State/Zip: &UA,4�- (444 OZA L 9 Phone #: 6)7'
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. g. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
uired.] officers have exercised their 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#l 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 their workers'comp.policy information.
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 unde the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: 6I>—6a'a
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#:
r
r
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 onto 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
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 permitilicense applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
Town of Barnstable
.
` Regulatory Services
�MA&q_ Thomas F. Geiler,Director
,
0 ►'�� Building Division
Tom Perry,Building Comrnissioner
200 Main Street,Hyannis, M-A 02601
www.town.barnstable.ma.us'
i
Office: 508-8624038 Fax: 508-790-6230
t
a .s
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Ownerof the subject.property .
hereby authorize to act on my behalf,
in all matters relative to work.authorized by this building permit application for.
(Address of job).
t �
Signature of Owner Date'
Print Name -
If Property Owner is applying for permit please complete. the
Homeowners License Exemption Form on the reverse side.
.v
Town of Barnstable
�ppTHE rp�y
o Regulatory Services
y �
Thomas F. Geiler,Director
NUSM
Building Division
ED Tom Perry, Building Commissioner
200 Main•Street, Hyannis,MA 02601
www-io wn.b arnsta bl e.ma.us
Office: 509-862-403 8 Fax: 508-790-6230
HOKEOV NER LICENSE EXEMPTION
Please Print
DATE: 3 J 13 1
JOB LOCA-nON: LA 6CGi, f-,—,j 7 4�17'S GA 6 o I-
/number street village
"HOMEOWNER": ►✓�VN
name Q, ( home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellin>s of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINMON OF HOMEOWNER
Persons)who owns a parcel of land on which halshe 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 constrgcts more than one home in a two-year period shall not be considered a bomeowner. Such
"homeowner"shall submit to the Building Of5cial on a form acceptable to the Budding Official, that be/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.be/she understmds the Town of Barnstable Building Department
T„in;mum inspection procedures and requirements and that he/she will comply with said procedures and
requirem
goer ' omeowncr
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 pernvt is required shall be exempt from the provisions
of this section.(Scctian 109.I.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for biro to do such
wor,that such Homeowner shall act as supervisor."
Many homeowner who use this exemption are unaware that they arc assuming the rcsponstbilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack ofawarmess 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 w ou)d with a licensed
Supervisor. The homeowner acting as Supervisor is u)timatc)y responsible.
To ensure that the homeowner is fully aware of his/hc7 responnbilitics,many communities require,as part of the permit application,
that the homeowner certify that hrlshe understands the respansibilitics 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 fornJcertification for use in your community.
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
MASS. Building Division
i639• �0
Tom Perry Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
COMPLAINT/INOUIRY REPORT
Date:
G Rec d by: /,t v T?GS
Complaint Name: 1 fZY1" Al Map/Parcel a �'
Location.
Address: y.3 06
Originator Name:
Street:
Village: State:
Zip:
Telephone:
Complaint Description-. Po e i'c e C4 c c c~0 (�, .� /T
FOR OFFICE USE ONLY
Inspector's Action/Comments Date: ZO Inspector:
P&G_�fv 6/0oS,6 -i- CowT1 c7 -o Oiv.v,1r/" To
• /� s/ S i�E G � , -r.��tG� h��` S�i to i i I�+..r'o ri L
Additional Info.Attached
q:forms:complaint I '
Barnstable Assessing Search Results Page 1 of 2
Home: Departments:Assessors Division: Property Assessment Search Results
436 BEARSES WAY
Owner.
DASILVA,JORGE C Property Sketch Legend
Map/Parcel/Parcel Extension
292 /007/ Q lu / 2
Mailing Address (G
k
DASILVA,JORGE C /J `y N f✓
�o �
436 BEARSES WAY .
HYANNIS, MA.02601
2004 Assessed Values:
Appraised Value Assessed Value
Building Value: $94,800 $94,800
Extra Features: $0 $0
Outbuildings: $0 $0
Land Value: $76,100 $76,100 Interactive Property Map: ap requires Plug in:
Totals:$ 170,900 $ 170,900 1 have visited the maps before
Show Me The Man '
April 2001 photos available
Sales History:
Owner: Sale Date Book/Page: Sale Price:
CLARK,LINDA J 6/30/2000 C158265 $90,000
DASILVA,JORGE C 8/28/2000 C158832 $ 135,000
JAMESON, ROBERT H C247860 $0
2004 Tax Information: Tax Rates: (per$1,000 of valuation)
Town Tax $ 1,129.65 Town Fire District Rates Other Rates
6.61 Barnstable 2.01 Land Bank 3%of Town Tax
Hyannis FD Tax $346.93 C.O.M.M. 1.10
Cotuit 1.52
Land Bank Tax $33.89 Hyannis 2.03
West Barnstable 1.36
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/A... 2/4/2004
`{ Barnstable Assessing Search Results Page 2 of 2
Total: $ 1,510.47 Due to rounding differences these values may vary
Land and Building Information
Land Building
Lot Size(Acres) 0.21 Year Built 1945
Appraised Value $76,100 Living Area 1440
Assessed Value $76,100 Replacement Cost$ 124,690
Depreciation 24
Building Value 94,800
Construction Details
Style Family Duplex Interior Floors Vinyl/Asphalt
Model Residential Interior Walls Drywall
Grade Average Minus Heat Fuel Gas
Stories 1 Story Heat Type Hot Air
Exterior Walls Wood Shingle AC Type None
Roof Structure Gable/Hip Bedrooms 4 Bedrooms
Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms
Total Rooms 8 Rooms
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
Property Sketch Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
i
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/A.... 2/4/2004
oFIMME T� Town of Barnstable *Permit#
Expires 6 months from e date
• BARNSTABM . Regulatory Services Fee
"ASS
i639' Thomas F.Geiler,Director
10
A'FD1AP�A Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 ®PRESS �. _ 77 7
Office: 508-862-4038 `' - !i
Fax: 508-790-6230 - MAY ;j - 2005
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint N OF BARNSTAGLE
Map/parcel Number �� /
Property Address
Residential Value of Work 3 QdV-OD Minimu a of$25.00 for work under$6000.00
Owner's Name&Address .S. Ss/
s G✓� nos 11P-,g.,86)4J 3n�s
Contractor's Name �p/� Tel phone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
am a sole proprietor
NE-31
tave
m the Homeowner
Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to -tou/rl�rz �OnP
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U=Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home Im rovement Contractors License is required.
Signature
Q:Forms:expmtrg
Revise063004
f�
The Commonwealth of Massachusetts
Department of Industrial Accidents
=- Office of Investigations
600 Washington Street, .,rh Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit:Buildin lumbin lectrtcal Contractors
` s��. r.V
name: C'A eC-S S S-Vria
address C,0' O
ci ljyo:vh rac S state' 111/4 zit):, e.201 phone# ef3 167 s0-0 /
work site location fuH address): 36 O 64
I am a homeowner performing all work myself rojecttype: ❑New Construction(/Remodel
❑ I am a sole ro rietor and have no one working in any capacity. ❑Building Addition
'r:' '� :� .�."iet o >'_c?'..s, •.:.�_•.i"t'�x`a"::
❑ I am an employer providing workers' compensation for my employees working on this job.
company name: --
address:
city. phone M
i raneg ttsn co. 11; oli
11
❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers'compensation polices:
COMPRny name: -
address:
Phone M
insurance
co an name:
address;
city. phone#•
insurance co. oil #
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penaMes.of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 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 under thepains and pe aloes ofperjury that the information provided above is true and correct.
Signature Date
8n U pq
Print name ��r� S- 5;��� Phone# 77/' �3 6- 5V. 1
Luc
nly do not write in this area to be completed by city or town official
: permit/license# ❑Building Department
❑Licensing Board
immediate response is required ❑Selectmen's Office
❑Health Department
on: phone#; ❑Other
)
` ` Y
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
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 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 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 have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance 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 required to obtain a workers' compensation policy,please call the Department at the number listed below.
OR
City or Towns
Please be sure that the afdavit.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. The affidavits maybe returned to
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 questions,.
please do not hesitate to give us a call.
FK
MKQW
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,7`b Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617)727-4900 ext. 406
I
Town of Barnstable
SHE
Regulatory Services
CF Tp�
1.p Thomas F.Geiler,Director
Building Division
+ SARNSTABLE.
9 MAC �," Tom Perry,Building Commissioner
.q s63 ♦�
'•�E A 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Approved:
Fee:
Permit#:
HOME OCCUPATION REGISTRATION
Date: 12A - 03 0,
Name: n S Phone#: 5 c�
Address: 6 v Village:
Name of Business:
Type of Business: Map/Lot: � Z
INTENT: It is the 1 tent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the
activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual
alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,located
within that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there
is no outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular
matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess
of normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There is no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation. .
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person sh be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling
I,the undersi ed,ha read and agree with the above res ns f r my home occupation I am registering.
Applicant: / )-, Date:
H me oc Rev-/30/03
TO ALL NEW BUSINESS OWNERS
DATE:f23-o3-OS`
Fill in please:
APPLICANT'S YOUR NAM n
BUSINESS 'v YO R HOME ADDRESS: Q
TELEPHONE I. , Tele. hone NumFer Home
NAME OF NEW.BUSINESS TYPE OF BUSINESS L-1oQ1a11_a,
IS THIS A HOME OCCUPATIO ? YES O
Have you been given approv I from the building division? YE
ADDRESS OF BUSINESS a MAP/PARCEL NUMBER
When starting a new business there are several thingsjyoo m t do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is.intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed
below, you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall). You.MUST go to the following office to make sure you
have all the required permits and.licenses..
GO TO 200 Main St. - (corner of Yarmouth*Rd. & ain Street) and you will find the following offices:
1. BUILDING COM S ION 'S OThis individual has ee nfor d of arequi ements that pertain to this type of business.
j K riz Signature**
COMMENTS: 41
2. BOARD OF HEALTH
This.individual has been informed of the permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
3. CONSUMER AFF IRS [LICENSING AUTHORITY)
This individual ha en infor oft licensipg requirements that pertain to this type of business.
Authorize Signa ure*
COMMENTS:
Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L.
-it does not give you permission to operate-you must get that through completion of the processes from the various departments involved.
**SIGNIFIES APPRO VAL FORA BUS/MESS CERT/F/CATEONL Y.
i
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �a` Parcel Permit# O
Health Division V *L J J Date Issued _
Conservation Division Application Fee
Tax Collector_ Permit Fee °
Treasurer T.0 C r STD 25 raUS,'a
Planning Dept. t'"Z AUED IN coMpUANCS
g
`�TF;T�TL>E
Date Definitive Plan Approved by Planning Board C� IM Ta 5CODE AND
Historic-OKH Preservation/Hyannis
T01tA 'a REGUL ?-IONS
Project Street Addr
Village
Owner J (,,e- e D,4f Address �i6
Telephone 3 — .9 q� . zic✓�l�
Permit Request &-
LR / Lf'! k
C � d
� DA17" D //"o Vim'
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 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
BUILDER INFORMATION
Name `1�i �L�,f/,(/ Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
4 +
PERMIT NO.
}' DATE ISSUED -
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME f�to D 0, /t (�
INSULATION !I U
T ,
d FIREPLACE
ELECTRICAL: ROUGH FINAL.
PLUMBING: ROUGH FINAL
GAS: ROUGH ' '' s FINAL
FINAL BUILDING ° t
DATE CLOSED OUT {
ASSOCIATION PLAN NO.
Y
• � �° The Commonwealth of Massachusetts •. •
Department of Industrial•Aceidents'
`va
_ 0A16�if�li' �► '
66a Washington Street _
Boston,Mass. 02111 w
Workers'..Coin ensation.xnsnrance Affidavit-General Businesses
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dress: 150 ,Z 3 7
l " hone# �/
state:" _ . . _.
work site locatical full address :"
[] []RestaurantBai/Eating Esfablishment
I am B
•a sole proprietor and have no one ' psi.. .. Tree: Retail
ROeta��ElSales('including Real Estate,Autos etc.)'
worling in any capacity.
I am an em to er with etn"1 ees(full& art time Other111, ..;W.•�%1%/1%//
/U/%/%%/////%/%%%/�1,1116%%i %% ///%/////%/////////// %///%/////%/%�/////�%/%///Arkin on this job.. .
I arri.an employer providing vtorkers compensation for my em�l y _ g .•'
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fiisu'r�iice eb:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a Tine up to$1,500.00 and/or
one years'imprisonment as well as ctvil penalties in the fdrm of a STOP WORK OILDER and a fine of$100.00 a day against me. I understand that«
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under he pains and penalt' f 'ury that the information provided above is fiue nd a�Iec4
Date ?l
Signature L Phone#
Print name�� �t✓
official use only do not write in this area to be completed by city or town ofi-iciai
permittlicense# ❑Building Department
city or town: []Licensing Board
❑Selectmen's Office
[}check if immediate response is required []Health Department ,
phone#; ❑Other
contact person:
(revised Sept 2003)
Information and Instructions•
cha ter 152 section 25 re wires all loyers to provide:workers, compensation fvr .their.
eral Laws p q ,
4u etts Gen .
Massach f� another under contract
on m the service of anoth
is.defined as ev ers �'
employees: As quoted from the law', an employee �y p
of hire,' express or i nplied; oral or.written.
An employer•is deft ied as an individual,partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in djoint 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 theloccupant,bf the.dwelling house of
another who empj6YS ersoiis to do,mainten?nce, construction or repair work on such dwelling house 6r on the grounds or
building appurtenant thereto shall not because of such.eriiployment.be deemed to be a' employer. ,
MGL chapter 152 section 25 also-states 1hafev.ery. state-or local licensing-agency shall vrithhold the issuance dr renewal
of a license or pernnit to operate a business or to construct buildings in the. mmonwealth 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 unto
acceptable evidence of compliance with t�e insurance requirements of this chapter have been presented to the contracting .
authorityPP
A licants
Please%fa the workers'•eonVeusatiorr affidavit completely,by checking the box that applies to your situation.,Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits maybe 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 regardmg the'`law;or if you are
required 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 of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. i lease
be sure to fll;n the Pernritniccnsc number which will be used as a reference number. The.affidavits•may be.retmned to,
the Departmentby nia•or FAX unless othei'ariangements have been made.
The Office of Investigations would like to thank ybu in advance for you cooperation and should you have any questions,
Please do not-hesitate to give us a call.
The Department's address,!"elephoieand . ,
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Dino of Wesfiggens
600 Washington Street
' Boston,Ma. 02111
fax#: (617)727-7749
� f
LLD i.
COMMONWEALTH OF MASS CHUSETTS
COUNTY OF BARNSTABLE
1, JORGE C. DASILVA, if436-438 Bearses Way, Hyannis. . 02601, hereby appoint
EDMUND J. FLYNN, of 791 Pit hers Way, Hyannis, MA 02 60 1, r i true and lawful attorney in
fact (my"Attorney") for me and io my name, to do any and all thing,, necessary with respect of
the sale or management of proper y situated at 436-438 Bearses Wal , Hyannis, Massachusetts
(the"Premises"), hereby ratifying and affirming that which my Attoney shall lawfully do or: cause
to be done by virtue of the power herein conferred.
l
WITHOUT limiting the foregoing, the following powers are ,pecifically included: To
execute, deliver and acknowledge and make corrections and additio:aS to all leases, contracts,
agreements or deeds and other do uments necessary to effectuate tym transfer or management of
the Premises;to receive and disburse money; to execute all documems required by others in
connection with the premises and elated matters, including, but not "mited to, leases, evictions,
Settlement Statements, Affidavits regarding mechanics' liens, tenant!j and compliance with State p
and Federal Laws; and other affid wits required by a lender in connection with the issuance of title
insurance or compliance with the equirements of potential assignee iiof any mortgage.
t
It is expressly understood hat said "attorney" will be compw,isated for his efforts in the
sale/management of this property. l
� b
TIES Power of Attorney hall not be affected by my subseq°. nt disability or incapacity.
EXECUTED as a sealed i istrument this day of O.Jtober 2003. F
i
fif /
®RGE C. DASILVA
a
COMNV NWEALTH OF MASSACHUSE: TS
i
� f
Barnstable, ss I October 2003
Then personally appearo before me the above-named JORCTE C. DASILVA and
acknowledged the foregoing instrument to be his free act and deed as i:bresaid, before me.
I
i ery Johnson
My commission expirE:.: 11/06/03
(SEAL) f
i
g\daa il.,®V irnitpow-fly.+. ;
i
1
tioFt Town of Barnstable
Regulatory Services
sARxsz, EM ; Thomas F.Geiler,Director
MASS.
0 9. ..�A Building Division
rED AAP't
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
/ /��/ Please Print
DATE: / I V
JOB LOCATION: j/
number street village /� y
«HOMEOWNER": ����VN� y%�'/L� / //��r � ���� %�✓/
name home phone# work phone#
CURRENT MAILING ADDRESS: �C 3 3 7
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 requirements and that he/she will comply with said procedures and
requirements
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control. .
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many 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