HomeMy WebLinkAbout0417 FALMOUTH ROAD/RTE 28 / Ehgineering Dept.(3rd floor) Map Parcel ermit# ll0 9 9
House# Date Issued
e
Y�✓ L Fee ,Ps
LLED IN
WITHWIN REEEEF
TOWN OF BARNSTABLk
Building Permit Application
Project Street Address 17 'FA I M n Q4 2y A d
Village ��Vl!1 H wl i S
Owner -J cg r2e 1 _Rq u l A A CIA III /-Address 11/7 F f M 6014 2dA GP.
Telephone -7 75 - 03S q
Permit Request e S"i m 2 Ie— 1d6� y sib"
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ 1-0.6. (�
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure 19 S3 Historic House ❑Yes M'110- On Old King's Highway ❑Yes 2,1 O
Basement Type: fWfu'll ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing I/Z New Half: Existing I New
No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: p'Fas ❑Oil ❑Electric ❑Other
Central Air ❑Yes &flTo Fireplaces: Existing _I New Existing wood/coal stove ❑Yes 0<o
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
215(itiached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes M150 If yes, site plan review#
Current Use Res o de&I C P__ Proposed Use CQ e ki C-(---
Builder Information
Name (ne 72 p h 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 DA ( I
BUILDING PERMIT DEZA OR THE FOLLOWING REASON(S)
+` The Conttnottirealth of Afassacltusetts
ayi - ---��; :- Department of Industrial Accidents
A � j•'
Office 8118 SM92tfotts
M. 600 ►f'asltin,tun Street
Boston,Ala.u. 02111
Workers' Compensation Insurance Affidavit
�pplc�nf information• . !_'�. . • Please P12INT•leb�jy"�`_ _ .""!'�•"'.,"'"w ----•-- .-----
/iac I 1'A I/•� 0
I am a homeowner performing all work myself.
I am aass'ole proprietor and have no one working in any capacity
-.7A!7••'.._.r:w..+,Y'�-�+�.r.r '1ET".!I'As�rr'!!�7lFT..+..1w-.!TR�pr.• n -- ,,.wow+.�`w.w�...�w.,1 !�.!e�^,r'!.�1'+.�r�•.-r•=r
_ ...n-:.,__ y"'i:'I,l.••-Ws.:��rGN..:iir..�' -ir.��w
I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: _phone#:
insurance co. policy#
Tam a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comunnv name:
address:
city phone#•
insurance co. _ (►oiicv#
,' - • - - ,/c.i!:::.+,,,::?1�40'_,.�-r;••:'.T:R"'.��.:bT"'-__.. re••,•y-c�:�'-.�'S7`�f.f��w,`^,' r7n::.^`wa•;!-�rr-::a::n•+r_..";f!:!^?;';.e.�•.-_---:„
comyinv name:
address:
city: Phone#•
insurance co policy#
Attach additional sheet if necessary,• t +�' � �•�..rr�r.,.,.,;• _• _ _•{: .�• •�.•^`.„;__.,•;,�..' .r3f. _ i^'-*.Mwr•• .
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andiur
une years'imprisonment as well as civil penalties in the form of a STOP NVORK 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 D1A for coverage verification.
I tlo herebt•ccrtij'rntr! r pni,ts n rd pertn,ics o perjun•that die information provided above is true and correct
✓/ / � rk
Si_naturc Date Print name Phone# `7 7 S_—63 Sq
ofGcial usc�onh do not write in this area to be completed by city or town official
city or town: permitAicense# rilluilding Department
[]Licensing Hoard
[]check if immediate response is required C3Sciectmen's Office
C311calth Department
contact person: phone#• rlOther ,
iiY�Yr•Y
(revised;;")9 PJA)
t
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compeilsatlon for their
employees. As quoted from the "law", an etnpl(�ree is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An enrplt►ver is defined as an individual. partnership, association. corporation or other legal entity. or any two or more :
the forcgoing enLa�_cd 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 -
dwellin- house of another who employs persons to do maintenance , construction or repair work on such dwelling lfous
or on the `_rounds 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 commoum-ealth for anv
applicant Nvho 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 ha-,
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. Tile
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.
.. _ ... -777777
_ --k
City- or Tovi•ns
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. Pleas.
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
Tile 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. -
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
• �1}IE� a
The Town of Barnstable
De artment of Health Safety and Environmental Services
059.,��� p 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, long with other re irements.
� Est.Cost � 0o® do
Type of Work: r
Address of Work: 4 (� A M f) t7 1� QQ A� ►'1 VA r S
wner's Name ;Ee�e S- Y?
00 (A
Date of Permit Application: 0 7 — 94
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Oilding not owner-occupied
wner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME E"ROVEMENT 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
L r le:�
Date Owner's qiAeo
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE /*
�OB LOCATION [7 *FPC • ' .
'Number Street address Section of town
oMEowNER" �"e� 2e `� (a A M677—
Name Some phone Work phone
PRESENT MAILING ADDRESS of I ,4IX40
City t difn State Zip c,
The current exemption for "homeowners" was extended to include owner-occ:
dwellings of six units or less
dividual for hire Who does not possess aal licenser
ow such homeowners to engage an
acts as supervisor' provided that the owner
DEFINITION OF HOMEOWNER:
Person(sj who owns a parcel of land on which he/she resides or intends tc
side, on which there is, or is intended to be, a one to six family dwell'
attached or detached structures accessory to such use and/or farm structl
A person who constructs more than one home in a two-year period shall not
considered a homeowner. Such "homeowner"• shall submit to the Building 0
on a form acceptable to the Building Official, that he/she shall be resDc
for all such work performed under the building permit. . (Section 109.1.1)
The undersigned "homeowner" assumes ,responsibility for compliance with th
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 require-
and that he/she will comply .wi aid proc dures and requirements.
mt
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35,000 cubic feet, or larger, will be requir
to comply with State Building Code Section 127. 0, Construction Control.
0
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for w4cha bus.
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided tl
Home Owner engages a persons) for hire to do such work, that such Hon
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assr
the responsibilities of a supervisor , (see Appendix Q, Rules and Regula
' for .licensi.ng construction' Supervisors, Section 2.15) . This lack of a
often results in serious problems, particularly when the Home Owner hi
unlicensed, persons. In, this case our Board cannot proceed against the
inlicensed person as it{ would with licensed Supervisor. The Home Ovine
as supervisor is ultimately responsible. .._. .�•
To ensure that the Home ;Owner 'is fully aware of his/her responsibiliti
communities require, as part of the permit application, that the Home
certify that he/she understands the responsibilities of a supervisor.
. last -page of this issue 'is 'a form currently used by several towns. Yo,
care to amend and adopt such a form/certification for use in your comm7
i
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