HomeMy WebLinkAbout0173 FAWCETT LANE �.
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The Commonwealth of Afassachusca
Department of Industrial Accidents
_; Ol/fceollayesl/gat/ons
600 ►f asltittf;im Street
fir;�`; =�.:+ Bovon.Alas. 02111
�- Workers'Compensation Insurance.AMdavit
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t-1 am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
1 am an emplover providing workers' compensation for my employees working on this job.
enmpatn•name-
address!
c6tv• phone#-
insor�nce co J o1 is# -
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:
company nnme-
address•
coll, phone#s
insurance co peiicv#
I�:: .y.� ...-_ -_- �:_ - �..-.�..a.-n-r�-�s•r-r•rR!esr•+r.►�.s�r_., -- - ---- -- ,Pa!JrvS3!�'�r'S�.::!�'p:T.�!��,.�T»"-_•�!f'8'�'��7'=:"`:"r•#S
e�ram•name•
nddre•
city, phone#. -
insuranc�co policy# _
Atiaeh additional'sheet if tiee �:mow: '..r�s:" sit.w+ r'a.Y" —�.:.;:..mot►{•.. �a"_ '%.+ :L
'fnilurr to secure coverage as required under Section 25A of DILL 152 can lead to the imposition of criminal penalties of a fine up to SI.500.00 and/or
une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER nod a tine 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 herehr certif}•under the pat s and penalties of pelf ury that the information provided above is true and correct
Sianature ate
Print name A Ir'D " ' Pero is Yv Phone
o—&ial use only do not write in this area to be completed by city or town official
cis, or town: permit/lieense# nBuilding Department
Licensing Board `
check if immediate response is required OSeleetmea's Office
Dlteattb Department ;t
contact person:
phone#; rIOther
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 cnrplover is defined as an individual, partnership,association, corporation or other iIgal entity, or any two or more o;
the fore=oink engapcd 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 i'S2 section 25 also states that even,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 in 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 hav-
been presented to the contracting authority.
—"R..q`• _. -777. S !y•`'h..�.I"...1;;;, r'. f'f. .t.
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 required
to obtain a workers' compensation policy, please call the Department at the number listed below.
77
77
to •::.-• ;�'�•, '«�';"7xx+::
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. Please
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.
The Office of Investiaations 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.
r:a!!T�!�^•�': ... .. 77777.
The Department's address, telephone and fax number.
The Commonwealth Of Mass
achusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
— Boston,Ma. 02111
fax#: (617) 727-7749 '.
phone#: (617) 7274900 ext. 406, 409 or 375
f • . The Town of Barnstable
DUAL Department of Health Safety and Environmental Services
Building Division
367 Main Stn%1,Hyannis MA 02601
Off c� 308-790-6m Ralph Cmsscn
Fate 508-775-3344 Buddtag CAmmL
For office use only .
Permit no.
Date •
AFFIDAVIT
HOME MOROVENOT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation, moderazzanon,C°nvetsi°n,
intprvvaae:tt.. kd
=Mcr.-1, demolition. or consuac ion of an addition to any pm-c sdng owner �
building com2ining at least one but not more than four dwelling units or to SUM=u=which are adJaaat
to such residence or building be done by registered conuactors,with certain exQptions, along with other
Type of Work: VV t jd —t-ry E= Cost
Address of Work: ��� 11 �a'N-P
Oaner.Name:
Date of Permit Application:
I hereby certify that:
Registration is not required for the folIoming rrason(s):
Work colluded by law
Job under SI.000
_
uiIding not owner-ooaPied
=Owner puffing own permit
Notice is hereby given that:
OWNERS PULLING 7 EIR OWN PERMIT OR DEALING WI IS i7NREGI D CONTRACTORS
FOR APPLICABLE HOME WROVEMENT 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 Registzation Na.
OR '
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE .3 _ _ U
JOB LOCATION 7 3 L4 /IJ /`C1 ryJV rs
Number Street address Section of town
I .
"HOMEOWNER" A L
ame Home phone Work phone -
PRESENT MAILING ADDRESS 541-n 4 S j/�� `.
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 supervisor.
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 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 Stat
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
APPROVAL OF BUILDING OF CIAL
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.
LOT 57
1O0 00,
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LOT 56
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LOT 55
RES. ZONE. "RE" This MORTGAGE INSPECTION Plan is For FLOOD ZONE- "C"
Bank Use Only
TOWN: BARNSTABLE — _ _ — — - REGISTRY OWNER: HAGOP J HEROIAN do MARILYNNE J. HEROIAN
DEED REF: _CERT.-120513 — _ - -BUYER: REFINANCE — — — — _ - - - - -
DATE: 0gz101/98 — — _ — — — _ PLAN REF: _22825 P — — -SCALE:I"= 20___FT.
I HEREBY CERTIFY TO BANK AMEFLICA_FSB_________ Uf
Uf
�A
---------------------------THAT THE BUILDING YANKEE SURVEY
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS p ��u�. ��'
SHOWN AND THAT ITS POSITION DOES ---- CONFORM i ��s CONSULTANTS
'-W
s�=
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE , 40B INDUSTRY ROAD
TOWN OF --_BARNSTABLE_____________AND THAT �, �Cf � MARSTONS MILLS, MA. 02648
IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD �'
AREA AS SHOWN ON THE H.U.D. MAP DATED 8 19 85 _ � .fib FAX
420—5555
Co unit -Panel ,250001 0005 C � � � FAX 420-5553
_ ________ THIS PLAN NOT MADE FROM AN INSTRUMENT 18339 JDR
PAUL A. MERIT PLS SURVEY, NOT TO BE USED FOR FENCES, ETC.
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FOR DATE TIME P.M.
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PHONEO=.;'
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RETURNED
PHONE
Yf]UR CALL,;
AREA CODE - NUMBER EXTENSION
,:MESSAGE �` '� T/yy+ll PtEASECALt
' WILL CAtL
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WANTS TO
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IGNED IUVElSal" 48003
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Map �� Parcel Q J�ermit#
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) JY1'\-°I(. *W& Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) -,VA0V -N-\ d-2)
Engineering Dept.(3rd.floor) House# IKE
y Gj j STABLE
19
TOWN OF BARNSTABLE
Building Permit Application ,
Project tre t d r s , fa W e-C � lVe _ +>
Village ._ tihl t
Owner a Ici to Address �7 3 4 LA)
Telephone 1 '
Permit Request _��/,n {G Q, l��,L,t�i'✓
0
First Floor Da N& square feet
Second Floor square feet
Estimated Project Cost $ _ _ S,O oo
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ?
Zoning Board of A peals Authorization Recorded
Current Use 'tS Proposed Use
Construction Type \1.)yi b j) WD VT f,
Commercial Residential y
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure Basement Type: Finished
Historic House [VO Unfinished
Old King's Highway
Number of Baths Z No. of Bedrooms
Total Room Count(not including baths) First Floor i
Heat Type and Fuel ��� Central Air Fireplaces I
Garage: Detached Other Detached Structures: Pool
Attached Barn
None t/ Sheds
Other
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 =G&rIV I 12
�m
SIGNATURE DATE n I„
BUILDING PERMIT DENIED O HE FOLLOWING REASON(S)
r` gyp} FOR OFFICIAL USE ONLY
P ER MIT NO.
D ISSUED f
P/PARCEL NO.W
ADDRESS VILLAGE
OWNER s _
DATE OF INSPECTION:
FOUNDATION
FRAME ""'
INSULATION
FIREPLACE i
.ELECTRICAL: ROUGH FINAL
. F
PLUMBING:*'- ROUGH FINAL
GAS: `ROUGH FINAL
e
FINAL BUILDING ,
DATE CLOSED OUT ` !
ASSOCIATION PLAN NO.
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The Town of Barnstable
BARN Department of Health Safety and Environmental Services
$
Building Division
367 Main Street,Hyannis,MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice
Type of Inspection
Location ��' �C�� J`� LLj
Permit Number
Owner A Builder
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
���.: � "AL ` �Les >u o
'J A-b
Please call: 508-790-6227 forr((eeinspection.
Inspected by Vr`�
Date
TOWN OF BARNSTABLE
-BUILDIING PERIMIT
P R 'L ID 270 104 _�0311 A C!,.-.E I G11 U-12 1D 17749
ADDRESS 1703 KFAWC11-K-TT LANE PH 0 N"R
Hy'arin ia ZIP
BLOCK LOT SIZh,'
1)2A DEVELOPMENT D11,3TRICT 14Y
P E_Rlk I Ir �610 DESCRIPT."( 1i KITCHEN ENLARGEMENT
I
F_1;R M.T_T T Y'PF &_i'�EMGD T I'I'l-JE RESIDENTIAL ALT/CODIV
0 N f f 21 A(""i"0 R S PR.OPEF,110Y 1.';WNER Department of Health, Safety
A T?C.f-i and Environmental Services
TO'I'AL FERS $255 0 G)
BONID
0"0' STRUCTION, ;. STIS VISI
1_1 3 R`ESID 1-1 R1 V A T F P STABLF,
16 9.
0 W N E i I'ETROIAi11, HAGOP J
ADF)RE'SIS) 1;ziN12L1._j_ MARiLYNNE J
FAWC17= �,�'INE 1. 1_1 BUIL
f-I YALN N 1,I'D' MA BY
-1)A"flE. 1,, Fr, 9 6, ER RATION DATE
O.D..) _1 03/04/19, XP 11,
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS
PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS TH S CARD KEPT POSTED UNTIL FINAL INSPECTION
2.PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU_ PERMITS ARE REQUIRED FOR
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH-
3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS.
4.FINAL INSPECTION BEFORE OCCUPANCY
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
W,
/0
S- Ce c x0Vj;",0//
2 2 2
3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
2 BOARD OF HEALTH
OTHER: SITE PLAN REVIEW APPROVAL
it
WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS
THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE. TION.
NE r The Town of Barnstable
o�
BARNSTABLE. Department of Health Safety and Environmental Services
9 MASS. g
039. N0
�FOMP�� Building Division
367 Main Street,Hyannis, MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice
,s
Type of Inspection �1
Location N f�-U a `J G fJPermit Number ]
m
Owner �} ,.l . �� Builder
(j,-\ nP
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
de
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Please call: 508-790-6227 for 1r'eeeinspection.
Inspected by (�
Date
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