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HomeMy WebLinkAbout0173 FAWCETT LANE �. Lk 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 a o rvI1 S ohnne 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, 3p:�- eCK O / 0) OV LOT 56 i o� -'00 00, 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. '� � �� ', ��� � � r� C C� .�.. ,, C � \vjA�wl w�� �� _ � � �� . - i 't I y - _ - - --. _ _- � I� 1 � I � � \ _ �� v ._ � _ � i i _ ,� PHONE CALL A.M. FOR DATE TIME P.M. M PHONEO=.;' OF RETURNED PHONE Yf]UR CALL,; AREA CODE - NUMBER EXTENSION ,:MESSAGE �` '� T/yy+ll PtEASECALt ' WILL CAtL �P ,4G !�`� #� AGAIN r AW TO /v i/ SEE YOU WANTS TO e�(s S IGNED IUVElSal" 48003 I z a � � � rn I cn 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. 1 � �` I o � � �. � � \ � � � � � � �`` � � � � y � � � � � � � I �. -�. � � I i ��. � e: 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 \0 � � ������,�' `� ,��'��.� -b�71ff. �``�(AGM-•-� Please call: 508-790-6227 for 1r'eeeinspection. Inspected by (� Date i _ i� i 9• e r („/ate �NTB �t.�Nalb I JO1� I i x �I I. .he ll A }� 1 Iii l/uyA� 7i0� G 1� v f o��3cP �sb�c /i y /✓ �- � �Xr� nd PLYweu� 7 L 1- fti5 Gv � J i w � fit t lip ,t r je Cowc.re IL F'4-,(w�-- ?ter Z-