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HomeMy WebLinkAbout0016 HARRINGTON WAY � ACTIVE Town of Barnstable Building Post' is Card So That it<is Visible From the_Streeta A , roved Plans:Must be<Retamed on.3J.ob andatliis Card Must be'Ke t .639 ` Posted UntilF�nal Inspection Haas BeenMade s ; Where a Certificate:of Occupancy-Is Required,such&Bu�ldmgshall Not,be`Occu,pied;=wntil,a�Final Inspection has been made Permit >.;,3`1., * -,....:�.,., �, _, .•. ? a ;:M.:;.>�:c »`,5.. s,:;r < »R -:.;& nY".+ :�a: ....:; .n.;; .. t,.,. ..,Y4 ,.'e: :;,.< Permit No. B-17-4417 Applicant Name: RETROFIT INSULATION, INC. Approvals c Date Issued: 01/02/2018 Current Use: Structure Permit Type: Building- Insulation=Residential Expiration Date: 07/02/2018 Foundation: Location: 16 HARRINGTON WAY,HYANNIS Map/Lot 288-049 Zoning District: RB Sheathing: NFf Owner on Record: SMALL, DAVID R& MARCY A Contractor;Name RETROFIT INSULATION, INC. Framing: 1 rr Contrator;License 160461 2 Address: 16 HARRINGTON WAY , P fi c s z . HYANNIS, MA 02601 EstV.ProJect Cost: $ 1,050.00 Chimney: �> Y Description: rization �Weathe 3 . Perms F e: P t .e �, � � $85.00 y Insulation: Project Review Req: � Fee Paid' $85.00 Date 1/2/2018 Final: r r y — Plumbing/Gas YR Y "+ �w 5 f r�' tiLL ii Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work aut ton d by This permit is commenced within six month after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents foK. ich this permit has been granted. All construction,alterations and changes of use of any building and structure shall be incompliance with the local zomrig bylawsand codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or�road and shall be maintained open for public inspect on for the entire duration of the work until the completion of the same. ,' Electrical � ' The Certificate of Occupancy will not be issued until all applicable signatures by the�Building and Fire Officials are provid n f ed oh s permit. Service: Minimum of Five Call Inspections Required for All Construction Work:' Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected atthe throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 7Conservation TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION o f�':`� v fi r" ,r RN TABLE Parcel T�s ApplicationDivisionDate Issued Division Application Fee Planning Dept, - ..,..r y Permit Fee Date Definitive Plan Approved by Planning Board - Historic - OKH _ Preservation/ Hyannis Project Street Address (to 21z�t u wm� tit r-J, J ' Village Owner M P"r G_, Sven c1 1 Address-1 Go A Telephone ��-� "7-7 Permit Request At r Z CO/VN M Z r &C4 ry Z)W 1-J f—A^Ak Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o- W Construction Type 1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Lk"" 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Sc? l` �L. / r �l. Telephone Number���'� Address -Q� I��r l S� License Ic,-0A, y ?? / Home Improvement Contractor# L Email IMAM orker's Compensation # ALL ANSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 0,k DATE l 1 k. FOR OFFICIAL USE ONLY APPLICATION # I DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts _ Department of Industrial Accidents - I Congress Street, Suite 100 vZi- XV Boston,MA 02114-2017 wwwmass.gov/didorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . TO BE FILED WITH THE PERMITTING AUTHORITY. i AApnlicant Information Please Print Legiblv" Name(Business/Organization/Individual):RetroFit Insulation Address:PO Box 105 City/State/Zip:Seekonk, MA 02771 Phone#:508-989-6436 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 1 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.a I am a homeowner doing all work myself:[No workers'comp.insurance required.]t 9. El Demolition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.E]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. '13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14.[E]OtherWeatherization 6.❑We are a corporation and its of6 cers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any 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. $Contractors 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:STAR Ins. Policy#or Self-ins.Lic.#:V9WC802160 j Expiration Date:8-2-18 Job Site Address: 16 Harrington Way City/State/Zip:Hyannis, MA 02601 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as-required under MGL c. 1.52, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the p and penalties of perjury that the information provided above is true and correct. . Signature: Date: 12/20/17 Phone#:508-989-6436 Official use only. Do not write i is 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#: 12/20/2017 7154-other-9.3eb95dae108129324a4.jpc (960x1230) , t. j y / a https://ng-ma.energysavvy.com/media/task_dsta/7154-other-98eb95dae138129324a4.jpg 1/1 . �, . :, . . , � * ' s : ra ' 5s € F z 5 ,v 4 \ 3 'x d Y § y l i c . v v t' t c t; I. '(vthe x to Am a �i r ,� x ` ,� a ikT�ai a.:i ` t w,. y t S h t '�' �(VY ' e( 3 Y S 3 3?5" rl..: ;l R, T � �� limp pi:: Yh i r! ty ~ � .:. .. t. J : .... F 3A ,�04wtno�""O"140—n----�---Wn�a��..W--U"- - -WAS I 9 1p wIR a % r,: r i 3 �„ e< Y r ;t rx a .a� .r h a } s xT :; z ;�r t ^r ° e r 4 r , A. fI'll K .fk 1�11 ` § a S W a 0 S i x 24 f Y F2 q ^. # t. y Y ,g y h Vi :+? y %t $ F. �3 i 1­11— a. t_111.7'r 4 Y ' X f •:, : y Y to , � sir 3 a a t: �. x.r,. - -><.x s'} .' r 5 QA en ti h '� 1 4 s P 2 s� K `1. i ` °�' 11f .x 1sa 7 s. r 7Y a € 5 r. a :tea a '3 Do WI&M �h ::.,i p } 9, a x l 8 i i � � � a c y t W 2 +v R 2 3'S i L t k ;�7 .S i fi A .iit F;< > y -„ e: 1 ,� \ ..:.�.: n v r g a , "> cz. 'F, -ynWAQjQT �`4' �` 2 ra ;n '7 a1. "x x �a ., #aa*, is s xVOW ,�', i a ,� S Yr 4 t - WITY 3 u a AMAMI RIM WOR Cow 01 low YFUMS HM > T a , 1 I _ , D r , UWE 1, y to oasis QW�� 4" 3 •1J�y�"+"` giIN lot i t�. t \ C � z ...... ........r .. ., ::: 5 ':'�:s ..:.: .. ::,i, ..•;: ._ Y,.... 5,u�tt�-, .:.w:� \ E ,fir.""`• 'S `Fx how r.iJ. s 5 , ?l R i y� A �vke Y Y ty " a { 'c 2 $i. �K MET : F' 8G OWN 'A AMC WN munmn- too ` a , 1 ti x r x r t \ is ter. f ` RETRINS-01 DCARVALHO ACORi3` CERTIFICATE OF LIABILITY INSURANCE DATE(MMloolyryY) 0712712017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LICenSe#1780$62 NAMEACT Diane Carvaiho HUB International New England 222 Milliken Boulevard (AICi o,Ext►: (AIC,No): Fall River,MA 02721 n oR'E .diane.carvalho@hubinternational.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Selective insurance Company of South Carolina 19259 INSURED - INSURER B:National Liabili &Fire Insurance Company 20052 RetroFit Insulation,Inc. INSURER C: PO BOX 105 INSURER D: Seekonk,MA 02771 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSR TYPE OF INSURANCE INSD WVD SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX OCCUR ( ( S 2187653 08/15/2017 08/15/2018 DAMAGE TO RENTED nce S 100,000 I MED EXP(Any oneperson) S 0,000 I - PERSONAL&ADV INJURY $ 1,000,000 - 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE S 2,000,000 POLICY ima El LOC PRODUCTS-COMP/OP AGG S OTHER: COMBINED SINGLE LIMIT S 1,000,000 E A AUTOMOBILE LIABILITY - ANY AUTO A 9100182 08111/2017 08/11/2018 BODILY INJURY Perperson) $ OWNED SCHEDULED I AUTOS ONLY XAUTOS i I BODILY INJURY Per accident S A Padet AMAGE $A ( err X UTOS ONLY SO NLD r � S A X I UMBRELLA LIAB X OCCUR ! EACH OCCURRENCE S 1,000,000 ExcEssLUA6 CLAIMS-MADE S 2187653 108/15/2017 08/15/2018 1,000,000 AGGREGATE S DED A RETENTIONS I $ B WORKERS COMPENSATION SER T OTH- AND EMPLOYERS'LIABILITY YIN, I 9WC802160 08/02/2017 0810212018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEN/A E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? Mandatory in NH) L i I E.L.DISEASE-EA EMPLOYE $ 1,000,000 if yes,describe under I 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S ' I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road 02451 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 13 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel C4 q . Permit# 0 3� 7�E Health Division 16)1Y � Date Issued Conservation Division a 6 1 ! Fee Ate, C)o- Tax Collector A •4.�.. '� f � SEP77C SYSTEM MUST E INSTALLED IN COMPLIANCE Treasurer WITH TITLE 5 Planning Dept. t ENVIRONMENTAL CODE ArlD TOWN REGULAR Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Stre etAddress �, W Village Owner 'fi. �,► h�" Address lO r Telephone Permit Request �� / 6,/v, —�y_oc— Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation svG Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ;L Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes `No On Old King's Highway: ❑Yes Basement Type: 5d-Eull ❑Crawl , ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Numbe,. of Bedrooms: existing -3 new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other ventral 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 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �r �V FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ' F ADDRESS _ VILLAGE —' OWNER—, DATE OF INSPECTION:: FOUNDATION , FRAME INSULATION FIREPLACE ELECTRICAL: 'ROUGLL FINAL PLUMBING: ROUGH FINAL ' s GAS: ROUGH FINAL 1 FINAL BUILDING a d EiiJ i DATE CLOSED OUT ASSOCIATION PLAN NO. � e ff l , FF7j � AB/�I'MalY S,41111 CGS BAlyeU./lD/rYC�SJ /S lOGASrllaYOrY AiYO DOES CONFD,pW TO TiS'f IOCAT/OrY,�FDU/,Pf�>1fiYTS OF T//f �OrY/rYC d1=ZXWI OF t//f TOIi�iY/C/l/' OF HYA NN/S A, EFFECT f/T//f,P 1yaW ae AT /f OF COiY- Sj,PUCl/Oil', AIW DOES NOT l/f /iY A SPEC/.4l FLOOD 114Z,4APD IOiYf AS DETf,P 11tZ,,D .� FfD"'PAI fill CfiYCy iY Gfy a OF APE STf,PED !A � v�� c G� V � o W ATLEY "' o.24397 o T///.S plA/Y S//OlYS A�p,P` if 9U/!D/rYC lOC.9l/OrYS A1YD S//DUID iYOl Bf�fD FO,P P,PDp- frlf' l/iYf DfF/iY/l/OrY NOTE:Subject to a easement, taking doc.no.78,437 doc.no.137, 701. 105015 LOT 2 o LOTI ° 6 LOT 3 � o 17'. 105.00 N' HA RRI TON WA Y P/01 P/Gn of Land in HYANNIS prepared for ABINGTON SAVINGS BANK % "=30' ✓UL Y. 2/, /.988 fy 4,rzz; CO !/YC IAiYD S//PyFyOPS E fiYC/rYEEPS 70D BKWa,(V ST,PffT 'a .BASS s F THE The Town of Barnstable • anxivsTnaM • T1� MASS. ��$ Regulatory Services 0319. ArEo M,r A Thomas F. Geiler, Director Building Division Elbert UlshoeMr, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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. C Type of Work: i'XI Estimated Cost_ Address of Work: 4o ( ' " Owner's Name: 1, aE 4 Date of Application: 10 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 O9wner 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. Date wner' Name q:forms:Affidav __=' "'— The Commonwealth of Massachusetts � � Department of Industrial Accidents .�� '_- ,d -- 3 Office ot/aYest/989019s -_-` y 600 Washington Street Boston,Mass. 02111 Workers' Co m ensation Insurance Affidavit name: ft) CA� �rr-L-a 1 location: city In 6 '� dC� hone# �L am homeowner performing all work myself. ❑ I am a sole r rieior and have no one worldzg in anv acity ❑ I am an employer providing workers' compensation for my employees working on this job ... comaanv name. address :......::. .:....... citw aae#. ' . ff :.:. :.;:.;: Itsurance co. olicv# ❑ 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: :::. ... :..:..::::..::.:::::::::::::::::::. • ..........::.......... :::::..:. .. address. ....................:...:.:...:.:..,....,.,..:::...,,... ::...:.:.:.... .:.. ....... ................. .....:.:.:.:.;.::::.:.::.:.._::::..... :....::..... .............:..:....... ::.......:::::.: ........ :..........................:..:.:.......:...... ...... :................................................................................................................................... city T.. ........................................................ ......................... .........................................................: .... vim.,.. :......... :....:- .....................: . .... ..............................................-....... .........Lyn:•:::::::.�.�.�.�::�.�::: ':::.. .................................................................. ....... ...... ..........:::::...................................................,-::•:i•:�i::::::.y.............................. ... ................................................................, hanrance•caa•. ,.::,......., ..... :.:'. -..::::..;,:.::.:.y..;'<.;;•:.�:::;.:.::�::..;:. o�icv# i anv names clty� phone r. ON: I lvllllllllllllelllv,MEMO nsnrant:e:�co:: Fai>nse to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of trinninal penalties of a fine up to si w.0o and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 3100.00 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 here y certi under the pains and enalties of p ury that the information provided above is tru Date e•and correct Signature Print name Phone# official we only do not write in this area to be completed by city or town offl ial city or town: permit/license# ❑Building Deparw=t ❑Licensing Board ❑check ifimmedlate response is required ❑Selectmen's Ofnce ❑H rt ealth Depament contact person: phone#; . ❑Other (revved 9/95 PIA) 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 license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has of a P ce with the insurance coverage required. Additionally,neither the not produced acceptable evidence of compliance g 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 checidng the box that applies to your situation and `supplying company names,address and phone manbers along with a certificate of insurance as all affidavits maybe submitted to the Department of Industrial Accidents for confianadon 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 pemut 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. 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 pcii ce se number which will be used as a reference number. The affidavits may be rertiaR 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. The Department's address,telephone and fax number. . The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Inuestigauens 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 The Town of Barnstable &uwsreata:. • y 94, MAS& �0�' Regulatory Services 1659.. Thomas F. Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION // 11 Please Print DATE: (9�) tr,_ �I 4 JOB LOCATION: G to `ten number street vii ae W "HOMEONER":A�OASY&� t�b$ is-6 `G�` b name 1- home phone# work phone# CURRENT MAILING ADDRESS: �O rl YL9` w l,. 0 M4 e)-G a �-Jyltown 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 beconsidered 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 dures and re re nts. Signature of Ho eo ner 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 Licensing of construction Supervisors);provided that if the homeowner engages a provisions of this section(Section 109.1.1 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:EXEMPTN I