HomeMy WebLinkAbout0017 KELLEY ROAD Cl,
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��oFT► t � 'Town of Barnstable Permit#
O Expires 6 months from issu aye
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' Regulatory Services Fee
lARNSTS.
�� 1 ���$ Thomas F. Geiler,Director659.
�rFD�y l
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street; Hyannis,MA 02601
-,vww.town.barnstable,ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESDDENTIAL-ONLY -
Not Valid without Red X-Press Imprint
Map/parcel Number c; 7
Property Address f-7 lWe l 1?14 Nvu
[Residential Value of Work d,,500-01-ti Minimum.:fee of$25.00 for:work under$6000.00
Owner's Name& Address
Contractor's Name CS6 Telephone Number X- 6g A 3(cq"c1 Y9 G
Home Improvement Contractor License#(if applicable) /&gLlq 6
Construction Supervisor's License# (if applicable) 51— 7.3 9.5.6
❑Workman's Compensation Insurance V
� %
Che k one:
L l am a sole proprietor
❑ I am the Homeowner JUN 2 2 2010
❑ I have Worker's Compensation Insurance
"OWN OF BARNSTAB
LE
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. Q,1oing over existing layers of roof)
[�Re-side
# of doors
❑ Replacement Windows/doors/sliders:U-Value (maximum .44)"#of windows
r
*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.
01
SIGNATURE:
Q0,TFILES\FORMS\building permit forms\EXPRESS.doc
Revised 090809
The Commonwealth of Massachusetts
\ Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
�sy www:mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information Please Print LeEibly
Name (Business/Organization/Individual): ��
Address: 143 44-�_
City/State/Zip: Cen-6-yillt Imo QA, a;A Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
* have hired the sub-contractors.. .
e am a sole proprietor or partner-mployees(foil and/or part-tiirie). - -
listed on the attached sheet.
_./,I 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' ❑ Building addition
[No workers' comp. insurance comp':insurance.
S. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.]
3.❑ I a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions
right of exemption per
myself. No workers comp. 12.[+� Roof repairs
insurance..required.] t c. 152 §1(4), and vie have no
employees. [No workers' 13.( Other
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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and jab 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 MOL 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 STORWORK ORDER and a fine
of up to S250.00 a day against the violator. Be acvised 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 under thepains and penalties ofperjury that the information provided above is true and correct.
Signature r�lW- P"r. Date (4 41®
Phone#: sot S(,q_aqgb
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. d. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
In
formation and fn,structx®ES
Massachusetts General Laws chapter 152 requires all emP1 Yero provide
r their emp
inn thesserviocekof another Linder° °
anycontract of lhire .
Pursuant to this,statute, an err,ployee is defined as '.,.every person.
express or implied, oral or written
An einr /aver is defined as "an individual,partnership, association, corporation alives of a other weceased employeal entity, or any r, ootheore
P
of the foregoing engaged in a joint entelpnse,;anal including the legs representatives
receiver or trustee of an individual,'partnership, association or ols an er d who resides thgal enti eroein, or heloccupant of the
the
owner of a dwellhouse
ing house having not more than three spar
risth
n such
dwelling house of another who employs persons to do maintenance, cot because of such employmeniction or p air work °
t be deemed to bedaneelmpl ye'"
or on the grounds or building appurtenant thereto shall no
MGL chapter 152, §25C(6) also slates that "every s Late r to ocons licensing
truct buildings in the comhmonwealth issuance
for any r
renewal of a license or permit to operate a busine
applicant who has not produced acceptnble evide the of
omtnonwealth nor any ofiance with the nts politicalgsubdigvisioMs shall
Additionally,MGL chapter 152, §25C(7) states IN •
enter into any contract for the performance of public work until acceptable evidence of compliance with the msrrrance
requirements of this chapter have been presented to the contracting authority."
Applicants -
'Please fill ou
t.the workers' compensation affidavit completely, by checking the boxes that apply
to your
sit at on and, if
necessary,supply sub-contractors)name(s), addreof
sses)and.phone numbers)along w�
insurance, Limited Liability Companies (LLC)or Limited Liability Partsurancpes If an)LLC or LLP does have
her than the
members or partners, are not required to caT6 workers compensation m of
�m loyees a policy is required. Be advised that this affidavit may besubmitted t°the Department frdat The affidavitlshould
P
Accidents for confirmation of insurance coverage, Also be sure to sign
be returned to the city or[own that the application for the permit o law oreif is ei age equestrtquired to obtain not the D wo-kers't of
Industrial Accidents. Should you have any questions regarding theSelf-insured companies should enter their
compensation policy,please call the Department at the number listed belcm.
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and punted legibly. The Department contact yocaragarding the appl a space at thp- otantn
of the affidavit for you to fill out in the event the Office of Investigations h a rPfcTencc number. In addition, an p licani
Please be sure to fill in the,permit/licenss chum ali whit will
lgbvensyaars need only submit one affidavit indicating current
that must,submit multiple permiillicens pp __( Y
policy information (if necessary) and under"Job Site Addresses the
applicant
d bysho the caty orttown locations
provided to the °r
town).''A copy of the affidavit that has been officially stampOut cach
ant as roof that a valid affidavit is on-fiIc for future permits or licenses. Anew bfi ness or commerc al venture
applicant P
year. Where a home owner or citizen.is obtaining a license or permit not related to any
NOT required to compl
(i.e. a dog license or permit to burn leaves etc,) said person is ete 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 Indus tr]a] Accidents
Office of InYestigations
600 Washington Street
Boston, MA 02111
Tel.. 4.617-727-4900 ext 40.6 or 1-877-MASSAFE
Fax # 617-727-7749
' -- - -I J:- w'
1
Of Town of Barnstable
- a
Regulatory Services
uxwszAeiE Thomas F. Geiler, Director
9`b b 9 N\ Building Division
Tom ferry,Building Commissioner
200 Main Street;Hyannis,MA 02601
yyw-tiv.t own.b arnsta bl e.ma.us
Fax. 508-790-6230
Office: 508-862-4038
Pro
perty Owner Must
Complete and Sign This "Section
If using A Builder
I ,as Owner of the.subject property'
hereby authorize u
to act on mybehalf,
in all matters relative to Work authorized by this building permit application f or:
(Address of Job) .
�6119
Signature o Cr
Date
Print Name :
if Pro e Owner is applying for permit please complete the
rm on the reverse
Homeowners License Exemption Fo side.
Town of Barnstable
�P ofYr1F r�o
Regulatory Services
Thomas F. Geiler,Director
R&RNSTABLE, • -
rrAs� Building Division
s639• ��
a Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
w�v-w.t own.barnstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038 ,
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: village
number street
"HOMEOWNER": work phone tl
name home phone#1
CURRENT MAILING ADDRESS:
• 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 an
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/ 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(Sectiorr,109.1.1 -Liccnsing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that.thcy arc assurr ng the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often resuhs in serious problems,particularly
when the homeowner hires unlicensed persons. 1n this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner actiog m
as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many comunities'rcquire,as part of the permit application,
tands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
that the homeowner certify that he/she unders
several towns. You may care t amend and adopt such a form certification for use in your community.
n\umF1T_F.C\FnRMS\homccxcmpl.DOC
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Board of Bwldin Reulat
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Construction Sup
CS 92958
License y
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Rest tricted to 00
SHANE pAGHECO ,
143 HAYES RD '
CENTERVILLE, MA 02632
Expiration: 10/17I2011
Tr#: 4144,
('ummissiuner
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i License or registration valid for individul use only
i
before,the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 51.70
{� Boston,MA 02116
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Not valid without signature
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e
Assessor's office(1st Floor): (�o^ G , .
Assessor's map and lot number 1 OS TN E>o�`
Conservation
Board of Health(3rd floor): ; t • •
Sewage Permit number >i DASIM=
ya rua
Engineering Department(3rd floor): o 039.
House number �o esr
Definitive Plan Approved by Planning Board 19 -
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00,-2:00 P.M.only ,
TOWN OF BARNSTABLE
BUILDING .=(INSPECTOR
APPLICATION FOR PERMIT TO /` f�. �f//n.-dl C•�.
TYPE OF CONSTRUCTION c;0- 'I0-t-,
v
C1 gt: G 19—�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location
Proposed Use s �� �+r. r/}✓� /rr tad _�l�^-
Zoning District Fire District y A-1yV r s
Name of Owner J U u-�-� L® a-� Address 0.0 ox JL AA0-544r -c M t�
Name of Builder (2r- Fes✓ 1�`'a I-�- ' fa/ Address �'? al?i ^
Name of Architect Address
Number of Rooms Foundation_ 'v,2�e -Lo
Exterior Roofing
Floors ( / D ti ti Interior - /20(G" "1
Q
Heating -'ic •ems Plumbing .b Q_ A-
Fireplace A/ ,P- Approximate Cost - �, DDf?
Area _ V 0
-** p p
Diagram of Lot and Building with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable gardir g the above nstruction.
Name 2
Construction Supervisor's License �� /`/
Avwv? � /C) �r��
LOGAN, JANE
No 36019 Permit For REBUILD FIRE DAMAGED r
Single Family Dwelling
Location 17 Kelly Road
4 ` Hyannis '
! Owner 1 Jane L6gan
f .Type of*Construction Frame
Plot 'Lot
i Permit Granted July 12 ,:: _ 19 " 93
19
Date of Inspection / pa
Date Completed 19
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