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Home My WebLink About0296 LINCOLN ROAD a9� L,�Coi � Rd TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION i Map l/ Parcel CJ� Application # '70 r rC-0(0&0 Health Division Date Issued ( Conservation Division .Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 7 1(o' 71 Historic - OKH _ Preservation / Hyannis Project Street Address c ��o /�✓1�c1,�>✓�Z Village C;Z�4AII /S Owner / Z; A dress Telephone G/ �� !1 / Permit Request , i`'10V_YA1�✓� / FJ / Square feet: 1 st floor: existing proposed 2nd floor: existing _proposed Total new Zoning District Flood Plain-1 Groundwater Overlay Project Valuation X4 ad0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure L Historic House: ❑Yes cAAo On Old King's Highway: ❑Yes Lro Basement Type: Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 41 Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: _:3 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 14 Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑:new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: r--? Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes i, No If yes, site plan review# Current Used�2 Proposed Use ��L._ " APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Qa� � Telephone Number Address/ /- ✓� License # N//Y A Home Improvement Contractor# Worker's Compensation # N/Ar ALL CONSTRU EBR SULTI G FROM THI PROJECT WILL BE TAKEN TO SIGNA E DATE / { r r- FORjOFFICIAL USE ONLY ti APPLICATION# DATE ISSUED " MAP/PARCEL N0. ' ADDRESS i VILLAGE i OWNER DATE OF INSPECTION: FOUNDATION FRAME ' ` INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL , PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. �s The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations �C�!u 600 TVashington Street Boston, MA 02111 " c.Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Nam-c (Business/Organization/Individual): A-ddrFss C-i-- /State/Zt �swc_ y o Phone #: SIU� �� aj Are you an employer? Check the appropriate box: - Type of project(required): 1.0 I am a employer with 4, ❑ I am a general contractor and I ,6. ❑ New construction , employees (full and/or part-time).* have hired the sub-contractors ; 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7, }2emodeling ship and have no employees These sub-contractors have R. ODemolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its fi 10.❑Electrical repairs or additions required.] officers have exercised their �dl I am a homeowner doing all work right of exemption per MGL I I.[I Plumbing repairs or additions yself, [No workers' comp, c. 152, §1(4), and we have no 12: ] Roof repairs insurance required,]t employees. [No workers' comp, insurance required.] ]3,❑Other- *Any applicant that checks box#I 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. tContractors that check this boz must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below it the policy.and job site information. Insurance Company Name: Policy#or Self-ins, Lie. #: 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 MGL 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 STOP WORK ORDER and a fine of up to$250.00 a--day again tna the.v' Be advised that a copy of this statement may be forwarded to the Office of Inveatig ns ofthe DIA for ' urance cove ge verification. J o hereby certify and the ains and pen Ide, of perlitry that the information provided aboveIftrue(r d correct. �-i natu— Phone#:_ y, 1 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 4. Electrical Inspector 5. Plumbing Inspector 6, Other Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 ajoint 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, §25C(6)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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"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 have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking die boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have `y employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant . that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete 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 faxtnumber: 'P The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MAS.SAFE Fax # 617-727-7749 i Town of Barnstable �o?T ray Regulatory Services Thomas F, Geiler, Director t 6Q�. Building Division �� PrFD '�a Tom Perry, Building Commissioner r 200 Main.Street Hyannis,MA_02601 www.town.barnstable.ma.us Of5ce: 508,-862-4038 Fax: 508-790-6230 13011EOWKER LICENSE EXEMTTrON Please Print DATE;—.-= ' — OB"LOCAT70N: number j street village / IIQ1v[FAWNER' _r .. �2 cS�� "7�U� W, eS na e home phone# work phone tF CURR�ENT;MAILING-ADDRESS: ,23 3,6ck city/to state zip cod 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. DEFVTMON OF HOMEON ER . Persons)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 user and/or farm structures. A person who constrycts 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 th e Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) 1 The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. eTu'ndersu ed "ho wner"c 1cs that,he/she understands the Town of Barnstable Bui_'ding Department um inspc on procedures an requirements and that he/she will comply with said procedures and require-men t �Signitiuc Hom ~cr Approval of+� ilding Official ote: Three-family dwellings containing 35,000 cubic feet or larger will be required`o comply with the State Building Code Section TO Construction Control HOMEOWNER'S ExEma'TTON The Code states that: "Any homeowner performing work for which a building pernvt is requimd shall be exempt from the provisions Of this s0Ction.(SeCti0n 109.1.1 -Licensing of construction Supcn�isors);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 cxcrrrption arc unaware that they are assurning 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 bomcowna hires unlicensed persons. In this case,our Board cannol proceed against the unlicams 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 responnbiliti s,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Super-65M On the last page of this issue is e form currently used by several towns. You may care t amend and adopt such a fonn/ccrtification for use in your community. `HME r° ti Town of B a Tastable Regulatory Services � B.IRNSi'ASLE, Thomas F. Geiler,Director,: Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: S0,8-862--4038 Fay: 508-790-6230 Property Ow7-e Must Complete and Sign . his Section If Using A udder r'. as Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to work au by this builcUng permit application for- (Ad ss of rob). Signature of Owner Date e _ Print Name If Property Owner is applying for permit please complete e Homeowners License Exemption Form on die reverse side.. r� '--i-- '. "i—. '-- I i -_.�. _ I�--i i - �I I I �Y 1 r ,`r/ t �-• �.._j - Y _..� _: —$'aY''�..j --- -- i----I--.._ loki - ° 1--- -- I I I I - _.._. d A, .._ TF : - I t Ki I- : i I i _ }w ° Lw o . , I I I I I i I : i h : , t : I ( Al .. 115 I !� I i , 'I I i e I • I I 1 , n ' I I I I I � I I I I : I• � L. _i _.. �� I- vd.r _L_ _ I ._ � 1_ _. .._.J__._.. III I _.. - _ _ _ I I I. I I j � I j I I ••i� �I I .'.. -_._. _ _ .. � ... 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