The URL can be used to link to this page

Home My WebLink About0318 LINCOLN ROAD �r -- - - 7 I a---o� � . -.. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application �- Health Division Conservation Division Permit# a Tax Collector Date Issued _ Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Tow), Project Street Address Village' W Owner a Address lei lU , Telephone Permit Request �� `�� Mew �� , `�� Q - S 51�� !'��c1c,� d- , Square feet: 1 st floor:existing_ proposed 2nd floor:existing proposed Tot I Zoning District Flood Plain Groundwater Overlay Project Valuation \I_DZxb Construction Type Lot Size ,IM Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. czy Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) ` Age of Existing Structure Historic House: ❑Yes o On Old King's Hi vay: ❑des r' o Basement Type: U Full ❑Crawl ❑Walkout ❑Other ' Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:a 'sting new Half:existing ne Number of Bedrooms: ex g 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 Us� 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 i' FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED r j MAP/PARCEL NO. 'r ADDRESS VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL S P FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO.- e Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations y. 600 Washington Street Boston,MA 02111 c 3- www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/lndividual):,—)�� n ' Address: A, A *�3, City/State/Zip: ' , Phone#:. �re you an employer? Check the appropriate bog:ElI am a employer with 4. ❑ Type of project(required)I am a general contractor and I ❑New construction employees(full and/or part-time).*. have hired the'sub-contractors ❑ I am a sole proprietor or partner listed on the attached sheet.t 7. ®'Remodeling ship and have no employees These sub-Contractors have 8. ❑Demolition working for me in any capacity, workers' comp:insurance, g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required] officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per 14GL. 11,❑Plumbing repairs or additions . myself. [No workers' comp. c. 152, §1(4), andwehaveno 12.0 koof repairs' insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] . my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. rm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: licy#or Self-ins.Lie.#: Expiration Date: 6 Site Address: City/State/Zip; tach a copy of the workers' compensation policy declaration page(showing the-policy number and expiration date), ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . .e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of vestigations of the DIA for insurance coverage verification. :a1urre: hereby cer ' under the pains and enalties of perjury that the information provided above is true and correct e Date: one#: Official use only. Do.not write in this area,.to be completed by city or town of,ficial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.BuiIding Department 3. City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: -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 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, §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 the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cer4cate(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 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.airy 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 multiplepermit/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 bum 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 fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Mee of Investigations 600 Washington Street Bostoh,MA 02111 Tel, #617-727-494 ex 40.6 or 1-977-MASSAFE. Fax. 617-727-7749 Revised 5-26-05 w��.mass.gav�dia /ZHE 1pk, i V TT JLL V A J P CLA LL 7 L"L)iar Regulatory Services ,$ Thomas F.Geller,Director 9� 1639• ,�• Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town..bzrnstable.m2.us fi6e: 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 cerka exceptions,alongvsdth other requirements- , Estimated Cost Type of Work: > Address of Work:. p . Owner's Name: �� Date of Application _ I hereby.cer*that: Registration is not required for the following reason(s): 0Work excluded by law []Job Under$1,000 []Building not owner-occupied (Owner pulling own permit Notice is hereby given that: RED OVyNER.S•FULLING 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 Signature Registration No. • R Owner's Signature Date Q;wpfli es.forms:home�dxv ' Rev: 060606 Town of Barnstable P o Regulatory Services BAMSTABIM4 : Thomas F.Geiler,Director y MASS, .9. Building Division rf0 MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:\\ �( JOB LOCATION: numbe street village "HOMEOWNEIV': name ` ! home p o e# work phone# CURRENT MAILING ADDRESS: �, c ty/town 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. 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 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/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and .11puirements. Signature o 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(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act_as-supervisor." Many homeor s who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q; f_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:forn-mbomeexempt 96 O 17— O �i �i 60 i i f i Bathroom Drawing Scale: 1/4" = 1'-0" Project Designer: Brenda Anderson VAN-GO Project Contact: Owner Pro ect# wo# (508)771-7864 111222 N/A Date: Rev. Date: 12-03-06 N/A