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Town of Barnstabl Building
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Post This Card SoThat it is Visible;From the Street Approved Plans Must be Retained onlob and,,this Card Must be Kept
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s * Posted UntiF Final Ins ectio�n Has Been Made ,r aPermt
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Where a Certificate:of Oceupancy�;is Required,such BuldmgshallNotrbe Occupied untila Final Inspection has been made 1
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Permit No. B-19-2964 Applicant Name: HALLAM, ROBERT D&SUZANNE N Approvals
Date Issued: 09/10/2019 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 03/10/2020 Foundation:
Location: 119 LONGVIEW DRIVE, HYANNIS Map/Lot: 251-090 Zoning District: RC-1 Sheathing:
Owner on Record: HALLAM,'ROBERT D&SUZANNE N s Cortractor'Names Framing: 1
}Contractor Or,
Address: 40 JOSIAH S PATH 2
WEST BARNSTABLE, MA 02668 f �ESt Project Cost: $500.00 Chimney
:
Description: SIDING ` _ Permit Fee: $35.00
Insulation:
fee Paid $35.00
Project Review Req: 9/10/2019 Final:
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Date�,
Plumbing/Gas
` Rough Plumbing:
Building Official
�. Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
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All work authorized by this permit shall conform to the approved applicatiop�aA the`approved construction documents?.for which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures_shall be in compliance with the local zom g by lays and codes.
This permit shall be displayed in a location clearly visible from access street or,road and shall be maintained open for publ c�nspecto
n for the entire duration of the Final Gas:
work until the completion of the same.
The Certificate of Occu anc will not be issued until all a licable si natures b the4fBwldan and Fire Officials are rouide�d on�th!s ermit. Electrical
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Minimum of Five Call Inspections Required for All Construction Work: Service:
1.Foundation or Footing
2.Sheathing Inspection r Rough:
3.All Fireplaces must be inspected at the throat level before firest flue Irving is installed
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4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection Final:
5.Priorto Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage.Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
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. Health
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
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Application number.. .......................................
Fee ..............................................................................
Building Inspectors initials..........
Date Issued.:..........��...,1....../..............................
bARNSfABLE
Map/Parcel... .......... .........................
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: 10 at•..)
NUMBER STREET VILLAGE
Owner's Name: yot T ' Phone Number_ tTWr?) 9
Email Address:141 LIVI Q q �' . �f -. Cell Phone Number
Project cost$ S Check one Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property Y I hereby authorize
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to make application for a building permit in accordance with 780 CMR
Owner Signature: Date:
TYPE OF WORK"
t� Siding ❑ "Windows(no header change)# ❑, Insulation/Weatherization
❑ Doors(no header change)# Commercial Doors require an inspector's review
❑ Roof(not applying more than 1 layer of shingles)
Construction Debris will be going to wN+Pi �✓
i
t CONTRACTOR'S INFORMATION
Contractor's name'
Home Improvement Contractors Registration(if applicable)# (attach copy)
Constr ction;Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION.NUMBER...................................................4W...
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
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Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X I X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent
Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required.
Natural Gas Yes No ,if yes,a gas permit is required.
If food is being served at.your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval.
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
-Homeowner's Name:
Telephone Number ` U7 «6 —`Cell-or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the constructio inspecti Von procedures, specific inspections and documentation required by 780
CMR and t T of Barn e. -
I `Signature" Date ( Y
ANT'S SIGNATURE
Signaturi4�J45f:�_ f — Date a
'-All permit applications are subject to a building official's approval prior to issuance.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111 u
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: Cx-)tfckJ
City/State/Zip: �;,_ ._v LAPhone#: C r�
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
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. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance - comp. insurance.t
re fired.] 5. ❑ We are a corporation and its 10.❑.Electrical repairs or additions
3. am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions
Vill
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Qther V � r
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: —
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: r (Ova C� cJ ' � tsS City/State/Zip: A. ' C)2d3 Z
Attach a copy of the workers'comlVnsation 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
frte 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby=1idertWhepa penalties of perjury that the information provided above is true and correct.
Si ature: Date:
Phone#:
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
Contact Person: Phone#:
A
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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 ari 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 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
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 maybe 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
Office of Investigations
600 Washington.Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia