HomeMy WebLinkAbout0059 MEGAN ROAD �I ��� ��
I
rt1 Town of Barnstable Building
,Post-This Card So That+�*sAl�tnhr"SnfsAa L'iR�. WPofisteercel EaU Certina1 sI n;s<pectio;,,n""�HasBee n';M.t✓h-a„e d eS treet' - pt ronved"Pt
lans Mus�t-1�be" R�e�ta ineds on Job and ths Card MubrK,.epts `rt isV07io Ap n�, tiaFiaphabm
irerm1Fntil ifcaeO equred,such Build� ghalNtb eo •
Permit No. B-19-2812 Applicant Name: Brien Lan gill
Approvals
Date Issued: 09/24/2019 Current Use: Structure
Permit Type: Building-Solar Panel-Residential Expiration Date: 03/24/2020 Foundation:
Location: 59 MEGAN ROAD, HYANNIS Map/Lot: 292-255 Zoning District: RB Sheathing:
Contractor Name: BRIEN LANGILL Framing: 1
Owner on Record: CAHOON,CHRISTOPHER P g�
Address: 59 MEGAN ROAD Contractor license: CS-106675 2
HYANNIS, MA 02601 Est: Project Cost: $23,540.00 Chimney:
Description: Installation of roof mounted photovoltaic solar systems,34 panels Permit Fee: $170.05
10.71kW ` Insulation:
Fee Paid: $170.05
Project Review Req: -Date: 9/24/2019
Final:
Plumbing/Gas
Rough Plumbing:
fricial
This permit shall be deemed abandoned and invalid unless the work anthonzed'by°this permit is commenced within siwmonths after issuan 2. Final Plumbing:
All work authorized by this permit shall conform to the approved application and theapproved construction documents fo ,Which'this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning=,by la ks and codes. Rough Gas:
This permit shall be displayed in a location clearly visible from access street&46ad and shall be maintained open for public mspeetion for the entire duration of the
work until the completion of the same. Final Gas:
a
The Certificate of Occupancy will not be issued until all applicable signaturesbykthe Budding and Fire Officials are=provided on this Permit. Electrical
Minimum of Five Call Inspections Required for All Construction Work."
1.Foundation or Footing r; z Service:
2.Sheathing Inspectionk
3.All Fireplaces must be inspected at the throat level before firest flue limn is'nstelledz, Rough:
p P g_
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Final:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Rough:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final:
Work shall not proceed until the Inspector has approved the various stages of construction. Health
"Pers s con g 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:
c
a able Building
�. own o Barnstable
PostThis`Card So That it.", Visible From,the Street-Approved Plans`must'be RefdilleJ onyJob and thi.,.CardylVlust bee r j
BAItNBPABt$ .'�' -r-
M" Posted Until Final'Ins ection Has Been.11�lade - _
�". t'titir to � rs� ,,.,P,�,:m»." .�°,i�""" 3 a ,�r seer kin. .� __� ..i��,.#'.> .-3.� a�. -, ..,,a a.v�� � x � �
t' Where axCertificate ofOccupancy is Required;such�Buildmg;shall Not;be Occupied until aF�nahlispection�haslieen:made: _ Permit
Permit No. B-18-2932 Applicant Name: CAHOON,CHRISTOPHER P Approvals
Date Issued: 09/07/2018 Current Use: Structure
Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 03/07/2019 Foundation:
Location: 59 MEGAN ROAD, HYANNIS Map/Lot: 292-255 Zoning District: RB Sheathing:
Owner on Record: CAHOON,CHRISTOPHER P _ Contractor NameN Framing: 1
� '
Address: 59 MEGAN ROAD 9 �' .;_ - . 2
.Contractor License
HYANNIS, MA 02601 ffEst. Project Cost: $0.00<> `
m
Y:Chine
PermitiFee: $35.00Description: shed 12x16
;
Insulation:
Fee Pa In
id,;" $35.00
Project Review Req: 12x16 shed placed as shown on submitted propetty.map
r Date 9/7/2018 Final:
w
r
T 1 '�-� � , ��y�.' �� '/ /�//) Plumbing/Gas
} £
� Rough Plumbing:
r Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorzed by this permit is commenced within six.-months after`issuance. Rough Gas:
All work authorized by this permit shall conform to the approved application and•the�approved construction documents for which:this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and 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 in ecti n 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 provided on thi's permit. Service:
Minimum of Five Call Inspections Required for All Construction Work T 4
T a � � �4as a �'a' *r*Q°o.'�
1.Foundation or Footing f.i ' x n ` a w Rough:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
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
Town of Barnstable
" Building Department Services BUILDING �
Brian Florence,CBO SEP 07 2018
snxrrsrnat,E Building Commissioner
200 Main Street, Hyannis,MA 02601 TOWN OF BAPINS fA&L
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
PERMIT ,16_ / FEE: $35.00
SHED REGISTRATION
RESIDENTIAL ONLY
200 square feet or less
�j Me, koad- Hc�ann k '-s
Location of she address) Village
508 s 3 ! 5- 9 5-o 0
Property ownerl name Telephone number
(Mad_d ('6 IOC.[.)
� x 0?907 /a55-10?9ua5�5-
Size of She Map/Parce #
E-Mail
Signa to
Hyannis Main Street Waterfront Historic District? AA)
Old King's Highway Historic District Commission jurisdiction? b
You must file with Old King's Highway
Conservation.Commission(signature is required) Q
r
Sign off hours for Conservation 8:00-9:30&3:30-4i30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE
ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION
FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
'E THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shedreg
REV:08/6/17
Legend
• ; x ; Parcels
Town Boundary y
292257 �31 Railroad Tracks
2.92312 #4
-me_µ Buildings
1
.._.. #63 s; �' { 29223 I Approx.Building
,j2 FJ Buildings
Painted Lines
a ( E Parking Lots
Paved
j Unpaved
2922.56 f l Driveways
#.51 M' Paved
E Unpaved
r ! Z92.2.39 Roads
Paved Road
w 292313 #.50 Unpaved Road
-ft 7"3 '. :: i �a�, ? Bridge
i Paved Median
�treams
Marsh
Water Bodies
a
#59
292 44
&
292314
83
292254 . - �t
!i #67a
ti
t�` 292241
-- i
° 66
292315
E ---.... ;. -
s
93 292253
.......:.................
Map printed on: 9/6/2018 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit
adequate for legal boundary determination or representations of Assessor's tax parcels.They are
Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026o>
0 42 83 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624
reflect current conditions,and may contain such as building locations.
Approx.Scale: 1 inch= 42 feet cartographic errors or omissions. gis@town.barnstable.ma.us
i� P —
Assessor's map and lot number �Pl
SECYSTE6J M 1VIUS7/
INSTALLED IN CO 1IMPLIANCE
WITH ARTICLE 11 STATE �
Sewage Permit number .........:. ... ............................ §ANfARY CODE AND T®W
�����ATIt3�9S, .��~•-� _ _ram.
�OFTHE-tp�y ®W� -O BAIL NSTABLE
•
BABISTADLE. i
=voOY��e� DUILDIC INSPECTOR
0 �^ , GLG /C Ccj
APPLICATION FOR PERMIT TO ........ ....T...............................................................................................
TYPE OF CONSTRUCTION .....ei.... ``................. ...............................................................
.........!!v.. ........................9.
TO THE INSPECTOR OF BUILDINGS:
The undersigned ereby applies for a permit according to the following information: t
Location ... ..... ............ ... ..... ..................Al.. ..........................
Proposed Use ........��/.. 0� ....... .f���. � ..........1-� 1��1'e..J ..................................................
Zoning District ........../4... ..............................................Fire District ......... ...... �����
Name of Owner ..L�./ ,l% ..... � liF.�....W.A�ddress .. U....�`'s.../'/!�./..�.. .......g.� !
G
Nameof Builder v ....Address .................... ........................................... ...................................... ............................................
Name of Architect i ro r� i
.................:.:.............!.:...............`...............Address .........`..............:............................................................
... ..
Number of Rooms .............��—............................................Foundation .../�../ u/'z.!5�.�..�%®dJG��...
Exterior ....... .....: f. :, ��.............Roofing ............. !?.. ............................................
,. 4 ......Interior ..........
Floors ...... ii �[/.. ..... .. ' T...'/. /1� �`..............................
.. .................. . ....
Heating ......... .... G✓ .....,�yc(...��...... .........Plumbing ........... ..
Fireplace /................................................................Approximate Cost ��00
................. ............ ........................................
p
Definitive Plan Approved by Planning Board ---Z��ff'`_��'----?_ 19 Area ..../. ��....... S
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
911
a �
I hereby agree to conform to all the Rules and Regulations of the Town of Bar ble regarding he above
construction. _
Name .. �.....
..........
�Ir
Dacey, William E. Jr.
16401 one s o
No ................. Permit for ...................... .... ........
single family dwelling
.............j 'q ..................................................... i
Location J ` E.gan..Road 1
.... ...... ..........................................
Hyannis
...............................................................................
Owner ..........William E. Dacey, Jr.
......................... .............. ..
Type of Construction frame
........................
.........................................................� ................
Plot ............................ Lot ......... ..............
July 16 73
Permit Granted ...............................��1J���Mxr��'
Date of Inspection ..�... 3 ...r.?
Date Completed ............. ....................... 19 I'
PERMIT REFUSED �~
................................................................ 19 '
...............................................................................
4
................................................................................
............................................................................... ,
............................................................................... ,
i
Approve .................................................19 ,
I
...............................................................................
...............................................................................
SEPTIC SYSTEM MUST BE
Assessor's map and lot number .. `7Y... ... �p.......... i"dSTALLED IN COMPLIANCE
.� 73 /00 /7d6orrr/vtz0ow- 4,ITIH ARTICLE II STATE
� �"�.j SANITARY CODE AND TOWN
Sewage Permit A/ rfS t a. *011� REGULATIONS
yo`tHETo�y TOWN OF BARNSTABLE
3BAHB9TODLE, i
aI .�� BUILDING INSPECTOR
4
APPLICATION FOR PERMIT TO ...... ...
TYPE OF CONSTRUCTION
zd(7 .:y.......1..�7..........I9../—,f
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies. for a permit according to the following information:
Location ......... ...............................................................
ProposedUse .......... ........`: f .....:.........................................................................................................,.........................
Zoning District ........ ........... .../............./� Z�................Fire District ............................
..............
..................................
Name of Owner T
........ .�..............................................Address ............ ......,..b........: ..............�...... !/!?°{
rr
Name of Builder �/ �J � ......Address � ............
. ................ ..... ..... ............ . ............ .... ...... .................... ..............
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ..................................................................Foundation ..............................................................................
C!6— e/ ...Roofin ........j ..................................................................
Exiei ior ............................................... ..................... g
Floors ......................................................................................Interior ....................................................................................
Heating ..................................................................................Plumbing ..................................................................................
Fireplace ..................................................................................Approximate Cost ......11� 04...�... .... a......................
Definitive Plan Approved by Planning Board ________________________________19________, Area A4ct.e#,S-
d
Diagram of Lot and Building with Dimensions Fee s"
SUBJECT TO APPROVAL OF BOARD OF HEALTH
.4
� fS�
80
I hereby agree to conform to all the Rules and Regulations of the. Town of Barnstable r garding the above
construction.
Name ......& ,(.......................................
L
FNo
ven, E. Roy
6399 Permit for ..,,, dormer...............
n 6th .Avenue
..................... .......................................
West Hyannisport
.................................................
Owner E• RoY Neeven
..................................................................
Type of Construction frame... .................
t
Plot ............................ Lot ................................
Permit Granted ...........july..16..............19 73 l
Date of Inspection .............. ........... ........19
I
Date Completed ..... ...... ..... ...319
t.
PERMIT REFUSED
................................................................ 19
r
...............................................................................
................................................................................
............................................:.................................. I
...............................................................................
o _
y
Approved ;k
a
...............................................................................
! ................................................................................
............................................. ........
Engineering Dept.(3rd floor) Map gal Parcel 5�—Permit# 9/-
House# � v J Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) _` - Feed`d
Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00)" - r
t ; ,
Planning Dept. (1st floor/School Admin. Bldg.) IKE
Definitive PI roved by Planning Board 19
BARNSTABLE.
039.
TOWN OF BARNSTABLE
Building Permit Application
Projec tree ddress__ 9
Village � 1 zd
Owner Address
Telephone -7 7/- t
Permit Request
� r
'First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ /, CIDD,All
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family a<-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
No.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
Garage: ❑Detached(size) Other Detached Structures:, ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name / ,�,�e ('Dn ) Telephone Number ' "77S-77
py
Address P.Q. ° t License#
Home Improvement Contractor#
Worker's Compensation# 9 d 7/Z 419 d f 7
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT,
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
1
SIGNATURE DATE
BUILDING PERMIT DENIED�QRIFQLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED t
MAP/PARCEL NO. {
ADDRESS VILLAGE �.
_ I
OWNER - �� ; •; � ". -' V•{ 4 � '
DATE OF INSPECTION: - t
•. , - ♦ -J r
FOUNDATION '
FRAME -
YNSULATION = t
FIREPLACE
ELECTRICAL: ; ROUGH '- FINAL
PLUMBING: ROUGH ' FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT { '
ASSOCIATION PLAN NO.
y
The Town of Barnstable
mum
I" .f' Department of Health Safety and Environmental Services
Building Division
367 Main Savo Hyagnis MA 02601
OAee: 509-790.6ZZ7 Rao Cmssea
Bic: SO&790-6Z30 Building Commissio,
For of ice use only
Permit 46.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL e. 142A requires that the "reconstruction, alterations, renovation, repahr, 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.
Type of Work: - Est.Cos_ A fD®,D D
Address of Work:
Owner's Name
Date of Permit Application: /Zdl Z
I hereby certify that:
Registration is not required for the following reasou(s):
—Work excluded by law
_Job under S1,00L
Building not owner-occupied
__Owner 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.
OR
The Connmrntrealth of
; ; Department of Industrial Accidents
,;,, � Office D/lnvest/gallons
' \ ;" :r 6110 !f'axhirrrturn Street
'•�.;�.�����':. Bustun..11uss. U2111
Workers' Compensation Insurance Affidavit
Atmlic:int inforrnatimi� Please PRf1V'T'lebj�jjv �•"�`—� •'� `� —�---
location
o• . hop•# _
i] I am a home wner performing all work myself.
I am a sole proprietor and have no one working in any capacity
....n�..-.�:�w.s..�.s+�arc s..';.n+ 'r`� - ...�w�-�•�......r'�w-.�.�.,.w�... e..wr++.---..---.-�
[] I am an ent plover providing ,.vork/e/rs' compensation for my employees working on this job.
comnanc n'tmc•
address: �•�. Lam,.(/ i}^/� •
cite. z2). [!hone#• -77 -- 7 94,-3
insurance co. ���BDJ� policy # ®®74 /Y q V ell?
['I I am a sole proprietor. beneral contractor, or homeowner(circle orre) and have hired the contractors listed below who have
the followinn workers' compensation polices:
comminv natnct
addresc•
phone#•
insurance ro. polio•#
cmmnanc name
addresc-
cin•� �thonc#•
insurance co. policy#
Attach additional sheet if necessary..
�_ r :•a...y ....�� �..�__.......----rr-_'�_.. i�Y!•�i_it•.rw:a was.
Failure to secure cuccrage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties ol•a line up to s1.500.00 andiur
one v cars' imprisonment:is well as civil penalties in the form of a STOP NVORI:ORDER and a fine of 5100.00 a day against me. I understand that a
Copy of this staternent mac be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby cerrift•Under the paints and penalties of perjury that the information provided above is true and correct.
Si_nature Date 7
Print name , lam.. % Phone# 7 7Z 7 7123
:.' official Ilse unly do not write in this area to be completed by tiny or town official
a city or town: permit/license# r iBuilding Department
aLicensing Board
tt a check if immediate response is required aScleetmen's Office t
k 0111calth Department
contact person: phone#; rj0ther. S:
r.
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for
employees. As quoted from the an einploree is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An emplo,rer is defined as an individual. partnership. association, corporation or other legal entity. or anv two or inc.-
the fore___oin�� en��a�_cd in a.joint enterprise, and including the legal representatives of a deceased employer. or the
recci%,er or in►stee of an individual , partnership. association or other legal entity, employing employees. However
owner of a dwellina, 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, tic.
or o►i tile __rounds or buiidi►ig appurtenant thereto shall not because of such employment be deemed to be an empio-,-e-
MGL chapter 152 section 25 also states that ever}' 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 anv
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionaliv. neither the commonwealth nor any of its political subdivisions shall enter into anv contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names. address and phone numbers as all affidavits 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 cite or town that the application for the permit or license is being requested.
not [lie Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are requirez
to obtain a workers' compensation police, 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 o.
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie--
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned
-lie Department by mail or FAX unless other arrangements have been made.
Tlie Office of Investi=atioils would like to thank you in advance for you cooperation and should you have an} questior
please do not Hesitate to uive us a call. .
�_..a...-r....- ...�_._-v,... .�..+e...++•.. �.v�-s-�.....-�.+_.r r�w-w+..�_. -.w�.rt+v.nla_.'r"r. vn�..+�...��.--
TJie Department's address. telepiione and fax number:
The Commonwealth Of Massachusetts Yf.
Department of Industrial Accidents _T
Office of investigations
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406. 409 or 37S
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;R
1 Town of Barnstable * ermit�#
Expires 6 months fronr issue date
Re ulator Services F
BARN$TABLF- g Y
MAR& $ Thomas F. Geiler, Director
Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
ap/parcel Numbe G} (� ,\ `n
'Property Address �� 1 �G�(YLY\ 1�� jC\rV\\s rnl i C�D_Glo t.
Residential Value of WorC` Minimum fee of$25.00 for work under$6000.00
1 /Owner's Name&Address \,r\�AA,
V
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance ®PRESS PERMIT
Check one:
❑ I am a sole proprietor JUN I 2009
I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTA BLE
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
Re-side D/?e 5fde 6)/2L/
❑ Replacement Windows. U-Value (maximum .44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: rop wn ty Owner Letter of Permission.
Ho I tors icense& Construct Supervisors License is required.
SIGNATURE:
Q:\WPF[LES\FOf; S\Express\EX RESSPERMIT.DOC
Revise06O4O9
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A H ut Information Please Print Le ibl
Name(Business/Organization/Individual):
Address: `�lC Mcouy 1 )
City/State/Zip: ice- yxy,� Phone.#: '�SO C/9-)C)
Are you an employer? Check the appropriate box: Type of project(required):
L❑ I am a er w employer 4. I am a general contractor and I
p Y 6. ❑New construction
employees(full and/or part-tune).* have hired the sub-contractors
listed on the attached sheet. T. ❑Remodeling
2.❑ I am a sole proprietor or partner-'
sub-contractors have
ship and have no employees These 8. '❑Demolition
a have working for me in any capacity. employees and h v workers g, E]Building addition
[No workers''comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its '10.❑Electrical repairs or additions
3 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. o workers' 13.❑Other
_ Cl`I
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.
IInsurance Company Name:
Policy#or Self-ins.Lie.M 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA ce coverage verification.
I do hereby c tify u he ain d penalties ofperjury that the information provided ab vez
true and correct.
Si ature: Date: � �
Phone
Official use only. Do not write in this area, 16 be completed by city or town official
'City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Realth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.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 tiustee 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),-addresses)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 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass..gov/dia
ti
r-
Town of Barnstable
Regulatory Services
HAM9 MAB& Thomas F. Geiler,Director
1619- 16�� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Propex-ty Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to wo authorized by this building permit application for.
.(Ad s of rob)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please comp to the
Homeowners License Exemption Form on the reverse side.
n
Town of Barnstable
THE
Regulatory Services
Thomas F.Geiler,Director
RkRNsrwsr.e.
1w
><63�. �•� Building Division
prED Tom Perry,Building Commissioner
200 Mairi.-Street;Hyannis;MA 02601 __.......
vrww.to wn.b arnstabl e-ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
(A 1 Please Print
DATE: v
JOB LOCATION: SCI Me—(ACLV\ Rb Lr\rk%A1�
nuumVcr� V` street village
"HOMEOWNER": (./� `�\J ►`mil �.�NiDU� S�D'3 C 5'7 V Sc, v\-.-'L_
name c home phone,# work phone#
CURRENT MAILING ADDRESS: cXa Y�`e-- lit b N/-�
cityhown 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.
DEFINTI ION OF HOMEOWNER
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 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 undersi ed.` to r"certifies that.he/she understands the Town of Barnstable,Buildit?g Department
minim a ores and requirements and that he/she will comply with said procedures and
re men
Sign cowncr
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 homeowoa 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 pmon(s)for hire to do such
work,that such Homeowner shall ad 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}rdshe understands the rrsponsi'bilitirz of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may caret amend and adopt such a fonnlcertifrcation.for use in your community.
Q:forrns:homccxempt