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HomeMy WebLinkAbout0500 OCEAN STREET (9) Oa ocPaY\ S4- �I. E TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 3Z To ° n P 4 (9V4 Zsf 2 Map Parcel ��d � 0 A f7r £�: �TA F Application Health Division Z�fI 17 ^�� Date Issued � ►3 -ILA P� ~, Conservation Division Application Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Cyr _e as 1- 2— Village 14Li oar\-n i Owner �l v l n ir- y�c.��; Address Telephone S z F - 3 Permit Request C,v t �-�- i►� wa`/ y �[vn..�. ,j� �2+./ /�c, vn -� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new _ Zoning District Flood Plain Groundwater Overlay Project Valuation* 36 Construction Type�� Lot Size Grandfathered: ❑Yes L- o If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)`'sue Age of Existing Structure 14 o _ Historic House: ❑Yes 4No On Old King's Highway: ❑Yes 4No 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 Number of Bedrooms: S existing knew Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: Cg'Gas ❑ Oil lirflectric ❑Other Central Air: ❑Yes ® No Fireplaces: Existing Y New Existing wood/coal stove: ❑Yes�W'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 Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ._NameA7_/kPk Number 5-0y- - 6 Address -4ai � aY-� ���.�e___--- License # CS a 9 o k/. �?_� Home Improvement Contractor# 1 ,4 2.4 a zE Worker's Compensation # 6Z7-uL O�i�`(a n 4;J - --1-3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S (� SIGNATURE DATE C �' A it FOR OFFICIAL USE ONLY APPLICATION# s DATE ISSUED ' MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' r� GAS: ROUGH FINAL FINAL BUILDING l �a ' DATE CLOSED.OUT ASSOCIATION"PLAN NO. L 1 S r. 1 The Yachtsman 500 Ocean Street, Hyannis, MA 02601 Yachtsman Condominium Trust P.O. Box 1283 Hyannis, MA02601-1283 (508)775-1515 - LATE RE: Umta�'-/ ;Yachtsman Condominium Trust, 5.00 Ocean Street, Hyannis To the Town of Barnstable Building Commissioner, The Board of Trustees for the Yachtsman Condominium Trust voted and approved the attached proposal to be performed as is delineated in the request we received from the Unit Owners. This letter serves as notice of that vote to approve the proposal, which has been noted in the Minutes of the Board Meeting. Signed Under the Pains and Penalties of Perjury this day of �">L 20 l�/ e etary, B and of Trustees Yachtsman Condominium Trust 500 Ocean Street(c/o Manager's`Office Hyannis, MA"02601 Enc./File i Y' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A,46L�, Please Print Legibly Name (Business/Organization/Individual): Address: Y'cf City/State/Zip: K1, OZ,6 '� Phone #: 77 AWoam n employer?Check the appropriate box: Type of project(required): 1. a employer with (5 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 workingfor me in an capacity. employees and have workers' Y p ty 9. ❑ 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 1 I.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof pairs insurance required.] t c. 152, §1(4),and we have no 9 employees. [No workers' 13.ZrOther 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.#: (:!2 06 SG 1,1 S:�2 S Expiration Date: Job Site Address: C`S_2�6 OUAV-, Cs�' (11;1- Z L City/State/Zip: 11(4 0.Wr1, S 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 for insurance coverage verification. I do hereby certify under the ains and penalties of perjury that the information provided above is true and correct. Signature: "n. - Date: Phone#: — 6 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 f Contact Person: Phone#: Information and Instructions r 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-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 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 1 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 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 r� 1 t`CoR"® CERTIFICATE OF LIABILITY INSURANCE 4/11/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Nancy Burns NAME: y Cleary Insurance Inc PHONE (617)729-0700 FAC No:(617)723-7275 226 Causeway Street 2DRess:nburns@clearyinsurance.com INSURERS AFFORDING COVERAGE NAIC p Boston MA 02114-2155 INSURERA:Peerless Indemnity Insurance 18333 INSURED INSURERB:Zurich American Insurance Co. 16535W Sandy Neck Builders and Remodeling LLC INSURERC: Anthony Nese INSURERD: 84 Minton Lane INSURER E: West Barnstable MA 02668 INSURERF: COVERAGES CERTIFICATE NUMBER2014-15 BOP Auto WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM DD POLICY EFF MM/POLDD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 A I CLAIMS-MADE FxI OCCUR CEPS813111 /2/2014 /2/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 }( POLICY PRO- LOC I $ AUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED RA5813110 3/2/2019 /2/2015 AUTOS X AUTOS BODILY INJURY(Per accident) $ X }[ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per a.Zd Optional bodily injury $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBEREXCLUDED? FN-� NIA (Mandatory In NH) 622UB-0656N52-5-13 6/19/2013 6/19/2014 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below f E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Chatham ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept. AUTHORIZED REPRESENTATIVE 261 George Ryder Road Chatham, MA 02633 _ Nancy Burns/NAB AA7 1 4- ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 nrrrnnsi m Tha arrion name�nrl Innn mra raniafarafl m*rlea of Arrion �1ze �ovnouveae a 0./�aaoac�eecaelta - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR ' Registration: ,,i59608 Type: Expiration: 5/_15/2014 Ltd Liability Corpo SANDY NECK BUILDER$ = r ANTHONY NESE _z + 179 ROBBINS ST OSTERVILLE,MA 02655a.E Undersecretary P — { 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards i Construction Supervisor License: CS-090335 ANMONY M NEST: " 35 BISCAYNE DRIVEa. Marston MiIls Nl2t+ 02�648 i Expiration Commissioner 11/09/2014 F Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m3)of- enclosed space. I •' Failure to possess a current edition of the!Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS Las�nse o registration valid for individtil use only before tfi'e Jp-irifid date: If found return to: Off ec of Cc usumer Affair's and Business Regulation i 10 Park?Iiaza-Suite 5170 Boston,MA 02116 Not valid without signature Y Town of Barnstable Regulatory Services * s MM�is Richard V.Scali,Interim Director 1639. �`e� 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 Property Owner Must Complete and Sign This Section If Using A Builder I as Owner of the ero subject l P P m' hereby authorize oV6 �qs to act on my behalf, in all matters relative to work authorized by this building permit 5(Z 6QAtJ Am)i, AA- va.9J (Address of Job) F• *Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant V Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 10/13 r Town of Barnstable Regulatory Services - pFttE r, Richard V.Scali,Interim Director Building Division t snarisT"14 Tom Perry,Building Commissioner MAm 1639, ��� 200 Main Street, Hyannis,MA 02601 �''°rEn w►e� www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: :OB.LOCATION: number street village "HOMEOWNER": name home phone# work phone# 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 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 hermit. (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 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(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 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 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 The Yachtsman ' - �.,, 500 Ocean.Street,.Hyannis, MA 02601 Yachtsman Condominium Trust PM Office: (508)775=1515' Unit Owner Improvement bequest 1, (we) KA V(tJ TATVE01:" owners of unit# ' do hereby apply to the Yachtsman Condominium Trust, pursuant to Article V,Section 5.6.2.of the By-Laws of the Y.C.T.; permission for our contractor to carry out the following improvements/alterations; Contractor Name:: Place an"X"in the box to indicate type of improvement Include below and in attachments the type of equipment&location of installation below ❑ Windows/ Heat/.Air ❑ UnitFront Door/ ❑Other Sliders Conditioning Remodeling Front Screen Door Improvement Attached pages, where needed,.to provide details of the improvement being planned. 4c, (\t D) Ao b EJI 6 OP .QED ©off U-)A 31al /I 4 • Unit ner. gnature Date Submitted. 01,4 432� - bl"55 kw' k P�i 9'Va�%oo Co V\ Unit Owner Phone Email Address 7 Please submit this form to the Property Management Office(PMO)for Review Date received by PMO Date of I"Submission to the Board for Approval: Date final Board Approval Received: YCT.Improvement Request Form(last updated Mar'2014) ,. 41 t s �. ��-. � z �� N T � ._.___.__.___M . ........ � �I �. .�s, , .._ 500 Ocean St.#19 d. Hyannis,MA 02601 Yachtsman Condominiums MARC ROBINSON RESIDENT MANAGER Off.508-775-1515 Res.508-775-0878 Pager780-8249 E-Mail mrobin@capecod.net 't TOWN'OF BARNSTABLE BUILDING PERMIT APPLICATION ap ParcelO '• �M Permit# F�.@u n— / _ d % ®��' N'�� a `i Date Issued Fee w —'Tax Collector ' { r ----Treasurer - rir?g-BePt• • a , .Date Cle# tive�Pla -A� ed aoP rang B'o'a"rd -Historic�0 Project Street Address iS ,y 2,1 c 1 Village �> n !Owner � Gddres ✓ } Telephone Permit Request M D tle e �s CFI�-r 1�QJ. -x iS-I-� r �-f �)r�p ��dw� T> _ �+�r bad, �111A} -rt P 14 `S c S. l KJ + V 3� r j sh s � s f?,Q t e S'�, �a � fi e.c Square feet: 1st floor:existing proposed Sa-► t 2nd floor: existing. proposed Total new CJ Estimated Project Cost h Q Zoning.'District Flood Plaines Groundwater Overlay Construction Type 3 Lot Size - Grandfathered: ❑Yes two If yes,•attach supporting documentation. Dwelling Type: Single Family ❑ Two Family, ❑ Multi-Family(#units) CMDO, Age of Existing Structure X Historic House: ❑Yes . 20 On Old King's Highway: ❑Yes Basement Type: [9'61 ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq'ft) �— f -Number of Baths: Full: existing- 2�� new — -Half: existing I new Number of Bedrooms: existing _ L-- new Total Room Count(not including baths):existing new 'First Floor Room Count Heat Type and Fuel: 0 Gas ❑Oil 81"Electric ❑Other Central Air: D Yes Flo Fireplaces: Existing f.JNew_ '" Existing wood/coal stove: ❑Yes Detached garage-❑existing O new size. Pool:❑existing ❑new size Barn:❑existing ❑new size 0 Attached garage:0 existing{❑new size VO ' Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ ` Commercial. ❑.Yes MrNo If yes,'site plan review# Current Use Proposed Use BUILDER INFORMATION _Name ( :� Telephone Number Address License# A Home Improvement Contractor#` Worker's Compensation# FALL CONSTRUCTION DEBRIS RES TING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE,ONLY — r' .PERMIT-NO. �: •r - �. - •''• _ I - ,•' ,,� y { ._ T - •. ` _ - DATE ISSUEDol MAP/PARCEL NO. �cg r ADDRESS '` C" 'VILLAGE OWNER { ' . ! 3 -• 4; ,: a -� r . DATE OF INSPECTION t FOUNDATION FRAME INSULATION F' FIREPLACE ELECTRICAL: ROUGH FINAL: t - - r c 7 • ' r PLUMBING: ROUGH FINAL- GAS: ROUGHFINAL. i _ FINAL :- _ • „ Y FINAL BUILDINGall DATE CLOSED OUT ASSOCIATION PLAN NO. a ' ± x � p Y, Y -Y� Ems' � 1�, k.r � � P J Y � �w:io �➢ .. }; ,.,-.a.,. h I l reP ` AC! WUMT i t � f �41 - l f 4 Ake a • ? L e Town of Barnstable a�arrsrsa�. _ • 9M. �• Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner 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 ati addition to any�pre-existit g 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: 1 t Estimated Cost 000 Address of Work: d O - Owner's Name: MA A" �A&2, A Date of Application: 01 —�C] I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied 06wner 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 V L'a:== Date Owner's Name q:forms:Affidav a Of 111,IN 5AR IwoA I i • '� e j �r / r �i r�ioi r r i a aai� Sri •raiiraai�iiaiai�aii�iiiaiia�airi�iaraiiiiiaii as r�i��i��ai�iaiiriiiiiiaiiiiiiy Elm Elm=i r iiiioaiiaiiiaiaiiaioiiaiiiii�ioaiiaioiiiiiioiaaiiioiiaiaaia�iioai�iiioaiiiiiiiooaiaiioiiaiiaiiio��iai�raia����iii�i�ii Rugg i Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for then" employees. As quoted from the"law",an employee is defined as every person in the service of another under any cont --- 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 o: the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the rc=.%•e: 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 swA dwelling house or on the grounds c. building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa. 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,neither the commonwealth nor any of its political subdivisions shall eater into any cone=for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the c�*n*a n 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 along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance covwage• 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. City or Towns 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 permitlliceose number which will be used as a reference number. The affidavits may be returned io the Department by marl or FAX unless other arrangements have bees made. The Office of Investigations would like to thank you in advance for you 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 Imsnoadons 600 Washington street Boston;Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 oFTMe o Department of Health Safety and Environmental Services Building Division ' ■AMSTABM ` 367 Main Street,Hyannis MA 02601 t►AS& 9A 1639• A 'Cp�E AAA'I O Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION DATE: 56j� Please Print ��.1. L� � I ( JOB LOCATION: D V S Miw C� 4u a.�,M- number �. es/tree`t vill e ..HOMEOWNER': .j �o V V� 1:a`t► 1{Lri �,3 3�© x I name �\ ' I _Ahome phone# / ` /� work phone# CURRENT MAILING ADDRESS: `-'� lam()1(p1J�' �V�Q1J�� �INap—, 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 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 buildingjermit. (Section 109.1.1) A 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 requjnts. 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(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 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 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 to amend and adopt such a form/certification for use in your community. QTORMS:EXEMPT ' rabb.l3:ZIb(eeemanar� �. F,..ipt[n Paelca8o!or doe and TwaFamiilr RastdmtVl Boddlnga Mmd with Foal Finch wall E7oor 8aaemmc Slab H WWCmlk9 UD aiug Z vW wl &valuo'' 1Gvduas wall Pab=tw Waaw? pftckw I & wog I &%,aiud 9701 to 6500 Hadar;Degtsa Days' Q 12% 0.40 3E 13 1 19 10 6 Normal S 12% om 30 19 19 10 6 Normal S 12% 0.s0 33 13 19 10 6 u AFUE T iS9i 036 3f 2S WA WA Normal 11 13% OA6 n 19 19 10 6 Normal V IM O44 n 13 2S WA WA ISAFVE Lz 13 i5 am 30 19 19 10 6 SSAIRM 1119A amn 13 2S WA WA Normal IVA 0.42 33 l9 2S WA WA Normal 18% a42 3i 13 19 10 6 90AFUE IV/. 0.S0 30 19 19 10 6 90 AME 1. ADDRESS OF PROPERTY: 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-1980303a Footnotes to Table J5.21b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, sky► 4t`,•anti basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall. rea area,expressed as a percentage.Up to 1%of the total glazing a may be excluded from the U-value requirement.• For example,3 ft of decorative glass may be excluded from a building design with 3001f,of glazing area. 2 After January 1, 1999,glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRQ test procedure, or taken from Table'JT 5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ailing R values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness-over the exterior walls without compression, R30 insulation may be substituted for R-38 insulation and R 38 insulation may be substituted for R-49 insulation. Ceiling R values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R values represent the sum of the wall cavity insulation plus insulating sheathing (if used).Do not include exterior siding,structural sheathing,and interior drywall.For example,an R-19'regttirernent could be met EITHER by R 19 cavity insulation OR R-13 cavity insulation plus R-b insulating sheathing. Wall requirements apply to wood-flame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawispaces,basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R value requirement as above-grade wails. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements•am for unheated slabs.Add an additional R 2 for heated slabs. • If the building utilizes electric resistance heating use compliance approach 3,4, or.5. If you plan-to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table 15.2.1 a ROTES: a)Glazing areas and U-values are maximum acceptable levels.Insulation R values are minimum acceptable levels. R-value requirements are for insulation only and do not include stucan-A components. b)Opaque doors in the building envelope must have a U-value no greater than 035. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available,include the4l area of the door with our windows and use the opaque door U-value to determine compliance of the door. glass Y One door may be excluded from this requirement(i.e.,may have a U-value greater than 035). c)If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels,the component complies if the area-weighted average R value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(035 for doors). 43 bi. 9 I I i �, ' � I. i h �_- __- - ___ r^'V 03/09/1959 k13:52 5084202063 MARIE 50UZA R EX PAGE 01 Fa : .) -3 0 Ati n: Lo'�l S Re, 03/09/1999 13:52 5084202063 MARIE SOLIZA R EC PAGE 02 P �...�:..y�. _ ._ . �.�........... ....- , g r� Y K1� 1 i y Y i ,. 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