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HomeMy WebLinkAbout0060 OLD TOWN ROAD Town of Barnstable Regulatory Services Thomas F.Geiler,Director 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 PERMIT# O `� �V� FEE: $ SHED REGISTRATION 200 square feet or less (,c� old Af4rJ Location of shed(address) Village G/b-tCr✓t�Afifi �r,��,t,w � I�dVc`� JCa�•iF'l'-YL S4� 1:H (, O�i �'� Property owner's name Telephone number Size of Shed Map/Parcel# Signature Date Zz 3kd C) Hyannis Main Street Waterfront Historic District? Old King.'s Highway Historic District Commission jurisdiction? � _' c a Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 j 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. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN CJ Q-forms-shedre 8 REV:042911 �J� iKE rT own of Barnstable *Permit#� �D 7 _ �� Expires 6 mantis from issue date BARNSTABLF Regulatory Services Fee v� 6& ,�$ Thomas F. Geiler, Director ATF039a Building Division rry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 SBPERMIT�AKPPLICATION - RESIDENTIAL ONLY // ^ Not Valid without Red X-Press Imprint Map/parcel Number c�6 7 QDc Property Address VC �� � 4 �� a-a t1 S 1''�7 © Residential Value of Work .ate Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address , 1 i'-104C va A-k—x'"J f3 L—A 9� A'" 5""t SL L�/t� f6�A�Gon �/9� y�7 Contractor's Name A rt!Irir. U Telephone Number 11q f o_r 4d'2_ Home Improvement Contractor License#(if applicable) Construction Supervisor's License 4 (if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy 4 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 4� Re-roof(not stripping. Going over existing layers of roof) [ ( Re-side ❑ 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: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFIL:ES`:FORh4S\Express\EXPRESSPERMIT.DOC Revise060409 The Coinmonwealth of Massachusetts Deparfinent of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 i,•� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information rr Please Print Legibly Name(Business/Organization/Individual): A,wed c,,j it (' N-�.,6r� Address: l -1 RCA'st:s P114 VJr r City/State/Zip: Ci4Afl4A,,-• p p 01-03 Phone.#: 2-1d 04Y�— Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2. listed on the attached sheet. T. M`Remodeling 0 I am a sole proprietor or partr]er-' ship and have no employees These sub-contractors have 8. "Q Demolition workingfor me in an capacity. employees and have workers' " Y P h'• $ 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 11.[]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. [No workers' 13.❑Other 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. xContractors 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.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 tip 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 statemerit may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Si ature: Date: /2 �/a _ Phone#' TO ZN E o q& 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#: 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 s to do maintenance, construction or repair work on such dwelling house dwelling house of another who employs person 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«zth 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-contiactor(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 .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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related Eo 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 e6nunonwealth of Massaobusetts Department of ladustri.al Accidents Office of Iuvestigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-$77-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass..gov/dia "b Tow)a of Barnstable THE Regulatory Services Thomas F. Geiler,Director s.axtvsresr,e, - " Building Division plFD a Tom Perry,Building Commissioner -. - -- - - 2QO Main�Street—Hya�is;Ivfr�0260 www.town.b arnsfable_rna.us Office: 509-862-4038 Fax: 508-790-6230 H011'IEOWNER LICENSE EXEMTTTON Please Print DATE: JOB LOCATION: U o O 1 m -Fy-- � l/t/. /iy A Al":y yt_ l .number street village "HOMEOWNER": 1f N9d �+ V" ��/ioA�T name home phone# work phone# CURRENT MAILING ADDRESS: , 13 C 4^-5 c`s 1 0`y'd' C/f✓J N4401 O L'6-3 3 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. DEFu4MON OF HOMEON'VNER 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 be/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 Barpstable,B.uil&g Depariznent min.n.I inspection procedures and requirements and that he/she will comply with said procedures and I equirements. A /_ tc, Signer of Homco . R 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 statrs that "Any homcowoer performing work for which a building pa-rnit 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 dosuch wcel-1 that such Homeowner shall ad as supervisor." Many homeowners who use this exemption are unaware that they an assurrring the responnbiliti a of a supervisor(sex Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Scetion 2.15) This lack of awareness often results in serious problems,particularly when the homcowncr hirrs unlicensed parsons In this case,our Board cannot prococd against the unlicensed perrsori as it would with a licensed supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the bomwwncr is fully aware of his/her mspann'bilitics,many communities require,as part of the permit application, that the homeowner certify thkt he/she understands the rrsponsibilitics 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 curb a fonn/ccrtification.for use in your community. A � �► rti Town of Barn-stable ` Regulatory Services �,swxx %ear � Thomas F. Geiler,Director 16 Building Division 0 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 T, ,.as er of the subject property hereby authorize to act on my behalf, m all matters relative to work authorized by ding permit application for. .(Address f job) r Signature of Owner Date �- Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. ' TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY ( PARCEL ID 267 062 GEOBASE ID 16874 , ( ADDRESS 60 OLD TOWN ROAD PHONE (508)778-5654 I W HYANNISPORT ZIP LOT 36 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 29315 DESCRIPTION INT REN/VIN WIND,DRS, (WORK COMP UNDER #240451 PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: NE BOND $.00 � /,1, CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE * •ARNSTABLF, MASS. 0 9. A�O� E�Mpl I BUILDIN D Is ON r DATE ISSUED 03/10/1998 EXPIRATION DATE TOWN OF BARNSTABLE BUILDING PERMIT PARCEL IDIWJHyannisport 267 062 i7EOBA-SE `Ill " '1:6874 ADDRESS 60 OLD TOWN ROAD PHONE` , ZIP LOT 36 BLOCK ' 1/011 . Pa F BA DE tLOPMEN'T DISTRIGT HY, PERMIT 24045 DESCRIPTION INTER.RENOV.VINYL WIND.DRS.SHTOOCK/CABINETS PERMIT TYPE BREMOD TITLE RESIDENTIAL ALT/CONV e CONTRACTORS: PROPERTY ,OWNER Department'of Health, Safety ARCHITECTS and Environmental Services TOTAL FEES: , $81.�00 BOND' $.00 THEti. CONSTRUCTION COSTS .$1.0�000.00 . 434 E ID ApX)/ALT/CONY 1' PRIVATE, Pc * BARNSTABLE. #' MAft 1639. OWITER I ADDRESS BO p v: .I W HYANNISP{31 'TMA. BUILDIN • .-DIMS BY DATE ISSUED 06/27/1997 EXPIRATION DATE {,N- THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR vs'� ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF.PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS 1 PERM IT DUES NOT-RELEASE THE APPLICANT FROM THE CONDITIONS-OF'ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED o FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS ^'THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU (READY TO LATH). FANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE 'ELECTRICAL,PLUMBING AND MECH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS. "4.FINAL'INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM BUILDING INSPECTION A,P/'P_R,OVALS �rPLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS krx' 2 Sri 2 2 3 _ '' 1 HEATING INSPECTIO APPROVALS ENGINEERING DEPARTMENT 2 �.. i -�7 BOARD OF HEALTH aA OTHER: SITE PLAN REVIEW APPROVAL f WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF.CONSTRUC- MONTHS OF DATE THE PERMIT 1S ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. — l..-f�1 •r � R, I . y: I - rot• I I I f I I I I I - • ti t -_ DEPARTMENT OF PUBLIC SAFETY-D[VISION OF FIRE PREVENTIO 1010 COMMONWEALTH AVtNut. HOSTON HYANNIS r-� (City or wnT jUate of issu CERTIFICATE OF COMPLIANCE CHAPTER I48, SECTION 26F, M.G. L. This Certified that the property located at 6o has been equipped with approved smoke detectors and was found to be in compliance with Chapter 148 Section 26F, Hassachuset General Law. " Inspection/Testing completed on: 1p 1 By- tAnsp-ectdr Fee Paid: HAROLD S. BRUNELLE , C h i e f Head of Fire Department Notice: This cert:_icate expires sixt:: (60) days after :!ate .of issue. (seller' s :.opy) �lime The Town of Barnstable SAE.RNSTABL MASS. Department of Health Safety and Environmental Services t63q. �0 QED Ma+a Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection �' w Location �� �� --tz'I W n Permit Number 40 +L Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: -Ta 7 2r\. b F(2)0rz co S Gu6d QV1 Lev Li^ _©a Please call: 508-790-6227 for re-inspection. Inspected by S � � Date Engineering Dept. (3rd floor) Map . Parcel_ Permit# 6�2 House# 66 Date Issued Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30)U--2 awe- Fee Conservation Office.(4th floor)(8:30-9:30/1:00-2:00) Planning Dept. (1st floor/School Admin. Bldg.) CEFTIC S4REUS '� LLNCE efim ve Plan Approved by Planning Board 19 W1 ENVIRONMAND TOWN OF BARNSTABLETOWN r i Building Permit Application Project Street Address ,o C L rD %/fi t/Xt Z,:,z LoT 1W,3r. Village —j;�r-f,7— Owner :Di�wat�� I`Z(5 ri/v rZ Address Telephone '7 Permit Request LlN (fMLr35,) , CA® Pr s 'T/SA' F&,01Vs IR aSO.APkc-g7 Aap4 CUon -' A yur �' First Floor square feet Second Floor square feet Construction Type 1;—)p tt-rlenc S Estimated Project Cost $ %0, DUG Zoning District Flood Plain Water Protection Lot Size 3 & Grandfathered ❑Yes ❑No Dwelling Type: Single Family 2. Two Family ❑ Multi-Family(#units) Age of Existin g g Structure LA­6 _ Historic House: ❑Yes PkNo 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_a New Half: Existing New No. of Bedrooms: Existing L New _ 3 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 &U New Existing wood/coal stove ❑Yes ❑No - Garage: ❑Detached(size) Ae 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 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# 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 SIGNATURE DATE d�G/7 BUILDING PERMIT DEN FOR THE FOLLOWING REASON(S) . �V .0 FOR OFFICIAL USE ONLY s PERMIT NO. i DATE ISSUED MAP/PARCEL NO. s ADDRESS �ILLAGE *' OWNER 1 � r _ r DATE OF INSPECTION: " FOUNDATION s FRAME ,r a,a '„� �n INSULATION FIREPLACE ELECTRICAL: ROUG FINAL PLUMBING: ROUGH FINAL GAS: .RTD FINAL' FINAL BUILDING 7j , / ✓ /A ' DATE CLOSED OUP ' wtv ASSOCIATION PLA N t Y ;. The Town of Barnstable BnBxsenBM • 9eb ,a�' Department of Health Safety and Environmental Services i°rEc - Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT,CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION'. T MGL 'e. 142A requireds that I 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 certain exceptions,along,,with other requirements. Type of Work: Est.Cost Address of Work: /_0 ;Owner's Name D 13NNtJCCf ✓Date of Permit Application: /� 7 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 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 Date Owner's N e' The Cut11111011tt-c1111I! Of.Ifussachusctts • li; : Dc partnturt njludurtri+al,9ccirlcnts OffIceo/111FOS -7110nS r 600 11 aAhiginn Street Basta». A1ass, 02111 Workers' Compensation Insurance Affidavit (i ant information• PIc;,N PRINTle� ]v k—lam W • hem a homeowner performini all work myself" I am a sole proprietor and have no one workin_, in any capacity '�.... •..+�._..._-_•a...-.--....._-��•.� Mv�...f' 1�C7 �/Wr•_�ii�T-.�!+•ww.�•!�.���� w...n.�w�+..ww_.r• [� I am an employer providing workers' compensation for my employees working on this job. enmpanv name•: addresr. city nhnne#• . insurance cn. nnlicv Of [I I am a sole proprietor. beneral contractor, or homeowner(circle acre) and have hired the contractors listed below who have the following workers' compensation polices: cmmmtn,, name! arltlrrsc� phone#• incnr_nnrc ro. nniicv# cmmnanv nitric- adtlresc� ahnne#- insurnnce co policy 4 •Attach additional sheet if nlCCSSarv =• •=:'� - --•+� _ _ _ �`•'•:� ••�''^'.^`-'�'•• +•—+—=• '-��'-• --�" Failure to secure coverage as required under section 25A of AIGL 152 can lead to the imposition of criminal penalties ol,a line up to 51.500.0U andiur une i cars' imprisonment:is%%cll as civil penalties in the form of a STOP NVORK ORDER and a fine of s100.00 a day against me. I understand that a cope of this staicnictit ma% be tortva rded to the Oflicc of Investigations of the DIA for coverage verification. I do hereht•certij•tinder the pains and penalties of perjure•that the information provided above is true and correct. Si�aaturc Datc � 10�/&A? 7 Print name Phone# - ' official use univ_ do not write in this area to be cumpicted by city or town official city_ or town: permit/license# rIBuilding Department CLiccnsing hoard L check if immediate response is required selectmen's office ► E311calth Department contactperson• phone#: -Other 1. information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compettsation for tl employees. As quoted tront the an einpluree is defined as every person in the service of another under am contract of hire, express or implied. oral or written. An emplarer is defined as an individual. partnership, association. corporation or other legal entity, or any two or me the fore�_oin�_ en��a`_ed in a"joint enterprise. and including the le`_al representatives of a deceased employer, or the recen,er or trustee of an individual , partnership. association or other legal emity, employing employees. However owner of a dwelling_ house haying not more than three apartments and who resides therein. or the occupant of the dwclling house of another who employs persons to do maintenance , construction or repair work on such dwelling ! or on the _,rounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo., MGL chapter 152 section 25 also states that even.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•. 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 been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation atic 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 city or town that tite 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 require to obtain a workers* compensation policy. please call the Department at the number listed below. I City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P1 be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returnee the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questic please do not hesitate to give us a call. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts 4 ; Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone L: (617) 727-4900 ext. 406, 409 or 375 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. . ,�E JOB LOCATION � ,� �Ip Sao 7�- Number Street address Secti n of town HOMEOWNER" ?y C .e cs�-cn ClJ tS / _,53 s Name Home. phone Work phone PRESENT MAILING ADDRESS dJk XS Ci y town State Zip cods The current exemption for "homeowners" was extended to include owner- occur-dwellings of six units or less and to allow such homeowners to engage an is dividual for hire who does not possess a license, provided that the owner acts as surervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to side:, on which there is, or is intended to be, a one or two family dwellinc attached or detached structures accessory to such use and/or farm structurE A person who constructs more than one home in a two-year period shall not t considered a homeowner. Such "homeowner" shall submit to the Building Off_ on a form accaptable to the Building Official, that he/she shall be responE for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requireinen-_ and that he/she will compl ith said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be requires to comply with State Building Code Section 127.,0, Construction Control. T tz v RACE d LOP" 55 TOWn R°°pg, 131) w �' ................. (19 p1. 8k. 1 9�d®) y ( (40 h B.R.B. Fnd. ET C.B. Set - o Held V 1, 07-23-2-009 S o Existing c Barricade o s 36' Fence 0 112' r (Typical) m o C.B. • i 0 Fnd ....... 0,5 1< ry Pan k 85 ro Hub Stake /^. P,g, 105 — & Tack. Set s -2012-09-18 Existing Stone r (typical) 1 � Dec l< Proposed 8' k 'o� 6 - 14' Shed ` � tin9 � EnEris. , Z -' . . *44 StorY Lot 36 Rf e pWeliin9 Pl. Bk. 85, Pg. 105rx Lot Area 12,.107 S F.f v :3 o • '' or 0.278 Acres ` En c -' 107.24 162. Set o 0 .07-23-2009 Q " .J , y , 41 a r TERRY WAYNE ELDREDGE C.B. ;SEt � No, 3 d 07-23-2009 Doter 09-19-2012 - - — -- - Scale.•. I- = 20- Project No.: 0 20 40 60 b-1697-020 Sheet No ® Copyright LLC `1697 020 Site-Pion:2012dwg of f . X:1Archive 2011\1697 020 -Greenblat-Old Town Road. t3arnstable\1697 020 Site Plan 2012.dwo