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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 Please Print Legibly
Name(Business/Organization/Individual): L)fi16_C f-
C
Address: P,O _
City/State/Zip:(� )IY4 C3,-A(, a Phone #: SQ?)- _1 1 S - QS 1 ry
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4. ❑ 1.am a general contractor and
— - - 6._❑New construction_
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' HE Other
comp. insurance required.]
•Any applicant that checks box#I 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 their workers'comp.policy information.
1 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.#: Q$1., eC R T't!d,1L1 __ Expiration Date:
Job Site Address: a-i `i'"f"p 1m LIA(>E_ City/State/Zip: Plpfw5
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.
1 do hereby c ify under the ains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: 3
Phone#• '509 O 751(1
Official use only. Do not write in this area,to be completed by city or town gf ciat
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#:
APR, 23, 2013 8; 28AM HART INSURANCE NO. 735 P. 1
CERTIFICATE OF LIABILITY INSURANCE °A ; /z4;3''
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(ie5)must bo 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 endorsemen s.
PRODUCER HART INSURANCE AGENCY,INC. KIT 4aura,l Murphy
243 MAIN STREET
PHONE 508.769-7326 X207 FAX No):508-759-7366
PO BOX 700 ADDRESS, Imurphy@hadinsuranceagency.com
BUZZARDS BAY,MA 025320700 INSURE S AFFORDING COVERAGE NAIC K
INSURER A: ARBELLA PROTECTION INS CO 41360
INSURED Briggs&Heino Plumbing&Heating,Inc. INSURER n3; HARTFORD CASUALTY INS CO 29424
PO BOX 538 INSURER
CentaMlle,MA 02632
INSURER D
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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. NOTMTHSTANDINO 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 13Y 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 TYPE OF INSURANCE URR POLICY NUMBER MPM13h Yrvr POUDY EXP LIMITS
A GENERAL UAVILITY 8600058309 02W2013 02/22/2014 EAcH OCCURRENCE S 1,000.000
COMMERCIALGENERALLIABILITY EMI ET0 , [[� a 300,000
CWIM9-MADE 17 OCCUR MED EX P one yemn 5 5,000
PFJRSOWL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PERt PRODUCTS-COMPfDPgGG 5 2,000,000
POLICY JECT PRO LOC S
A -AUTOMOBILELIABILIiY 1020008627 09/11/2012 09/11/2013 00 E IN LE LIMIT 1,000,000
kHlRrDAVTOS
O BODILY INJURY(Per person) s
ED SCHEDULED
AUTOS BODILY INJURY(Porayal0B11<) S
AU OSNON-OWNED PRD MADE•ALIAU OCCUR 4600058318 02222013 02/22/2014 EACHOCCURI3ENCE 5 1.000,000
IA6 OLAIM3MADE AGGREGATE S 1,000,000
RETENTION$5,000 $
B WORKERS COMPENSATION 08WECRJ6614 DUM2013 02/22/2014 we TArL> ern.
AND EMPLOYERS'LIAMUTy Y I N
ANY PROPRIMBER,EXOWER/EJCECUTIVE ® NIA A EL EACHACCIOENT S 500,000
OFFlCERlMEMBIRI7CCLUDE07 ,
(MA 0awry in NN) Jr E.L.DISEASE.FA EMPLOYEE S 500,000
byyees describeunaer •
DwdRIPTIONOFOPERATA'INSbeIDw E,L.DISEASE-POLICY LIMIT i 500,000
DESCRIPTION OP OPERATIONS I LOCATION$F VEHICLES(AMach ACQRp 701,A1lERIOnal RamarRa Schedele,Nmorq,:p�og le nqulre�
Operations as performed by Terms&Conditions in the policy
CERTIFICATE HOLDER CANCELLATION
Fax#:(508)$62-4717
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
230 SOUTH STREET ACCORDANCE WITH THE POLICY PROVISIONS.
HYANNIS,MA 02601
AUTHORIZED REPRESENTAVA
01988-2010 ACORD CO�Auoh,.reserved-
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Jun. 2U. 2013 11 : 12AM.. No. 54'94 P.
Town',0f B arjI8fble
Regulatory 86Mce
KAM x'honias F.GeHe'r,Director.
i6s� SazldrnLr-D sibti
xom)Periy,Building Commissioner_
200 Main 5freoi;Ryan*MA'02601
_ - . , i�^ww:town.b-arpcfiable.ma.ns- ' • -
Office: 50.8490-6230
Property Owner Must
....Complete acid Sign,TMs Section
If Usinp"A Buitder ;
i::�TOi1 00 n 6,S ;m Ownelt of the subjectpropefty
hercbp sat orize it/fir� �7�/ ��• �7`/C� �'�t� to act an my behalf,
in all=ttm relative to-work authorized by this building pr-ml
(Address of Job}.
Pool fences.and alarms are the responsibility of the appf,cant. Pools
are dot to be filled or utilized Before fence is ihs, talled asad all final
in-spections are petfouned acid accepted.
true o es S' tare of Applicant' '
Nut Namc tint Namc
Date : .
r
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 310 Parcel /O/ Application 4�90 3 D 9 d
Health Division Date Issued
Conservation Division Application Fee J
Planning Dept. Permit Fee 1 rn l��
Date Definitive Plan Approved by Planning Board ESIC S t—r 3 PP
Historic - OKH _ Preservation/Hyannis
Project Street Address .Z � �i 6/,/m Lg 4 e
Village /T Ya44/1
Owner C'Lr Ato4 Jo eS Address k 601110Q1114 Ah
Telephone ce/! 791 90W a/�
Permit Request if em opem 9 m fodloll d,-cq y Se o� yal 51Ro k ` 419s e,
lmenle/^ P/M -1 �'�rva/L i /nr��g��oh one/ h nerlw
Pcry'iGG gc-*G,,,y4 or4J 61 cor t1,1cre/'S /T 4eedV
6//1 el:
Square feet: 1 st floor: existing G,?/ proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 2-/ a d Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes A No On Old King's Highway: ❑Yes O:No
Basement Type: ❑ Full Jai Crawl ❑Walkout ❑Other C7 S? C)
Basement Finished Area(sq.ft.) Basement Unfinished Area ( eft)
Number of Baths: Full: existing / new Half: existing =' now
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing S new First Floor Ro m Count
Heat Type and Fuel: 94 Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes No Fireplaces: Existing / New Existing wood/coal stove: ❑Yes No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
'Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name] 11 jaHCf Telephone Number 7rl 36 7 5"2J 4
i Address .-Yf License #
R6y/'Lt?? rog Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
J
SIGNATURE DATE L fF 2�/�
4
FOR OFFICIAL USE ONLY
r.
s ✓
r--
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
q f
DATE OF INSPECTION:
-FOUNDATION_.
FRAME
t
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
r
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. .�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
i 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organi tion/Individual): af-cra q '74 4C'S
Address: 51r
City/State/Zip:.. 0le0 Phone#: 78/ 367 SZ/
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a em to er with 4. I am a general contractor and I
P Y 6. ❑New construction
employees(full and/or part-time).*
have hired the sub-contractors
2.El I am a sole proprietor or partner- Listed on the attached sheet. 7. XRemodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers'comp. insurance comp.insurance.$
required.] 5. 0 We area corporation and its 10.0 Electrical repairs or additions
3.X I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.[1 Other .
comp. insurance required.]
*Any applicant that checks box#I.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.
tContractors 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.Lie.#: 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$1,50.0.00 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 pains and penalties of perjury that the information provided above is true and correct
Si mature: Date: 2.9 ZDI
Phone#• 7 V 3 6o ;lr S Z I /
Of 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.ElectricaI Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
t
Information and .Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee.of an individual,partnership, association or other legal entity,employing'employees. However the'-
owner,of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on.such dwelling house.'
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean 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 maybe 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
fiat must submit multiple per:nit/license applications in any given year,need only submit one affidavit indicating current.
policy information(if necessary)and under"Job Site Address"the applicantshould 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 4-24-07
www.mass.gov/dia
� tT Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
mils.
9g, 16.59 Building Division
pTED MA'l a ..
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.b arnstable.ma.us
Office: 508-862-4038. Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: Z ` LGHe �T 9 yff �1'
number street village
•`HOMEOWNER": cl—A N d 04 elr 7F/
name / home phone# work phone#
CURRENT MAILING ADDRESS: 7 LC'xl rax
I3U�l��cgrer� /yl/� WSo-F
city/tOVA 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 permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
SipatuyCof Home er
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. I
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:forms:homeexempt
c
oF�E Tom, Town of Barnstable
ti
Regulatory Services
* snxxsr�sr.E,
nsass Thomas F.Geiler,Director
iOlFo,�na'�° 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
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
**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
Print Name Print Name
Date
QTORM&OWNERPEPOMSIONPOOLS 62012
i
27 Pilgrim Lane, Hyannis, MA
On Saturday the 201h of April 2013 four houses were set on fire by an arsonist. 27 Pilgrim Lane was one
of the four homes. The fire damage was confined to a kitchen cabinet the counter top above it and the
gas stove beside the cabinet.
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Extent of fire damage was located to Kitchen Cabinet.
There appears to be no damage to the structure of the house. However,the smoke and soot permeated
the entire house. To remove the present and possible future smoke odor,the interior woodwork,
drywall and insulation needs to be removed. The frame needs to be cleaned and sealed. Then the
insulation, drywall and woodwork can be replaced.
I need to have a licensed electrician certify the integrity of the hose wiring before Nstar will replaced the
electric meter that was pulled during the fire. I have some concerns about the in wall and in ceiling
wiring near the site of the fire. The over the stove microwave, recessed lighting above the counter and a
ceiling light in the adjacent utility room suffered some melting of plastic parts. The condition of the
electrical wiring to recessed lights, ceiling light fixtures and in the wall behind the kitchen cabinets need
to be exposed, evaluated and replace as necessary by a licensed electrician.
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Melted recessed LED light.
The copper piping to the kitchen sink was blackened by the fire and the PVC waste piping may have
suffered some meltirg. So the supply and waste pipe needs to be exposed.Evaluated and replaced as
necessary by a licensed plumber.
61 owo,00-0
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Plumbing inside kitchen cabinet that may have been compromised.
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While the house is open to the framing, it would be advantageous to replace the old gas furnace and
duct work with new more efficient equipment,than to just clean the existing HVAC equipment.This will
be done by a licensed HVAC contractor.
Item Description Estimated Cost
Demolition and Dumpster $1,000
Electrical work $1,200
Plumbing work $1,200
HVAC Furnace and Duct replacement $10,000
Insulation and vapor barrier $1,500
Drywall installation $2,500
Replacement of woodwork $1,200
Kitchen cabinets and countertop $1,500
Painting $900
Estimated Total $21,000.00
PA /
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Pam"
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Town of Barnstable
oFTME Regulatory Services
Thomas F.Geiler,Director
Y Y
BARNSTAB
' SS.MAs� ' Building Division
�
.eT 1639. ,0� Tom Perry,Building Commissioner
FO M1►�
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
L" 0
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ffffice�08-862- 038 Fax: 508-790-6230
F—
csy
c PE-RMIT# ' (0 6I FEE: $
SHED REGISTRATION
200 square feet or less
Z 7
Location of shed( ddress) Village
CLI4roh J-e4 PS 70':I 167 S.2I'V
Property owner's name Telephone number
8 X /2 3 /0 //a l
Size of Shed Map/Parcel#
�-.41 Lvlw / 2-all
Sign ure Date
Hyannis Main Street Waterfront Historic District? .
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature is required) C�
Sign off hours for Conservation 8:00-9:30&3:30-4:30
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
Q-forms-shedreg
REV:042911
Town of Barnstable Geographic Information System May 31,2011
Tit'r
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& l��i?•�° 5° '�'b b F��� 0 r^�
DISCLAIMERS:This map is for planning purposes only. It not adequate for legal Map:310 Parcel:101 Q
boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel W+
1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:JONES,CLIFTON T Total Assessed Value:$120400
are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner Acreage:0.14 acres Abutters E'
boundaries and do not represent accurate relationships to physical features on the map Location:27 PILGRIM LANE
such as building locations. Buffer
n�
Town of Barnstable Permit#
Expires 1 onths rom issue at
Regulatory Services Fee 419I
BARNWABLE, Y
9� b. Thomas F.Geiler,Director
ArE'D PAA'I A
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
n � Ivy
Map/parcel Number t
Property Address 2 -7 P11c,111n
%Residential Value of Work 50 t�) Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address C L rf ro/1 J d r)es
9�d,4 Sr /yr llAJ ro4 IYA o W2
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
RE
❑Workman's Compensation Insurance
Check one: J U L 2 7 Z O 10
❑ I am a sole proprietor
lam the Homeowner TOWN OF BARNSTAB.1,E
I have Worker's Compensation'Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
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 �j
II #of doors L-
Replacement Windows/doors/sliders.U-Value AT, (maximum.44)#of windows
*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.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QKIH716E\EXPPESS.doc
Revised 070110
r
a r-
the Commonwealth of Massachusetts
Department of I idustrial A ccidertis
ti1flwe of Investigations'
- 600 Washington Street
Boston,AL4 42111
i m�tv.ma-&Lgov1dia
Workers' Compensation Insurance Affidavit: B,folders/ContactorsfEd'ectrieian,&Mttmbers
Applicant Information Please Print Lezibly
Name(11m messloaaamzatwn udividuai): C L AO—A La1
Address: ZR�MZeLi d1 SAC
City/State/zip v i/1 r'o/! N4 0/g&43 Phone#. ?g/ 361 51/4
Are you an employer!Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am general contractor and I
b. ❑New construction
employees(fill an for part-time).* have wed the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
work' for me.in an capacity. employees and.have workers'
� y � ��''• 9- ❑Building addition.
[No workers' comp.insurance cow.insurance:.;
required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3AI 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.]I c.152, §1(4},and we have no
employees.[No workers' 13.0 other
comp.insurance required]
*'Any apphtant that checks boa#1 most also fill out the section below showing their workers'compensardon policy Wbrmation.
I Homeowners;wbo submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a nea,affidnit 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
etaplogees. If the sub- anuactors have emplopeea,they must provide their workers'comp.policy number.
I afar art emptoger that is protriding ttwrkers'comperisation insurance for my.emph7jwes. Below is the policy arrd job.site
inforivation.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration hate:
Job Site Address: 411M 44 C City/State/Zitr-
Attach a copy of the warker 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 criminaI penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as cit it penalties in the form of a.STOP WORK ORDER and a fine
of up to$250M a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification-
-------- -------- _-_ ---_-_-----------------
I do hemby certify ruder t1teprains and penalties o,,fperyttry that the iuforatation prinided abotre is trace.and correct
Signature: Date:
Phone#;
Official use onto'. Do not write in this area,to be completedd btu city or town o2icial.
City or Town: PermitfLicense#
Issuing Authority(circle one).
1..Board of Health 2.Building Department 3.City/Towm.Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
- b
�tH Town of Barnstable
Regulatory Services
� r
9B^ MASS. Thomas F.Geiler,Director
��FDpAC'IA`� 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
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: /� r
JOB LOCATION: � 7 ������/�r � �y J
/�numbeer st eet village
"HOMEOWNER": /
"HOMEOWNER":HOMEOWNER": ` L r4ra j j O/) y�t/rr / 1/y) .20 FAY 7 57 ?y 7
name home phone# vAefk phone#
CURRENT MAILING ADDRESS: ` j y ctil
MA 01,'o3
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 permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures nd requirements and that he/she will comply with said procedures and requirements.
Signa a of Homeowne
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.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QK1H7J6E\EXPRESS.doc
Revised 070110
= ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION '
U� C� W
Map v Parcel Application #
Health Division Date Issued (:.0
Conservation Division Application Fee I'
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address 2,7 J911y0&1 Leh e
Village lya n�1S
Owner CC,-4fon ;5y_,^P5- Address W L,Pzr,7:27w Sr 13vr1ia9ry4 A14
Telephone 7?/ 3 G 7 SZ/`f
Permit Request 9'117- 117 rr 'ryUTAII /e0eZa4-1h9 147`r11or o�do�f
/c eza c1o�4 tifi f,:n ie tLda��/lg t�cp�/r: ¢T k
e�4/1, -va
Square feet: 1 st floor: existing O proposed 2nd floor: existing O proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation ���� Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure t _a4i Historic House: ❑Yes ANo On Old King's Highway: ❑Yes No
Basement Type: ❑ Full Crawl ❑Walkout ' ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) CS!f
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: 2 existing _new
Total Room Count (not including baths): existing 5 new First Floor Room Count
Heat Type and Fuel: )A Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn 0 existing 4 0 new.;; size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other v
.a�
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ .,
Commercial ❑Yes 4No If yes, site plan review # .a
--Current Use - - - - Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Nana CZ l41ddl �a4 P5 Telephone Number 791 36 7 SZ ,lq
Address W LeXi1iYfio, License #
&,r ra/7 AIA a/ga2 Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE L DATE a �O,/�
r
t - FOR OFFICIAL USE ONLY
. .. :,...ter►
r APPLICATION#
r
DATE ISSUED
MAP/PARCEL NO.
` ADDRESS VILLAGE
l
j OWNER
t DATE OF INSPECTION:
4 : FOUNDATION_ j
3 FRAME
z '
ti
INSULATION' t
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
-IGAS:� ROUGH €-t!;N ' = FINAL
<,,FINAL BULL-``DINGfa-;L:•"41
DATE CLOSED OUT t
1' ASSOCIATION PLAN NO.
" The Commonwealth of Massachusetts
• - Department of Industrial Accidents
-r
Office of Investigations
600 Washington Street
l� Boston, MA 02111
yy www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information PIease Print LeEibly
Naive (Business/Organization/Individual): C 1,4rpn t7d4ef
Address: ex toa ff
City/State/Zip: I` o Al OXO Phone #: 78'/ 3,�y S1/
Are you an employer?•Check t e appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and 1 6. ❑ New construction
einpl6yees (full and/or pant-time).* have'hired the sub-contractors
2.❑ t am a sole proprietor.or partner- listed on the attached sheet. 7. M Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
workingfor me in an ca aci employees and have workers'
Y P tY� 9. [] Building addition
[N.o workers' comp. insurance comp.insurance.$
required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions
3.X I am a homeowner doing all work officers have exercised their 1 LE] 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' 1.3.❑ Other
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workcrs'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 workcrs'comp.policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti jab site
information.
Insurance Company Name:
Policy# or Self-ins. Lic. #: 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 for insurance coverage verification.
I do hereby certify tinder the pains andpenalties ofperjury that the information provided above is trice and correct.
Si nature; -ate.
Phone#' 7LD , 47 571
Official tcse 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#:
hformation and fnstructzons
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 a❑ individual partnership, associalion,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, constniclion,or repair work on such dWe1]ing house
or on the grounds or building appurtenant thereto shall not because of such employment'bc deemed to be an employer.'
MGL chapter 152, §25C(6) also slates 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 ofits political subdivisions shall
enter•into any contract for theperforrnance ofpublic•Work until acceptable evidence of compliance with the insLUance
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-contraclor(s)name(s), addresses)and phone munber(s) along with their certificate(s) of
insurance, Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
rnembers 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 th•e affidavit. The affidavit should
pen e thnit or license is being requested,not the Department of
be returned to the city or town that•ihe application for
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 bas to contact you regarding the applicant.
Please be sure to fill in the penniUlicense 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 a davit indica ting current
' policy information(if necessary)abd under"Job Site Address" the applicant should write"all locations in
_(city or
town),"A copy of the affidavit that has been off
officially stamped or marked by the city or town Jay be provid e d to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavi t'must be filled pt1 t each
year. Where a home owner or citizen is obtaining a license or permit not related to any businessor commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this afliidavil.
The Office of lnvestigations wou�like to-LJi�n yob i�d f �-0 coopPratin� and show➢d shave any questions,
please do not hesitate to give us a call.
The Deparlment's'add.ress, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InYestigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
Town of Barnstable
Regulatory Services
t > tuv�tist� Thomas F. Geiler,Director
MASS.
Building Division
PrEa►nay a
Tom Perry,Building Commissioner
200 Maiti Street, Hyannis, MA.02601. _.
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEWNER LICENSE EXEMPTION
Please Print
DATE:
JOB VOCATION: .27 /1/^gym Zan e
number strr=t "village
"HOMEOWNER": CG 176 o4 �dl&f 761 .L71 If 2 � Tel ��/ 5�2 J174
name home phone# arkp hane#
cell
CURRENT MAILING ADDRESS: �� Lax/rl9 rah ST
/YI/4 oi�o3
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.
D&INZI ION OF EOMFOwT\'ER
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 sinrctures accessory to such use and/or farm stnrctures. A
person who constructs more than one home in a two-year period shall not be considered a bomeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building?permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws, rules and regulations.
The undersigned"homeowner"certifies that.be/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/sbe will comply with said procedures and
requirements.
Signer 'rc of Hom cr
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 pcmvt is required shall be exempt from the provisions
of this section.(Section 109.1.1 -Licensing of canstruction Supervisors);provided that if the homeowner engages a pason(s)fir hire to do such
wofk,that such Homcowncr.shall act as supervisor.,,
Many homeowners who use this exemption are unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q,
Rulcs&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 hDMWWner is fully aware of his/her responsbilitics,many communities require,as part of the permit application,,
that the homeowner certify that he/she understands the msptmsibilides of a Supervisor. On the last page of this issue is a farm currently used by
several towns. You may care t amend and adopt such a form/cmifieation for use in your community.
Q:for7tts:homccxcmpt
1 q
-VKEr�ti Town of Barnstable
i t Regulatory Services
p Huss $ 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
Property.�v r e,"Must
,Complete and,Sign-This Section , t
.a} If Using ABuilder
I, C L►4-Oli -7di7 V-s , as Owner of the subject.property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O WNERPERMISSION