HomeMy WebLinkAbout0092 PITCHER'S WAY �� I
C
I'
OxforV
d NO. 7521/3
ESSEL`TE 10%
Town of Barnstable
BARNSlABLE.p` Regulatory Services
9 MASS 0
`6A i639. Building Division
ren Mpy a,
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230
Inspection Correction Notice r
Type of Inspection
Location 9 7 P- 1, c s LsJa Permit Number
i
Owner Builder
One notice to remain on job site, one notice on file in Building Department.
rrT``he following items need correcting: /
�J
kP 1 c; % S IM"', 2 Q ne ra. C' S
C ec'Tc' 1�1v� Tom; �'�IOW (.tAa'CC-C- (' J;Je_)
J
Please call: 508-862-4038 for re-inspection.
Inspected by ���'.c t . �
Date
i
• - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
0(�,o ® APplicatiMap Parceln 4
Health Division Date Issued U
Conservation Division Application Fee
Planning Dept. Permit Fee &o
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/ Hyannis
Project Street Address / 2 P/t tc/I ele5
Village#yj4 YJ N��5
Owner Dells o r t, /jo vru" AddressYy
Telephone S o 9--77S_833 f
Permit Request r3oii b _SLR' 7ce-� 7 Y
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type �✓� n
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 ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑'Yes ❑ No
o Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn ❑ existing ❑ news 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# -0 nil
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name A:YZD6t1Q Telephone Number <9 7 o:7
1� C'S
Address /D d 6L U L o �f2 � �����. License # l 735
I<f�� Nw S Home Improvement Contractor#
Worker's Compensation # AVIA_
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 13A1vu5n;4gLr
SIGNATURE Gull — DATE
t
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
// II
FOUNDATION
FRAME
INSULATION
FIREPLACE
J
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH ,j FINAL
FINAL BUILDING holid, kA,
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Co mill 0rr Wealth of MassachusetyS
DeparYmerct oflndustria1,4ccidenfs -
Office of rrtvesdgrrtion.s,
600 WashOzgton Streel
Boson) AYL4 021JI
'. �ls�l-p.tnass'.gov/dia •
Workers' Compensation Tnslzrance Affidavit;•Builders/Contractors/EIt;ctyiciansf Iutabers
. Please Pant L
` AppLlcant Info rmattori
Name (SusinosslOrganization/Lndividuel
77�m310�.
City/State/Zip: �{ ./ r+/IJ 1s, &2, 6 y Phone.#:
Are you: an employer? Check the appropriate bor: Type or project(required):
1.'❑ l am a employer with
4. 0 I-am a general contractor and I 6 Now construction
cmployccs (full andlor part-time).* Hstc hired the s chr-d shzrtors RCmodcling
2.� l ama'solc proprietor or partner- listed on the attached sheet ❑
Tlieso sub-contractors have g• ❑Demolition
ship and have no employees
working for ma in any capacity.
cmployces and have workers' 9 [j Building addition
comp, insuzance.�
[No workcrs'•comp.•insvraucc 10.[]�Elcctrical rcpails or additio
5. [] We are a corporation and its
r�qu�rcd] ot�i.ccrs have exercised their 11_❑Plumbing repairs or adtiitio
3,FT I am a homeowner doing all work right of exemption per 1v1GL
rnysoll; [No workers' comp. 11E]Roofrcpairs
c, 152, §1(4), and we have no
inhu-ncc rcgiurcd.]t 13.0 Othcr .
employees. [No workers'
comp, insurance required.]
'A-by applicant that choel=bor tt1 trust also fill out the roetion below showing their workum' compczvv4 on policy information. ;
t 1-lomenwotrt who rubroit this s$idavit indicating they arcing
all work and that hire outside contraclnr5 must submit au nw agdavit indi eating such.
rContraeinrs fiat check Er box Irnrst attached m additional rhea showing the name of the sub-conl -tars and rain whether yr not those tntities have
t,they marl pravidb their workers'comp.policy number.
employers• if the subcontractors have employce
T am an employer tltd is providurgworkers'coiripensatinn insurance for my ernplayeeS� BelarV u•the policy artd job sile
' information. - •
Insurance Company NamL:
Expiration Date:
Policy# or Self-ins. Lic.#:
Job Sitc Address: City/Stkc/Zip: -
Attach a copy o (
f the comprnsati'on policy declaration.page showing the policy number and expiration date}
Failure to secure covarago as required under Section 25A of MGL c. 152 can Iead to-the imposition of criminal penalties of a
find Lip to 31,500,00 indlor ono-year irrprisonrnent, M well as civil penalties in the form of a STOP WORK.ORDER and a ti
of up to $Z50•DO a day against the violator. Be advised that a copy of this statr-mcrit may bo forwarded to the Officc of
Invcsti ations of the bIA for inspr-ancc covers c vcrif cation.
I do hereby certify under the puins•and perialttes ofperjury tAaf the inforntaiion provided above is true and corre-ct
Datt: G —
Si stare:
Pbone #: �� — 7 v
Dffccial use only, Do not wrlle inth' area, to be completed by c'lfy or town'offictal
City or Town;`
PernvtJL
icen #
Issuing Authority (circle one):
l• Board of Health 2, Building Department 3• Cit-y/Towm'Clerk #. Electrical inspector 5, Plumbing Inspec{or
6. 0ther
rue Ions
Information and Inst '
Massachusetts Gcneral Laws chapter 152 requires all employers to provide or ofsanotb r ndaroa'ny o �
contract of hdir,es:
pursuant to this statute, an ernptoyee �s defined as ...every person in
express or implied, oral or written"
hi sociation, corporation or other legal entity, or any two or more
An en-cptoyer is defined as "ao individual,partncrs P, as
of the foregoing engaged in a joint entzrprisc, and including the legal rcprescntatiYes of a deGeasiod c�1H vcrhtho
receiver or trusteo of an individual,paiton association or other legal entity, employing mp y
or the Dc�cuPant Of tho
owner of a dwelling Douse having not more than three apartmcnand who �neo tcpacrcirwo k on such dwelling bDUSt
dwelling house of another who cruploys persons to do mint n ,
ng applirtr-nant thereto shall not because of such employrmcnt be deemed
or on the grounds or buildi to be an employer."
MGL cbaptcr 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or,
in the
reLleQYai of a license or permit to operate a busl ence of tom li nee�sith theess Or to construct slnsuranceco erag��q�d.for Y
appllcantwho has notprodu2, §2-5 ceptable eYld P
AdditionaIly',MGL•ohapGcr 152, §25C{7)states 'Neither the commonwealth nor any ofits political subdivisions shall
enter•into any contract for.the performance ofpublic work acup�lc widener, of compliencc Rath the insurance
requirements of this chapter have bccn proseated to the contracting authority.
Applicants•
' sation affdavi.t completely,by checking the boxes that apply to your situation and, if
Please fill out the workers co mpen.
nocessaz � supply sub-contractors)namc(s), address(es) and phono numbcr(s) along with their ecrti.EG tc(s) Of
with
insurance. Limited Liability Companics(LLG� or Limited Liability na n insurance.c. if an)LI.0 oroLLP doeschavC than c
mombers.or partnors, arc notraquircd to carry workers comp Of
employees, a policy is required. Jac advised that this affidav 5t ma tbe
sub nd date tha aaffldvit.ntThe a•ffidEytlshould
Accidents for confirmation of insurmcc coverage. Also b sign
bo zeivrned to tho city or town that the*application for.tho permit or license is br if ocinaga=guts cd ton bnIl a Pam x of
Indushrial Aceidents. Should you hay e any quRti tt�hc gardi glitho l below.. Self-insured ompamCS aouldcnter their
compcnsalionpolicy,plcaso call the pepartm
self insuranp license number on tho appropziatc lino.
City or To-KP OtIlclab;
Please be sure that ihe affidaYitis'ce bottoza
omplctc and printed legibly. ThcDcpu menthas Pro aiding thcapp>lcnnt
of tho atfi.davit for you to fill out in the event the Office of Investigations has to contact youre g
Plcaso bo sure to fll in the permit/liccnsc numbcx which will be
cdarsn cd only s'ubmircncr tonc�der. In alvit indicating current
that must submit multiple permiVliccasc applications in any gr y , in
policy information(if peccssary) and under"lob Silt Address" lho applicant should write"all locationsro ded tho or
d or Mix
town)."A copy of the aid affidavits on filefoxfuturc pcerzioits okccnsasA nowoaffidavitmust bo Glled out each
appvra nt as proof that a v
year..-Whero a home owncr or citizen is obtaining a license or ppmiit not related fo any business or comm.crcial vcnturo
(i e. a dog license orpermit to burn leaves etc.) said p'ersou is NOT requirod to comoplcte this affidavit,
you in advance for your cooperation and should you baYc any que
Thv Office of Invcstigabons would lake to thankstions,
please do not hesitate to give us a call.
Tlic Department's address, tcicpbone•and fax number.
T b C6mmoRw(-, a.th at'MassachusOtts
1�ep rt�nrrnt of kdi s�O A.ccidr<nts
Office of Iuestigatioas
60Q Wa--in ton Street
$pstan, MA 02111
TGI; # 617-727-4WO ext 4-M pr 1477-MASSAFE
Fax# 617-727-7749
Revised 11-22-06 ! ww-.mas•s.gov/dia
oF�H�r Town of Barnstable
R.egul2tory Services
1A3'NSTA13LE, ' - Thomas F. Geder, Director
�. ,
t6s� - g
Buildin Division
Torn Perry,- Building Commissioner
200 Main Street, Hyannis, MA 02601
www.toivn.barnstable.ma.us
Office: 508-862-4038 Fax: 509-790-62_
s •
Property ®- nct Must
Co-mpitte and Sign This Section
if Usiaig .A Buildei
a
V, , as Owner of the subject property
n
hereby authorize a v►a 6 4 .Q 9' '� S �— to act on my behalf,
in all matters relative to work authorized by this building perrnit applicatiDn for:
(Adci.ress of Job) -260 1
I LJ61 b 0
�-
Sig-aature'of Owner Date
Print Name
If Property Owner is vapplying•for perrnit please complete theHomeowners License ,
EXC M -6 0n Por1A on th'e reverse side. .
Town of Barnstable
ofJHE rp�y�
Regulatory services
Thomas F. Geiler, Director
BARN TAaLE, .
MASS - � Building Division
sa7p'
PT'ED µPt" Tom Berry,Building Commissioner
200 Main Street, Hyannis, MA 02601
/ wwSY.town'b2r list able.ma.us
Fax: 508-790-6230-
Office: 508-862-4038
B0njEOwnT,.R LICI;NOSE ExEMPTTON
please Print
DATE:
10I3'LOCATION: street Village
number
"HOMEOWNER": home phone work phone#
name
N
CURRETIT MArLINO ADDRESS:
city/town
state zip code
ss and
The current exemption for' owners"was extended o include
not Pner
osses a Ic n 6,roina d tha the owner acts as
to allow homeowners to engage an individual for hire who does n p
e isor. VNER
su rY ftOhiE01 ,
DEFII�I-PION OF '
litended
to
-
I erson(s) who owns a parcel of land on'which he/she resides or atends ceesso o r touch use and/or itic, oil which sefarm sti•uctures A
be, a one or two-family dwelling, attached or detached structures ry
shall not be,
person who constructs snore than one home ui a on.a formta d eptable to the Building Official, that hcs he shall be
"homeowner"shall submit-to the Building official
res onsible for all such work
performed under the buildingcmut, (Section 109,1.1)
onsibility for compliance with the State Building Code and other
The undersigned "homeowner" assumes zcsp
applicable codes, bylaws, rules-and regulations,
Th'e undersigned "bomcowlier" certifies that he/she understands/sh hc i j co P nwithtsaid procedures and
minimum inspection procedures and requirements and that
requirements,
t
Signature of Homcowncr
Approval of Building Official
ng 35,000 cubic feet or larger will be required to comply with the
Note; Throe-family dwellings containi
State Building Code Section 127.0 CobmcHon Control,
O).EOWNER'S EXEMPTION \
The Code st+trs that "An )York for which a building permit is required shall be exempt from the provisions
of
this secdon (Section 109,1,I -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work, thal such Nomeojrncr shall net es supervisor," the res onsibtlitics ore supuvisor(sec Appendix Q,
},,tarry Tomeowncrs who use this exemption Are unaware That they are assuming P
articularly
ness
Rues &'Regulations for Liecnnensedn c onsonin thiss case,s,.Section our BDafd in>of p This
rocc do ga nstethe unl`eensed personen rcs-ots in a soil wouldus Hitltp lirenaed
when the homeowner hires unite p
supervisor. The homeowocr acting as supervisor is ultimately responsible,
To cnsurc'thal the homwwna tcrsla fully
nds(hc rcosponshbilt'tiCT cs ofsa Slupervi or,many0n the 1 si tics, Il ipagc of this&isssue is parl o atform Rhe permit ppiication.
an iy used by
that the homeowner eertifythat hdshe and — r/r.,rn;F)eation for use in your community.
J �
Q J
Q
�4 a
qq J
GA
U .o
'l�J• AvBiLWC7 � `. I
FND EL-'97.o
I . /
AL
�4 �T.lC O jI
H
(]
IL
(4c,wlo� - 19�9
Tow +?��E�c�.�.
IsriNv LEGEND
+Sri
!)SHE 0 C0"OUREvarION Oxo � H Or
ISHED co°NT ELEVATIO "- °� - �� CERriFiE �-
0 U R ---._.. 0 `� PLOT
)ROVED � 60 wE,N . Loy E p PLAN '
BOARD OF HEALTH � i"A N0 3b. 1 T
H I �>-fe Q,s
Ov
AGENr
CGrsTERE EEC/NG co /N SCALEt
r►►.l, ,Q" C�iE�tr u,,-,. . . DATE
q �
N
Cf� -
s
m
c
0
r
0
u
J
V
00 _
opt
uf
r
d
y
_ a
(�• �1q tR,S�tRrNg2Qg y j.l'L
,n t
n
pit, ,�A�' iiutJst>�ak tr�t> � 1 G..se .i 1 ;d for itidividul use o ilv a
f i registrat or v
FIU1lE Ih1PROVEMENT CONTRACTOR ,:;,i,efore the expiration date. If found return to: ,
f Board of Building Regulations and Standards
Registration:" 105352 Gni Ashburton Place Itm 1301
- iratio 31.,�.
�,sfi
• /17/2010 Ti'/
p 7
t1
_ � 13pon D1a.02105
3 TY1,e incvidual
9 �. r efi ro.x
AND A:+PAY NE JR
R yimo hci Payne Jr ;
1GvBlue'b yHillRd
aafannis PdF G7_6G1 �t i'nistraroi
Not valid without siena re
.. ...•. z.bv..-._e. +!aF. ..a ._ _ {,s.`W�:.F:::wnow.J.:e•e_.Y....v.r.,�....--..! ,ef' ..-___- _- �.-..�..._,.._�-
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
- Construction Supervisor License
Licenser CS 11357
Restricted to 00h Y
RAYMOND A PAYNE JR g
l 100 BLUEBERRY HILL RD
HYANNIS MA;02601'.
ztr
-3� Expiration: 7/11/201.1
C'�rmmt„tune':" ` r Tr#: 19559
Town of Barnstable vermic �vv v I
Regulatory Services Date:
pp Tp� ; Th.o:mas F. Geiler, Director
�HE `
Building Division �ee:
« BARNSTABLE, Tom Perry; $gilding Commissioner
MASS.
v� i639• ��� 200 Main Street Hyannis, MA 02601
AtED ,�a www.town.barnstable.ma.us
Office: 508-862-4038 - Fax: 508-790-6230
TOWN OF BARNSTABLE
SOLID FUEL.STOVE PERMIT
Owner:-De k • Ov, ,V, Phone: -7 7 S- 9
Install at: �� l (,vim Village: ` :- 4 viii I
Map/Parcel: p� VV1D6V f Date: tIZ'5 J zo ID
Stove
A. New/ sed
B. Type: Radian / Circulating
C. Manufactu Lab. No.
D. Model No.:
Chimney
A. New/Existing (If existing, please note date of last cleaning)
B. Flue Size A-.p 1) 4--1 AQ- �cY 2-0L71
C. Are other appliances attached to Flue?
D. Pre-fab Type.and Manufacturer
E. Masonry: ine nlined
Hearth
A. Materials: e 1-'
B. Sub Floor Construction: C k 4 ,zl t0 41
Installer -�
a
Name: Address: '
Phone:
Location of Installation:
H.LC Registratio w
��
Construction S pervisor# A'
OR check Homeowner Installing; no license required Uj
APPLICANTS SIGN TURE
APPROVED BY:
Please make checks payable to the Town of Barnstable
*This constitutes an official stove permit after inspection, photographed, and approved by the
Building Inspector
Q:forms:stove
Rev 103107
Town of Barnstable Permit-ju I
Regulatory Services Date:
NHE 7-. , i t c
�oF o�� 1� ( ,• ,,Ttro;mas.F. Geiler,Director
fee:
Building Division
saxxsrns "' TOrn Perry; Building Commissioner
y Muss. '
s639. 200 Main Street, Hyannis, MA 02601
.www.town.barnstable.ma.us
Office: 508-862-4038 �I ti�� Fax: 508-790-6230
TOWN OF BARNSTABLE
SOLID FUEL STOVE PERMIT
Owner: Phone: 7 9 ?5, 39
lnstall-at:-q �� � (, )0"-4 /V llar g�ge fl--L4 Ci✓ ,- -S
Map/Parcel: O? l VV�C) Date: I Z'5 1 ZO I�
tt
A. New/ sed
B. Type: Radian / Circulating
C. Manufactu Lab. No.
D. Model No.:
Chimney
A. New/ Existing (If existing, please note date of last cleaning) CztQ
B. Flue Size
C. Are other appliances attached to Flue?
D. Pre-fab Type and Manufacturer
E. Masonry: ine nlined
Hearth
A. Materials: 3^ e 1'-
B. Sub Floor Construction:
Installer
Name: Address:
Phone:
Location of Installation:
H.I.0 Registratio #
Construction S/tIpervisor#
OR check Homeowner Installing, no license required
APPLICANTS-SIGN •URE ,_-;�
APPROVED BY:
Please make checks payable to the Town of Barnstable
*This constitutes an official stove permit after inspection, photographed, and approved by the
Building Inspector
Q:forms:stove
Rev 103107
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): Q- p�-at. ! r `�A
Address: Z �'►` t k4 r S' Lje—A 1
City/State/Zip: Phone.#: �)D `T 7 _ — �4
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with . 4. I am a general contractor and I
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 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'-comp.insurance comp. insurance.$
required.] 5. [� We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised.their 11. Plumbing repairs or additions
3�^�"�I am a homeowner doing all work ❑ g P
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.❑Other
2 ✓V� rrtV 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 under the pains and penalties ofperjury that the information provided above is true 77—Y-1
dcorrect.
Si afore: W( � Date:' _
v
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
.City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees.
Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall .
enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),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. 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
4ffiGe of Investigatlons-
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
Q. Who is responsible for making application for the:
- -- - -
permit?l
Application for a permit is required to be made by the owner or lessee or
their agent of the building (e.g.; the HIC registrant ). If application is made
other than by the owner, written authorization of the owner must
accompany the application. Such written authorization shall be signed by
the owner and shall include a statement of ownership and shall identify the
owner's authorized agent, or shall grant permission to the lessee to apply
for the permit. The full names and addresses of the owner, lessee,
applicant and the responsible officers, if the owner or lessee is a corporate
body, shall be stated in the application.
Please note: It is the responsibility of the registered HIC to obtain all
permits necessary for work covered by the Home Improvement
Contractor Registration Law, M.G.L. c. 142A. An owner who secures
his or her own permits for such shall be excluded from the guaranty fund
provisions as defined in M.G.L. c. 142A.
Back to Top
Q My contractor told me I need to obtain the permits for.
my construction. May I obtain the relevant permits from
_ .
My local building department, or is the contractor.
._ _
required to do that?
While you may certainly obtain your own permits, be aware that if you do,
you will fall into a homeowner exemption that will disqualify you from being
eligible to receive recourse through M.G.L c. 142A, the HIC Law, or the
statutori.ly authorized Guaranty Fund, should a problem arise. It is the
responsibility of the registered HIC to obtain all permits necessary for work
covered by the Home Improvement Contractor Registration Law, M.G.L. c.
142A. If the HIC you are contracting with refuses; you may wish to
reconsider using that contractor's services.
Ly��THE Tp� Town of Barnstable
K ~�
Regulatory Services
r
r BMWTABLE. Thomas F. Geiler,Director
Mass.
1639.
139 $ 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
mplete and Sign This Sectio
If Using A Builder
7
I, , as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work autho y this building permit application for.
(Address of Jo
Signature of Owner ate
Print Name
If Property Owner is applying for permit pleas e
Homeowners License Exemption Form on e reverse side.
Q:FORMS:OWNERPERMISSION
ram.
Town of Barnstable
oFtlE
"o Regulatory Services
" Thomas F.Geiler,Director
BARNSTABLE, ►
MASS. ,�� 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
EDAT E---20 � 1 1 �?
JO _ATIO_14 �n j � � (d ✓11 S
number street -- L village
AH_0MEO_WNER"' �\` i ✓ L 7 T�
--'dame home phone# work phone#
C _MAIT IiJG ADDRESS: O �0)( �3� r'
WA,114- ,-
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. 11
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
l
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
re uirements. f
_
ignatuTe of Homeowner j
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
m 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 caret amend and adopt such a form/certification for use in your community.
Q:\WPFILES\FORM S\homeexempt.DOC
i
o-
+* ;
s I:b�
fill
14
0
cp
v °
0 0 01 9
r, y� 'gyp+ ,"i 4 a AL74
\ ..
re
t;.
rf flOV 0
�MMti
V �
(p 4. ,
ch
9
s
-od
r _ € x.
AUll
r '
9
,} F
v
, a
3t.'
9 j
a. hM5
Town of Barnstable
ermtt#
Expires 6 monf'is from issue dete
Regulatory Services
Thomas F.Geiler,Director Fee '
Building.Division
Tom Perry, CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www:town.barnstab l e.ma.us
Office: 508-862-4038
EXPRESS PERMIT APPLICATION Fax: 508-790-6230
RESIDENTL4L ONLY
Not Valid without Red X-press Imprint
Map/parcel Number 0 0
Property Address I �—h�W K I S L �
Residential Value of Work_ tnimum fee of$25.00 for work under$6000.00
Owner's Name &Address � 1�11 e
Contractor's Name -jG�1'`� W '7�O ��j�,
Telephone Number -1✓��
Home Improvement Contractor License#(if apph ble) �� V
--------------
Construction Supervisor's License#(if applicable).
❑Workman's Compensation Insurance
Cheoek one:
[d? 1 am a sole proprietor -
❑ lam the Homcowner "
❑ I have Worker's Compensation Insurance
OCT 1
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
�Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping, Going over _ existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required:.Issuance of this permit does not exempt compliance with other town department regulations i.e.. Con I
s 1 ,
***Note; wr Property Owner Letter of Permission.
cop, of the ome rovement Contractors License is required. j
SIGNATURE '�Ji�1 S JO 608 I
-�:Ftn-ms:expmtrg `�b
Zevise061306
I
- The Commonwealth of Massachusetts
Department oflndustrialAecidents
Office ofI"nvestzgations
600 Washington Street
Boston,MA 02111
` www.mass.gov/dia
Workers' Compensation 111su once Affidavit: Builders/Contractors/EIectricians/PIumbers
Applicant Information ,• Please Print Legibly
Name(Business/Organization/Individual):. J �
Address: 31
City/State&ip: ���s, m� �(1�� Phone.#: O "44'Ju U
E
an employer? Check the appropriate box:
4. 0 I am a general contractor and I Type of project(required):a employer with
loyees (full and/orpart tirne).* have hired the stab-contractors 6• ❑New construction .
a'sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling
and have no employees These sub-contractors have g• Demolition
king for me in any capacity, employees and have workers'
workers'comp.insurance comp.insurance.# 9• []Building addition
ired.) 5. [] We are a corporation and its 10.❑Electrical repairs or additions
a homeowner doing all work officers have exercised their 11.❑ bing repairs o' additionself: [No workers' comp. right of exemption per MGLance required.] t c. 152, §1(4),and we have no 12• Roof repairs
employees. [No workers' . •13.[]Other
comp, insurance required.]
*Any applicant that checks box#1 must also fill out the section belowshowing(heirworkers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and thcn hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additionalahect showing the narne of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors lave employccs,they must providt:their SPOTI='comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
Information
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 IDIASgi insurance covera a verification•
I do here cerh :r er a pain -and enalties ofperjur)i that the information provided ab ve i true and correct;
Sienature:
Phone #:
9 Q Date: � U
Official use only. Do not write in this area,'to be completed by city oy town official
City or down: Permit/License#
Issuing Authority(circle one);
I.Board of Health 2.BuildingDepartment I City/Town Clerk 4.Electrical Inspector 5:�bi
ngInspector
6. Other
Contact Person: Phone#:
' �pFYHE, , . Town of Barnstable..
Regulatory Services
1ASNSTASLE, +
MASS. Thomas F. Geiler,Director
Alfo �" Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
W'ff'w.town.barnstable.ma.us
Office: 508-862AO38
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 rnY behalf,
,
in all matters relative to.work authorized by
this building permit application for: ,
(Address oJfb
)
Q' 64N JA9V
Signature of er'7
Date
bwGfM 0i�
Print Name
WORM S:OWNERPERMIS S ION
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registratiori __1..24310 One Ashburton Place Rm 1301
Exp4raf�on 6%1/2009 Tr# 130873
Type Individual Boston,Ma.02108
•
James Curley
James Curley
287 Fuller Rd.
Centerville,MA 02632 Administrator Not valid without ure
e
Massachusetts- Department of Public SafetN
Board of Building Regmiations and Standards
Construction Supervisor Specialty License
License: CS SL 99138 f
Restricted to:. .RF,WS I�
JAMES CURLEY !
287 FULLER ROAD
CENTERVILLE, MA 02632 j
I
i
Expiration: 1/28/2012
f �/ Commissioner Tr#: 99138
A....0ssor's map and lot number f' 6z..Q...�"� .0.1l6 k.
f E
Sewage Permit n ` � Y s SE® C SYSTEM lST
umber ... J INSTALLED IN-COMPLIA °ya�sasTsn
i
House number .... •• N a
. L
......... .............
WITH 5 'oo 039,
y i ! ENVIRONMENTAL CO
DE A 0MPYa\e
:TOWN OF BA., NS1
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ....../�N%.<. ........ ............................................. y
TYPEOF CONSTRUCTION ..............41lGC..0 r................................................................................................
• � ..............tom. .... ....�•.�.............19.Q.c
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according 'to the' following information-
Location .... . .....G.�d . I. .�/�1�� f-P . .............
.Proposed Use ......5/.1��1` ...... �i'�'y1................ ......................................... :..
40 Fire District ....
Zoning District .............. .. ;..?........... �r�L.......,.........................::................
Name of Owner fir/Il,/..., .Ili•G.i!!�.W..%1
.............Address
Nameof Builder ...........................::..........:..............:............`.Address ....................................................................................
Nameof Architect .............................................................. ...Address ....................................................................................
Number of Rooms .......... ......................................................Foundation ...eQ.......... .............
Exterior ......4.4 r:/...i.,... C k/.......:..:.........Roofin9 ..... , C / ....................................
`iG„�.�. Interior .... .C '�4�/.� Q�LrK...:..:..,
Floors ........ ...........................
Heating �� ...�rP�. ...........................:......Plumbing ....... ��.....fGk✓ �• ...............................
Fireplace ....... ......................................:....................Approximate Cost ......... /j ..............................
Definitive Plan Approved b Planning Board _______________________ �
pp Y g - 19 - ---. Area. ................. ............
Diagram of Lot and Building with Dimensions Fee ......p l . !.. ...........
.... .. .' 1 n
SUBJECT- TO 'APPROVAL OF BOARD OF HEALTH
360,
{
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
. � • • - . T 1 ' it
I Hereby agree to conform to all the Rules and Regulations•of the Town of Barnstable regarding the above
construction.
' _.. Name . .... .. ........................... �.
Construction Supervisor's License ....... /'.
ICKULAS, LARRY
r 25135
tN
One S y
No ................. Permit for ......... .. :.....
_. Single Fami Dw ling
Location ..Lot...E...... 21 itch.ers...Way....
F Hy anni.s
` .................. ........................................................
r' Owner .Larry...............................................Nickulas ........
Type'of Construction. ....Frame.........................
r
Plot .. %.................... Lot .................................
Permit Granted ..i:.May.. 31 .:..... 19 83
14
Date of Inspection ................................ ;
' Date Completed ....... :. *. ...'........1.9 r i /
av
�• Ste! . . � �- � � '' - � ,
1 yr. �i•+ .� ... -r� '�.+',� l - � J �` f` •„
O�, E•*p � - �� i ��+ !` I �w try '"a ` 1.�
UOA1Avns ONV'1 '0 31VO
'SSVW 'S1NNVkH
is S
'ssb ` 3 VISNNV8 J0 FAI
�, ANns �33�f1ON3SIAV1 ONINOZ 3H1 01 CWHOANOO �'' 'aNV a31VOlONI sv aNnoUS 3H1 NO Qa l Jl `om ®P ;` s103v a3�31s103
a31V O 01 Si NV 1d s I H l NO N�14 HS -----�-�--
1Pl1"9�►
IVC-.�� +r uw/7oy 3H1 1dHl Adl1�130 I s�n��/N :>�, / O 0NIM33 ION-7 .39 .� 07
NI
NVId 10°ld ®3L411113O
d..
r
eo aL' '
�.j 's. � '�-s •cam► +` _ -
t-- cq I r� ,Coo i _
o
dl
• i
Ste.
�/ Ir
II
}, ♦ V
r
e TOWN OF BARNSTABLE Permit No. _.2 - _' -.-----.-.
Building Inspector
smx Cash ------------------- ---
• wa ` t;
"" OCCUPANCY PERMIT Bond __---- -1�
Issued to Larry Nickulas Address
Lot E, a92 Pitchers Way, Hyannis
Wiring Inspectors /` Inspection date
�^ Inspection date
Plumbing Inspector' .✓o"_
Gras Inspector Inspection date "P,1, 4
Engineering Department `R Inspection date'
Board of Health � • ��' 7 '2�, 1 Inspection date
G
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
✓� 19.. 1 ....................................................I .... ......_...r. /i' �� ...
�� ..... ......................... _. Building Inspector c'c-
ip
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
* BARNSTABLE,
9 . MASS. g Building Division
s639• ��
039 Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
PERMIT# wl SoLi, FEE: $ O��J
SHED REGISTRATION
a 120 square feet or less J `
Location of shed(address) V lage 4,
CU
L s'y
Property owner's name elephone number -o
�U X /� f't-(A ZIM U 1 cn
m
Size of Shed Map/Parcel#
Signature Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature required) 3 51 40 3
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 A 21901
1
Z�y,G3 �
\
+� 0
P
t� vP� ,n
�io.aa
v\ 11 4�
b
X certify that this property is
located in Flood Hazard Zone C (out_
side the j00 year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
DateOF CERTIFIED PLOT PLAN
q EDWARD LOCATI01Vi9.erVSy,
SCALEPATE �A .Q�C ZE?
Reg �v 2 ..... .... r
• �sf urR PLAN REFERENCE
LL LAlIQrs
that. they fo Pe Cod Bonk aTr.and its title ins.co. , .. , . . . . , . . . . . . .
re are no visible encroachments I CERTIFY THAT THE ...•iTJ ]l�/
or easements except as shown and that this THIS PLAN
IS LOCATED u OUN0•
Plan was prepared under my immediate As SHOWN HEREON AND THAT It CONFORMSGTO THE
supervision. SETAACK REQUIREMENTS OF THE TOWN of
`� •.,. . . . ,WHEN CONSTRUCTED.
/}{'y DATEW'W'W�-1� 404
REGISTERCO LANn Stln
Sewagj Permit number ... ......� ...........................
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ......
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Zoning District .. .. ...10�. ................................................. el�l Y
Name of Builder ----------------------'A66reo ---------------------.--...-..
Name ofArchitect -------- -------------.A66reso --------------------..-,-----.
| � .�' ~'
Number of Rooms --'°��~----------------'Foun6ohon -^��/--'�-����../-+-.^�'' ........................
x�
|
| Exterior ....... ....... ------..RooGng - ...............
. Floors ........ .............................................. ...... ......................................
Heating � -.. �z'~'~ -------.�um6ing -- ... . .....---__-..
'
Fireplace --'5+~� !..--'-----------------.Approvimote Cox ---"�°� �. -____~_______
w i
���
Definitive Plan by Planning Board lV---- . ^ Area _- ---'
Diagram of Lot and Building with Dimensions . Fea ..........
SUBJECT TO APPROVAL OF BOARD OF HEALTH
-
/
\ ~
. /
\ '
~
�
�
[---- - |
� } /
|
` .
,
i �� |
. OCCUPANCY PERMITS REQU|nc�u�`FOG NEW DWELLINGS �
`
! hereby agree to conform to all the 8u|ou and Regulations of the Town of 8o,nsto6|m regarding the above
construction. `
'
/ *��»^.v�/ �:�����---'-.~
` -
. Construction'Supervisor's Lic
ense
NICKULAS', I,ARg,Y
f A=289-60-1
25135 ' One Story
No ................. Permit for ................
.......Single F:amilX Dwelling....
Location ...Lot "E" 92 Pitchers Way
..........................................
Hyannis
...............................................................................
owner ..LarrX„N.............................................
Type of Construction ... rame'-
................................................................................
Plot ............................ Lot ................................
Permit Granted ..... ay. 31.....................19 83
Date.of Inspection ....................................19
Date Completed .......................................19
1vg ,�T« C40