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' TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION
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Map 1 Parcel -.Application #
Health Division Date Issued .�
Conservation Division Application Fee
Planning Dept. Permit Fee.
Date Definitive Plan Approved by Planning Board
Historic - OKH _Preservation/ Hyannis
Project Street Address �i S /�� ��. �� n "� 1 (Y7J
Village „\V.-%_S
Owner Address1 rS 4zl0`2-
Telephone
Permit Request LA.i-3r-�,
Square feet: 1 st floor: existing proposed 2nd floor: existing 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 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other c-
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new e ,,
Number of Bedrooms: existing _new y`?
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
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 _C�f^"�� ^ o� . L��- �-�sv� Telephone Number—7
Address Q:g—gc,L,. V-C43 License#
J 1 -Q) Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULT G FROM THIS PROJECT WILL BE TAKEN TO
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SIGNATURE DATE �' 2
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FOR OFFICIAL USE ONLY
1
APPLICATION#
DATE ISSUED T
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MAP/PARCEL NO.
ADDRESS VILLAGE
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OWNER
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DATE OF INSPECTION:
FOUNDATION
FRAME
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` INSULATION`?
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FIREPLACE
ELECTRICAL: ROUGH FINAL
a` PLUMBING: ROUGH FINAL
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ROUGH FINAL
} _;'FINAL BUILDING,!—
DATE CLOSED OUT
t ASSOCIATION PLAN NO.
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The Com•moriwealth o`fMassaclausetts
I * Department of Industrial Accidents
l Office of Investigations
600 Washington Street
4 / Boston, AM 02111
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www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEiblj
Natnc (Business/Organization/lndividual):
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Address:
City/State/Zip: Phone M —7 ? D
rAan employer? Check the appropriate box: Type of project(required):
a employer with 4. n I am a general contractor and I
loyees(full and/or part-time).* - have hired,the sub-contractors 6. ❑ New construction
a sole proprietor or partner- listed on the attached sheet. 7. ,0 Remodeling
These sub-contractors have
and have no employees 8. Demolition
ing for me in any capacity, employees and have workers'
comp. insurance.x 9• ❑Building addition
workers' comp. insurance p.
red.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
homeowner doing all work 1 1.❑Plumbing repairs or additions
f. [No workers'comp. right ofexemption per MGL 12.0 Roof repairs
nce required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.Vther (_6-1AD4 nc
comp. insurance required.]
OAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name.of the sub-contractors and state whether or not those entities have
employees, f f 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:
_ I
Policy#or Self-iris. 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 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 certi un er e pains an penalties ofperjury that the information provided above is true and correct
Signature: Dated 02 0l
Phone M
E
only. Do not write in this area, to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectorson: 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 ofanother.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, it
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 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
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy iriformation(if necessary)and under"Job Site Address"the applicant should write "at] 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 021 1 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www.mass.gov/dia
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ypf THE r�D
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&tRNSTABY.E
MASS,
�rFo6 TOr� Of Barnstable
ReguIa tort' SeryzeeS
'Thomas l± GEilcr, Director
Building,Division
Thomas Perry, CBO
Building Commissione1•
200 Main Stree4 Hyannis, MA 02601
wtvw.town,bnrnstable,Mn,as
Office: 508-862-4038
PRX: 508-7904230
Property Owner 11'.tust
Complete and Sign This Section
If Using A Builder
,r'�sw1ler of the subjectpropertyT -�L _.. ....
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hereby authorize T v A41
to act on my behalf,
in all matters relative to work authorized by this buildingpernlit application for:
(Address ofJob)
Signature'of wnet ------�_
Da to
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Ptint.Nam e
1 f Property QWner 1s applying for permit,please complete Nye Nomeo►vncrs License Exemption For
reverse side. m on the
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IN 'HT ANNIS BARNSTABLE FOR NEIL R. Inegy _ era the lines dlVlding existing
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