HomeMy WebLinkAbout0075 SEABROOK ROAD � s � � ems,
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NON
Town of Barnstable Final'Inspection Affidavit ;
Date:
Thomas Perry, CBO
Building Division
200 Main Street
Hyannis, MA 02601
RE: Insulation Permits
Dear Mr. Perry,' r
This affidavit is to certify that all work c mpI ted at:
Street: t
Village: akn;
has been ins ected by a certified Building Performance Institute (BPI) Inspector. All work
performed meets or exceeds federal and state requirements.
Permit application number: . 26( ®0 34Q
Issue date:
Sincerely,
x ; - 0,3
Francis Shee an . %
President
Frontier Energy Solutions,-,Inc. ..R : ?
502 Harwich Road
Brewster, MA 02631
Office: 774-237-0410
Email:,fssfrontierenergy@gmaii.com ' f
t \
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3�lParcel, v Application #_i ( (D dZ
Health Division Date Issued v
Conservation Division .Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH —Preservation/Hyannis
Project Street Address S S rAi?,m o is izok
Villages
Owner i►J A '�►� Address
Telephone
Permit Request E'Pt"TH . l"U4`TI 64 woitle-- AiDD t NSU i A-n-olls
U , t IJ E EP O R, W D P,,IC-
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
VProject 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 a =;
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq."ft)
JNumber 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
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#
J Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name `dJ1NZ M �1 A)13IZ�1 Telephone Number ?G1 3Zk23
License # D2Address CO Ef"
;
`3 re
LA M A 02 S bZ Home Improvement Contractor# I �� �5�7
Worker's Compensation # (0617'S!4
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 19
SIGNATURE DATE
FOR OFFICIAL USE ONLY -
APPLICATION#
DATE ISSUED tt zf F 2'f k y
MAP/PARCEL NO._- _:
ADDRESS VILLAGE
` OWNER
r♦ ..
DATE OF INSPECTION: - L
-D KFOUNDATION'
FRAME t
INSULATION:
FIREPLACE
`. ELECTRICAL: ROUGH FINALm'. _
PLUMBING: ROUGH FINAL
-v:GAS . :-ROUGH ' =: 2; FINAL '
=:-FINAL BUILDING. t f w >
( -DATE.CLOSED,
4{} ASSOCIATION PLAN.NO.
I
a
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
t l Boston, MA 02111
sy www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: C)
City/State/Zip: SrTL;rl SQ-+ ()aZ6V2, Phone #: �
Are you an employer? Check the appropriate box: Type of project(required):
Ili 1. I am a employer with `
4. ❑ I am a general contractor and I
* have hired the sub-contractors . _ 6. New construction
employees(full and/or part-tune). _ .__._ _.___.....___... _. ...._ . .
2.❑ 1 am a sole proprietor.or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P h'� 9. ❑ Building addition
No workers' comp. insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
t c. 152, §1 4), and we have no
insurance required.] (
employees. [No workers' 13.0 Other Weoe �M2 i
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.
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: A—k_
Policy#or Self-ins.Lic.#:� 2,46 L4 O ( 2,40M Expiration Date: l . S 16
Job Site Address: /5 Silab✓Wk P City/State/Zip: 414 Gtd}y►is MA
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 certi under the pains andpenalties ofperjuty that the information provided above is true and correct.
Si nature: Date: Z 1 O
Phone#• 396 - fig?- 21r79
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 S. Plumbing Inspector
6.Other
Contact Person: Phone#:
THEr Towne of Barnstable
` Regulatory Services
•
• BARNsrest.F.
MAB& $ 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 Owner Must
Complete and Sign This Section
if Using A Builder
as Owner of the subject property
hereby authorize ro -�W �� to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
Z ZZ IQ
5igna e of Owne K, Date
EQ1A)
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O WNERFERMISSION
Town of Barnstable '
�pf iKE rgyy
Regulatory Services
t Thomas F. Geiler,Director
MAS" awxxsa�ste. .
{, 1 � .leg Building Division
PIED Tom Perry,Building Commissioner
200 Main Street,_.Hyannis, MA 02601
www.town.barnst.abie.ma.us
Office: 5087862-4038 Fax: 508-790-6230
HOKEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a.license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEONVNTR
Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that 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
minirrrum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION.
.The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 1 D9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a pmon(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 helshe 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:homccxcmpt
�1
Massachusetts ',Dep r.rtment of Public Satet}
f Board of Building; Reputations and Standard:
Construction, ,fl A visor Specialty License
'ocense: CS SL 102778
1 6e r'icted to IC
_ -. =FC ;
:CONOR .MCINERNEY
�39 SIASCONSET DRIVE ,.
SAGAMORE BEACH;MA 02562 y
i !r,
Expiration: 8/19/2012
Cununissuiner Tr#: 102778
�: ✓lie i�omrm�oizusea,�i o�._/Gfaaaaclaaell
Office of Consumer Affairs&Business Regulation.
HOME IMPROVEMENT CONTRACTOR
Registration 60.854
Expiration 9/8/2010
#�YPSrippfer�.`nt Card
E FRONTIR ENERGYS OLD .
i. � S UTIONS
CONOR MCLNERNEY 01
239 PARKER ST",!', 7
INDIAN 0RCHARD� Or181
Undersecretary
•
KIVC'u UUL*U BY TOE POLICIea BELOW. T9I6 CERTIFICATE or
a�� �o\ —,I HOT COMITPTE A CONTRACT BETWEEN YTHE ISUVIH6 IHOVRER(d),HTE: BOLDER. gOmeORISED REPRE6EHTATSVE OATEEeBoovcEg, AHD T
mPORTANT' If the certificate holder is an ADDITIONAL IN$URFO, the POlicy(ies) must be andorLad- If SUEROGhTION Is wnzv6D, ubject
to the terms and condicjonc of the Policy, certain policies may require an P y q endorF6ment. A statement on this certificate does Dot
confer ri hts to the certificate hOldec in lieu of such Oodor:oment(�)-
eAAAJet,
cavY u f
Rogers & Gray Insurance Agency
Inc
lyc, av oal: Wc.By},
FO Box 1601 ¢
•nonLss:
South Dennis, MA , 02660 veDn acca
i
�afo<uA z�.
1RSVaf1 IBEUR¢A(SI 11PfO9.abD cDraasDy paLc r
Frontier Energy Solutions LLC D[svaen n: A.I.M. Mutual Insurance co
39 SiascoDset Drive
Sagaimcre Beach, MA 02562 EowaFa `
A+bvDlA al
I I4SV1¢A B!
zasurza r:
COVERAGES CERTIFICATE NDtIDER:
REVISION NUMHI�R:
71S a Zv 70 CIRTWy TEAT THE POLICIES O4 INEUMCS LI57$O M.— HAU6 � 14'lum 710'�+.W-Vam NA.E,D ABOVE FOR T—POLICY PERIOD
ILD
HOI9TlH57WgDIDU MY REVVM!"' TERM OR CONDTTIOM Or An CONTRACT OR OTHEq DOCUMENT WITH RESPECT%0 WHICH 7RI3 PgRTAM, Tn IN"MCS AHB'OADSD BY TEE POLICIES DESCRIELD grRSIH IR BU8J T TO ALLTIPSC&W MLY OE IS"=OR MAY -
bMY RM Mtn RLDQCLD BY PAID CLAIM. T� �' 68CLNSI08S AWC COOIMMONR or SUCH EOLZCIES. L121IT5 SHOWN
I m,
to r Mp or Mo k"= POLICY NU®EW POLICY EFF POLICY ERE
r muaeirrtz �vvNvRz*zr Lmm;
F6sE8gL Lz$B=3;iy
0CCM9RCLV, GUaSQ L LIAeMKTK BAC11 DCGORMcr Q
Dauas¢ xo ac.tca
lu ❑a.x.ro manr ❑OCCUR QDgS[56§(Ge.00wQlrol) Q
�I �°A'>!P fMY erot perronl B
Paa§DAL G ADv IruuAx Q
Gar'L ACG Ra n LgI7 wL]AQ VA: Ct!¢ay KCim'aeV6 Q
❑PoiicY DeRwtcr❑TAC vRDnucrs-rnm•/Df ncc Q
AU7CMMILE LIABILTIY Q ,
R G� C116D§IU— LEUXT ARi 1'(0 r+Da
IBA ece19<n L) a
ALA O!�AD ATIOS e4nfLY Wvgr (aor Drr.e<.1 Q
40 c
II�8�6entRBD AOa'o'., eDaCu wm[r(aer vrzaamt> Q
�. L_J P�R86 earoQ raorcaza Dwutg
tDar Era eB[vrtl Q
F .: BOa`O.CD BD 4alOD
� Bn-RaklAdkis
❑ ac0}:aAu:a MhDRD
B$DLIABII.IT•YTHE PR /PAP- R./MCUTCERS ARE ¢.L. Mcm ACCIDanr s 500,000
❑ in excl D,§Rq§g _Fap�DDa 500,000
07/25/2009 07/25/2010500,000
RaklADa§Da LDCeSAuvi:
ALL MEMBERS ARE EXCLUDED FROK THE WORKERS'COMPENSATION POLICY.
II
ri
I
I '
CERTIFICATE HOLDER CANCELLATION
EINISTARCORIPOIRAT9;'
6 CAS CoRP
OFFICES SHOULD PAY Oa THE ABOVE DESCHIem POLICIES RE CANCLLLM BEFORE 7EE
V= B& ' A=UMCEWITH7"D090 Aaxaoat¢Sn M-Usul'Artva -
2657
' e
°F� r
'own of Barnstable � *Permit#
Fxpire ro tfrsfrom issue date
Regulatory Services Fee
$ Thomas F. Geiler, Director
®P . MI
�;p�'�`�4 � Building Division p I
fd Tom Perry, CBO, Building Commissioner
AU G Z�aB 200 Main Street, Hyannis, MA 02601
TOWN OF BARNSTABLE www,town.barnstable.ma.us
Office: 508-862-4038 Fax: 508=790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint.
Map/parcel Numbe
Property Address j - Sea, b,yt?k
Zesidential Value of Work LD 7_00,Ott—) Minimum fee"of$25.00 for work under.$6000.00
Owner's Name&Address Keo o) oe nd Tt tllt Eo I
3� (�c (U.U�
Contractor's Name Telephone Number S-01's'29'Y' �{ 7
Home Improvement Contractor License# (if applicable) 22- b
❑Workman's Compensation Insurance
Che ne:
I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name_ AAt7iH -UCH! C`
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file:
Permit Request(check box)
e of(stripping old shingles) .All construction debris will be taken to ✓G�j 7�' �_ 5
❑ 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.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Horne Improvement Contractors License is required.
I
t
SIGNATURE:
Q:\YYPFILES\FORMS\building permit forrnsTXPR_ESS,doc
a
andarJs
T 9f,�� ►ons and St.
ulat
Board of Building Reg T CONTRAC TaR
►-TOME 1MPROVEMEN
ti0220 Tr# 264271
Re9istraon 15
Exp3raf�on 3L1512010
JEREM�
�AH GAGNON
lr F
3EREMIAH
W ALE VVAYe ; ' Administrator
61 GUN MA 02675
YARMOUTHPORT, -- j
: F
License or registration valid for individul use only ar
befoi a the expiration date. If found return to: 1 y
gulations and Standards
Boasd of Building Re
One.Ashburton Place Rm 1301
Boston,Ma.0210
,; Not valid hou signature a
The Commonwealth of Massachusetts
Department of Industrial Accidents
UvOffice of Investigations
600 Washington Street
Boston, AL4 02111
www.mass'.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elechicians/plumbers
ffi
Applicant Information �) Please print Ledil
NaInne (Business/ t;o
niTpn/lndividual):'� t jo m Q,
Address:
City/State/Zip: - �C,LuMa;,tA � /f?� Phone.#:
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 1 6. ❑New construction
loyees (full and/or part-time).* have hired the sbb-contractors
�-,�� a sole proprietor or partner-
listed an the attached sheet 7. ❑Remodeling
2_ 1 am
ship and bavc no employees These sub-contactors have 9. ❑Demolition
employees and have workers'
working for mein any capacity. 9. .El Building addition
No workers' mrop.-rnstranc0 comp.in&ura 1GC.
5. [] We am a corporation and its 10.❑Elrctcal rcpaus or adriifior
rtquit�j officers have exercised their 11.❑Plumbing repairs or addition
3.El am a homeownLr doing all work
myself [No workers' comp_ right of exemption per MGL 12 W,,Kf repairs
insurance r t c_ 152, §1(4), and we have no
�� cn�loyces. [No workcn' 13.❑ Other
mmp.msnranee requiredj
«Any applicant that chc;h box#1 roust also fill out the section below showing their wm+czs'cranpais4on policy information.
t Hmucowocrt who subn-att this s$davit indicating fbcy a=doing all work and thm him outside contractors must submit anew affiaavitindicating such
XC tmtractors that chrxkthis box uwst attached an additional sheet showing the name of the:sub�ntract ns and state whctha or not thos6 tntitics have
employers. if the sub{.onhacbxs have employees,they must provi&thcv worker'curmp.Policy number_
I vm arc employer tAid is providing workers'compensation fr-Eurance far my ernptayees. .Below is the policy and job site
information.
!non-ancc Company Name: -
Policy#or Scl-f--'vas.Lic.#: Expiration Datc:
fob Site Address: City/Statr/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 erird penalties of:
fin=tip to$1,500.00 and/or ono-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a f
of up to$250.00 a day against the violator. Be advised that a copy of this statc=rrit may be forwarded to the Office of
lnvesti tms of the Mk for' c coves c verification.
I do hereby fy under e p and penalties of perjury that the information provided above is true and correct
Si c: Datc: -
Phony#: C;D Oct o/57
Official use only. Do not write in this area, to be completed by city or town of xIaL
City or Towa: Permit/License#
Zss dug Authority(circle one):
1.Board of Health Z.Building Department 3. City/Town Clerk 4.Electrical lnspector S.Plu Inspector
mbing
6. Other
°F�H�ry Town of Barnstable
Regulatory Services
4 awxxASS. ,� Thomas F. Geiler,Director
�p i63q, ti�
rEo �a Building Division
Tom ferry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete. and Sign This Section
ff Using A Builder
i )Cev i scotAb ri , as Owner of the subject property
hereby authorize rh 1al\ 6�illa�l to act on my behalf,
in all.matters relative to work authorized by this building permit application for:
(Address of Job)
71 O�
Signature of Owner Date
"-�o 411t
Print Name
If Property Owner is applying for permit Tease complete the Homeowners License
Exemption Form on th:e reverse side.
l
1
Town of Barnstable
�oF THE ray
y�� o Regulatory Services
* swxrasrwsc.e. «
Thomas F.Geiler,Director
v Mom.16-151. Building
Division
�ATED µA't A1$
Tom Perry,Building Commissioner .
200 Main Street, Hyannis, NfA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units Or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on'which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, b laws,miles s:les and regulation y
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department '
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
,State Building Code Section 127.0 Constriction 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 s
Many hall act as supervisor."homeowners who use this exemption aie 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 Suptrvisor 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 hdshe 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 forrrAcrtifieation for use in your community.
lt
,. '1 1 11
• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Permit# T
Health Division 2,�?z5l d � ��*_0er i Date Issued
Conservation Division Fee IY,7 7. S`D
Tax Collector Z ��
Treasurer Cfi F!/2 o Do SEPTIC SYSTEM MUST BE
Planning Dept. INSTALLED IN COMPLIANCE
WITH TITLE 5
Date Definitive Plan Approved by Planning Board ENVIRONMENTAL COW A'
Historic=OKH Preservation/Hyannis TCWN RECUI.`2 `T
Project Street Address / 5 15R cin 6?n) �
Village t
�) p
Owner�(_() �_ ��J Address 8,-VO6 iS
Telephone
Permit Request G U 4! 'rI yc C Pit o e/. /� ' f L We/►Y'o
c�hoc i e 1"I-A
Y�ivoav✓ o , c��J on J
Square feet: 1 st floor: xisting proposed `'2nd floor:existing proposed Total new
Estimated Project t 2J �n o Zoning District 4 Flood Plain Groundwater Overlay
Construction Type '
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family L Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes X No On Old King's Highway: Cl Yes .kNo
Basement Type: JIFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: . Full: existing new Half:existing O . new
Number of Bedrooms: existing new Q
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas 2�Qil ❑Electric ❑Other
Central Air: ❑Yes )21,No Fireplaces: Existing �_ New Existing wood/coal stove: ❑Yes ¢JNo
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:Aexisting- ❑new size Shed:N(existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No , If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name 0 w/Velc—e Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO A`5S )olef e .
.S
SIGNATURE XeDATE _._
FOR OFFICIAL USE ONLY
PERMIT NO.'
DATE ISSUED
MAP/PARCEL NO.
' ADDRESS VILLAGE
OWNER R
DATE OF INSPECTIO : ij
r
FOUNDATIaN •� • -
} FRAME
a INSULATION'
FIREPLACE
ELECTRICAL: ROUGH . ._ FINAL
PLUMBING: ROUGH r FINAL
GAS: ROUGH FINAL
FINAL BUILDING F —3 -610
DATE CLOSED OUT r €
ASSOCIATION PLAN NO. 1
i.�"f
/P/TMEThe Town of Barnstable
a�uvsraszs.
• ' E HAS& g Department of Health Safety and Environmental Services
9�A i659. Building Division
TFD MP -
367 Main Street,Hyannis MA 02601
Ralph Crosser
Office: 508-862-4038 Building Commissior.e:
Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
of Work: G timated C/st-
Type
Address of Work:T7 6'"
Owner's Name: iJ /
Date of Application: Z vU�
I hereby certify that:
Registration is not required for the following reason(s): '
❑Work excluded by law
rlJob Under S1,000
[]Building not owner-occupied
XOwner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Date Contractor Name Registration No.
OR
Dace Owner's Name
q:forms:Affidav
The Town of Barnstable
i �OptME Department of Health Safety and Environmental Services
Building Division
' sn i�
MASS. 367 Main Street,Hyannis MA 02601
Mass.
'7 1639. `eg'
�ATFD MA'I a '
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Jr 7 Please Print
DATE: �/ I Z Q
ff
JOB LOCATION: � ,t h Iq A f T
number street village
"HOMEOWNER": PU(l-1 Zf=,_Q&t_rj
name / home phone# work phone#
CURRENT MAILING ADDRESS: to e5 ✓O
r
c' 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,provide
d
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
pr es and require fits.
-:n k,
sigii-aLurl of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply
with the State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the
provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a
person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see
Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in
serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the
unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit
application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community.
Q:FORMS:EXEMPTN
The Commonwealth of Massachusetts
n D.. '° - Department of Industrial Accidents
Office oflmrestigatioos
w 600 Washington Street
Boston,Mass. 02111
workers' Compensation
m ensation Insurance davit
name:
city
hone# �� ' 937
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Failure to secure coverage as required under Section 25A of MCM V can kad to the imposition of eaimival penalties of a 11u►e tip to S1,50 1.00 and/or
one years'imprisonment as well as civa penalties in the form of a STO of the DIA for coverage verlfication.WORK ORDER and a fine of 00 a day against ma I understand that a
copy of this statement may be forwarded to the OiBce of Tavatlguilom
I do hereby under the pours p of perjury that the information provided above\is true and correct `
Date -
Signs
Print name
Phone#
omciai use only do not writs in this area to be completed by city or town.official
city or town: permitNcense# [3Building Department
❑Licensing Board
❑Selectmen's Office
❑check if immediate response is required ❑Health Department
contact person:
phone#; ❑Other
(ievrmed 9/95 P1A)
Information and Instructions r ;
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from.the"law", 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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit "
davit should be returned to the city or town that the application for the permit license is
being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the perntit imnse number which will be used as a reference comber. The affidavits may be returned fe
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a calla
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
0mce of emrestloadons
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone_#: (617) 727-4900 eat. 406, 409 or 375
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