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Home My WebLink About0106 SEABROOK ROAD 1 i� M 1p � FTC, Town of Barnstable *Permit# Qy° °��{ Expires 6 months fro r ssue date Regulatory Services Fee (4 � y r * BARNSTS. i fL, v M^ $ Thomas F. Geiler,Director i639• �rfD tAA'I A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 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 Number �n, .7 Property Address Jvk117ll-AAL le Residential Value of Work D v v Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable)Construction Supervisor's License#(if applicable) ®PRESS PERMIT IT ❑Workman's Compensation Insurance MAR 1 9 2010 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABL E I am the Homeowner ❑ 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) LIKc--roof(stripping old shingles) All construction debris will be taken to—&, ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value (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. copy o Home Improvement Contractors License&Construction Supervisors License is required. SIGNAT E: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 090809 The Commonwealth oflVlassachusetts Department of Industrial Accidents Office oflnvestigations 11 600 Washington Street Boston, MA 0211.1 iviviv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: Gi%/usi �7 City/State/Zip:V (// e t�(�! /Phone #: l ' —73 Are you an employer? Check the appropriate box: Type of project(required): 1.El 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 g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.t �required.] 5. We are a corporation and its 10.0 Electrical repairs or addition ❑ 3,&Oam a homeowner doing all work officers have exercised their I LE] Pltubing repairs or addition myself o workers' com right of exemption per MOL y [N p. hoof repairs insurance required.] t c. 152, §1(4), and we have no e13D employees. [No workers' Other, comp,insurance required.] 'Any applicant that checks box P 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: — 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 MOL 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 fin 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 s penalties f perjury ihnt the�inform�atioonr• vided a ove is rue and correct. i a u e` /U . Phone#: (16 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#: 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 riot more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction 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 tvho 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 numbers)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 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.inass.gov/dia Town of Barnstable- pFIHE t o Regulatory Services Thomas F. Geiler,Director BARrtsrABLE. F ' Mnss i639. ,m Building Division _ Plf Mho a 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: /D JOB LOCATION: number �sstttrr�eetF. village "HOMEOWNER": . � � � ✓VO � � ^2�S�r ��FO/ name home phone 4 work phone#1 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,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the To of Barnstable Building Department minimum. pecti n pro s an equirements and that he/she will omply with said procedures and requirements. Signatur eowne -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 dq 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 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 form/certification for use in your community. Q:\WPFILF-S\FOPMS\bomEc-xcmpLDOC R tit d i THE 7p�'l Town of Barnstable Regulatory Services ana MBLJE, Thomas F. Geiler,Director 39. �Rua9. �0.11 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 I, 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. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ` Map SC;7 Parcel ® 7 l Permit# 3 g7 rl ,A Health Division Date Issued' r �8 f • Conservation Division' , Fee ./Tax Coll pm",,, 711 Treasu Planning Dept. Date Definitive Plan Approved by Planning Board t ; Historic-OKH Preservation/Hyannis Project Street Address 1016 S e�.d r o e A Ale, 1 i. Village Owner A. S' a-ras, Address %At SGa Are.,A /$4 ffy nyosTi� Telephone S®B ' 77 3/yo Permit Request Sr v o 1P P. m let- rev o o 1.5 17/3 s t, Pf', ov /a Square feet: 1st floor: existing 1,713 proposed 2nd floor:existing proposed Total new L.-4stimated Project Cost $ 70 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. / Dwelling Type: Single Family W Two Family ❑ Multi-Family(#units) Age of'Existing Structure 36 Historic House: ❑Yes • CA No On Old King's Highway: ❑Yes X No Basement Type: 9 Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) /, 7/7 Number of Baths: Full: existing / new Half:existing / new 1t Number of Bedrooms: existing 3 new i r Total Room Count(not including baths) existing new first Floor Room Count Heat Type and Fuel: ❑Gas N Oil ❑Electric ❑Other Central Air: 0 Yes 3 No Fireplaces: Existing _� New Existing wood/coal stove; ❑Yes ®No jDetached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size ` Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: i Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes XNo If yes,site plan review# Current Use Proposed Use t I BUILDER INFORMATION Name v w ti e. Get Telephone Number Address License# ` Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE, 5 A7 �9� _ FOR OFFICIAL-USE ONLY - PERMIT.NO. �� L�• Y` t r - DATE ISSUED k i MAP/PARCEL NO. _ ADDRESS x +VILLAGE 4 r -' OWNER- �• '" e; _. �'' � _ _ - ` - -� f= ' DATE OF INSPECTION FOUNDATION FRAME r' INSULATION •- � �,, •; .r ' ' _ - ry_ '* `: ..} _� , 10 FIREPLACE - ELECTRICAL: ROUGH FINAL. PLUMBING:` ROUGH FINAL GAS: ROUGH FINALL • FINAL BUILDING { DATE CLOSED OUT D ✓ `,�, ' w , j p ASSOCIATION'PLAN NO. . .~ The Town of Barnstable • r�►aysresre. • Department of Health Safety and Environmental Services 1659. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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. � Type of Work: it ,5 t yl/Ig il c o F Estimated Cost i i Address of Work: /®6 5e-e h ro®le IP, y e w m o Owner's Name: /.��'s dl SAa 4a5 Date of Application: . S" �. -- I hereby certify that: Registration is not required for the following reason(s): Work excluded by law �ob Under S1,000 Building not owner-occupied Wwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Narfie q:fbffns:Aftidav The Commonwealth of Massachusetts Ir4U. -_� OW Department of Industrial Accidents . - :1. . -= � Olfice ofln�esti0ations 600 Washington Street sO' Boston,Mass 02111 Workers' Comlensation,Insurance davit mta"r' i'ur %%////`////%,+///%!%//�%�///,////////%% """ C `'Y////%%%%/''///////%%/////i'//��%%%%%//////%�/�%��//// name: �.P-cu S S �I 49 S location: /®( SP,4 ry0 city 11 V-q,?l,4 i f . M if o a 6vl --- -- phone# 5`0 8 '7'71 7 V 0 Imam a honwo%viterperformingall work myself. ❑ I am a sole Pravrietor and have no one ivorkin in arty ca acity " ❑ I am an employer providing workers' compensation for my employees working on this job. comonnv name: address: city: phone#: insurance co. 2011cy# r ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the foIloning workers' compensation polices: comoanv name: address: city. phone#t msarnnce co. comnanv name: address: city- ... phone#: ::::>.....:::::•-.. ..::::... :...' . Insnrance co. P,011tv# �3� '� f3A3t98%�//%%////////%�%%�///�%%�% Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to 51.500.00 and/or one vears'imprisonment as well as civil penalties in-the form of a STOP WORK ORDER and a One of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DU for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature �-_ a � �Li Date A-2 Print name �e, ee.a^s JP, � � 1,� S Phone it .5 Q 6 77 (contact IIdal use only do not write in this area to be completed by city or town otItdal ty or town: perndt4icense# ❑Building Department bLkensing Board cheek if immediate mponse is required ❑Seleemuen's Office ❑Health Department person: phone#, ❑Other (M-A a 9,95 P1A1 w Information and Instructions 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 cc= 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 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 occupam of the dwelling house of another who employs persons to do maintenance , construction or repair work an 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 Iicensing agency shall withhold the issuance or renews.: 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'tl e�affida`vit: The affidavit should-be returned toile cityor town that-the application for the pennit-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. 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 penaitllicense number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would IOce to thank you in advance for you 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 0mce of Inlesduadens 600 Washington street Boston' Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 ` Y The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 9� i639• ATFD MA't� Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION / Please Print DATE: 37/ 7. 7 1?9 JOB LOCATION: /O 49 je.�h O& A number n/ street village "HOMEOWNER":Acc-e5 L/C hitron FOR ` 71-71V® name home phone# work phone# CURRENT MAILING ADDRESS: /®A se C b r^OV k, AA- MA 6A6® / 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 ermi (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. 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 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:FORM&EXEMPT