Loading...
HomeMy WebLinkAbout0158 SEABROOK ROAD Ile_ i I f I i I I 1 I Q I 1. I I . U Town of Barnstable *Permit# / - sa q$ � m tres�6 nths from issue date Regulatory Services ����� r .. MASS. Richard V.Scali,Director NOV 3 2016 1e59. ,.� Building Division tY Paul Roma,Building Commissioner �-" �� ���!V 200 Main Street,Hyannis,MA 02601 ,,A,L E www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Map/parcel Number 3 0 3!Q Not Valid without Red X--Press Imprint Z� ` Property Address , (S0 V- V.0 C)I6 0 ❑Residential Value of Work$ (i, 000 . a o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �e�.e�bS CxonZ�o.�2 0 S 4 %eo,No c o b V- N14 A'a• o L6 0 l Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor VI am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ st(check box) [1�Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to(�jat1�$�al�lt �naa.�r t Id ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. ' *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: GI61\zA1L22 Q:\WPFILES\FORMS\building permit forms\E)2RESS.doc 06/20/16 t, Ike Com' mo peakh ofMarsadiuuetts Department afruthutrial Accede s Office of�atiom . 600 Wasilingion street Bastrin,MA 02111 -- kt��vt�rrrass:�a�din 'VtT'or.Dees' Carnpensatian.Ius=nce av&Bmliiex-s/Cc ntractars/ElectricianstPiumhers Ap Infarm,aian Please Pant Eerily Name C Addrew- \S(Z Sto.V v aok Gtgf tatel o. s o Z,G o I Plane Are you an employer?:Che. l the appropriate bom Type of project(required _- I.❑ I am a employervith 4 ❑I am a general coutmctor and I 6. [—]New eonsixatcEio n employees(andfor par-timed* have luredtfte sob�ontmctors 2.❑ I am a sole propiietor orparbuT- fisted on the attached sheet. 7. ❑RemodeHrng sbx p and bave no employees These sub-contractors have $. ❑Demolifioa worming far me in any rapacity_ employees andhnre wod ers' 9..❑Bni1 adxii$aa [No❑rO&MW Comp-fimirance comp_ftmuranc, 5. ❑ We are a cotporatiza and its 10-❑Electrical repairs or adcEt ons officers]rave exercised their 1L Plumbin r airs or additions 3_ r ama bomeov�et doing ail tsar ❑ � ep n sem[Nagy work='CAMP_ right o exemp ion per have 12.❑R.00frepairs insurance rid]l 1�_❑otheremployees.(No workers' co=p_bmuano a required.] ��c[yapplicsvvd�atcbedxbosinmastaLsnfiIIo thesectioabeIoa sbatsiug�eirwos3cexs'compensatiaape&cyiafo�a o� eoa�ass�osabotdvasffda� i�du QtLeygmdm'elfwaksaddmbimoum&c,•,n.Rctms— submit a new aTdaviYindirytaasarfi. ZCam=actn iff=cberI tbiz box mast wftrh sa addilirmal sheet slowing the nmne of the sub-can=cwm m2d state vdmther or not fhnze entities ba- employees.I€tbe it<== tash oe employees,9heynmsrpmv1&&ek sradr!xs'gip.parity mmmlseL I am art Baloav is ilia paucy and jabs sue Frcf ormrrfian. Insurance Company Nam - Porficy 4 Cr Self-im Limo- Expiration Date: Job Sif�Address: CifylStafe/2.p: Attach aropf of the workers°compensationpolicy dedaration page(showing the policy,number and expiation date). ' Failure to secure coverage as required under Section 25A of MGL c.157 can lead to the imposition of criminal pensWes of a fine up to$l,50D 0D im d nor otie-gem imprisvz=enk as well as riv2 penalties in the fbn m of a STOP WORK ORDER and a fine of up to -00 a dap against the vioLdur. Be adedsed tbat a copy of this statement may be forwarded to the Office of Iavestrgations oftbe DIi4 for insurance coverage mrificahm y d'a here-by carlrf,}r uard`ar die paints and nanalfcss ofF t}'fltatdta iraf arttxatzvrj prmidad abotv fig true artd correct sip: Q\NaS G6,At0Le7__ •.z t),ftiat use only: Do not aunts in this=a,to be.evinpWod by city artotvn ajj`ac&I City or Taws: Permitfr kense;g Issuing Aufl=4(dude one): L Board of Health g Depaa-neat 3.CitpTmn Clerk 4 Electrical hmpector S.Plumbing Inspector C.other Contact Person: Phone#: - — — 6 o o o •P (Ppa 0 ' �d qq• ' gypp . �,�•' "y � ,.��.. � H � � A � ' �: �. R � ErH P� P p p P v L P CP Er ° 8 445 OH a ,,yFO am � nPh � 'Q A O ° . Fn r01 tY 7 P, Co n.+ CT' y p k 4 � Er . P, Vq % " ' � 8 g d' M � pq 8 a � p b Fd CP k�' !'�' Q' p' - Cy ' C➢ H' '54 �o P. j4 A � . O �t ri 5. g4Zi ry n Er f 0 r1 Cp F I Town of Barnstable Regulatory Services ` Richard V. Scab,Director 1"9. �,,ua► Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must _ 1 Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf:, in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature-of Owner Signature of Applicant Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOLS f Town of Barnstable Regulatory Services oxt Richard V.Scali,Director Building Division > Paul Roma,Building Commissioner i639. ��� 200 Main Street, Hyannis,MA 02601 Ep www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: ` JOB LOCATION: I S p S Q-a�To O k kk36 V' x S I Nm- © U O I number ((�,' street village "HOMEOWNER": 0—A•'-keS `�lo t�'to►142. S O$—4d y—1 3 3 0 - name home phone# Q ` work phone# CURRENT MAILING ADDRESS: �tia�.h:g - - - Ma• o ZG o 1 city/toA 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 mere than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Coo pi-ta LQZ 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 wtto use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rides&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 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:\WPFILES\FORMS\building permit fonms\EXPRESS.doc 06/20/16 (- s - �T Town of Barnstable *Permit# Expires 6 th m issue date ` Regulatory Services Fee 3 . p ®l� Richard V.Scali,Director Building Division ` Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY T "2�\l Not Valid without Red X-Press Imprint Map/parcel Number C�� �)�, mope 7,,Vdd re'ss VS cff'i-e is dential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name.&:Address-`-- M`� S C;L W�Z��Z Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insuranc- Check one: ❑ I am a sole proprietor 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) r i--- Re=roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to IBC-y r\s a(V- 7-MI\ -k a ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re uired. SIGNATURE Q:\WPFILES\FORMS\buildin�s\EXPRESS.doc Revised 061313 r� rs., s• The Commonwealth of Massachusetts Departinent of li dustrial Acciden& OJ)7ce of Investig ons 'r 600 Washington.Street Boston MA 02111 Workers' Compensation Insurance Affidavit- BuRI{hers/ ntraetors,]I rici;ans/Plumbers Applicant Information Please Print Legibly CN;1 e(Bus"Drganizationrindicidaal): Q S O R1 DI�QS� Address: g SQ0.�v hod 10 (--City/State/Zip: �k WN. Phone# J O 'i 'Va Are you an employer?Check the appropriate:box: Type of project(required): L❑ I am a employer with 4. ❑ I ant a general contractor and I * Have!tired the sub-contractors 6- ❑New construction employees(full and-or par#.�ime).2.❑ 1 am a sole proprietor or partner �- Remodelinglisted on.the attached sheet. ❑ ship and have no employees These:sub-contractors have g_ ❑Demolition. working for me in any capacity- employees and have workers' 9- ❑Building addition. [N©ci;orlmrs' comp.insurance. comp-insurance,, �e, d 5. ❑ [ale.are a corporation and its ME]Electrical repairs.or additions 1. I ani a homeowner doing all work officers.leave exercised their i L.❑Plumbing:repairs or additions myself [No workers'comp. right of exemption per MGL 12_[_1 Roof repairs insurance required.] c_152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required-] ;Any apphcant that checks box#1 r st also fill out the section below showing them wmorkers'comtpensation policy information. &omeowmers who submit this.affidavit indicating they are doing all wod and then hire outside comtractors mmst submit anew affidavit indicating saute TC'ontmcmrs that check this box must attached as additional sheet showing the name of the mb-costars and state whether or not those entities have emp]oyees.Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is prm iding workers I congmmation insurance for my errrpIoyees Below is thepoM7 and job site informahom Insurance Company Name: Policy 9 or Self--ins.Lic.4: F.xpirationDate: Job Site Address- City/State/zip: Attach a copy of the workers'compensation.policy declaration page(shoeing the polity number and expiration date). Failure to secure coverage as required under Section 25A of hfGL c. 152 can lead to the imposition of criminal penalties of a. fine up to S 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 DLk for insurance coverage verification. Ida herebyr eaWfir wider U e pains earn rlabiees of pe.rjrrrt'thatthe inforrrtntioir provided above is tare acid correct l a _ - Date:' 2 3 0' l Phahe 9' So `1 o `l Official use only. Do not write in thfs area,to be conrpieted by city or town ofcia£ { City or Tomm: PermitUcense 1smuing Authority(circle one): 1.Board of Health. 1.Building Department 3.City/Touu Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: phone#. 6 a . Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division * * MRNSTABLE, Tom Perry,Building Commissioner MASS. Q� 1639• 200 Main Street' Hyannis,MA 02601 ArFQ MA'I A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: � Z -3 0 ' y JOB LOCATION: I S SQL b � ft,yjo-n'' -3 Wa O -Q 1 rnumber street village "HOMEOWNER":` O C\z0-(& 7 3 3 07 name home phone 4 work phone# CURRENT MAILING ADDRESS: T—A ke�a�,��S `Zci_ t6wn __--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"certifes that he/she understands the Town of Barnstable Building Department minimum inspection z edures d u' ents and that he/she will comply with said procedures and requirements. Isigriatur meowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 061313 j THE � f MASS Town of Barnstable q, 1639• �� r- ArF Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must t Complete and Sign This Section If Using A Builder I, s Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this b/uilding permit application for: 7 (Address o'Job) Signature of Owner Date Print Name If Property,Owner is applying or permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit forms EXPRESS.doc Revised 061313 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION O , 67) Map Parcel. Z .,Application Health Division Date Issued7>21 Conservation Division Application Fee Planning Dept. Permit Fee 571 9 Date Definitive Plan Approved by Flanning Board �►`- Historic - OKH Preservation/Hyannis PProject`Street Addr_ess___ e0wnerF� Village �,,\Z-o C C;cl -`�- Address 15 $ �•�o c 0o yC c1 �yarn�s MQ.aZ�a i �elephon�e—�-�-���-�5 PermitrRequest---�`���Di�Cav�� W.r��o�S o•n� �� a:nq c�.n.� d.®oc S uare feet: 1 st floor: existing ro osed 2nd floor: existing ro osed Total new q 9—'proposed 9—proposed Zoning District Flood Plain Groundwater Overlay Project Valuation C� 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 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 -141 --r Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood al stoveQ3LII Yes > ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size_ Barn: ❑existing ❑anew �gize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Uj Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ m Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C.OX\ZS 6 R C � t"Telephone.Number: a� `' y-S 3 3 Address License # yya,Rnk` S �0.• 6 �� a I Home Improvement Contractor# Worker's Compensation # t ALL CONSTRUCTION"DEBRIS,,RESULTING FROM THIS PROJECT'WILL-BE TAKEN TO-1 -kVL y SIGNATURE DATE-��'f- 1 0 J I s 1 FOR OFFICIAL USE ONLY APPLICATION# DAfE ISSUED - w 4 .MAP/PARCEL NO. ADDR ESS VILLAGE � t OWNER Lf r DATE OF INSPECTION: FOUNDATIONS.' I FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL K PLUMBING: ROUGH FINAL u GAS: ROUGH FINAL ;#+FINAL BUILDIN_GI«: - DATE CLOSED OUT ASSOCIATION PLAN NO. r "4 The Commonwealth of Massachusetts ! Department of Industrial Accidents _ ' Office of Investigations ��... 600 Washington Street tltr„ i Boston, MA 02111 f - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nam(BBu nst ess/Organization/Individual): Wd"dre s'sue\e5i eO��i'�6®�. City/Stmezi0: OZf.41 Phone 1t6l-A 3 -3 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 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. I am.a.horneowner doing.a 7 ll work right of exemption per MGL 11.❑ Plumbing repairs or additions ,myself_ o,worker--' comp c. 152, §1(4), and we have no 12,❑ Roof repairs insuranc q ired:J=t-­ employees. [No workers' 13.0 Other comp, insurance required.) *Any applicant that checks box#l must a:so 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 their workers'comp.policy information. 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✓iolator. 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 t e flai ' nd penalties of perjury that the information provided above is true and correct. 3i n� atu'r 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 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 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 I 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 °° stamped or marked b the city or town may be provided to the town). A copy of the affidavit that has been officially s p y ty y 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 bum 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 5-26-05 www.mass.gov/dia I ' v Town of Barnstable �OFTHE Tp�y Regulatory Services + BARNSTABLE, = Thomas F.Geiler,Director 9 MASS. �,, =659• A�0 Building Division RFD 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 t �{ Please Print 4!=ZDAT_ E '`JOB`LOCATION: I eO.��000� �IO.�'��S I�`�• y number 1 street cs 1 village C, HOMEOWNER": ��n1A.VLZ 50U� I II"c���3 Wig - Li0y"�33 ��name G home phone# \ work phone# CURRENT,MAILING ADDRESS: city/town i 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. j \11, DEFINITION OF HOMEONVNER 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 perrrrit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility r 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 require ents. i r Signatu o owner^+-� 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.thls exert ption 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 v.ith a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and,adopt such a form/certification for use in your community. Q:forms:homeexempt °FtHEr�� Town of Barnstable Regulatory Services rQsnxxnsi.E$ Thomas F.Geiler,Director wp sG3q' �� rfDAAAIA 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 ction If Using A Buil r as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to wo authorized this building permit application for: (Address of Job) Signature of Owner Dl,e A - Print Name If Property Owner is applying for permit please completethe Homeowners License Exemption Form on the-reverse-side. QTORMS:O WNERPERMISSION n _36 GIA. _. +- f - - �� - _ ; - � - - 1 _ _ �� � - - 1 - - I I �_ , , � - � - - - _ f i L I T I + T � � J a4y w -wl., ' i y I I _ ORI INS Do�P. r i { i a L i T i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r, Map Parcel Applicatio Health Division, S / Conservation Division y��l. I1��' Permit# Tax Collector Date Issued Treasurer Application Fee O ` ®o Planning Dept. Permit Fee � Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address— t S R S . Village ��`^ 5�4�� MA Owner r 10 S �o c4y� 60—20 1 Address Telephone 5o�g ` �,2,s — 5 , "-4( 1f01f 9359 Permit Request &�%�� s f Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation L�O(7 "v Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. \Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) A e of Existing Structure Historic House: ❑Yes ❑No On Old Kin 's Highway: ❑Yes ❑No 9 9 9 Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) F-0 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 entral Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑:Yes r-❑No u 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_ofAppeals Authorization ❑ Appeal# __ Recorded❑- - Commercial ❑Yes ❑No If yes., site plan review# Current Use Proposed Use BUILDER INFORMATION NameC�40s �e �a� 4(�� Telephone Number aR 1(01/ 83-39 Address �g k�-���JD� License# 5¢¢ G Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 629'l��/" 0 6 .� FOR OFFICIAL USE ONLY s PERMIT NO. DATE ISSUED , MAP/PARCEL NO. r ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME �/ _ 6 ' O(o •s INSULATION H' FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL G FINAL BUILDING I r'�— O DATE CLOSED OUT ASSOCIATION PLAN NO. k' r c r 1 ne uommonweaim of lvlussucnuseeis Fs Department of Industrial Accidents Office of Investigations ' a 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plui>iibers Applicant Information Please Print Legibly Name (Bnsiness/ora nization/Individual): C._r�o5 -b-,-C�2 60"-: Q t---a- t Address: City/State/Zip: - ,5.-h b Phone M SO- W L( - 3� Are you an employer? Check the-appropriate boa: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.[ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§l(4),and we have no 12.0 Roof repairs insurance required.] t employees. (No workers' 13,❑ Other 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 than hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is-the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie. #: Expiration Date: Job Site Address: City/State/Zip. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,.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,$256,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date:O r Phone#: So 3Z S -_e�t'-_y (,W jq job 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 l Contact Person: #., Phone r _ { IKE�°� Town of Barnstable Regulatory Services BARNSTABM ' Thomas F.Geiler,Director y MAss. $' 639. 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 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; Estimated Cost Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 []Building not owner-occupied E40wner 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 Signature Registration No. tab OR Date Owner's Signa Q:wpfiles.forms:homeaffidav Rev: 060606 Mortgage Loan Inspection LAND SURVEYS INCORPORATED REGISTERED LAND SURVEYORS 51 KNAPP CENTRE JAN 6 2004 BROCKTON,MASSACHUSETTS 02301 0 Dale: 1 508 )588-1877 - Job No. 3 319 Land in: BARNSTABLE,MA. Ownerls►:GARY STAGLIOLA & CARLA RANIA Title Reference: BK. 12980 PG . 40 Registry District: BARNSTABLE - • 74.54' L07 C; 8,4.24 s� ± s d s � _ f kG � Ce0 1 .. , Q .84' - Mre00 SCALE. 1 = 2..0. FOR MORTGAGE PURPOSES ONLY- Not to be used to determine property lines or to construct fences, or landscaping, etc. I CERTIFY THAT THE BUILDINGS ARE LOCATED AS SHOWN. AND CONFORMED TO THE ZONING IN EFFECT WHEN CONSTRUCTED EXCEPT AS NOTED i THE PROPERTY LIES IN of y ZONE It AS C 11 AoBERl ;,,.�,; �:;;;'`��■ SHOWN ON THE NATIONAL FLOOD INSURANCE MAP o PELAGGi Na 29 0 dC4 P en•. 1 ;fie f B"f' -`� ':i '`� T' ;''� �l' �. � '✓ Y �' o'��•1,;^�� �-F�r.� e� �B : 1 I I I � : : ' AlED I � I i I �N I •'! L I i i 'Q y I I i I : I I I i I I I I j I I I : I i i I I i i I I ; I I : I I t I I 1 p� I ! � 7 rJ , J L... I '. � �• �.. �-� - .� j : I I ... � i ( i � �� L� I •j i.. i I- L. ..,. - • I I j I I i t � I � .I ' : I I f : cly Clio �i. I i Spa i y ;f _- -- i ! : i I i et i 4 I I h � : I I ; I• I j I I I ! i I i 1 i I i i , � L7/ _ i I i I I i I I � i i , ' •� I , I i i � I i I I I i i I I I I I I 1 I ! I i i i : : ! h?fZ rn_u 0m + I I 96 ; I i. ' i : i I , ; , I � I I i I : I i i I , , � I 1 ---- °'_ 77 - ----- �- ®�� - L rc f - Ogyp ------- THE Town of Barnstable CF )per Regulatory Services BARNSTAIS Thomas F.Geiler,Director MAC 019• Building Division �0 °jFD MA't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ;e: 508-862-4038 Fax: 508-79076230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: /� / JOB IACATION: I S ��26 roy)� Yid- 01f 7/ v Lam. number street village •HOMEOWNBR'•:��r10 s or'�(t_ ?,?-59 .name home phone# work phone# CURRENT MAUJNG ADDEMS: 152 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 of 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 woik-performed under the building permit. (Section 109.1.1) The undersigned"homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,.rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature,45arozlKwner 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.•1n this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/ce cation for use in your community. Q:forms:homeexempt TOWN OF,BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel'... .-.�.Applicatioh Health'Divisioh Date Issued _ Conservation Division .:AppI icati6n Fee Planning Dept; Permit Fee' Date Definitive,Plan Approved by Planning Board Historic 70KH ::Irdservation Hyannis Project Street Address et-1, C66 Village 041(1 Address CL Owner 0_5 f)2-a- 6QA S Telephone Permit Request zepa` *NI-00 (//,009 J .2nd floor: existing---- proposed Total new Square feet: 1 st floor: existing proposed Zoning District' Flood Plain GroundwaterOverlay Project Valuation I060 -Construction Type Lot Size 71 Grandfathered: U Yes Q No If yes, attach supporting documentation. Dwelling Type: Single Family . U/ Two Family LJ Multi-Family(# units) q, r Age of Existing Structure n Historic House: Ll Yes V<o On Old King's5iljghway��Y6--§­ Ao U3 Basement Type: iFull LJ Crawl LJ Walkout LJ Other 1 t 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 (notincl ding baths): existing new First Floor Room Count Heat Type and Fuel:(not LJ Oil 0 Electric LJ Other Central Air: 0 Yes gTlo Fireplaces: Existing New Existing wood/coal stove: L]Yes U16/0 Detached garage: LJ existing U new size_Pool: Ll existing Ll new size Barn: J existing LJ new size Attached garage-t?existing LJ new size —Shed: Ll existing Ll new size Other: Zoning Board of Appeal horization ❑ Appeal # Recorded L] Commercial Ll Yes 7N 0 LJ If yes, site plan review# . Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) a;yg C t-L L Name Lkaljcl Telephone Number Address 159 Sew F00k License # Home Improvement Contractor# Worker's Compensation # -ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Z o ,SIGNATURE DATE J f FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP PARCEL NO. ,I ADDRESS VILLAGE r OWNER . DATE OF INSPECTION: FOUNDATION FRAME �' I`-""� 7 '-(� 1�- ' ,-0 ot`-- INSULATIONok- FIREPLACE ,I ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL j . ,4 GAS: ROUGH g FINAL �g FINAL BUILDING J -7' z9 / DATE CLOSED OUT ASSOCIATION PLAN NO. 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 Le 'bl Name(Business/Organization/Indivdual): S6L, e Address:_( City/State/Zip: N Phone.#: �a(� 7 I `� 0 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer to er with 4. ❑ I am a general contractor and I 6. ❑ w construction employees(full and/or part-time) have hired the sub-contractors 2.❑ I am a§ole proprietor or partner-' listed on the attachedsheet. 7.. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an ca ac_ employees and have workers' Y P tY• # 9. ❑Building addition [No workers'comp. insurance comp.insurance. tequired.] 5. ❑ We are a corporation and its 10.0Electrical repairs or additions 3.[ am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant.that checks box#1 must also ill 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. ZContractors 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.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 certify uuvde�e pai and penalties of perjury that the information provided above is true and correct Si afore: X, / Date: Phone M 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 of 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 bum 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 D e,partment 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 11-22-06 www.mass.gov/dia ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: c DN.7 A�� Site Address: I ��� AV) b�c�c�— p.;,;r � Town: Applicant Phone: "! li L Applicant Signature: Date of Application: I (g q . NEW CONSTRUCTIO .choose ONE of the following two options) 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE-AND TWO-FAMILY BUILDINGS MAXIMUM MINIMUM Ceiling or Slab ff��11 Option 1: Basement 1_I P Fenestration exposed Wall Floor Perimeter U-factor floors R-Value R-Value Wall R-Value AFUE HSPF SEER R-Value R-Value and Depth National Appliance Energy 3 5 R-3 8 R-19 ' R=19 R-10 R-10, Conservation Act(NAECA)of 4 ft.- 1987 as amended,minimums or eater as applicable Note: This form is not required if you choose either of the two versions of REScheck as listed below. ❑ Option 2: RES check Version 4.1.2 or later variant software analysis must be completed (780 CMR 6107.3.2) REScheck—Web which can be accessed at http://www.energycodes.gov/rescheck/ ADDITIONS OR ALTERATIONS,TO EXISTING BUILDINGS.OVER S YEARS OLD* *Buildings under 5 years old must Lse option#1 or#2 in New Construction section above. Complete the following formula to determine the %o of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b_ a) SF 100 x - _ % of glazing (b) Glazing area equals SF b a If glazing is<40% use.the chart below. If glazing is> 40 % proceed to "SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM MINIMUM Fenestration .Ceiling and Wall Floor Basement Wall Slab Perimeter U-factor Exposed floors R-Value R-value R-Value and Value R-Value Depth .39 R-37 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area(i.e.not compressed over exterior walls, and including any access openings). SUNROOM—An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form (found in Appendix 120.P) tz t� Town of Barnstable of roty . „�. Regulatory Services BARNS.,BLF- Thomas F.Geiler,Director fib ' .•� Building Division Arfo �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: I�G I l]q JOB LOCATION: 5 .�j�f T?,tT.E� number street village "HOMEOWNER': k -Ar ) CON Zdkl 1:�!;2 -.C-1 CL name home phone# work phone# CURRENT MAILING ADDRESS: 1 'n r=ARTcnE&t om_ �- l NNI� . city/town state' .Y .,`, 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 A#• Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is;or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such " " "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building Permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he%she will comply with said procedures and requirements. . 4: Sgnattl✓ �• m was ' Approval of Building Official Note:.jThree-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 ;p The Code states that: "Any homeowner performing work for which a building penult is required shall be exempt from the provisions of this section(Section l D9.1.1-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 exemptian are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application., that the homeowner certify that he/she understands the responsibilities of a Supervisor: On the last page of this issue is a_form currently used by several towns. You may care t amend and adopt such a form/certification for use in your cornmunity. rn Q:forms:homecxept tr , Town of Barnstable Regulatory Services EMMSTABLr- KAS& $, Thomas F. Geiler,Director i639 �� f Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MAI02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790,6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in.all matters relative to work authorized by ibis building permit application for. (Address of Job) Signature of Owner Date F R Print Name If Property Owner is applying for permit please complete the - Homeowners License Exemption Form on the reverse side. Q:FORMS:0 WNERPERMISS10N P I p 9 d r 00, S j 9 Rt-103 a 3 e • q � p ' � + i � e � IT i C, ii e 3 , ° yy -3 i IM p+ y z f ' , g q, 9 + , , i 1 + { 3 , j f s i , 1 � r ¢ + } t 4­1 i k .._....�_.., r .,-�- F 1,. i q I "-_ _ � _ —� --—g•—��-- , d r e { • � f s s q i I 1 r , I 1 , I a t r , _ i 0 i d 1 { 1 9 r f i tt w J i bx , a f I a 4 i I E 0 ' , . P f ' t � _m _ __ e— ._ _ -- _ �. _ .. _ _ __ -_ � -_„ _...t _ _ _. __. ._ r � -�'w'- _� r-�- r - , ' r_ [ r � r r r � 3 i _._ ._. _.. ,. _. _ _ .. _ .. _ _ _ _-.__ e.._a _ _ - _. _ � _ ._ - _ __ _ _ _ -_..,_. _ __ ma _.._ a ` � 1 I. ! { � _. ..` � ,.� i i f i —`�—..� I -9 a.G.�_�.,..-.-®_.� 3 F,.....�.x-.-M,..--��. «,�,�.e..._. ....w. i 4 .,�..,.»N«...,._ .�,,.--,_...�.-m_.._.I� c,......r I_: � � >< s F �j. �4.. ll _.. � _ r _ � _..}}� 7 - _ � � r i � a i _.._ __e�� � _.. 1 i 3 a t f f i {@ �� � � � r i � r _�._.�_._._,vg...�-.- _. s.-.---�--fir"'' 7,__.,'; -ti-'"_•E.. .... ." _.. ... -_{ _- __.. � -- �_ '_� A .-- -.- � � 9 � i �«.�. � ` f , �-^-- r � ., , � t t 9 ^�R i I e _. erg. . .. _ .. � _ _. - .... _ __ ._ . .._. ., - - -- - - - r.__ -^�---�.,�..._ _. _t.._ --_a _ f..._,_ . _ � _.` _ k__. ,.e.. _ __.! •� w � ._.a._ .....�... _� ` _ .-_ .._ �_ � _�� I c .�k,.__ ___�--.a�._,...mom-,�?.....,.-._.r,._�� ..P..�pa..-.�-�,..«y,,...�..- �,... W,a..yp„e..a...,..`_._..®a�...- � _ 4 e..-� �._... -r_ _I � ' _ _. .' _ y R ____•�.- ._ ,>.-_r. •_ f � , i Y , r i � i i � i i ._ .... __.._.__.�„v,,,, _ - _. _._.. a .�.- �--. . .._ -- -- � ._. a,,,.., f e 4 1 � , a i � -p _ .�. �_ .._.�_ {.. ..,� a__--_.t. � �.�� k i t - _ 5 -- � P� y � � � � f � f � ' r �i. ; i _c ! _ — —. _ ._..— - _ __ .� —- -— .._— __ _—- — — — —tl — ——� — — � _ � — � 4 f r P + , ' .�. i � f � � r f � i I s � � t � �I i --- � ± '_ 1 � s � f i � s g ; e A E f � s P i _a_- � � � � � —; �._ � Ji g 1 � I � 1 r � _ _ i r i , t _` � __ _ '_.� e _ _ _. _ _ .a� .- �' -_ -��.-. ..._ ... -..-n -.� -�. _. .- P F r .,..--..-�_.-Imo....-,�..h�.._.�, —�,.-,.._P,s.. �-- .�' �_�--..._ .' i 1 ' �� �� - 4a p � �.._ j � -_. _. _ ... �_.._ �` ».`..,. e f � ._ _ § _" _" i v r y _ .. �+ _ -.I_ r _ L- - .�, _1.>r _ I� r , .j. .. _ _ _ _ �_ _ w.._. _ _f ..I.e.. _ � 1 _ � J. _... _... I ...._.�.'»ate ' � _!_ s. ..-.... �-_ .�_ - _. I' -_ .. _, •- - � - �._ ._ „�� � ; ; ._... .,f._._- .. ._ __ � _ .... .... � ._ - � � ._ ._ ._ __ - r L . f � I r � � ' f -r {y f a ' -; ��- —. i .� _.. as _i...._ _ _ i_ I _ .�.-. � _ .._.:. -1 _ ¢ d. - ._ '1 i f i t F � i 4 y � 1 � S w f. .-�, i � � i � e r I Y r � i i f � � Y � � � r r �- . r— _ _ _ _ _ _. ,� _ _ __._ .. _ _ _ _ _..__�_ . .._ .. __ i i - � r` —_ _ _- ---- - - --.� .m __ - - - - - - - --_- -- -^- - --- - --- - - - - -�--- _ - - - ... - -- - - -- I p c • J - ...1_ , - - °_ - ...—..... ..... .. .p......_...�._ ,...». .. ..�....,.,,.,,.j- ._-....w., .,..,.�... ..,1...«.....,.L..,.._..p,,......_. .�. m., .,..�,,.,—,...f ,. ,..�... ._._. ._.l.e.,,,.p. _ ...r.,,.a r. _} _5 _ ' d _ - ._. jj CO. I ti ,.g....,._..,._...... .._ _. _., _ ,,.. s F V..____._W «.�'»--.•_G I.,., ».,w .,°� ..# a.»,.,.. ,...-.,�a 4 4 '.,. ..,..�,,.._�._-..�.F-r...,�, q .----. `-__ ._ -W-- - -� - , — ' i s 1 I W .. 1 a m � _„a, �»._... ._.r ,,.,,....#..._ _,�,,..•. _ »„'.,...,. R _. ,» ._#.._..-A,1., - ! �-- -r -_' d u- ° .}- -' - I a i •_ _ _ �- d m »s .'......,�.,{ p ,--,�.a°».., _,ap.-.,__»r. u4..,,_._„�....._-,,..�-��.,.,_�i_..�..rW_._..Wes.--_--a b , a , b 9 4 ` P I f I -- a t a g a a s n _ yy j- a p5 a 1 ` I i y 9f --.-__.�'...-._:. ,- - - .. ._ ._ - - �._...--- -,- --�• - �-- - —o'- - a- - - - �- -^ -- - ° -W-" .. ._! __ _..-y_.,....,. __..,..�.- -- - -- � ---- .,_.,_..y_....-.._yam .. ,..,...-_ � S � � � I I , � } ' y � � i I ' 3 -, � � � � t �_ _ , t i • _ � $ 4 } "# � � i o ' - � I S i y ' d � � ' 9 , _ i i ¢ r � a a e i �" d i y �__ � � � v I � � t S r 1 i I �1R ' ....a,... _...!„_ � a , — � � � �— __ t f d i _�. � { s � 4 9 ��� Y � } t r a r o , {{ i 1 d P � �,� �. r 1 • e s i d r s � � } 4 I � ' __ _¢ � _ , r 1 � 0 y � _� � �_ � E � ,d 9 _... � � ��..�-h �- -- � - � --�� � �i � .�_ .�. a �. � � � F h ,,— � t_ - -- -� -�� - '1' 6� � o { �— y i I � , ' � _ L ' y 1 a ! [ y' t # � r r y _ i � � - ..�. t � 1 � g � ,: r 1 � y � , 1 r P � � � T S� � pl d � S V _.... � ; � , -_a .._ � — � f _ j �. � - S ._. � ._a _. �. ;_ A.�.•v,mi� S — _l .. � �. � - .s .. � � __ � ._. M _.. - .._ ___ y_ � � ...-e � � _• ,. _ -. .�_.- -. __ - � __ _ ..._ t w i. __ � .. r _ � __ �. �_ __ Jr � _ .. - i_ - _ Jt _ .r .. .*_ _ � i y _ r _. ._ _ _"'.y.. s i `, 4 d_ � f i � t .� i. � _ ._ f i i 3 1 � I i , _ _ _ �_ .__ - _ _ _ ___ _ _ _. _ �_._.__s_ _ � .._ _ _ _ _ _.. !rj _ _ _ _ .. ._ � _ � _._ _ .,�. y t � ; � a i ' t ' - �^ ' ._ ���M^.iwir dY ti!/�l/T/— ��u/a H�wi. _ _ -•A � _— ...�. ... � ...,.°,.;.. _ { ,. I �� {. _.L—µ ¢ _ i { �..—�_ —{ — i { I_ # — V�._ _ t_ ..— �- y. 6 _ .� ° # W , e I 6 I � W Y w y i • 1 I 0 I , { � � � a , _w d I s ; 1 4 W i i # - a ' W , , P T 4 , r I � ' y @ —_.- __ -.-,,,A. ._._-.e..— s i -•^` --+ -- '- ---'--``--.'-i - ___ _S..-®_�� _s-._ r '-'td�`-�s_ _ � ! � ! ± ' # I i i # j 4fi , - I f ` 6 d }} , r o r I r r { g -.-'- � 'y__ �—-^_° ._`.`. -�_.— _.--e .. �- --r.. -,� -� i I �-�—I ..._... _ ' �,. � ...,..°,..I.�_®.-, _._,.�.. ..._.r..,a....-„..�,,..«.......,�....�.,A«.._....�_.m__8.�.._t..__..._.�,._._.-.'_..-"_9"--_-R-.._.rm�•.�... # i 1! I , r d V � 7 r . t { r r ' p t � 4 n ' p t d - : : a • " 'ors!dad � b� ��- w , P : , skiv � '(�V:r,\+✓0 Gv0 l Y T':.: ,. :. _......s.....:,+.-�.,.��.-,d,.= ,..,• .. p ..,- .. __.- - -- ..._ ... ..s»_ - —�-�`:�- � b�'.—._.�.v.—� � � ...e_ � .,__`` -Imo.---..r�'.�..,,,±_.... _.�..-...-w.....„:-�._. _��...--.» , C " I r _ r , ° f ' r _ __ � `. I—-— — ®_� .b�—a— _.---!. _ _•.mot- ._ -®..ram ..,....._...#.-..,......—�..«._�...—_,..��t• ..-,,. .—.. —..�.�f,w,..�.,<.,....�._}.�.._.�,.,. �� ° _ a _ � ° �'� � � p � � $ w , r R I 71 , y r t , t � — , V } 4 t � , , I . 1 i , , � 1 , 2All 0. _ _ C e q_. . k4 a C i vo { LAC _ a � qp 1 � o 8 I 3 � i I Y - - i r o �. � I b C ~pc � . � s � � t l I w i � s C� ' � F � t �� � —T i ! e -i^— �� e j —e �... p .6. ..�{-. a � t i � i 1�» Va �� 1 � � � • , f � � o t 9 i � , � � . � _ _ _. _ ._ _ _ .._ _ .__ .. _ ' � � Y - - ---'-. y.T.. 6 1 , 1 1 a � n � ; 4 B I i r , i 1 y ' f I ' ff. ;gp. _ y .. '.. ..I f .. � � i � � - i 1 r h I € � � � 6 j I � � ( �t ' a- i � I i � � s. � -- r.. ..�..�.,, ter_ i r �... �- .a -_ � � .....--.�.. _—.:-m _. �....� R , ._... m_ _.._ __.__ ..� � _.. .. _ .�,_,_.. M... ._,..._ ._ _._.. _ .�_. - - -- - --- � ! � Y �. � 1. � _ e � 9 - € �� � � � � � � k , , a I f � j E X � Y I � � � 1 1 a � I � � t � � Y f i 1 - i r �. r I �� � . 4y f y e.,.. -.„._ _ .___<. eP .... .....,q„,,,,,, a,,m — q., ......�...._ �. i._.. _.:—f ....w._ -i._ .-. �._..�"F'. —..�.. _�,.._....J.,� ha��. { � __ ` _.w __ _ -.e.._ m.t.. § — .... �. _ 1«... ... J�� �. .d _. .. _ ,. S � 1 F � i � , F � i I 1 � • i � i' i ! I i i 1 ' i i r � i i � 1 1 t ' Y i #. .�_ e - _ _.. I ___ _ _. _ _ .. _,,,� ._ r _ �_ � ._._.,_ _. 4. x...--{. — �.-._ �.___ .. _ _ __ ._ �_. _.�_ _._ 1�_�. _ � _ . . -, _ -�. .,. - - - - - --_ . ._ - -- - __ - __ - —I- _ __ .�— -- - -- - - . . _ _ --� _. -- _ -- -- - — - . -- - -- - - -m _.,�. 4 � IL r � ' 4 P I : i 1 j LA. .. 9 9 I 1 i ..I.,_.' : 4 i µ_ n , 9 _ 9 € • di I 4-.tiY - ooPr° I 9 f 1 6 ' • 9 I � i N.�� 1 s - -. • .. _ __ _. _.-R_..._. ,F�r,_wow....,.,-_.. � ..,,. j�.�. � �..._ _ _ .— ".a�», .a.�......rr. o-... ._.. »�_ i •— — — _._. r .i. 4 4 1 { , yy F i I r t • I 9 r , a I 1 e r a I • 1 , I r ! f � • • f 4 4 , i V A IIt , I .C n a t r • I I t THE'T���� TOWN OF BAR.NSTABLE i BAWSTA➢LE. i 639.G Y BUILDING INSPECTOR O� PY a�9 APPLICATION FOR PERMIT TO ...... .... ......... .. ....... . .... ... .... ....................... ........................ TYPE OF CONSTRUCTION ..............l:d[1..:". ......---...19.��1� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for Ba permit according to the following information: Location ............: -�-t�L... .......................................................................................................... ProposedUse ............ ............................................................................................................................ ZoningDistrict ........................................................................Fire District .............. ...................... Name of Owner (...!... .....Address ...... Name of Builder ... / Nameof Architect .............. ............................Address .................................................................................... Number of Rooms ...................... .......................................Foundation ........ . .. .. ...... . .. .......... v.. ..�-•........ Exterior ... .. ...................Roofing ..................... . .. . . .. ............................................ .........."�-..... . . . ..................Interior ..... .... . .. - / - .. ...../ Heating .........�. ..........Plumbing ..... ............................................................. Fireplace ....Approximate Cost .................... . .... ......................... Difinitive Plan Approved by Planning Board ------------------------- J Diagram of Lot and Buildiria with Dimensions �i i�� • V x1adV l I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. C� Name ......).. 4.... ...................... Hart, Robert H. No ..12664... Permit for ......one...story,......... single family dwelling ............................................................................... t ocation/S;S.SEabroo ...k Road....................... ...... ...... T'a.?... ................................ kobert H:...Hart..................... Owner ................ ......... Type of Construction ..........frame..................... ...............................................................:................ Plot ............................ Lot ...........#2Q.............. Permit Granted October 2 69 .......................................19 Date of Inspection ....................................19 Date Completed 11."..- 0......................19z/ PERMIT REFUSED ................................................................ 19 ................................................................................ ................................................................................ Approved .................................................. 19 ............................................................................... ............................................................................. x tJ�' `r`0 ViD ►�-jVU �`o.���L j b poSED .. ACHE THE SU rPLy, SRNITARY WATER HERBY APR� �O L DRAIPMAGE"1S AND - Of gaiNA �� G, TOwN HE i t BOARD INSTALLER MUST OBTAIN SEWAGE; LIGp INSTALL SYS' l• PERM A f+ a A.aA •' 1`w .. v\ � o j