ࡱ> bda5@ ;9bjbj22 SZXX!1HHHHHHH$l P@!\!dl0~!(!""""" 6" B"=0?0?0?0?0?0?0$<2R4c0Hc&""c&c&c0HH""x0(((c&FH"H"=0(c&=0((((r/THH/"!  &U//d000c/V5W(F5/llHHHH5H/ J">#(#x$J"J"J"c0c0ll (ll  TOWN OF TISBURY BUILDING INSPECTION & ZONING ENFORCEMENT POST OFFICE BOX 1239 VINEYARD HAVEN, MA 02568 Kenneth A. Barwick Phone: (508) 696-4280 Rhonda DeBettencourt Fax (508) 696-7341  HYPERLINK "mailto:Rwelty@ci,tisbury.ma.us" Rwelty@ci.tisbury.ma.us - BUILDING PERMIT APPLICATION - FEE: ____________ OTHER PERMITS/APPROVALS REQUIRED: BOARD OF APPEALS: _______________ PLANNING BOARD: _______________ BOARD OF HEALTH: _______________ CONSERVATION: _______________ FIRE DEPARTMENT: _______________ HISTORIC DISTRICT: _______________ MARTHAS VINEYARD COMMISSION: ______ SITE PLAN REVIEW COMMITTEE: _____ ************************************************************************************ PROPERTY OWNER:_______________________________________________________________ MAILING ADDRESS:__________________________________________________________ TELEPHONE:_______________________________ PREVIOUS OWNER IF PURCHASED WITHIN 1 YEAR_____________________________ APPLICANT NAME:________________________________________________________________ MAILING ADDRESS:__________________________________________________________ TELEPHONE:________________________________ PROPERTY LOCATION: STREET: ______________________________________________________________ ASSESSORS PARCEL: _____-_____-_____ ZONING DISTRICT: _______________ DATE OF DEED TO OWNER: _______________ BOOK: __________ PAGE: __________ DESCRIPTION OF CONSTRUCTION ACTIVITY: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ DIMENSIONS: _______________(LIVING AREA) SQUARE FEET: _______________ NUMBER OF EXISTING BEDROOMS: __________ BATHROOMS: __________ NUMBER OF PROPOSED BEDROOMS: __________ BATHROOMS: __________ DISTANCE FROM WETLANDS, BOG, MARSH, BEACH, OR BODY OF WATER: __________ BUILDER: _________________________________________________________________ MAILING ADDRESS: ___________________________________________________ TELEPHONE: ___________________________________ CONSTRUCTION SUPERVISOR: ______________________________________________ MAILING ADDRESS: ___________________________________________________ TELEPHONE: ___________________LICENSE NUMBER________________ ESTIMATED COST OF STRUCTURE:________________________________ (MATERIAL & LABOR) PLANS REQUIRED (3 SETS EACH): A. PLAN OF LAND REQUIRED FOR NEW CONSTRUCTION OR ANY CONSTRUCTION OUTSIDE EXISTING PERIMETER OF STRUCTURE* B: DETAILED BUILDING PLANS INCLUDING DIMENSION LUMBER, INSULATION VALUES, MATERIALS TO BE USED, ELEVATIONS, SECTIONS, ETC.** C. APPENDIX J (ENERGY AUDIT) *All such plans and computations shall bear the Massachusetts Seal of Registration and signature of the qualified Registered Professional Land Surveyor. **All building plans must comply with 780 CMR Building Code. This application will not be processed unless it is deemed complete including attachments as required. ------------------------------------------------------------------------------------------------------- Signed under the pains and penalties of perjury. Signature: OWNER___________________________________________________________________ APPLICANT________________________________________________________________ ************************************************************************************* OFFICE USE ONLY APPROVED: __________ DISAPPROVED: ___________ COMPLIES WITH ZONING BYLAW SECTION: ___________________________________ PERMIT NUMBER: ___________________ DATE OF ISSUE: ____________________________ _________________________________________________ SIGNATURE OF BUILDING INSPECTOR APPLICATION FOR: ATTACHED___ DETACHED___ TEMPORARY STRUCTURE___ NEW - DWELLING___ GARAGE___ SHED___ OTHER_______________ ADDITION TO - DWELLING___ GARAGE___ SHED___ OTHER_______________ BUILDING TYPE (SELECT ONE): BUNGALOW___ CAMP___ CAPE/SALTBOX___ COLONIAL___ COMMERCIAL___(see Page 4) MODERN/CONTEMPORARY___ TWO-FAMILY___ RANCH___ RAISED RANCH___ SPLIT-LEVEL___ OTHER_______________ STRUCTURAL DATA (MUST BE COMPLETED FOR ALL BUILDINGS): A. FOUNDATION TYPE B. FOUNDATION CELLAR___ BLOCK___ CRAWL SPACE___ POURED CONCRETE___ OTHER__________ OTHER__________ EXTERIOR WALLS (SELECT ONE, UNLESS THERE ARE EQUAL PROPORTIONS OF TWO) COMPOSITION/WALL BOARD___ WOOD ON SHEATHING___ ASBESTOS SHINGLES___ STUCCO___ BOARD & BATTEN___ STONE ON MASONRY___ BRICK ON VENEER___ BRICK ON MASONRY___ STONE ON MASONRY___ CLAPBOARD___ VINYL SIDING___ ALUMINUM SIDING___ CEDAR OR REDWOOD SIDING___ WOOD SHINGLES___ GLASS/THERMOPANE___ PREFAB WOOD PANEL___ PRE-FINISHED METAL___ CONCRETE/CINDER___ LOGS___ OTHER_________________ D. ROOF TYPE (SELECT ONE. IF MORE THAN ONE, CHOOSE THE PREDOMINANT) FLAT___ SHED___ GABLE/HIP___ SALTBOX___ MANSARD___ GAMBREL___ ROOF COVER (SELECT ONE. IF MORE THAN ONE, CHOOSE THE GREATEST AREA) ASPHALT___ WOOD SHINGLE___ CLAY OR TILE___ SLATE___ METAL OR TIN___ ROLLED COMPOSITION___ BUILT UP TAR/GRAVEL___ OTHER____________________ F. INTERIOR WALLS MASONRY___ PANELING___ PLASTER___ WOOD PANEL CUSTOM___ DRYWALL___ OTHER__________________ G. INTERIOR FLOORS (DO NOT COUNT KITCHEN) PLYWOOD___ PINE OR SOFTWOODS___ TILE___ HARDWOOD___ CARPETING___ PARQUET___ LINOLEUM___ VINYL___ OTHER_________________ H. HEATING FUEL I. HEATING TYPE WOOD/COAL/KEROSENE___ NONE___ OIL___ CONVECTION___ GAS___ FORCED AIR - DUCTED___ ELECTRIC___ FORCED AIR - NON-DUCTED___ SOLAR___ HOT WATER___ STEAM___ RADIANT ELECTRIC___ J. AIR CONDITIONING NONE___ CENTRAL___ HEAT PUMP___ K. OTHER DATA NUMBER OF STORIES:___ NUMBER OF FIREPLACES/WOOD STOVES:___ OTHER SIGNIFICANT FEATURES IF ANY:__________________________________ ********************************************************************** ADDITIONAL DATA (FOR COMMERCIAL BUILDINGS ONLY): A. HEATING/AIR CONDITIONING PACKAGED___ SPLIT___ NONE___ B. STRUCTURAL FRAME NONE___ WOOD FRAME___ MASONRY___ STEEL___ FIREPROOF STEEL___ REINFORCED CONCRETE___ OTHER__________________ C. CEILING & WALL (CHOOSE ONE FROM EITHER SUSPENDED OR NOT SUSPENDED) SUSPENDED NOT SUSPENDED CEILING ONLY FINISHED___ CEILING ONLY FINISHED___ CEILING WITH MINIMUM WALL___ CEILING WITH MINIMUM WALL___ CEILING & WALL FINISHED___ CEILING & WALL FINISHED___ D. OTHER DATA NUMBER OF ROOMS PER FLOOR___ WALL HEIGHT___ PERCENT OF COMMON WALL___ TOTAL NUMBER OF RESTROOMS___ IF RESIDENTIAL UNITS: NUMBER OF UNITS___ BEDROOMS PER UNIT___ BATHS PER UNIT___ Suggested Affidavit for Home Improvement Contractor Permit Application TOWN OF TISBURY AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGLc.142A requires that the reconstruction, alteration, 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 dwellings 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:__________________________________ EST. COST: $___________ ADDRESS OF WORK:________________________________________________ OWNER NAME:_____________________________________________________ DATE OF PERMIT 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 ___OWNER PULLING OWN PERMIT ___OTHER (SPECIFY)____________________________________________ 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 the penalties of perjury. I hereby apply for a permit as the agent of the owner: _____________ _____________________________ __________________ DATE CONTRACTOR NAME REGISTRATION NO. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: ___________________ ________________________________ DATE OWNER NAME Office of Investigations 600 Washington Street Boston, MA 02111  HYPERLINK "http://www.mass.gov/dia" www.mass.gov/dia Workers Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: . Address : . City, State/Zip: . Phone #: . Are you an employer? Check the appropriate box: 1) ( I am a employer with . . employees (full and/ or part time. * 2) ( I am a sole proprietor or partnership and have no employees working for me in any capacity. 3) ( We are a corporation and its officers have exercised their right of exemption per c. 152, 1(4), and we have no employees. [No workers comp. insurance required]** 4) ( We are a non-profit organization, staffed by volunteers with no employees. [No workers comp. Insurance req] Business Type required): 5) ( Retail 6) ( Restaurant/Bar/Eating Establishment 7) ( Office and/or Sales (incl. Real estate, auto, etc.) 8) ( Non-Profit 9) ( Entertainment 10) ( Manufacturing 11) ( Health Care 12) ( Other . . * Any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers compensation policy is required and such an organization should check box # 1. ===================================================================================== I am an employer that is providing workers compensation insurance for my employees. Below is the policy information. Insurance Company Name: . . Insurers Address : . City/State/Zip: . Policy # or Self-ins. Lic. #. . Expiration Date: . . 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 o the DIA for insurance verification. ===================================================================================== I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: . Phone # . .  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