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Town of Barnstable TOWN Of BARN)TA.BLE
IHE r Regulatory Services
Thomas F.Geiler,Director 2D,2 —3 AM 9: 43
r
9B''R 'E,
MASS, Building Division
��F1)MA'1a,0 Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601 �aY
www.town.barnstable.ma.us DIVISj,0
Office: 508-862-4038 Fax: 508-790-6230
PERMIT# a O 1oZ0 2 V1 FEE: '$ r
SHED REGISTRATION
200 square feet or less
�Location of shed(a dress) Village
Property owner's name Telephone number
Size f Shed �� Map/Parcel# �
4a
Signature Date�—
Hyannis Main Street Waterfront Historic District? A ��
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature is required)
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE
ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION
FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shcdreg
REV:04291 1
C�1ti�f P4 4-
RANFI«LIB DRI VE
S88 78 20"E 125. 4 7'
C.Z (BY PLAN
i BY CALL **
HSE #45_=_-=====_ CO
LOT 5 -_____________________ CA)
__=======_ 2'=-_-_=-- o
59 f o
CIQ
? LOT 6 ��' o�
t AS/LOT 32
N867730"W
157. 00' _
AS/LOT 15
RES. ZONE.- 'RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C"
Bank Use Only
** THE DISTANCES AND MEASUREMENTS ON THIS ELAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY
TOWN: -00-MtT_____-______ REGISTRY OWNER: IfAMQRT P RJLLEY____________
DEED REF: -d458/254--------- BUYER: -P-ATEW,[,4_A--0ALFY_____________
DATE: 1t 4,-/2000--------- PLAN REF: _19V31___ ___---SCALE:1"-
-
I HEREBY CERTIFY TO PLXMQ-0TM® Z=��IN�_____
THAT THE BUILDINGr ` , YANKEE SURVEY
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS `~ � ' CONSULTANTS
SHOWN AND THAT ITS POSITION DOES ____ CONFORM ► PAUL,% 40B (SUITE 1)
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE o ��� j
TOWN OF ---BARNSZARI,E-------------AND THAT " INDUSTRY ROAD
IT DOES-NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD �, MARSTONS MILLS, MA. 02648
AREA AS SHOWN ON THE H.U.D. MAP DATED_ 151�92 TEL: 428-0055
Co unit -Panel 250001 0021 D OQ` FAX: 420-5553
___ THIS PLAN NOT MADE FROM A SURVEY 29892 JF
PA LAME ITHEW NOT TO BE USED FOR FENCES BUI`L M PERMITS ETC.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map OrI3 Parcel d 3 oZ Application #� V��
Health Division Date Issued _ L,D
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board J
Historic - OKH Preservation / Hyannis
Project Street Address
Village=� C��
Owner s UQM'2(0eA Address: yl h'�P�� c[ AVC C6
[Teleephorre-7
Perueaue . c n
(rsh vtia wrv�dca�1 = `—�11A x S' a�'In% lU e w\,uih.C6,1.3 = �l 1-�X 7��i
Square feet: 1 st floor: existing proposed U 2nd floor: existing proposed A�Total new O
Zoning District Flood Plain /�/C� Groundwater Overlay Wp
Project V�aluatior -I T �� Construction Type
Lot Size 0.e • Grandfathered: ❑Yes ❑ No If yes, attach supporting documee tation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure 3 gQA s . Historic House: ❑Yes ANo On Old King"s_Highway:�b Yesm 1(No
Basement Type: J4 Full ❑ Crawl ❑Walkout ❑Other =
=a
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) 1 t 0�
sv
Number of Baths: Full: existing_ new Half: existing newer'
Number of Bedrooms: existing O new
Total Room Count (not including baths): existing new 0 First Floor Room Count
Heat Type and Fuel: %,Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes �0 No Fireplaces: Existing New d Existing wood/coal stove: ❑Yes A6No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_
Attached garage:Y�existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
1 CG A_
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes Ig No If yes, site plan review#
Current Use S\yiq1g 6AX A`.1a Aksg. Proposed Use 50'cwt,P' "
APPLICANT INFORMATION
cam_ (BUILDER OR HOMEOWNER)
Name ber' T�ele hone Num
p �"LA o L 5-1�
Ad red ss" okn V License #
ce VVI+' o.?Ca 35— Home Improvement Contractor#
Worker's Compensation #
ALLOTRUCTION.DEBRIS-.RESULTING,FROM THIS.PROJECT_WILL_BEIAKEN TO
SIGNATURE
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED.
...MAP/PARCEL NO,
!� 'l ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
j FOUNDATIONS
FRAME
INSULATION
FIREPLACE
.3
ELECTRICAL: ROUGH FINAL
' PLUMBING: ROUGH FINAL
� GAS: ROUGH FINAL
> _�,,FINALB_UILDINQT!, 'R-_ ' " 7 l �l/w
s
DATE CLOSED OUT "
ASSOCIATION PLAN NO.
c,
s
4IN The Commonwealth of Massachusetts .
, �. Department of Industrial Accidents
I y. Office of Investigations
600 Washington Street
Boston, MA 02111
r 71 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AIplicant Information Please Print Leeibly
Nane Bustness/O'r anization/Inrdividual : ;f
C-i_ /State/_ -i :_. O
Are iou an employer?Check the appropriate box: Type of project (required):
1.❑ 1 am a employer with 6-TI 1 am a general contractor and I 6. ❑ New construction
trnployees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 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 S. ❑ We are a corporation and its
nquired.] officers have exercised their 10.0 Electrical repairs or additions
6-X-fam a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs r
insurance required.] t employees. [No workers' 13.09 Other (ZAJdQU_V)11nJQte15
comp, insurance required.]
'Any appl&ant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowters who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractoa 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 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 c • er the pains and penalties of perjury that the information provided above is true and correct.
Si nature: t--Date:}
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 5, Plumbing Inspector
6, Other
Contact Person: Phone#:
Information and Instructions
Kassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
lursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
ocpress or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
cf the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
nceiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
ovner 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."
NOL 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-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employeesJother 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 ortown 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 5 26-OS www.mass.gov/dia
SHE Town of Barnstable
�oP t�ti
Regulatory Services
BARNSTABLE, Thomas F. Geiler,Director
MASS.
1639. ,0b Building Division
JFD '�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 Id
JOB"LOCATION: �`! tc�tP f�� Irl V�C _ � �1
numb_erL �— street village
"-HOM$OVJNER' — (}�[I^1Cl�Qt�G. o O '�r�Q cS6—����V�/✓/iOZG�
name Q home phone# work phone#
CU NRRE T MAILING ADDDRESS:
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 Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requireme
I
Signs re o Home 00
er
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 supensor(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 writh a licensed
Supervisor. The homeowner acting as Supervisor is uldmately 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 forrn/certification for use in your community.
i
f
ofTHET Town of Barnstable
Regulatory Services
saRxsTABM
KAss. Thomas F. Geiler,Director
rE1659. Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This' Section
If Using A Builder
as Owner of the subject property
hereby autho to act on my behalf,
in all matters relative t work autho ' d by this building permit application for.-
dress of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please mp e
Homeowners License Exemption Form on e reverse sid .
Q:FORMS:O WNERPERMISSION
• 1 ,
*10 �
fb
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m
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fF � �C °bra �,r y�,�� 'I'�► �j,�?�.�try � �.,�
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1.
oFr►��o� Town of Barnstable 'Perm Cp(�
it#
. '� Lrpirer 6 n1onlhrjrom isru nrr
Regulatory Services Fee
BARVSTXBLE, -
.y. MASS.
Thomas F. Geiler, Director
�AT�titp,�f A
Building Division
Tom.Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstab le.ma.us
Office: 508-862-403 8 Fax: 508-790-623 0
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
No/Valirl wilhout Rerl-X-Press Imprinl
Map/parcel Number &2 1(N,_a
Property Address �2 !., T�'I
Residential Value of Work Minimum fee 0f$35.00 for work under$6000.00
Owner's Name Address—::Pb
t
Contractor's Name J��lA
Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
� ., aa9 '
❑Wtirkman's Compensation Insurance
Check one: JE.0 0 6 2010
❑ I am a sole proprietor
I am the Homeowner TOWN OF BARNS ABLE
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)
❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of root?
( ] Re-side
�;'�'�i� �-�''�-ti%� "
Replacement Windows/doors/sliders. U Value n �#of doors
�Lt .�yl. (maximum .35)#of windows _
*Where required: Issuance orthis 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 wired.
:NATURE:
The Commonwealth of Massachusetts
r ^ 1 Department of Industrial Accidents
I ,r� Office of Investigations
600 Washington Street
1 tilru �
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeRibl
Name (Business/Organization/individual): : '&I't t"la allu(l
Address:5- )n oko�r� c�J�1w
City/State/Zip: CG ��} CJ��t'o��tl �� Phone #: j��' - ���y �
Are you an employer?Check the appropriate box: L13.fg
project (required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
El 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. tmodeling
ship and have no employees These sub-contractors have molition
working for me in any capacity. workers' comp. insurance. ilding addition
[No workers' comp, insurance 5. '❑ We are a corporation and its
required.] officers have exercised their ctrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL mbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no f repairs
insurance required.] t employees. [No workers' er r7 �(�I r1c66 WU1C
comp. insurance required.]
*Any applicant that checks box#I 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.
iContractors 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 andjob 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 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 andpenalties ofperjury that the information provided above is true and correct
-
Si atur Date: 12 1/0
Phone
v
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#:
�- A
Information and Instructions
Massachusetts General Laws chapter 152 requires all empIoyers.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-contractor(s)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
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-OS www.mass.gov/dia
k
01► r ti ` 'own of Barnstable
Regulatory Services
`Ws. Thomas F. Geiler, Director
Ws. $
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.t o w n.b a rns to b l e.nt a,us
Office: 98-862-4038 Fax: 508-790-6230
— ----------------------______—_
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: -J,;? -- b- 16
y
JOB LOCATION: q� :/3Ct M 6�I, (✓JI l l/� ( _Q��I�
number �— street village
"HOMEOWNER" !✓4 fIi �IJllllC� r1D� .y—�. It� p D(�?—
name home phone N work phone N^
CURRENT MAILNG ADDRESS: L_76n� g:xs"-
6(2
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 tine
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.
Sign re o omeow r
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.117.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code stales that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section
109,1.) -Licensing ofconstruction 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 ofa Supervisor. On the last page of this issue is a form currently used by several towns. You may care I amend and
adopt such a foirn/certification for use in your community.
of THE rp�
0
• &1RNSTABLE,
9� MASS.
rbjq: Town of Barnstable��
prFD MPS a .
regulatory Services
Thornas F. Geiler, Director
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
wivw.town.barnstable.ma.us
Office: 508-862-4038 fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
ff 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)
Signature of Owner Date
J
Print Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
� 4
�P t °
P� f�a�
4 "OICi
�oFrrur ��/V OFTownof Rarxistable *Permit#
O ARi'VSrABR[e-gulatory Services Lrrpres6morulisjrom issue
e
Thomas F, Geiler, Director
,Building Division /��
Tom Perry, CBO, Building Commissioner 0
200 Plain Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: SOS-790-6230
NO/Valid without RedmX-Press Inrprinl
Map/parcel Number
Property Address
Ile
LO 7 � .
Residential Value of Work 000 Minimum fee OrS35,00 for work underS6000.00
Owner's Name & Address '
Contractor's Name_ •�
Telephone Number36 5 5 1,
Home Improvement Contractor License #(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
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)
Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof)
Re-side
#of doors
❑. Replacement Windows/doors/sliders. U-Valtte (maximum .35)#of windows
*where required: Issuance orthis 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.
'i A copy of.the Home Improvement Contractors License & .Construction Supervisors License is
uiir^/ed.
Pot T y Town of Barnstable
' Regulatory Services
" at.�r�ssste.a Thomas F. Ceiler, Director
19. h. lb Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
wivw.town.barnstable.ma,us
Off-Ice: 518-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
DATE:
Please Print
� �� '�
JOB LOCA"r10N:_6� (4 e �O
number (r i.-1 street �villlla�ge
"I-IOMEOWN tic all-ER" t?,lrt?t Y Xb -Lido'���02 4�� 0� 7L q—
name -�� home phone N work phone N
CURRENT MAILNG 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 Town of Barnstable Building Department minimum inspection
procedur end requirements and that he/she will comply with said procedures and requirements.
Signature o Home r
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 stales 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 ofconstruction 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.
s
Of THE Tpk
HARNSTADLE,
9� MASS.
i679• Town of Barnstable
♦0
' �rfD hW`f A
Regulatory Services
Thornas F. Geiler, Director
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town,barnstable.mn.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
ff 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)
Signature of Owner Date
J
Print Name
If Property owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
The Commonwealth of Massach usetts
r ^ Department of Industrial Accidents
v Office of Investigations
600 Washington Street
a j Boston, MA 02111
-Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: J� )&V 6 (c JQ
City/State/Zip: (c5ub)L1rn Cj�?� Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1
6. Q 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. t I• ❑ Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. 9. Q Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
1 LEI Plumbing repairs or additions
3. I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, §](4), and we have no 12,Q Roof repairs
insurance required.] t employees. [No workers' 13.0 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 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi y it er the pains and penalties of perjury that the information provided above is true and correct
Sianatur : Date:
Phone#: l
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
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-contractor(s) 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 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 5-26-05 www.mass.gov/dia
0_o
�oFtrurok Town of Barnstable *Permit#
2
LC s 6l/ lit issue r/ale
.9'�•9 �i;�'
T Regulatory Services
s
' g
v bJq. ET Thomas F. Ceiler, Director
t�tj . Ar�:�YiJ Ict
Building Division
TOWN OF BARNSTASLE Tom Perry, CBO, Building Cornrnissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Vallrl without Red X-Press Imprint
Map/parcel Number �`�163,2
Property Add ress
Residential Value of Work T�(j�l Minimum fee ofS35.00 for work�under S6000.00
Owner's Nam e & Address
Contractor's Narne_ ns
Telephone Number - (.
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
Ej 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)
❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
Replacement Windows/doors/sliders. U-Value_/ , (maximum .35) #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.
A copy of the Home Improvement Contractors License & Construction Supervisors License is
re uired.
�IGNATUI2G:
r:\WpfILES+(ORMSlbuildiag permit forms EXPRESS.doc
The Commonwealth of Massachusetts
i Department of Industrial Accidents
Office of Investigations
600 Washington Street
j- Boston, MA 02111
`r; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): "-Pnkv�oia7)Aw
Address: "BQ K+�jp� ;�,��Q
City/State/Zip: ������� p�3� Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired,the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 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 arr a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.6a Other wivi
comp, insurance required.)
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
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 violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certi der the pains and penalties of perjury that the information provided above is true and correct.
Si atur . Date:
Phone#:
L
only. Do not write in this area, to be completed by city or town officiaL
n: Permit/License#
thority(circle one):
Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector
son: 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
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
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
o[►*r � Town of Barnstable
' °^ Regulatory Services
y iaAl;(sTABCE,
Thomas F. Ceiler, Director
`b r40 Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 518-862-4038 Fax: 508-790-6230
------------------------_—=_
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:�I
10B LOCA"1.10N: 1, _11y M ,,1A!/)IVJL (:0
number street village
"HOMEOWNER,7?_Q1Y\G��(��u bl —L4ar)— -102IC2
name home phone N work phone N
CURRENT MAILNG ADDRESS: V UGC
city/town state zip code
The current exemption for"homeowners" was extended to include owner-occupied dwellings ofsix 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 FIOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws, rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedureLDnd requirements and that he/she will comply with said procedures and requirements.
��r48, er
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.L l -Licensing ofconstruction 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 oRen 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[lie 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 1 amend and
adopt such a form/certification for use in your community.
• 0
Q:IWPFILESIFORMSIbuilding permit formslEXPRESS.doc
Revised 072110
IZA
Of THE TOE
O�
+ aARNSTADLE, + .
� MASS.r6S9: Town of Barnstable
7 ��
�1E0 MA'I a
Regulatory Services
Thomas F. Geiler, Director
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.ba rns to ble.ma.us
Office: 509-862-4038 Fax: 508-790-6230
Property ®wrier Must
Complete and Sign This Section
If Using A Builder
is 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:
(A'ddress of Job)
Signature of Owner Date
Pint Name
If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the
reverse side.
QAWPFILESIFORMSIbuilding permit fornls\EXPRESS.doc
Town of Barnstable *Permit
Expires 6 months from issue date '
X-PRESS PERMIT Regulatory Services Fee 2-,S-
Thomas F.Geiler,Director
SEP 2 7 2007 Building Division
TOWN OF BARNSTABLE 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 PERNUT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address �5_ 1' A/J"Fl CL D D ZI V& c OTu 11
[Residential Value of Work �' Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address CQ '1 C'i�2 .�i,l }��t// o .`�l`� l� �c� U nA oj6.js
Contractor's Name J01g jn J_A. Telephone Number Sd 8"467 SI a-
Home Improvement Contractor License#(if applicable)
Cisnstruction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name � r�,�l , I-'lC2
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file. 1.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
P, Replacement Windows/doors/sliders. U-Value ximum.44)
'Where required: Issuance of this pen-nit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
c y of the Home Improvement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
i
�oFIME, - Town of Barnstable
Regulatory Services
BABivsresr.E. Thomas F. Geiler,Director
�AT1619. A.�� 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
HOMEOWNER LICENSE EXEMPTION
l �7 Please Print
DATE:
JOB LOCATION: Am rl e Lp �I'L• CQ-�TT
number
L street 1 village t f Q�
"HOMEOWNER": 9Q'I Ir( C i Ct D o C 1 ��-�oZO� 5-5-1 CZ S��D{l- —1 74 V
name �I home phone# work phone#
CURRENT MAILING ADDRESS: d Env 7,�3`j
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 Town of Barnstable.Building Department.
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requ' em ts.
ig ature of Homeow r
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.
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 Legibly
Wi rie (Business/Organization/Individual): 'Ppl `eiii
Address:-- P13Sz 1 4'cR'S' tl��v��l" 0y.P��T��
City/State/Zip(�CU� 1 �/)/)� GAG �S Phone.#:_ 57)J�-
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
. employees(full and/or part-time).
* have hired the su'b-contractors 6. El 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 8. ❑Demolition •
working for me in any capacity. employees and have workers'
9. .�Building addition
[No workers' comp.insurance comp.insurance.
•$
_required.], 5. We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3. . �I am a homeowner doing all work . l 1.❑Plumbing repairs or additions
+--'" `'� right of exemption per MGL
myself:= oyorkeis comp.
---��. 12.❑Roof repairs
insurance required] t a C. 152, §1(4),and we have no 13.❑ Oth
employees. [No workers' er
comp. insurance required.] • t/i)h QA)6
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their worker;'comp.policynumber.
Iam an employer that is providing workers'compensation insurance for my employees. Below isthepolicy and fob 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 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 de the ains•and penalties of perjury that the information provided above is true and correct.
Siena Date: �- WU&/402
Phone #:
Official use only. Do not write in this area,tb be completed by city or town 0 iaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#: