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Home My WebLink About0913 OAK STREET (CENT./W.BARN) 57- 2 UPC 12543 No. 53LOR wna•,.,o. w+a r r s OFTHE Town of Barnstable *Permit# Expires 6 months j om issue date ` Regulatory Services Fee • enarrsrAate, MASS.1639. $ Richard V.Scali,Director �� Building Division : �c Tom Perry,CBO,Building Commissioner fQ1� 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number QI (,,20��/� Property Address L*cPP T ❑ Residential Value of Work$ ,boo 4 oo Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 4::�> Contractor's Name Telephone Number (R4 3 c at Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: �0"ES e��11 C1 RUMMY ❑ I am a sole proprietor ��1JI�n YI am the Homeowner ❑ I have Worker's Compensation Insurance DEC 2 9 2014 Insurance Company Name TOWN 0 F BA R N S—TA B I F 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) VRe-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. 11 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 quired. t SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 A The Commorriveakh o,fMassuchusetts Deparbne-nt of Indusaial Accidents Office of Investigations, 600 Washington.Street Boston,MA 02111 w► g vkt nzcrxs. ov/die MTorlcers' Compensation Insurance Affidavit Builders/Conti-actorslEie.ctiicians/Phimbers Applicant Information Please Print Legibly Name(HitsnessiOrganizatiowln&-,idual): f�)l)SG,✓�_ a Address: qS_1 0 a- ship e_- City/Stats/Zip- Phone# Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6_ ❑Near * have hired the sub-contractors employees(full aud,rorpar#,-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet- 7. ❑Remodeling slip and have no employees These sub-contractors have g.- ❑Demolition. working forme in any capacity_ employees and have workers' [No workers'comp.insurance comp_insuranmi 9. ❑Building addition. Dequied.1 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3. 1 am a homeowner doing all work officers-have exercised their I LE]Plumbing repairs or additions tuyself.[No workers'camp- right of exemption per MGL 12.❑Roof repairs insurance required.], c..152, §1(4),andwe have no employees-[No workers' 13.❑Other comp.insurance required.] *Any applicant di2t checks box'1 nm also fill out the secdou below showing their workeie cotupensation policy information. I amem-mers who submit this of &nit indicating they are daiag sJ1 wcA and rLen hire outside contractors amst submit anew affidavit indicating Mc =Contractors that check This box rams[attachM an additional sheet showing the A t1TA or the sub-com ractocs sad suite whether or not those enufies have employees. Ifthe sub-contractors have emplvfebes,they must provide their workers'comp.policymmnber. I ant an empZger that is providing morkers'congxwsation insurance for uty employees. Below it fhepolicp andjob site information_ Insurance Company Nance: Policy,4f1 or Self-ins.Lim#: Expiration Date: Job Site Address: City/Stat&Zip: Attach-a copy of the workers'compensation policy declaration page(shoe na the policy number,andexpiration 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 S 1,500.00 andfor one-year impF sonmenk as urell as civil penalties in the fomr of a STOP WORK ORDER and a tine of up to$250.0.0 a day against the violator. Be advised that a copy of this statement may be forurarded to the Office of Investigations.ofthe DIA for insurance coverage verification- I do hereby c:erti ender the pains id penalties of perjur} that the information prm ded abova is true and correct. t. Signature: Date: Phone i�: Official tie oidy. Do not write in this area,to be c4inpieted by city or toum ofdaL City-or Town.: Permid Ucense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/To au Cleric 4.Electrical Inspector S.Plumbing.Inspector 6.Other Contact Person: Phone#-z - _. .- _ ___ ..- - - - - _ _ _ _ - - - - Town of Barnstable Regulatory Services Q�°FTHE rp�� Richard V.Scali,Director Building Division HAHNSTABM Tom Perry,Building Commissioner MASS. v� 1 639. � 200 Main Street, Hyannis,MA 02601 ArFD MP'I s www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: P , number G '` e street village "HOMEOWNER":�G�li � saAn �5�55 lq- e y nam — ^� home p one# work phone# CURRENT MAILING ADDRESS: l►'NWTe 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 under,' ed"homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedure d requirements d that he/she will comply with said procedures and requirements. r ignat Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109.1.1 -Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section.2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 r « + HARNSTABLE, « "�: ,�� Town of Barnstable �ArED MA't A 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 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) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313