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Home My WebLink About0014 ALDEN WAY 1 19/den `A Town of Barnstable *Fermioo/s o/ / ♦ OF THE Tp� p� 0 Expires 6 month dat * Regulatory Services Fee * BARNSrABLK .7 MASS. Richard V.Scali,Director 1639. ATE p�,t a 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 Not Valid without Red X-Press Imprint Map/parcel Number ri/J-4 .2 Property Address 1 1 gel w � �Y�l Y1Yl QQ�(nU fl ❑ Residential Value of Wyk$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Add res' _s _&- i Y1 �-� • �C.lr ex� T Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) 171 Workman's Compensation Insurance APB Check one: T 0 ❑ I am a sole proprietor n' ®' [�)I am the Homeowner O W u OF � pnI ❑ I have Worker's Compensation Insurance Il ruS�jjq8! c Insurance Company Name ; Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) _ ❑ Re-side ''Replacement Windows/doors/sliders.U-Valuej maximum.35)#of windows t #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspection's required. Separate Electrical&Fire Permits required. . . *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is requirell.7? SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe Revised 061313 4 Ile Commorrivealih of Afassachusetts DeWinzentofIndustrialAccidmis 4 - xf !`ffke oflnmytigatrons N '�• 600 TEasllingtorr.Street , Boston,M4 02111 T YPiYk4}:rl`lit s&gv!?r did '3rorkers' Compensation Insurance?affidavit:$uilders#C ontracturs/El i ns/Phuuher-s AppheantInfbimalftan Please Print Le 'hI hTasne_(8_ '}Org dual): iddress_ 14 V-� &a-v- L --)2t- :j Y1 s U Y A CR_6c) _ C;it # taf2ip_ Phone# . e you an employer;'Check the appropriate box: TYPE,of project(required): 1.❑ 1 am a employer with 4-. ❑ 1 am a general contractor and I * have hired the sub-contractors 6_ �New construction. Mull l auilrorpaxt-time). 7_ Remodeling 2_❑ 1 am a sole proprietor orpartnes- listed on the attached sheet. 0 g These sub-contractor have slop and have no employees These ❑Demolition working for me many capacity employees and have workers' 99_ ❑Building addition a workers'comp.iasur-anee comp_insurance l eilnireci_] -❑ We..are a corporation and its lU_❑Electrical repairs or additions 73 a a f omeouner doing all work have exercised.tlletr lL[]Plumbing repairs or additions ye f o 1.vorken'c: right of exemption per i4iCiL � my" � �- 1:...,❑Roof repairs: insurance required_]s c-.1.52, §1(4),and we have no employees_[No workers' 13.0 Other comp.insurance required.] •my applicant ffisi checks box#1 nmst also fill out the section below*showing then v;uAe&compensation policy informs[eon- I onxeowners who submit ihis affidavit indicstiug they use doing all vrcuk and then hire autsidecoaMctors nmst suSsnm a nee affidavit indicaam,;such. lconrractors that beck this box must attached an sdditionai sheet showing the mun of the sub-contractors and state whether ornot those entities have employees. If the sub cortractur have employees,aaeynnEsrmmvide then mockers'comp.policy nut sber. lain an employer€lust is pros idirrg it orke.rs'cortgwzisat on insrirmLce for my etnp.lopees. Belon,is the puff 7 and jab site inforruahom Insurance Company INFame: Policy 4-or Self--ins.Lic_#fr 1r�.piratioxrDatg. Jab Site Address_ CitylState 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 andfor one-year impnsonment,as well as coal 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 maybe forwarded to the Office of Irrvestigations.ofthe DIA for insurance coverage verifration. I do hereby ce f}r rr rder is artd peitallies of perjury.that the iriforarntiarr prot�ded a re ot,g is true and correct Sierrature: Phone II clC1Q� 1 Of icial ttse only. Do not ivrite in this area,to be cantpleted by city or toner official. City or Tmvn: PermitUcense 9 issuing Authority(circle one): 1.Board of Health ?.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing.Inspector 6.Other Contact Person: Phone#: L Town of Barnstable : Regulatory Services . �oFSHe Toty Richard V.Scali,Director Building Division BARNSTABLE, Tom Perry,Building Commissioner MASS. v� 1639• �� 200 Main Street, Hyannis,MA 02601 ATFD �n www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print JOB LOCATION: LA a, l1J7\n 1 �u�er'—� �str tp\.-. Cn_l gep'l� .HOMEOWNER'! _Y_ '\�_ 0. 0 1 ��E�1 7 IO<, 0 1 ,�✓ 0 home ph6ne 31"""""1 work k_phone# CURRENT MAILING ADDRESS: It city,town'"'—" ^�. state p code The current exemption for"homeowners"was extended to include owner-occupied`d ellings 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 su ep rvisor. 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. g The signed"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro d e a irements and that he/she will comply with said procedures and requirements. Si are of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules & Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 061313 . . THE Y Y * BARNSTABLE, Y '0"9. i639• Town of Barnstable �� pTED µp'l A Regulatory Services Richard V. Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 026 www.town.barnstable.ma. s Office: 508-862-4038 { Fax: 508-790-6230 l Property O ner Must. Complete and ign This Section If Usi g A Builder l , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work autho ed by this building permit application for: Address of Job) Signature of Owner Date Print Name If Property Own is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWHILESTORMS\building permit forms\EXPRESS.doc Revised 061313