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Home My WebLink About0017 BIRCH STREET �� 8;,z�i ST- � � �� 0�11rlE Town of Barnstable *Permit# i Expires 6 morU iron i e dale • a Regulatory Services. Fee • BARN v� b�16 9, E, + q. Thomas F. Geiler, Director- . alE p MA't A Building Division 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 PERMIT APPLICATION -. RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address Y, � u D I 14Residential Value of Work. Minimum fee of$25.00 for work under$6000,00 Owner's Name &Address Scn Contractor's Name '" - g Telephone Number I Ionic Improvement Contractor License 4 (if applicable) —►i * *-%� Construction Supervisor's License # (if applicable) ❑Workman's Compensation Insurance Check one: -P RESS PERMIT ❑ I am a sole proprietor ®mil am the Homeowner MAY 2 6 Z009 ❑ I have Worker's Compensation Insurance Insurance Company Name. TOWN OF BARNS TABLE, Workman's Comp. Policy # Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) Q( Re-roof(stripping old shingles) All construction debris will be taken to I,?r-rL S. k-po.L,-aA, Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .44) '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 is required. SIGNATURE: ).'U IFII.IS\F()RMS\building permit Forms\EXPRESS.doc Revised 100608 fi 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 Name (Business/Organizatio ndividu Address:_ 2 r Q rn-10,n.S I L g of City/State/Zip: Phone.#: �- 3 C-- $ -7 9'P 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 prpprietor or partner-' listed on the attached sheet 7. .❑Remodeling ship and have no employees These sub-contractors have g.'❑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 3.LJd l am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp_ right 6f exemption per MGL 12.[ of repairs insurance required.] t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that 6ccla 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. tConbwtors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must pmvidt:their workers'cormp•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.#: 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 io sec rc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a finer 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. .[doher#1y`—c?hYyunder the and penalties of perjury that the information provided above is true and correct. i e ��.J S (p Phone#- Sd 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): I.Board of Health '2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: Informatioa 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 foregomg-engag in alomE-en iprise inclu3�ingthe leg -represch atti k—Y--dec as'etl empiuyer,�r he-=--.-.- - 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 in-surance 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),-addresses)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 permittlicense 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 onp 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 thaf a valid affidavit is on file for future permifs or licenses. A new affidavit must be filled out each year.Where a home 6wner or citizen is obtaining a license or permit not related fo 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: Tlo Commonwealth of Mas rlhuse,tu Department of Industrial Accidents Office of lnvestigations 600 Washington Street .Boston, MA 02111 TO. # 617-727-4900 ext-406 or 1-$77-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia Town of Barnstable iH�E Regulatory Services r RlRA1Ci'IHTt• : Thomas F. Geiler,Director . •htl�$.S: b yb3¢. Building Division prED Tom Perry,Building Commissioner tn ww.town.barnstable-maus Office: 508-862-403 8 Fax: 509-790-6230 HOMEOWNTER LICENSE EXEMPTION Please Print DATE ! y / t JOB LOCATION: 1-7 Z WC-4 S'E-,,e_V. � �`.�cz e_ number A / street village . "HOMFAWNER": JJ �1 a%�.'t L /`FIH�- ? Z" C 3 ,Y'o 4 3_�4 9 z 9 r name home phone# work phone# CURRWT MAR-ING ADDRESS: 4-rT 140 A. Coe 0-1- Fe.- &I (� LA-L Ra► eityhown 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 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 "homy-owner"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."homeownee'certifies thathe/she understands the Tpwn of Barwtable:Buildiug Depat. rnt 4inspection procedures and,mquiremcnts and that he/she will comply with said procedures and sp Signablim- nts. omcowner Appivval 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 bomoowmr performing worts for which&building permit is mqufizd shaft be exempt from the provisions of this section(Section 1D9.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a pason(s)for hire to do such work,that such Homr_owna shall ad as supervisor." Many homeowners who use this exemption errs unaware that they are assuming the respmrsibtlities of a supervisor(sec Appendix Q. Rules&Regulations for licensing Construction Supervisory,Section 2.15) This lack of awareness often trsutts in serious problems,particularly when the homcowncr hires unlicensed persons. In this use,our Board cannot proceed against the unlicensed persori 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 respormMlities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the tcsponsibilitics of a Supervisor. On the last page of this issue is a form currently used by several towns. You may can:t amend and adopt such a fomIcertifieation•for use in your community. Q:forms:homccxcmpt 4i- ' t TTti Town of Barnstable Regulatory Services pMAM�$; Thomas F. Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder I g as-Owner of the subject property herebyauthorize to act on m behalf, Y in all matters relative to wor authorized y this binding permit application for. •(AdCli�e s of Job) Signature o Owner Date r t Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side.