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Home My WebLink About0022 BIRCH STREET �i,�c� S'?7��T" e .ti 6a'96 4-17 S S� oFt ram, Town of Barnstable *Permit# Pv Expires 6 months roni issue date Regulatory Services Fee BARNSTABLE, MASS.1639. Thomas F.Geiler,Director ArfD MA'I a Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.towmbamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint 30 Map/parcel Number Property Address < 5 f At ❑Residential Value of Work Ainimum fee of$25.00 for work under$6000.00 Owners Name&Address ( f tt�Gc. �2 � 61- 0 9 1 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: X-PRESS PERMIT I proprietor am the Homeow ner OCT -- 5 -zoos ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name - ' Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. 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 #of doors ❑ Replacement Windows/doors/sliders.U-Value . (maximurm.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,eta. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement:Contractors License&Construction Supervisors License is -required. SIGNATURE: QAWPFILESTORMS\building permit forms\EXPRESS.doc Revised 090809 y The Commonwealth of Massachusetts Department oflndustrial Accidents:` Office of Investigations 600 Washington Street Boston MA 02111 ` s )vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individiaal): Address: City/State/Zip: "T Pr& Phone M Are you an employer? heck 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 sub--contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner listed.on the attached sheet. 7. E Remodeling ship and have no employees' These sub-contractors have g. [J Demolition wo rkin for in an capacity. employees and have workers' - g Y P Y i . 9: Building add tton � ❑ g [No workers' comp. insurance comp. insurance.t / 10.❑ Electrical repairs or additions 1 equired.] 5. ❑' We are a corporation and its I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions f r myself o workers' com right of exemption per MGL V Y P 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13,❑ Other comp. insurance required.] *Any applicant that checks box 41 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 anew affidavit indicating such. tContractors 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 tie sub-contractors have employees,they must provide their workers'comp.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 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 and pe of 17erjury that the information provided above is true and correct. St nature: Dater $� Phone#: �?f1� Q --7 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: e t� 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,constriction 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 onto 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 conunonwealth 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 pen-nit 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 fixture 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: 4 The Commonwealth of Massachusetts Department of Industrial Accidents f Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia t i �1HE, Town of Barnstable Regulatory Services �s"R'' '� Thomas F. Geiler,Director 039..� 0 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., , j Complete and Sign This Section ,i _ If Using A Builder f. 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 t__ Date Print Name If PropedOwner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION ,r/ 2 � Tow o n f Barnstable oFY�r� Regulatory Services t r;n MSrAB Thomas F.Geiler,Director Mass. 9�A 039. s`�� Building Division rED MP'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 V --- _-- HOMEOWNER LICENSE EXEMPTION Please Print rDATE: ZP "' �� C7 9 // �j� aa /' JOB LOCATION: o� //6 l'h �_ 3Ga�/1 / V 2 6 D number street village "HOMEOWNER' lit, �� Z� name home phone#�+-- work phone# CURRENT MAILING ADDRESS:-f Y Aknz � /l/` Lafe-1 /"� NL~ 6 LSO / lty/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 requirements. ature o 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. Y Q:\WPFILES\FORMS\homeexempt.DOC