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HomeMy WebLinkAbout0078 BRISTOL AVENUE 7� ��t� fV/enr�i �\ �. \ PP Town of Barnstable *Permit#-c;?d /3A G Y6 o Expires 6 months from issue dale Regulatory Services Fee C BARNSTAEM MASS. Thomas F.Geiler,Director X-PRESS PERM IT � 1639. ATED MA't� Building Division FEB 112013 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maus TOWN OF BARf�So Office, 508-862-4038 Fax: 50 - 0- EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY /� Not Valid without Red X-Press Imprint Map/parcel Number Property.Address In,1UN1, , G Residential Value of Work poZ�. _ Minimum fee of$35.0 for work under$6000.00 Owner's Name&Address y Q a' Contractor's Name mCt7�c-� ��°�'� Telephone Number 3:; C/ Home Improvement Contractor License#(if applicable) 1-1 14 t O- Construction Supervisor's License#(if applicable) 16(a kWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor i ❑ lam the Homeowner H ® I have Worker's Compensation Insurance Insurance Company Name 11e— �- Workman's Comp.Policy# :1 gn 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 ❑ Smoke/Carbon Monoxide.detectors 4 floor plans marked with red S and inspections 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 Improv t Contractors License&Construction Supervisors License is required. SIGNATURE.., ,.f Q:\WPFII.M\FORMS\building permit formsTMUSS.doc R eyised 051012 _. I r' . The Coxmrr imeafth of Maysachmeffs Deparhnent ref indusirial Accidents - , Office of lnvesti�ons ' 6#0 Washington Street Boston,M4 62111 "w w.rrromgov1dia Workers' Compensatim Insurance Affidavit: Builtders/Conti•actors/Electricians/Phtmbers Applicant Information ;;Z Please Print Leal Name(Busnew0garmtion/Ie�vidz�ai) Address: -7 40r City/St-t-(Zip: Cam I fir' Phone i `f Are you an employer?Check.the appropriate box: `� Type.of project(required): 1.p.�l I am a employer with .4, _ 4. ❑ I am a general contractor and I employees(fall andlar pa t im�e). * have hired the sx�b-contfactors 6- ❑New �io� Fml?� ) listed on the attached sheet` 7. ❑Remodeling�.El I am a sale proprietor err ship.and have no employees These sub-contractors have g_ ❑Demolition woddng for me many employees and have wo&ffs' ��Y• 9.' ❑Budding addition wodom'Comp.insurance comp-insurartmi .] 5. ❑ We are a corporation.and its 10.❑Electrical repairs or additions required 3_❑ I am a homeownt r doing all work txfficen have exercised their 1 I-❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per NIGL 12.❑koof repairs insurance required.]T c.152,§1(4)and we have no A employees-[No workers' 13. Other comp.insurzam required.] 'Any apphcaat that checks box#1 most also fill ow the section below shawmz their wa tere compensati©upoRcy infarantian. I Homeowners who submit this af#'idsvit mEcsting they are'domg all wat and then hu a outside coatxactaas mast submit a new affidavit iadica4ing sack. FCoatracmrs that rhKk this boot must attached as additional sheet shawiag the name of the Mors and stare whether or not those entities bare employees. Uthe sob-mntmaos have employees,they amsEpimvide their work'comp.pokey number. I trin an employer tltratis ptvviding worirers'congmzsrrdvn insnrarfce for my enTEoyeses. Bdow is thepoticy aud job site information. Insurance Company Name: e S r, Policy#or Self ins.Le.� (p��X����y����� C �o� Expiration Date: f�—�l —/3 Jab Site Address: `7 Ad _Gity/StataMp: �. Attach a copy of the workers'compensation policy ded!arationpage(showing the policy main and expiration date). Failure to secure coverage as required under Section.25A of MGL c. 152 can lead to the imposition of criminal pe nkes of a fine up to$I,500-00 and/or one-yeas imprisanmeat,as wen as civil penalties in The form of a STOP WORD ORDER and a fine of up to$250-00 a day against the violator. Be advised ttrat a.copy of this statement may be fwRareied to the Office of Investigations of the DIA for insurance coverage verifiratim y dip lnomby cetVfy n the pains and duty that the informatioen provided above is furs and correct 5 . Date: 7 - 1 Phone#(-77 of vial mw only. Do not write in M&area,to be err iplatetd by do or to mi offi rtiat City or Town:, PermitUcense At Lunina Authority(earcle one): 1.Board of Health 2.Budding Deparhumt 3.Gtyfl'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ; Contact Person: Phone#: I NOTICE H NOTICE TO = a TO EMPLOYEES EMPLOYEES � V O,�M Svc, The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21, 22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344=1450 ADDRESS OF INSURANCE COMPANY (GKUB-5B74879-6-12) 12-21 -12 TO 12-21 -1 3 POLICY NUMBER EFFECTIVE DATES ROGERS & GRAY INS AGCY 434 RTE 1'34 SOUTH DENNIS MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# RIDENER, ROBERT 87 HEMEON DRIVE 0 WEST YARMOUTH MA 02673 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above. named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services w_ provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably ' connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS wsuPicos TO BE POSTED BY EMPLOYER � iARNS1'ABLE. 9 ,�� Town of Barnstable �rfD MA'1� Regulatory Services Thomas F.Geiler,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 1 as Owner of the subjectproperty hereby authorize . 7�`C���QUI�� to act on my behalf, in all matters relative to work authorized by this building permit application for: 7J_' & r (Address of Job) II S' tore of Owner Da Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on;the reverse side. Q:IWPFILESTORMSUilding permit formsTXPRESS.doc Town of Barnstable O ' Regulatory Services BARNSPABLE, ' Thomas F. Geiler,Director MASS. �pTFo 3 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING 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 procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner t 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. n•\nrovii CMCnU�dc\i...:1.i.�a..n.mitFnrmc\FYPRI=SS Anc �� _. i / i _- Office of Consumer Affairs and Business Regulation {` 1 10 Park Plaza - Suite 5170 Boston, Massachusetts assachusetts 02116 ntra Home Improvement Coctor Registration Registration: 174077 Type: Individual }: Expiration: 12/18/2014 Tr# 234652 ROBERT JAMES RIDENER ROBERT RIDENER 87 H E M EO N DR f W. YARMOUTH, MA 02673 Y ''Update Address and return card.Mark reason for change. Renewal Address Employment �� Lost Card �J L�i L� - SCA 1 �.0 2t7M-05!11 � Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: i Type: Office of Consumer Affairs and Business Regulation egistration 174077 Yp 10 Park Plaza-Suite 5170 f-Expiration: 12/18/2014: Individual Boston,MA 02116 ROBERT JAMES RIDENER; ROBERT RIDENER ✓ 87 HEMEON DRY W.YARMOUTH, MA 02673 Undersecretary Not valid without signature i e a • Massachusetts -Department of Public Safety Board of Building R&guiations and Standards Construction Super ikor License: CS-106525 ROBERT RIDENE2 87 HEMEON DRIVE West Yarmouth NU 02673.,, �4 1 J �/� '. :ttXlfr�ti.CSti nsns"sssac�ner 08/07/2016 8.