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Home My WebLink About0169 BRISTOL AVENUE 9 i �a Xv " 5- 7 r �I i i -_ 1 Wf Town of Barnstable *Permit# 3 Expires 6 monihs from issue date y Regulatory Services Fee �6 Thomas F.Geiler,DirectorERMIT Building Division Tom Perry,CBO, Building Commissioner JAN 16 2007 200 Main Street,Hyannis,MA 02601 _ i www.town.barnstable.ma.us LIAR NSTABLE e508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY a.. Not Valid without Red X Press imprint FR_ ,` reel Number T7— ddress 10 erty A J/ 'Rest ential Value of Work Minimum fee of$25.00 for work under$6000.00 g 4 's Name&Address :ontractor s Name - _ Telephone Number [ome Improvement Contractor License#(if applicable) 's-I;icens #{iFappiible) ..... DWo kman's Compensation Insurance Check one: ❑ LArn a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance =ante Company-Name Vorlmlan's Comp.Policy# ,opy of Insurance Compliance Certificate must be on file. •ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to [�Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign roperty Owner Letter of Permission. W„ ; of the Home o ment Contractors License is required. IIGNATURE: 1:Forms:expmtrg .evise061306 C;. ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street . Boston,MA 02.1.1.1, i4wanass.gov/dia ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers ARPHcant Information Please Print Legibly Name(Business/Organiiation/hdividual): , Address: City/state/Zip: d2ft_, r Phone.#: � Are you an employer? eck the appropriate box: ;Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and I ' 'employees(full and/or part-time).* . have hired the stab-contractors 6, ❑New construction . 2.❑ I am a'sole.proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship.andhave no employees These sub-contractors have g, ❑Demolition ivorking for me in any capacity. employees and have workers' 9. Bu g fidin' addition . [No workers' comp,insurance comp, insurance.$ requited] 5. ❑ We are a corporation and its 10.❑•Electrical repairs or additions '3. I am a homeowner doing ill-work officers have exercised their, 11:❑Plumbing repairs or additions ' right o m elf. o workers co gh f exemption per MGL � � �' , P P 12,❑Roof repairs . insurance.requized.]t .c. 152, §1(4),and we have no employees, [No workers' ...13.[] Other comp,insurance required.] *Any applicant that checks box#1 must also fill Out the section below showing their workers'compensation poHcy information. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such, $Contractors that check this box must attached m additional sheet showing the name of the gub-contractors and state whether or-not those, entities have sub-contractors , , employees. If the sub-c ors have a to ees the Mu st st ovid'e mp Y Y their workers, pr t rs comp,poHcy 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/Zi P., 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP .0 .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 WA for insurance coverage verification. ' I do hereby certify under th pains and pen 'es ofperjury that the information provided above is true and correct, Si afore: Date; Phone#; Official use only. Do not write in this area,to be completed by city or town official City or Town: ' . Termit/License# . Issuing Authority(circle one): .1.Board of Health 2,Building Department 3., City/Town Clerk 4.Electrical Inspector. 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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,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.". AdditionaIly,MGL chapter-152, §25C(7.)states"Nejther the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public•.work until aceeptab}e evidEnse-of•compl�rice�ithtlie D ance requirements of this chapter have been presented'to the contracting authority."- Applicants r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,e necessary,supply sub-contiactor(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 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 Towp.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 permittlieense 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 markdd by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future 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 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 vs a call. The Depgi nenfs address,telephone-and fax number:. The CQmmonwWth of Mamoh=tts epare ofIndutlia Aecznts ' Offtee of lnivesidgai ons Bostc ,CIA 02111 • TO. 617-727 000 ext 406 or 1- 7-MASSAFE Fax#617-727-7749 Revised I1-22-06 WWW.InaSS.86VIdia o -IMF, Town'.of Barnstable Regulatory Services Thomas F. Geller,Director . 9�P %659. �.� Building Division RFD MAi ' TomPerry, Building Commissioner 200 Main Street, Hyannis,NIA 02601 Fax: 508-790-6230 OmGe: 508-862-403 8 Property Owxier Must Complete arid'Sign.This Section If.Using A Builder I ,as Owner of the subject property hereby authoe to act on mp behalf, in all tnattets relative to work authorized by this building permit application for.- (Address of job) Sigaatate of Owner Date Print Natae I Q:FORMS:OWNSRPEMS5IOI4