HomeMy WebLinkAbout0141 CASTLEWOOD CIRCLE I �l C�.sfle�.v��o� C��,
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]�.�, Town of Barnstable *Permit 67Z - - /V y
E�Tres 6 months rom issue date
Regulatory Services Fee_ f �s
S.IA
MASS. Richard V.Scali,Director �' r
i639
Building Division JAN 20 2017
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601T014/Aj OF 8 r�R n 1STABLE
www.town.barnstable.ma.us /'! !0
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
-02 9 ahvp
Property Address �--7 ����/e wood 0".irc,(e-
esidential Value of Work$- _��0 C) 0 c)' Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address_� ��� A/kas
C/ C'�rGCe
Contractor's Name Telephone NumbersltT
Home Improvement Contractor License#(if applicable) Email: dQb/�? Jj' h(yd.`CO�!'►
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
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)
Nil Re-side a
Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows _
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
r *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
required:
SIGNATURE: L4
Q:\WPFILES\FORMS\build ng permit forms\EXPRESS.dod
66/20/16
The CoIIimon7 realth of MaiSf#d 4metts
Dgwhneut Of rudzsf id AcQdews—
OJ.fwe Of b11 adem.
`600 Waslr u i Sheet
_ Boston,Mfg 02111
iwm-tmaxLg;oP1did
Workers' CmlapeIISatTffnInsu "t.uceAffidavit:BtdlderS/CoIIbr=wrsMect lCIS Ls/Plu lbers
Applicant Inforniatign Please Print
Nmm _
- C�fstatr plwno
Are YOU an employer? the appropriate bow Type of project f ��}-
r
I.El I am a employer with. 4 ❑I am a general contractor and I 6. ❑ er New oo�nstuctioa
employees(full=dkr party =).* have hired&e sub-contactors
2.❑ I am a sale proptieton orpartner- Usted on the aftached sheet. J- ❑Remodeling.
ship and have no employees These smb-contractors have g- ❑Demolition
working forme in any sty employees amdbave worms' 9. ❑Building addition
[No Wodoers'camp.fidX=e camp-zasura ce l
�e&� 5. ❑ We are a cosporatian and its 1 ❑Electrical repairs or a ddfsliong
3. am a homeowner doing all wask - officers have exercised their 1L❑Plumbing repairs or additions
lmyseM[No wc6mrs'camp- right of esemgfiou per MGL 12_❑Rflofrepairs
»ranceregtzired,]Y c_M §1(4k andwehaveno
employees.[Not7CU:I s' 13_❑other
coup-insurance mquired.],
6Amysppficzntdmtcbedmb=fflmastalsofin out the swionbelawslt=ntheuwoameanpmxadanpnTiLyiu5rmx=
Ekmim uerswho submit du s sflidntf mwEcztIRg deY sxe doing air WC I sad tine hie outside commoicmfsmm sari+ .
FCaatxscias Arr cbec3r thk box must%ttarh sn xA iitioaat shW showing&a nameof the sib-r�s ond stgtp-whethec arnot ihme 'h.
employees.I€theaab-c®:t actmhace employw-% wy=stpmv-ae&ek wodEers'tamp.pGhu number.
I am an euipIayer flint is protridirtg�oar&ets'can grerLsrdian utszirarrea for my emp&yzes $etoev is riTce paTicy arui jab site
�,farmaliars -
Insurance Company Name:
Paficy la,or Self-ins.I.ic. Expiration Date:
Job Sitee A,ddrem CitVIStafel4s:
Attach a-copy of file wailers'compensationpolicy declaration page(shoving the policy,number and expiration date).
Failam to secure coverage as nequimdunder Section 25A of MW-c�15 can lead to the imposition of criminal penalties of a
fine up to$1,50D OD am d for one-yeacimp isona=A,as well as civil penalties im$e form of a STOP WORK ORDER and a fine
of up to Moa a clap against the violator_ Be athised'that a copy of this statement maybe fkwarded to the Office of
ImvesUgaboms ofthe DJA for i0sII32co coverage verifcabcm_
I&herzbyc4dquzdff diepains andpena&w o,jpeCrury thatthe irrfarnr ff=prmirltd abM C&true atzd correct
Sites: Dhate o
`
phone Irk a qq-
(1,oicial use adr.. Do not write in dib aria,to be cmnpleted by city or town a})rc&I
Ciy or Town: Permfiff sense S
Issuing Anflority(carte one): t,
I.Sound of llad li I Buffiring Dgml ment 3.CitpTowa Clerk d.Electrical Inspector S.Phrml�Inspector
b.Other
Contact Person: Phone#-
hiformation and Instructions ,
Mai I=mfb--Ge:nCZal Laws cbapher 152=grdres 0 employ=S to provide Wmkmb-=MPens±on for flies employees. l
an M7VLVW is dcfzned as."�-CVMYp=6n.inihe smvicc of Mu thernnd=auy Contract ofhue, �
express or implied,oral or written."
An�IvyB is defined as"an individual,partnership,assocfidi corporation az ofher legal a ay,or any two or more
''' of the foregoing wed�a joint ,�d������es�es of a dEceased employer,or fbe
receiver or trustee of an mdividnal,pxtammbip,association or oche rlegal entity,employing employees. HOWever fhe
ow=of a.dwelling house having not more tbaa three apartments and odor resides ffier'eia,or fhe occagant of flu-, -
dweMag house of anolher who employs persons to do maml-eoance,constriction or repair work an such dwelling brow
or oa the grounds or building appmteuantIhemb shall notbecanse of such employment be deemed to be an employer"
MGL chapter ISZ,§25C(6)also states that"every state or local�s TM�g agen CY
shall wif3rhold$ire issaance or
renewal of a ficease or permit to operate-a DuAnms or to construct bufldiugs in the c:ommoawealth for any
applicantwho has notproduced acceptable evidmce of compliance with tIm h sorance-eovexage required•"
Additionally,M.GL cbapt=152,§25C(7)states-Nmd ear the nomm mcwcalfh nor Ely ofifs poTfical subdivisions shall
an into any contract for theperfxmzaW ofpublic W033cuufil acceptable evidmm of eompEgace;with the msm'nce-.
regtm ernes of-this ch apfer have been prese n f i d to the con ra CLing 317fa0ady."
App1i�
Please fill oizt the wor3='compensation affid avit completely,by checliag 1ho boxes!hatapply to your situation and,if
I sE b� ntractor(s)name(s). addresses)aodphcnD n= er(s) along Wifhthcz=tificate(s) of
necessary,�P Y s wi$ino to ees other than the
insurance. LimifDd Liabn7ity Campames(LLC)or I,nitcdT.iatnTtp•Parine*rsbip (IZP) � Y
members or pis,are not rbgaard to corny Workers'compensation-insurance_ If an LLC or LLP does have
emp joy ees,apolicyisrequ-ktd. Be advised that this affdaYrt may besnImiftcdto the,DeparfmentofIndustial
Accidents for confanation of msurance coverage_ Also be sure to sign and date the affidavit The affidavit should
be refrmmed to!He city or town that the application for the pennit or license is being requested,not the Department of
Tnrir,afi iaJ�s d �,ts_ Shouldyou have any questions regarding tine lave or ifyou am regaaed�obtain a Wo�rss'
coupe„catm policy,picase can tiieDepmtncm:tattben=berlmis dbelow Self-roan companiesshould eaterthaz
self-i s*-aace license number on the apprcF afM line.
City or Town Officials
f -
Plmse be sin a f3iat fire affidavit is complete anal prt3tedlegmly. The Deparfinea>tIm provided a space at the botfnm.
of the affidavit for you to fill out in the event the Office ofInvestigations has to ciontactyouregarding the applicant_
Pleas a be sure,to fDl io.fhe pe=WHcrose number vthich w1I be used.as a refe .mce number• In addition,an applicant
that must submit muj4jr,pennh/Iicense applications in,any given Year,need only submit one affidavit indicating c nrent
policy information.(if n_eCCScS*y)and uaclra"Job Site Address"fhe applicant-should write"all lorztions in (may or
town)-'A copy of the-affidavit that has been officially stamped or marked by tine city or town maybe provided to the
applicant as#oo-fthat a valid affidavit is on file for fatal permits or licenses A new affidavitmvst be Med olf each
year.Where a home owner or citizen is obtaining a license or permit not related 6n any business oar commea-cial venf�n e
(Le_a dog license or pemlit to bum leaves eta-)said person is N0T regLm�d is complete Ibis affidavit
The Of of lnvestigafi=Would like to ffiank you in.advance for yom:coopwzGf n and should yam have any questions,
please do not hesitafe to give'=a caIL
The Deparimenfs address,telephone and fax nnmbe�
of liners .
II ant of Iliad Accidenla
offi=of�M � t*=%
�Q4 tau -
�o1�fA
Tel.#617- -4 Md44f car 1-a77- CAS F
Fax 9617` 27'749
Revised 4-24-0*7 WW MaS5 gAFk
r '
Town of Barnstable
Regulatory Services
RAM� Richard V.Scali,Director -
�� Building Division.
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA.02601
www.town.barnstable.ma.us -
Office: 508-862-4038 } Fax:,'508-790-6230
Property Owner-Must ti
. .Complete and Sign.This Section
- If Using;A Builder
I, 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) .
**Pool fences and alarms are the responsibility of the applicant Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature-of Owner, Signature of Applicant
Print Name Print Name
Date
QTORMS:OWNERPERMSIONPOOIS
Town of Barnstable ,
Regulatory Services -
fiyy� Richard V.Scali,Director �>
Building Division
sARNIMAI . Paul Roma,Building Commissioner
� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
DATE: Please Print
�� � �� � 7 n
.JOB LOCATION: Ud r'Ic% �V
num er` ,y street J e
"HOMEOWNER": //� U11� "�,/(f F 4 6,a
- name home phone# work phone#
CURRENT MAILING ADDRESS:
'c6/&n 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
P q P
procedures and re uirements d that he/she will comply with said procedures and requirements.
gn o omeowner
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
this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
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