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HomeMy WebLinkAbout0025 CHARLES STREET �s C,h�a+�.les �I--. r~` Town of Barnstable *Peed �TOwti p Expires 6 months rove issue date Regulatory Services Fee * BARNSTABLE, MASS.� i63 9. �� Thomas F.Geiler,Director A rf0 MA'I A Building Division �� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 NO V — 3 2009 www.town.barnstable.ma.us Offl EE)Od8 F 4038 Fax: 508-790-6230 NM&P,,ERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 3Q 6636 Property Address ,A 5J C r 4 j2 L-L i� ��c7 c✓a�l /,�JJ o G (Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address L//sit /zr `G o G �L- Contractor's Name ;�;�/L,y-� �A ,Q/�r�i✓ � '� i r Telephone NumberG� Home Improvement Contractor License#.(if applicable) j 6 z1 e 9 j �r ' / am; f: Construction Supervisor's License#(if applicable) 1 ' '. 4-../ !J�4 e,,4 k �( J) ❑Workman's Compensation Insurance ~ Check one: —� ❑ I am a sole proprietor ❑ I am the Homeowner [9�I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# © l;o— 6 6 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) l Re-roof(stripping old shingles) All construction debris will be taken to /�D✓� A. � ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.44)#of windows *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 req . SIGNATURE-' Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc ' Revised 090809 a � 1 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations fj 600 Washington Street { + Boston, MA 02111 F rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): bQ Address: k"VCn GSn Ci /State/Zi �'0, O ' ty p: �^U ,q .�.G 6 U Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with L4 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time). * have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.El I am a sole proprietor or partner- 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.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12M Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks 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. #Contractors 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 the 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. � r Insurance Company Name: Policy#or Self-ins. Lic.#: GAG r✓ S'y s Z r/O Expiration Date: ter_ Job Site Address: 1—C/I-VAX Z11 f J1i 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 cover e verification. I do hereby certify it er' pains and pe alties erjury that the information provided abo a is true and correct.. Si nature: Date: . w �� �t/ Phone# 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: 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 Linder 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." 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 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-contractors)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 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 fiiture 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fak # 617-727-7749 Revised 4-24-07 www.tnass.gov/dia �pF THE Tp� Town of Barnstable Regulatory Services vMA $ Thomas F. Geiler,Director fo µ. 1. 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 Complete and Sign This Section If Using A Builder 1Za c/4 , as Owner of the subject property hereby authorize ��i9/�/L�=��(d.rJl to act on my behalf, f in all matters relative to work authorized by this building permit application for. (Address of Job) 0 Signature of Owner Oate �0L40NI, Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERP E RM I S S I ON s, u Town of Barnstable F'LHE Tp� o� Regulatory Services ! HAANSTABLE. ; Thomas F. Geiler,Director htnss. 9$A 1 639. ���� Building Division lFn � Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone i# work phone i# 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 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. Q:\WPFILES\FORMS\homeex emptDOC Board oT> ui mtiins an tan air s" Construction Supervisol tense ' L)'cerise: CS ,15041 expi anon 1/22/ZUUU Tr# TO U „ t estric ionJ M RICHARD R FAR IKO F , �• 3Z RIVERDIE SO,C -- - i S RENNIS MA 0266,(} t+.� Comm�siner i a/r ko�ryhig Ituea� oy� ctc �Jef�4 f3od of"Building Rebulatio(is.�nd Stsudar(is lu HOME IMPROVEMENT CONTAGTOR Registrat n; 104895 Ex{�IraGon 7/�15/20,10 Tr# 277519 Type InOfi,Jdual Rf,,,.,HA: D R. FARRENKOPF CONSTRUCTION Richard FarrenkopfJ' ` 37 Riverdale S Dt-nnis, MA 02660. Administrator 'HICRegistration Lookup Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home> Consumer> Home Improvement Contracting> j ...............-............ _._..__................_....._..................,.........................................................,........................-..........................._........................................._._............................_... Home Improvement Contractor Registration Lookup The list is current as of Friday, October 30, 2009. You can search/filter the registration list by any of the criteria below. RELATED LINKS Search by Registration Number r—� j Horne Improvement Contractor Search Registration Number Registration Home Page Search by Registrant Name FARRENKOPF Search by City I _ f Zip Code Search Registrants Click on the registration number to view complaint history.You can also view arbitration and Guaranty Fund history. Search Results REGISTRANT NAME RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS INDIVIDUAL NUMBER DATE CRAIG FARRENKOPF FARRENKOPF,CRAIG 110230 95 ACRE HILL RD 10/9/2010 Current BARNSTABLE,MA 02630� RICHARb R FARRENKOPF 'Farrenkop,Jr, „: 3'7 Riverdale "' I �'— r._ CONSTRUCTION' S ,Richard �Asa �i- 104895 _41S.Denms MA 02660 7/15/2010 Current ©2009 Commonwealth of Massachusetts http://db.state.ma.us/homeimprovement/licenseelist.asp 10/30/2009 WORKERS COMPENSATIONL `4D EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated industries of'Massachusetts Mutual Insurance Company Burlington,Massachusetts (800)876-2765 NCCI NO 2615$ POLICY NO. I AWC 7016775012008 PRIOR NO. I AWC 7016775012007 ITEM 1. The insured RRF Construction Inc Mailing Address: 37 Riverdale South South Dennis MA 02660 (No. Stream Town or City C—ay state ZIP Code ❑ Ind-Mdual ❑ Partnership Corporation ❑ Other FEIN 20-0391264 Other workplaces not shown above: 2. The policy period is from��� to 060412009 12:01 am.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here, MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The Wits of our liability under Part Two are: Bodily lryury by Accident$ 100,000 each accidents Q Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee: t :titCD C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A j D. This policy includes these endorsements and schedules: SEE SCHEDULE tV � M 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. N All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per s1w EsBmated No. Total Annual of Annual Remuneration Remuneration Premium I IITFRA 054709 SEE EXTENSION OF INFORI IATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 1,484.00 As indicated.interim adjustments of premium shalt be made: Deposit Premium $ 1,548.00 ❑ Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $1,159.95 x 5.5000% $64.00 This policy.inckiding all endorsements,is hereby countersigned by 05/22/2008 Auftdzed Signature Date IGOV GOV I KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Bjorkltmd&Reilly Insurance MA 5645 12 1704 Agency40 Willard SUW Suits 202 WC 00 00 01 A(11438) Quincy,MA 02169 inch wpyricltead rnatedd of ate National Cound on compensation lrr una v% used with its permiSSiwt.