HomeMy WebLinkAbout0162 CHASE STREET
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�IKE, Town of Barnstable *Permit# .
Fires nths from issue date
Regulatory Services Fee 6 .--_
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Mass. Richard V.Scali,Director
"'"14� ► Building Division
2016 Paul Roma,Building Commissioner
AUG 200 Main Street,Hyannis,MA 02601
A 4 SNI�NSTABLE www.town.barnstable.ma.us
Office: T.�;kVK4g38 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
3O^ _ p� Not Valid without Red X-Press Imprint
Map/parcel Number •'r' lJ
Property Address
❑Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �&Qiy: d7ef,`•^d�f
Contractor's Nam -a,,l v Telephone Number fz&4-1
S0 �lsli f
Home Improvement Contractor License#(if applicable) A17,JVlz Email: Zoe j'4l /.2Z
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
I Iam a sole proprietor
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) .
M_Re-side
❑ 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.
'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:
QAWPFILES\FORMS\building permit forms\E RESS.doc
06/20/16
' C��ze�porrunaarcweczlCfi o�G?�ac�wleCth
Office of Consumer Affairs&Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration:,,y'127006 Type: Office of Consumer Affairs and Business Regulation
Expiration==`:8%f9'/20:9.8 DBA 10 Park Plaza-Suite 5170
r =— Boston,MA 02116
COUGHLIN PROPERTY-.MAINTENANCE
BRIAN COUGHLIN
82 PRUDENCE LANE`<;.,
COTUIT,MA 02635 Undersecretary Not valid without ature
- ---- ------ -- - --------------
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Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-072354
Construction Supervisor
BRIAN P COUGHLIN
82 PRUDENCE LANE ` a
COTUIT MA 02635
r,
Commissioner Expiration:
-- -------- ---- 06/14/2018
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27w Comwomwakh of Massradr
Deparhment cr,f lnih h ial Acc ideitr
Office vfbnwsdgatio=.
600 washiivtont ►reet
Boston,MA 02.H1
--- �n�c�s�rnass: dia
Workers' Caffipensation.Insurance Affidavit:BmldexsICrnt mct trsMec€riciansJPhunbers
APPHcantIUfMM12fiGU Pease Print
a44,aI7
Addf
CitgfSta&ZIF l�,2G Phcn� S ji'
Are you an employer?Qreckthe appropriate ba=: Type of project(requimil--
I.❑ I am a employes with 4 ❑I am a general contractor and I 6- ❑New co nsfmcfion
employees(fall andtor part-limed* bave luredtbe sub-contmdors
2.10 I am a sale proprietor orpartuer- listed ea the attached sheet. I- ❑Remodeling.
and have no employees These stab-contmdors have g- ❑Demalitifln
worS:Yag for me i a any capacity- employ s aadbave x�orTotirs' 9. .❑BuilEag addition
LNO Wadoew comp.ins ire_ =e comp.*nererartrp
require&] 6. ❑ We are a corporation and its M❑Electrical repairs or a &tiom
3.❑ I am.a homeowner doing all Work officers have exercised iiiek 11-❑P3umbing repairs or addition
myself ' riot of es empfion per MGL ❑
�i, �, andwe bane no L- Rflofrepasrs
i asur'a=e required..][ c. 52,§l( )h
employees.(No wor=s' 13_(�t?ther
cam-iasmuce reqdired-j
6AmyWffcavt&atcbedmbux9loust also MoutihesecYimbdaaystws fiierwaaerecoxupmmt; PmHugiuF=ta=
Museuvmem who submit Bxis s$daei[ summit anew affidadt mdicatiao sacIL
ZCax $set checlrthis bax m=attarN as addi[i®a1 sheet dww"mg the name of&a sab-cam=Ctaa cad state tehethe;or xmtilwe e2itksbaee
empkayen.7fthe cshave em auyw-,twm=srpmvidethes warms'imp.PGHLY MmilsM
lam Below is diapVUcy and job site
irz,jormatian. _ .
It>saffice Company Hama:
Policy-4 or Self-ins.Lic--,1k iaaDate:
Job Eta Address: cityl5tafe� sp: -
Aft ach a-Lop5 Gf the workers'compensationpoEcp declaration page(shoving the policy number and espu ation date).
Failure to se=e coverage as required.under Section 25A of MO-c.1572 can lead to the imposition of crimfind penalties of a
hoe up to$UOD.OU andlor arse-yeir imprism=e nk as well as civil penaffies in the farm of a STDP WORK ORDER and a free
of up to$250-00 a day againd the violator. Be whised that a copy of this sbM meat maybe forwarded in the Office of
Itivest�gat of the DJA for insurance coverage Lit ti=
I AU IiMg y cetify tzudsr tltspm, s and penalties ofpedkq fhatthe iraforu[afyvrrptmi&d abm,9 i v true and carrect
S%a�ature: Date: 7
0,,0cial are an]FF. Do not write in fltis area,to be wmpTeted by tfty ortow n ojoiaiat
City or Tana: PermittLieense;g
Ling Autharety(circle ow):
L Board of Il ealth I lIuMhg Deparlmeat 3.CRylTown Clerk 4.Electrical Inspector S.gtunibing Inspector
b.Other
Contact Person: Phone 9:
— -- 6
4
ormation and Instructions
hfas- � C s Gewueral Laws chi M rec=es aII employers to provide worms compensation f=-their employees-
P tD this ,an esrrployPe is defined as .everppersonin die service of an ez ffide�any co** ofbfre,
espEress or iarplina oral or wziftr�
a associEft oration or other legal entity,or any two or more
An er is d----- as an incTrvidnal, arinersbip, �;corp
of foregvmg- d is a Joint ,and mcbafmg the legal fib
of a deceased emplayer,or s
receiver or trast=of an individual,parbamsbip,association or ofhex legal entity,employing employees. However the
owner of a.dweHimg house h aviognot more than tbree aparfineots and who resides f erem,ar thz octet of the -
dwPIIing house of a x&w who employs persons to do mafitmmi e,conc�on or repair work on such dwelling house
or as the grouads or burldmg appurtuoaot Siezefo shaIl notbex;ause of each.emp1 oymeat be deemed to be an empyes
MM chapter 152.g25C(6)also stairs flint"every stain or local licensing agency shall withhold$ie issuance or
renewal of a license or permit to operate a-business or to construct buRdb3gs in the commonwealth f
li or arrp
app&cani who has notproduced acceptable evidence of cdmpl-=m with the in mxance coverage required."
AddxdonaBy,MCEL chapter I52,§25C(7)states�NcZE rthr,cm= nyzaWi nor a'ay ofiis polaical subEvisions shall
enter into.any contract for the perf=ance ofpublic work u�I acceptable evidence of compliance with the ins ce..
req==ents of this chapter have been presented in the confract mg aufaozity."
r
Applicants
Please fi]l 0-[3t the wo&eas'compensation affidavit completely,by checking&e,boxes fiat apply to your situation and,if
necessary,Supply sab-co�s)name(s), addresses)and phone mr— er(s) along with then ceatffirate(s) of
msrnmzce. LimitedLiabflity Companies(LLC)or LimitedLiabilityPartnerships q 2)wifhno employees other tba .the
members or partners,ate not required to cant'wojkme compensafon insmmzce_ If an LLC or LLP does have
employees,a policy isrequn-ed. Be advised that this aflidayit may bembmiffi--dtothe Department ofludnstrial
Accidents for confnmatim of in�r-�,�p coverage Also be sure to sign anal date the of davit. The aihdavit should
be rDtr=ed to!he city or town that the application for the.permit or license is being requested,not the Departmeat of
LeLasirial A rQd6nta-'=Shouldyou have any questions regarding the law or ifyon.ai-e required to obtain a wormers'
compensation poTey,please call the Departmeut of the;mmmbea lisfed below. Self-msraed companies should ear their
self fi %-ra ce license number on the appropriate line
City err Town Officials
t _
Please be sore that the affidavit is complete andpradrd.leglIy. Tha Department has provided a space at the bottom
of the affidavit for you to fill out mitre event the,Office ofInvestigatien has to contactyottregardmgtbe applicant.
Please b e erne to fill in the pemLi/licease mrmber which will be used as a=fixence mtmbcr_ In.-addition,an applicant
that must sabmit multiple peonjUhcense applit ations in any given year,need only submit one affidavit mdicatng c=mt
policy infatuation(ff necessary)and under"Job Site Addrem"the applicant should write"all locations in (may or
;own).-A copy of the affidavit that has bey officially s upped.or marled by the city or town may be provided to the - .
applicant as pmof that a valid affidavit is on file for R±or permits or licenses Anew affidavitmust be fiI-ci oitt each
year.Wh=a home owner or citizen is obtaining a license or permit not related to any bnsiness or commm eial velure
(i.e.a dog license or permit to bran leaves eta.)said person is NOT required to complete this affidavit
The Office of Invesfigat[oas would 10e to ti=k you in advance for your coapeaaiion and should you have any qussfions,
please do not heshilnto&eus a caIL
The Departmcnfs address,telephone and fax rmmbm-- -
T th of . -
,� Depadmw±eha&stdB1Accidents
B MA 02111
Tf,-L#61 7- -4 Mft 406 Or 1477-I&A-SgAFE
Fax#617 727-7M
Revised 4-24-D7 ,M R
Town of Barnstable
Regulatory Services
` MAW ` Richard V.Scali,Director
%639. 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
Complete.and Sign This Section
If Using A Builder
I, P��A G E C ; IZ A-U E-n,S , as Owner of the subject property
hereby authorize !G �!t to act on my behalf
in all matters relative to work authorized by this building permit application for.
/(v 1 Cl�s,r
(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 AppfAt
79/1 nA_
Print Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOLS
Town of Barnstable
Regulatory Services
o�'THE Richard V.Scali,Director W
Building Division
• Paul Roma,Building Commissioner
MAss.
0.19. �� 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# work]Shone#
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 rovided that the owner acts as su ervisor.
ho gag p ,p P
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 ofa 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
06/20/16