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Home My WebLink About0080 DOLPHIN LANE jet Town of Barnstable *Permit# Expires 6 m nths rom issue date Regulatory Services . Fee .o • BARNSTABLFE Mass. $ Richard V.Scali,Director 1639. ATfD �A Building Division Y- q Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 FEB 2 3 2015 www.town.barnstable.ma.us TOWN OF 50$'��9 Office: 508-862-4038 F EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �� Not valid without Red X-Press Imprint Map/parcel Number Property Address go ULPTi ti L.IN) [residential Value of Work$!i Ti 000. 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address pin Contractor's Name �� ` y t�j'✓� Telephone Number 34:�7 ° l 7 7r Home Improvement Contractor License#(if app icable) Email: Construction Supervisor's License#(if applicable) C "' 9 f— ❑Workman's ompensation Insurance Ch one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Co ensation Insuran i Insurance Company Name t Workman's Comp.Policy# L_ 1 A431 L(T —93 Copy of Insurance Compliance Certificate must accoifipany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ e-roof(hurricane nailed)(not stripping. Going over existing layers of roof) v Re-side [Replacement Windows/ oor /sliders.U-Value (maximum .35)#of windows _ #of doors: Z 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 requ► d. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 } The Commonwealth of massachusetts Dquffftnent of Indusb al Accidents .� rr Off L€'e of f�71veSt3ft,Ttlfl(1715 I 600 Waslxiaigtorx.Stneet Boston,M4 02111 Wt WIVIV.niamgvv1dia Workers' Compensation Insurance Affidavit;BnildersICnnti-actois/Ele r cians/Phunber-s Applicant Information �, Please:Print Legibly Name(I3i�e&vDrganizaaonandnidual). �th�Ew- r'T Lu M f P'./ Address_ j S w 1 tv-T-e E�. :7— c�Z6®1 Citylstate/Zip: N1s Phone#_ S� . 3 (-7 " )7 Are you an employer?Check the appropriate bog:I 4. Type of i ' r am a eneral contractor and I yp project( ��e�; l.❑ I a employer with ❑ g 6. ❑NewNe construction. loyees(full and.ror part:-tame).* have hired the sub-contractors am a sole propraetar arpartrterm listed our the attached sheet. 7. ❑Remodeling 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 ttiorlaers'comp_insurance Comp_insurance l required.] 5. ❑ We-are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homed-Der doing all-work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp_ right of exemption per MGL 12:❑Roof repairs . insurance required.] e. 152, §1(4) and we have no n employees-[No workers' 13.❑Other� /�C N� - comp_insurance required.] ;Any appticami that checks box#1 must also fill our the section below showing their workers'compensation policy information_ Fo"meonmers who submit this.affidavit indicating they are doing all work and then hire outside cantractors mrost submit anew affidavit indicating sack Contractors thatch this box must attached an additional sheet showing the name of the sub-contrastors and state vrhether or not those entities have employees. It:the sub contractors have employees,they must provide their workers'comp.policy number. I agar an employer that is proizdi►g.workers'cox 4mmation insurance for my emplayees. $elaty is the palicy and job.site information. Insurance Company Nance: PrLL-1 Eq\--s 11y"'i EN1 C. Policy 41 or pelf-ins.Lie.4+: D�®�® t Z Expirat on Date: g �� Job Site Address: e,o L-Al_ City/StaWZip-. W - :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 S 1,500-00 and'or one-year imprisonment,as well as cixil penalties in the form:of a STOP WORK ORDER and a fine of up to$250.M a day against the violator_ Be advised that a copy of this statement maybe foruvarded to the Office:of Investigations of the DLL for insurance coverage.verification. I do Irereby certifjP wen r die pains artd s of Perju:r}'that the irrfarnratiorr prauided a cue is E and correct Sienature: 715' � Date: �Z- . Phone4 {7 G. �U? R��— Of ..vial use onlj. Do not tcrite in this area,to be czrnpteted by city orton-n of c aC City.or Tome: Permit/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 A- ��OFTHE 10�� + BARNSTABLE, 6 SS. ., Town of Barnstable prEQ��s Regulatory Services Richard V.Scali,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 I, 1 /�N '/�� , 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) Z3 f Signature of Owner Date w ,4A.IAI Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable Regulatory Services r ��FTHE Tp�� Richard V. Scali,Director �P �s Building Division BMMSTABLE, " Tom Perry,Building Commissioner 9 MASS. �p 1639• 200 Main Street, Hyannis,MA 02601 rFD �A 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 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 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\building permit forms\EXPRESS.doc Revised 061313 nu)ea�C��/�addacAudeM License or registration valid for individul use only t C �e ° O iration date. If found return to: Office of Consumer Affairs&Business Regulation before the exp' ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Type: 10 Park Plaza--Suite 5170 kl9re, istration 180974 Individual Boston,MA.02116 piration 214/20/7 ,; I -•f t STEPHEN TURNER 4 'a STEPHEN TURNER r g 336 WINTER ST Not valid with signature ,�. - � Undersecretary `. HYANNIS,MA 02601 —J Massachusetts -De Board of Building partment of Public Safety Regulations and Standards Construction Supervisor License: CS-092890 I STEPHEN J TURN_ R x P.O.BOX 893 OSTERV i IIZE Na0�6 c` y .)I'Itl C• Ex pi ration Commissioner 09f30f2015 --_