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Home My WebLink About0012 GROVE STREET to G,�-ore S� 3aq - 04°7 f i . i SMEA No. 10339 smead.com Made in USA co Application number FEB'2 6 20e S,00 Fee .... . TOVviv ..... ....,.. .... ...... MAM Building Inspectors initials......tVl.. Date 50 Issued...... .........................................:............. - Ma �7 �B Map/Parcel.. Zp� TOWN OF BARNSTABLE SCANNED EXPEDITED PERMIT APPLICATION: ROOF/SIDINGAVINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION FEB 2 8 2020 PROPERTY INFORMATION Address of Project: C 4- 01301 NUMBER STREET VILL,,APE Owner's Name: l.( n nee (,('(�° bPf, ape Phone Number S 4 �_5- Z 7 7 .1�m°s A- ux4 I)(r r 200q -DNS+ Email Address: re-U0g0t OeK*r-60 cro), CoM Cell Phone Number SO 8- 73:3 26 2 Z- Project cost$ (L7, 1000 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding M4indows (no header�change)# 0 Doors(no header change)# E3Insulation/Weatherization •F71 Roof(not applying more than I layer of shingles) Commercial Doors require an inspector's review. Construction Debris will be going to (_ \1055, 6L rU X U nif,(— C1n S I f 0 Certificate of occupancy with no construction(complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)#- (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ r *For Tents Only* ` Date}Tent(s)will be erected Removed on number of tents total Y Does the teri ��iave sides?Yes No (If yes please attach floor plan with exits marked) ,x Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Lo ne- f boot I kr 7- _6 e Telephone Number �'1 S ��7 7�� Cell or Work number 9 f_)33 Eao� I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction i pection procedures, specific inspections and documentation required by 780 CMR and the T n of Barnstable. Signature Date C:)- APPLICANT'S SIGNATURE Signature Date �- 0 1 40 All permit a p cations are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t)ne4, 4e Address: - Q ` City/State/Zip: rYl Phone #: 7 Are you an employer?Ch the appropriate box: Type of project(required): l.❑ I am a employer with 4. ❑ I am a general contractor and I _ ' 6., ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7:' Remodeling ship and have no employees These sub-contractors have 8. '❑Demolition working. for me in an capacity. employees and have workers' g Y P tY• 9. ❑Building addition [No workers'comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑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 12.0 Roof repairs insurance required.]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 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. jam 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/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 maybe forwarded to the Office of Investigations Of e DIA for insurance coverage verification. I do her by c rti under h pains d penal 'es perjury that the information provided above is true and correct Si ature: Date: 4 Phone#: ZJ 1 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): 1.Board of Health 2.Building Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M 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 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." 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 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 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.#617-727-4400 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#61.7-727-7749 www.mass.gov/dia