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HomeMy WebLinkAbout0125 GROVE STREET SIMEACrI KEEPING YOU ORGANIZED No. 10230 H163 0op ED F MML CYCL 94ITIffm CONTENTIO°h POST-CONSUMER 0M2M MADE IN USA GET ORGANIZED AT SMEAD.COM g1c41�� _ .R a �T ,�y, Town of Barnstable *Permit Aw TI/L.J01-1 ilding Department Services- y Expires 6 mo1�'erro 'sue '= MMSTABLE, �� . lorence,CBO. Mass Commissioner pTEpMp1► SFP O� Mani Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403l((��W/V%dA- Fax:•508-790-6230 H�STABLE EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY . f Not Valid without Red X-Press Imprint Map/parcel Number C Q '1 ' t Property Address ' off )Q- Residential Value of Work$ - .0® Minimum fee of$35.00 for work under$6000.00 IF Owner's Name&Address c 2—(, (9 ) Contractor's Name ' Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) . ❑Workman's Compensation Insurance ; Check one: ❑ I am a sole proprietor 0I am the Homeowner y f ❑ I have Worker's Compensation Insurance r Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request.(check box) is . ❑ Re-roof(hurricane nailed)(stripping old shingles)"All construction debris will betaken to ❑Re-roof(hurricane nailed)"(not stripping. Going over existing layers of roof) UR'Re-side ❑ Replacement Windows/doors/sliders U-Value (maximum.32)#of windows 777 , #of doors: *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: — Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC< , 08/16/17 f I f Town of Barnstable Building Department Services Brian Florence,CBO . ' r Building Commissioner - 200 Main Street, Hyannis,MA 02601 NAM www.town.barnstable.ma.us 63g6 Al Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EREM[MON 9 _ Please Print DATE: l JOB LmATION: �. 5 ��i©V Q S' ,O�YI(� �' Ma 7,6 O number sbW village "HohMwNER^: CO.!,c\oS �aru� 0��.1¢2 So�- yo - `� 33 e1 name home phone# work phone# CURRENT MAIIJ NG ADDRESS: `.S FS 20.\b V000 cityAd%M 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,Pmvided 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 RuWt. (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 proce ents and that he/she will comply with said procedures and requirements. ignature 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 homeo*ner,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:\WPFRM\FORMS\building permit forms\EXPRESS.doc 08/16/17 p Town of Barnstable -Building Department Services � ' Brian Florence,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 Usiriff A Builder I ,as er of the subject property hereby authorize to act on my behalf, in all matters relative to work autho ' d by building permit application for. (Ad ess of b) **Pool fences and are the respon 'bility of the applicant Pools are not to be fille or utilized before fen a is installed and all final inspections ar erformed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOIS Rev:09/16/17 Si 77m Commomvealth ref-Hassadjusetfs Departme7xt o,f rudus&hd Accidan!s. — f1}fce of'IlFmmaigadens 600 Waskington Street Boston,MA 02111 vmasagorld a Workers' Campensatian Insurance Affidavit;Builders(Contractars/Mecfr cianslPlumbers Applicant Infi irrmafran Please Print Y Phone 5 — `-t®'`1 — 3 3 OV Are you an employer?Checkthe appropriate box: 'Tyke of project(required}: L❑ I am a employer with 4 ❑I am a general conimckw and I * have hired.the sub-comtmctars 6. Q New c:onsimcfioa employees(full arxdl`or parr#�me). 2.❑ I am a sale proprietor orpaitner- listed onthe attached sheet: 7- ❑Remodeligg sbV and have no.emplayees- These sub-contractors have $- ❑Demolition wonting far me M- any capacity. employees and have wodwrs' 9. additionQ [No uprk=s'comp'.i7nsitrance Comp.inanranm1' Buil❑ 3-frequired-] 5. ❑ re We a a corporati an and its ld:❑Electrical repairs or ad�ions I am a homeovczner doing all wo dt officers have exercised their 1 L Q Plumabing repairs.or additions ;�,� o wo&=' tit of es�ptim per 1'S+IGL ry❑ mph c�e�Ed-j y � c.152,§l(4k andwe have ao 1.._ Roof employees.[NO Wot3rers' 1311 Other, cam-insurance required-] *dirty appli=9mt crFredsbcx#1 uarst also fiIloiti ee sm dcmbelowshmvug dmkwodme campensad=perk-y k5rm*ffm I Hameuwnemwho submit sbis atEdmra m c=m_q t5ey aae&mg sllwak and where autd&coatracims—st s*mkanew affdz;&indics im such- tCbntmctms tbst ebeclr tl¢s bmc mast attached m addW— sheet sbouiirg the nao:m of dte s sad state whether m oat those Mlddes ham employees.1ftbesub-coaaact=have employees,1hey=srpmuide.thek tsnrkea'tangpGHUnumbm I arr[a[[e[[[ployer tJ[rftis prouidua�g wark¢ts'conlper[satirrr[ir[sriratrca jvr ucy'enrPlnS�es Below is Elie paUcy and job rite infornzalion. _ Insurance Company Name: � Policy or Self-ins-Uc k Expiration Date: Jobe! ddress: i 5 C O'�Q- City/Stafel2sp: `�.ti t�nnQK A 07-J� n 1 Attach a copy of the workers'compensationtpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL m M can lead to the imposition,of criminal penalties of a fim up to$1,50U OD andror one-year inTrisonmenk as well as civil penalties.in the farm of a STOP WORK ORDERand a fine of up to$250_00 a day against the violator., Be advised that a copy of this statement may be forwarded to the Office of Investigations,of the D3A for insurance coverage vedficatian- . Itlo l[eraby d Rt fj�r a sulir f#ap�[i�ts nd�per[al?res a, perjury thatthe irzfbrma6wiptmzc dabmra is brans and correct Phone lk OoWal trse only: Do not wrke in tits area,to be completed by city ortewn a,,€ Ciat City or Town: Perudtll uense# Issuing Autherity(circle tcne): 1.Board of Health 2.BmIdfing Department 3.City,(Town.Clerk 4.Electrical Inspector 5.Plumbing Enspector 6.Other Contact Person: Phone#: Information and Instructions Massaclmse#ts Geheaal Laws chapter 152 requires all employ=to provide workers'compensation for their employees. . • pujsaantt[)this shame,an rniplaym is defined as.`-.every person in 1ho service of another under any coact ofhim express or izuplied,Qral or wrifta." An.vnp&yer is defined as"an individnal,parinmmbip,association,corporation or other Iegal entity,or any two or more of the foregoing engaged in a Joint uprise,and including the legal=p esentaiives of a deceased m1ployer,or the receiver or trastae of an iadividnal,partn=hip,association or other legal entity,employing e113PIoyees_ However the owner of a dweIIing house having not more tbm three apartmecs and who resides lherem,or the o=4mnt of the - dwzHing house of another who employs persons to do mace,canct-racti on or repair woik on such dweEiag home or.on.the grounds or building appuitcnnarathereto shall not because of sach employmentbe deemedto be an employer." MGI,chapter 152,§25C(6)also sis$s that'every state or local licensing agency shall withhold a issuance or renewal of a ficerrse or permit to operate a business or to construct buildings in the co mmonvPealfh for any applicantwho has not produced acceptable evidence of cdmpL-Mce wUh.the hLyurance.cov=gerequlred." Ad:ditionaIIy,MCTL chapter I52, §25C(7)states"Neither the commgmwraM nor fiy of its political subdivisions shall enter into any contract fur the pmfom=ce ofpublio work unfit acceptable evidence of compliance with the insurance.. raTia-emeafs of this chapter have]teen presented to the Miff -��Mfhonty." Applicants ' Please fill out the wozlrers'compensation affidavit completely,by chug the boxes that apply to your situation and,if necessary,supply sob-confractor(s)name(s), addresses)and Phone numbez(s)along with their cettificat*)of ice. Limited Liability Companies(LLC)or Limited Liabffity Partaeships(LLP)with no employees other than the members or partners,are not rbqui ed to cry workers'compeasation fuss aim If an LLC or LLP does have employees,a policy is regaaed- Be advised that this affidavit may be suhmift-,d to the Dep&tnent of Iudusixial Accidents for conformation of bsmmce coverages ffi Also be sure to sign and dafe the affidavit. The affidavit should be returned to me city or town that the application for the permit or license is being requested,not the Department of halos,mil A cmd=s. Should you have any questions regardmg the law or ifyou are retpum-ed to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should entor their s elf-insurance license number on the appropriate line. City or Town Officials t - Please be sure that the affidavit is complet$and pried.legibly. The Department has provided a space at the bottom of the affidavit for you tD fill out in the event the Office of Iuvestig has to contact you regarding the applicant Please be sure to fill in the pennitlIicense number which will be used as a mference cumber. In addition,an applicant that must submit multiple pennitUctense applitations in any given year,need only sahmit one affidavit indicating caarnt policy information Cif necessary)and under"Job Site Address"the applicant should write"all locations in (Edy er town)-"A copy of the.aff davit that has been officially stamped or n=Ekod by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled oirt each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial ventlae (i-e. a dog license or permit to burn leaves etc.)said person is NOT regc±ied to complete this affidavit: The Of of Investigations would IBM to tha ck you in advance for your cooperation and should you have any questions, please do not hesitate to give r s a call- The Department's address,telephone and fax mmnber: Thz CG=jonNMItic of M2ssachnalb-, ' Department Gf hidisfdai AWideats Bwtw4 MA Cdl U TFL 4 617' -4900 cEt 4€6 or 147-M&SA AM Fax#617 727 7M Revised 424-07 W M_s gavidig-