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Home My WebLink About0195 HINCKLEY ROAD Z- fTHE?I Town of Barnstable *Permit donl_o �?13 O.p Expires 6 mOKMs frDlR 'sue ate ' Regulatory Services Fee 9 1 Thomas F. Geiler,Director Buildm` Divisio n on. , Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATTON - RESIDENTIAL ONLY - Not Valid without Red X-Press Imprint Map/parcel Number I Q U V Property Address ` ❑Residential Value of Work T 8DO Minimum fee of$35.00 for work ander$6000.00 Owner's Name&Address rn R�\�\ Contractor's Name Telephone Number. Nome Improvement Contractor License#(if applicable) construction Supervisor's License#(if applicable) ]Workman's Compensation Insurance � E PEWT Check one; ❑ I am a sole proprietor Diu 2011 Ee'T-am the Homeowner ❑ I have Worker's Compensation Insurance ! ,)WNJ OF BARNSTfbL isurahce Company Name 'orkman's Camp. Policy# apy of Insurance Compliance Certificate must accompany each permit. rmit Request(check box) ❑ Re-roof(stripping.old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) Re-side FO Replacement Windows/doors/sliders. U-Value CP #of doors + (maximum.44)#of windows *Where required; Issuance of tihis permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc, ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. TILESTORMS\building permit fnrms\EXPRES .doc r . ?7se Commonwealth of Massackusetts Department ofIndus&ial Accidents ` O,fce gfInvest gadons 600 Washington Sbyet .Roston,MA 02111 nww.mass.gvvldia Workers' Compeasatian Insurance "Affidavit: Buddders/Contractors/Elec'hicianslPh tubers Appl cant Infannation Please Punt Ledbh- Name Address: y 7 s C) City/State/Zip: t p Phone# Are you an employer?Cieck the appropriate box: Type of project(required): I'4. aia a contractor and 1_El I am a employer with ❑ I ti. employees(fail muVerpait-time).* have hired the sub-contractors 0 New constructoix 2.[1 I am a sole pioprietor'orpartner listed on the attached sheet 7. 0 Remodeling have These sub-contractors have ship avihaveno employees •$- Q Demolition wcdm g for me iu any capacity. employees and have wcd=z' f No workers' comp-insurance cam+-r� l 9. ❑Building addition r d] 5. We are a corporation;.and its 10.❑Electrical repairs or additions �cers}save exercised their Iam a homeorvuer doing all vac 11-Q Plumbing repairs or additions myself [No workers'camp. right of exemption per NIGL 12. 1 Roof repairs insurance required.]r c. 152, §1(4),and we have no employees.[No workers' 13.0 Other comp-insurance mquired.] 'Any applicant that checks box#1 nmst also Mow the section sh below ooting tiles wvrkeis'compensation policy in an I Homeowners who submit this affidavit indicating they are doing&H wed and dm biae outside contactors mast submit a new affidavit indicating sac)z Mors that check this box must attached am sdditeoaa!sheet showing the name of the sub-comsacwn and stale wbe*er or not ftse emdr+es hime employees. If the subtaat=ms have empl 3-�es,theymust provide their workew:camp.policy number. lam an employer thrrtis provWng mvrkam'conTensmion iinsarancae for my employees; Below is thepoliry,and job sire iufortiQatfi7rL Tumnance Company Name: Policy i or Seff-ins.Lie.# Expiration Date: Job Site Address: CityfStatelZip: _ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration.date). Failure to secure coverage as required unties Section 25,A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to$1,500-0.0 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK OR1IER 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 coverage verifita#ioiz l do hereby,certify under the pains Penalties afperjui?'that the information protrided above is hue and correct 46 _ t [ O, inl use only. Do not mrite in this ar.&4 so be comper by city'er town officiaL City:or Town: Permit/Ucense# Issuing Authority(circle one): L Board:of Hraltli y.Budding Department frown Cleric .4.Electrical hupecter 5.Plumbing Inspector.: 6.Othes• Contact Person: Phone#: 6 J. - Town of Barnstable P o Regulatory Services snxrrsrnai E Thomas F.Geiler,Director MASS. 9�A i639• ,�� 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: i Cy 17 JOB LOCATION: � number street c village "HOMEOWNER": 1 r \A Oyl �� yB 7 75 "P / name home phone# work phone# CURRENT MAILING ADDRESS: `J Q Lj f� /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. Y /. Signature of Homeowner Approval of Building Official 1 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 caret amend and adopt such a form/certification for use in your community. Q:forms:homeexempt THE Iati Town of Barnstable °. Regulatory Services 9 BMWSTABLE, Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Us ing A Builder 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) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION Town of Barnstable *Permit# e / • Expires 6 months jron issue date SS Kr*pRegulatory Services Fee Thomas F. Geiler,Director Building Division wN OF a tom Perry,CBO, Building Commissioner 0 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us ice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red hr Press Imprint rcel Number Q t1 Address q ^ ►,�C -2 ,� �\�j dential Value of WorkA9000 Minimum fee of$25.00 for work under$6000.00 s Name&Address y�� a jv tor's Name �GQ11%k OoZA Telephone Number_ 00 nprovement Contractor License#(if applicable) Zan srlpwri anan's Compensation Insurance Check one: ❑ Jam a sole proprietor M I am the Homeowner ❑ I have Worker's Compensation Insurance e Company Name n's Comp.Policy# Insurance Compliance Certificate must be on file. equest(check box) -roof(stripping old shingles) All construction debris will be taken to Dy ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors,'sliders. U-Value (maximum.44) •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 o Impro ent Contractors License is re q ' ed URE. ,G pmtrg 06 The Commonwealth of'Massachusetts Department of Industrial Accidents Office.of Investigations. 600 Washington Street N- s Boston,MA 02111 °,M ,.• www.mas&gov/dia Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,pplicant Information Please Print Legibly fame (Business/organizationanavidual): 1 'lflP,1-00 ,ddress: �-'1 1©Wn :ity/State/Zip: a n n►s n'lA NIlQO 1 Phone#: 5d 8. 7 75-5 o�q ? re you an employer? Check the appropriate box:. Type of project(required): I am a employer with 4. ❑ I am a general contractor and I 6. employees (full'and/or part-time).* have hired the sub-contractors ❑New construction I am a sole proprietor or partner- listed on the attached sheet ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ] officers have exercised their 10.❑ Electrical repairs or.additions ]E I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing iepairs or additions. myself. [No workers' comp. c. 152, §1(4), and we have no.• 12.❑ Roof repairs insurance required.]:t employees. [No workers' 13.❑ Other comp.insurance required.] y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: irneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aSSdavit indicating such atractors.that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. n an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site )rmation. arance-Company Name: icy'#or Sellr ins.Lie.#: Expiration Date: Site Address: City/State/Zip: ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in tke-form of a STOPVORK ORDER and a fine ip to$250.00 a day against the violator. Be advised that a copy of this statemeaf maybe forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby certify under the 'airs a enalties of perjury that the information providef above is true and correct. nature: Date:. C' .1/ ;Roo Official use only. Do not write in this area,to be completed by city.or town official, City or Town: PermitUcense# . 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#: Information and. Instructions assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. irsuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, q ;press or implied,oral or written." n employer is defined as-:"an mdMauat.parmership,.association, corporation or other legal entity,or any two or more f the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,of the Ceiver or trustee of an individual,partnership, association or other legal entity, employing employees. Howev-er:the- weer of a dwelling house having not more than three apartments and who resides therein,'or.the occupant of the welling house of another who employs persons to do maintenance, construction or repair woik-on such dwelling house r on'the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. ZGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or enewal of a license or permit to operate a business or to construct buildings in the-commonwealth for any pplicant 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 uter into any contract for the performance of public work until acceptable.•evidence.of compliance with the insurance equirements of this chapter have been presented to the contracting authority." Lpplicants 'lease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if. Lecessary,supply sub-contractors)name(s), addresses) and phone numbers)along with their certificates) of asurance. Limited Liability Companies (LLQ or Limited Liability Partnerships(LLP)with no employees other than the n or pa rtners;artners• are not required to carry workers' compensation insurance. If an LLC or LLP does have i mPY to ees,a policy is required. 13e advised that this affidavit may be submitted to the Department of Industrial kcidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should )e 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' ;ompensation policy,please call the Department at the number listed below, Self-insured companies should enter their. r riate line. umber on the o >elf-insurance license n appropriate City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom )f 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 mast 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 theaffidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat'a valid affidavit is aonlile for.future permits or licenses..A new affidavitmust 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 (ie. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. : The Office.'of Investigations would hike to thank you in advance for your cooperation and should you.have any questions, please do not hesitate to give us a call Che Department's address,telephone and.fax number: , The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Iiuvestigations . a 600•Washington Street . Boston,MA 02111. " `Tel. #617-7.27-4900 ext 406 or-1-877-MASSAFE Fax#617-727-7749 vssed 5-26705 www.mass.gov/4ia