HomeMy WebLinkAbout0255 HINCKLEY ROAD ems- �j N��«-� y
aa�
' Town of Barnstable Uildin
Th
Post:This Card�So� at�t�s V�s�ble From:the Street=A roved�PlansMust�be Retained on iob,and�this Card4Must be=.Ke t`�� ..
M � -:
Posted Unt!Final�lnspection Has Been Made , � ��;,� - a•� � �: �� �. � � � � ,°�,° � � „
i, Permit
� R , Where a.Certlficate of Occu an:c, as"Re u�red such�Bu�ldm sh�al�Not�be Occu ied until a".Fina Ins ectidn has:been�made.
Permit NO. B-18-1848 Applicant Name: GONZALES, LANA I ESTATE OF Approvals
Date Issued: 06/08/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/08/2018 Foundation:
Location: 255 HINCKLEY ROAD,HYANNIS Map/Lot 310-076 Zoning District: RB Sheathing:
Owner on Record:,GONZALES, LANA I ESTATE OF A0,77Contractor Name; a Framing: 1
Address: 252 NORTH MAIN ST#G30 i Contractor License 2
SPRING VALLEY,NY 10977 Est Project Cost: $800.00 Chimney:
Description: siding Permit Fee: $35.00 ,
Insulation:
Fee Paid $35.00
Project Review Req: z
I fZ
Date 6/8/2018 Final:
n WE
Plumbing/Gas
4 � �
Rough Plumbing:
o
Building Official
{ Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorrzed by this permit is commenced within six"months aftef5issuance. Rough Gas:
All work authorized by this permit shall conform to the approved applicationjandthe approved construction documents for wh ch this permit has been granted. g
All construction,alterations and changes of use of any building and structuresshah be in compliance with the local zoning by laws an"d codes. Final Gas:
This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
_ Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fi ekofficials are Al provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work:
r
1.Foundation or Footing Rough:
(+ x � '°
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction. Final: "
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
Town of Barnstable Building
•AR671S��C'AB+Ss.E�. WPPoohss�'tte�e,rTe a a Cert�ficaw.t.e�of eOwe cu.p_ra. nc i.s,�Re�,,;umed;s,;ucr h ABu.�ldm� ,sha�ll fiNxo�.:t�be�Occ,�u, e.d. u,�n,til a�Final�=In..s. ecti�o�,n. h,�as be�e �,,s1 Permit
l t
Permit No. B-18-1848 Applicant Name: GONZALES, LANA I ESTATE OF Approvals
Date Issued: 06/08/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/08/2018 Foundation:
Location: 255 HINCKLEY ROAD, HYANNIS Map/Lot 310-076 Zoning District: RB Sheathing:
� R
Owner on Record: 'GONZALES, LANA I ESTATE OF Contractor Name Framing: 1
Contractor License
Address:' . 252 NORTH MAIN ST#G30 K- p 2
SPRING VALLEY NY 10977 . .. a EstPro�ect Cost: $800.00
4 Chimney:
;. Permit Ed
Description: sidingz $_ $35.00
r Insulation:
Fee Paid':` $35.00
Project Review Req: ,
Date 6/8/2018 Final:
'`
�F Plumbing/Gas
Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work a6th6'iIz6d(by,'ithis permit is commenced within si ofit hs�after2issuarce. Rough Gas:
All work authorized by this permit shall conform to the approved applicationi4ri the approved construction documentsWfor which this permit has been granted.
All construction,alterations and changes of use of any building and struct ru es NZIRbe in compliance with the local zoning by laws and codes. Final Gas:
4
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for pubhciinspection for the entire duration of the
work until the completion of the same. '
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures b, the=Building and,Fi"e Officials are provided on,th s permit. Service:
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing F = Rough.
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
Application number... •�
o 4 Date Issued.............. .� L�g..... ... ....................
N01�
NAM Building Inspectors Initials... ....... ........................
k� JUN O 8 2013
rO141AI Map/Parcel. 2 .. ..... ..
HfVS
ABU
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: S .
NUMBER E�
SIRE T LAGE
z Pone umer / /�/
Owner's Name: `�J�,b � `e� n �`�" � - h Nb "
Email Address:/ N. ter ' � Cell Phone Number
k /
�D(J
Check one Residential ✓ Commercial
Project cost$
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application for a buildin ermit in accordance with 780 CMR
Owner Signature: Date:
hV
TYPE OFMORK
it Siding E-1 Windows(no header change)# Q Insulation/Weatherization
0 Doors (no header change),# Commercial Doors require an inspector's review
Roof(not applying more than I layer of shingles)
Construction Debris will be going to
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 IF THESUBJECT PROPERTY IS IN
.iteT ,o1.- Annvnver RFFrW a PFRM/T CAN BE ISSUED.
APPLICATION NUMBER 4`
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides? Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
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
If food is being served at
your event leas e 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
Homi6owner's Name: U R Z .4 le
Telephone Number Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CAM the Massachusetts State Building Code. I understand
the construction ins
pection ection procedures,p p s, specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date 4-7--
APPLICANT'S SIGNATURE
Signature Date
All permit applications are subject to a building official's approval prior to issuance.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.n=s.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/El petriicci Pit b b
Applicant Information
Name(Business/Organization/Individual): If
z
Address: �� _
Phone
City/State/Zip: o
Type of project(required):
Are.youan employer?Check the appropriate bog: general contractor and I New.construction
1.❑ I am.a employer with have hired the sub-contractors
employees(full and/or Part-time).* 7. Remodeling
listed on the attached sheet. ❑
2.❑ I am a sole proprietor or partaer- These sub-contractors have g. Demolition
ship and have no employees employees and have workers' 9. ❑Building addition
working for me in any capacity. e t
o workers'comp•insin-ance ��.instnanc ' 10.❑Electrical repairs or additions
[N 5. ❑ We are a corporation and its
re ed.] officers have exercised their 11: repairs or additions[]Plumbing p
13. am a homeowner doing all work
' right of exemption per MGL 12.❑goof repairs
mysa[No workers'comp. c.152,§1(4),and we have no 13.❑Other
insance required.]t
ur employees.[No workers'
' comp.insurance required-1
*Awy applicant that cbodx box#1 must also fill out the section below showing their workers'de contmrOmPensatioa policy information '
t Homeowners who submit this affidavit indicating they are doing au work and then hire outside contractors must submit a new Dotthoie enicaei h such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or notthose entities have
to t provide their workers'comp.Policy number.
employees. If the sub-contractors have emp Yees,they mast
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information-
hm]rmce company Name:
Expiration Date:
Policy#or Self-ins.Lie.#:
City/State/Zip:
Job Site Address: the policy number and expiration date).
Attach a copy of the workers'compensation policy declaration page(showing .P c3' penalties to .
e as re ed under Section 25A of MGL c. 152 can lead to the imposition.of criminal p
Failure to secure cove2ag q penalties in the form of a STOP WORK ORDER and a f ne
as well as civil
fine up to$1,500.00 and/or one-year imprisonment, of this statement may be forwarded to the Office of
of up to$250.00 a day against the violator. Be advised that a copy
Investigations of the DIA far insurance coverage verification.
aloes ofPedurl, the information provided above is true and correct:
I do hereby cerd under the p ' p _ /
Date:'A
SS alle:'1
(Phone#:"
Official use only. Do not write in this area,to be completed by city,or town official
r Permit(License#
City or Town'
Authority(circle one): ector 5.Plumbing Inspector
Issuing
1.Board of Health.2.Building Department 3.City/Town Clerk 4.Electrical Insp
6.Other Phone#:
Contact Person:'
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 iri 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 budding appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states thiat"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to opemte.a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage'regnired."
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 numbers)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 pern it/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 enmity or licenses.. . p tenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit no r i g p t elated 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 Gommwwealth of Massachusetts ^
D�--Pmltment Of Industrial A.ecidents
Office of luvesilpflo s
600 Washingtazt Sh=t
Bad,MA 022111
Tel. 617-`T27-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#61 727-7749
w ,maW,gDVIdia
rrease retunr tuP Nuruun wren Payment /MVVVUIII"U. LUV I
f
Map/Parcel 310065 TOWN OF BARNSTABLE Bill Number: 14645
WATER POLLUTION CONTROL DIVISION
Location 617 BEARSES WAY Issue Date: 05/21/2018
260 HINCKLEY ROAD HYANNIS, MA 02601 Due Date: 06/20/2018 -
Owner (508)790-6335 FAX(5 8)790-6325
GONZALES,DANIEL
Make this the last bill you get In the mail '
- � Sign up tor Paperless Billing Today -
EW A E �L 01 www,townofbarnstable.us
a d CASH C HECK
Jd .
District Sery No. a Desc.
B W 4446
JIJNq0821I-OWN _ (� _Current Charges: OSTABL�Previous Prer �' ..__. .. Current 100 Cu.Ft. #of Current
Service Read Date Readin btiC eadin Usage fixtures Rate Charges
g �� -ge 4
RESIDENT 11/06/2017 510 02/06/2018 522 12 1.00 5.04 $60.48
Last Payment: Account Summary:
Total
Date Amount Amount Interest Current Total
03/16/2018 $55.44 Past Due Due Charoes Amount Due
$0.00 $0.00 — $60.48 $60.48
Account No. 2801
Bills are payable within 30 DAYS from ISSUE DATE.INTEREST at 12%per annum will accrue daily on delinquent accounts.
Your bill is calculated on usage figures provided Barnstable Water Co. Refer to read Dates COMM Water Co. Set rate or read dates
by your water company for the following periods: Fixtured Accounts January 1,2018 through Yarmouth Water Co. Refer to read Dates
March 31,2018
Barnstable Fire Dist. Refer to read Dates
i NOTES: A SEPARATE METER IS AVAILABLE FROM YOUR WATER COMPANY FOR THE PURPOSE
OF SUBTRACTING YOUR OUTSIDE WATER FROM YOUR TOTAL WATER USE.IF YOU s
USE A LOT OF WATER OUTSIDE YOU MAY BE INTERESTED IN PURCHASING THIS e
SEPARATE METER.YOU CAN CONTACT YOUR WATER COMPANY FOR MORE DETAILS.
Visit our website at www.townofbarnstable.us or email us at wpcd@town.barnstable.ma.us with any questions or concerns
Town of Barnstable *Permit g #Z I6
u
Regulatory Service 6 --- S
• BABNBTAKU& •
MAC Richard V.ScaIi,Director. JUL 2 8 2015
Building Divisio>T®WN �-t uF
8,ANSTAB R
' Tom Perry,CBO,Building Commissioner LE
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230-
EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY ,
Not Valid without Red X-Press Imprint
Map/parcel Number�l D
Property Address A"n Lci hqn- 60- 66'
9esidential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Land
c2,5-5 la4aa�<j 1 kii r) t,�
eContractor's Name ( Q, Telephone Number 13 / 7
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
El,
am a sole proprietor
'[ I am the Homeowner
❑ I have Worker's Compensation Insurance
. 1
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
[r Re-roof(hurricane nailed)(stripping old shingles)'All construction debris will be taken to `
❑Re-roof(h rricane nailed)(not stripping. Going over existing layers of roof)
❑ �de
ement 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.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 040215
Town of Barnstable
Regulatory Services
off . Richard V.Scali,Director
Building Division
Tom Perry,Building Commissioner
MASS
M�m� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: v 'ML 01a,1001
number street 426
11 ^�—2 village
"HOMEOWNER":I'L `t 5 — S
name home phone# work phone# .
CURRENT MAILING ADDRESS_6 6 H �p L
D
f ci /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
p 'ced s and requirem d that he/she will comply with said procedures and requirements.
Sign- a 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
yourcommunity.
Q:\WPFaM\FORMS\building permit forms\EXPRESS.doc
Revised 040215
o�
BARNSTABM
,' �,�� Town of Barnstable
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, , 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.
QAWPHLESTORMS\building permit forms\EXPRESS.doc
Revised 040215
2
Ile Comynorrivea.Ith o,f Massachusetts
Department o,f'irndusbial Accidents
0Ji a o,f Investigations
600 Washington Street
y Boston,.CIA 02111
tvisi?niax .gnv1dia
Workers' Compensation Insurance Affidavit.Builders/Contradurs/EIectr cians/Pl=bers
Applicant Iufmrmatian Please.Print LedbT
�;-ItiTe�vsffiessfl�rganizati � ' ';tS4��ta
1
Citylstate ip: h I U MIZ Planet `V Z-
Are you an employeritheck th propriajjj�V Type of project(regired)_
1,El am a employer with 4, ral contractor and I ❑New consfzuctu rt
employees(full andfor part-time)*
e hrredthe sub-contractors 6.
2.❑ I am a sole proprietor or doer- listed on the attached sheet. 7. ❑R,emodelmg
These sub-contractors have
slop and have no emplag�ees. $. ❑Demolition
yr g for me in any capacity. employees and have wodcers'
t3`. � 9. ❑Building addition
[v[No orke-rs'comp.'insu ante comp-insurance.$ ,
equired] 5. ❑ We are a corporation sand its 10 ❑Electrical repairs or additions
3. I am.a homeoumer doing all work officers have exercised their I L❑Plumbingrepa=' or additions
myseZ[No workers'comp- right of exemption per MGL 12.❑Roofrepairs•.
insurance required_]F c.152, §1(4�aadwe have no
employees-[No workers' 13.0 Other
comp.insurance required.] '
'Any appKcsat eat chedrs box i£1 must also flout the sectionbelow shoeing their.wakers'compensation policy information_
1 Homeovrnen who submit tins afflihm ft md5rating they are doing all wa l and rhea hire outside contractors amct submit anew affidavit indicatig such.
ZC'antrac:to s that check this boa mast attached sir additional sheet showing the name of the sub-cnarxomrs and state whether or nut those entities bst e
employees.If the subtantmctaes have employees,they musrpmvidetheir urorkers'comp.galicpnunilser-
I am an elrtpZger Hurt is pr4n dirty ivarkers'coitgwtsagaii fimirimceforwyenipLayear. Below it the p 4cy and job srin.
informs on.
Insurance Company Nam ,
Policy,or pelf-ins.Lic_ - Dxpirat oa Date:
Job Site Ad&ew: City/State/Zip-
Attach a copy of the workers'coampensation 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 penatiies of a
fine up to S1,500-00 and/or one-year imprisonment as well as chal penalties.in the form of a STOP WORK ORDER and a fine
of up to MO-00 a day against the violator.,Be ad-tiised that a copy of this statement maybe Exwanded to the Office of
Irsvestrgations of1he DIA for insurance coverage yerifrcatiom
I da hereby cfro,under the s a d pertald=o,f trY that t1ie infbrma€an pm r ed bmv fg bare and correct
Sitature: Bate_
Phone 0 7
tlfjZ al use only. Do not write,in this area,to be campletesd by city orto n officiat
City orTown: PermitUcense;9
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.(itytTown Clerk 4.Electrical Inspector S.Plumbing inspector
6.Other
Contact Person: Phone 9:
Information and Instructions
Mks&achmetts Gehezal Laws dmpti r 152 requites all empIoyees to provide workeza'compensation for their employees.
Pmmmmatto this statute,an.e7npZ yw is defined as.' every person in the service of another under any contract of hire,
express or iulplied,oral or wrftft:a"
An e�IoyEr is dewed as"an individual,pa lnersbip,association,corporation or other legal en ,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,pmtamsbip,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 occapant of the -
dweIIing house of another who employs persons to do mainten ce,consftuction or repair work on such dwelling house,
or on the grounds or building appurtenaatthereto shall not becanse of such employment be deemed to be an employer."
MGL chapter 152, §25C(5)also stems 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 k the commonwealth for any
applicantwho has not produced acceptable evidence of compliance with the inenran ce 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 ofpurblie wo1k unff acceptable evidence of compliance with the insurance..
requirements of this chapter have been presented to the contracting a afhodty_" :
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your sitnation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of
am -aance. Limited Liability Companies(LLC)or Limited Liabfii y-Partnerships(LLP)with no employees other than the
members or partners,are not reed to carry workers'compensation insor nce. If an LLC or LLP does have
employees,a policy is rmpirA Be advised that this affidayk maybe 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 retrmmed to the city or town that the application for the permit or license is being requested,not the Department of
o ,ctrial Accidents. Should you have any questions regarding the law or ifyou are regaz-ed to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-ir,crrrance license number on the appropriate line.
City or Town Officials .
t
Please be sure that the affidavit is complete and printed leg�ly. 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 Ell in the pezmiUlicense number which will be used as a reference number. In.addition,an applicant
that must submit multiple pennitUcensa applications in any given year,need only submit one affidavit indicating current
p olicy bafb ation(if necessary)and under"Job Site Address"tie applicant should write"all locations in (city or
tnwn)_'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 fut$e pezmiis 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 rcgaked 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,Departmenf s address,telephone and fax number.
Tht Ca=m:toa mjth-of Massachuactts `
Department of 11idustdal Accidenta
ace of jttvesdotio-=
600 Washi OGII Stet
TeL 4 617-727-4.900 Qxt 4-06 ar 1-977-MASSAFF,
Fax 9 617-727=7749
Revised 4-24-07 miasgov/dia-
Town of Barnstable
Regulatory Services
KME
v� rQiyti Richard V.Scali,Director
°* Building Division C
* 11AWMAJIM ` Tom Perry,Building Commissioner
MASS.
039. �m� 200 Main Street, Hyannis,MA 02601
v " www.town.barnstable.ma.us '
Office: 508-862-4038 Fax: 508-790-6230
_ HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
,JOB LOCATION: !TK/l l�i � t rI 1 S t Ip'd,
number street village
-`HOMEOWNER":
name home phone. work phone# .
CURRENT MAILING ADDRESS:U�
D
6it%Aow,i - state zip code
The current exemption for"homeo rs"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 requiremegits and tha a/she will comply with said procedures and requirements.
CJSignature 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 Supervisorsy; 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 040215
1t
oFTME tbyj�o
s
• BnniasrnBLF. «
�Ar �,0� Town of Barnstable
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 Usink A Builder
t
as Owner of sub' t property
hereby authorize to t on my behalf,
in all matters relative to work authorized by this building permit pplication fo
(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.
V
QAWPFILESTORWbuilding permit formsEXPRESS.doc
Revised 040215
r
0 �
O .
AAA .
Bedard, Mike
From: Ormont, Estee,(DPS) [Estee.Ormont@staf
Sent: Tuesday, May 12,.2009 8:21 AM
To: buildit12@aol.com
Cc: Bedard, Mike; Anderson, Robert (DPS)
Subject: Issuing Permits with Supplemental Cards
Paul —
received an e-mail from Mike Bedard who works for
permits and having the CSL holder present to obtain tI
Under MGL, Chapter 142A, 780 CMR R6,they provii
supplei»ental card for the following services:
1) To obtain permits : This provides larger com
with the same HIC number as the company.
Example: Home Depot, Inc., company's HIC-
supplemental card 9126893 of the company. "
obtained permits only. When the RUNNER sL
will have with them: Their supplemental card
HIC# (as required under MGL, Chapter 142A
IMPORTANT MESSAGE
For
Day Time •�(/ A M.
M t.,
Of O�
Phone C _ -1�Jq 57
FAX Area Code Number Extension
MOBILE
Area Code -,Number Extension
Telephoned Returned your call RU
Came to see you Please call " pecial attention
Wants to-see you Will call again Caller on hold,
Message
5 t
Signed
W NERSAL_48023 MADE IN U.S.A.
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