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Home My WebLink About50-52 NAUTICAL ROAD Town of Barnstable Regulatory Services Vw 6xOnthsftom issue date s i `� a � • 13A81YSrAgt,�, s M039-ASS Thomas F.Geiler,Director Building Division L o �. Tom Perry, CBO, Building Commissioner g `� 200 Main Street,Hyannis,MA 02601 -� www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL-ONLY Not Yafid without Red X-Press Imprint �. Map/parcel Number Property Address 90—_C2 ❑Residential Value of Work I Ot ® � Minimum fee of$35.00 for work under S6000.00 Owner's Name&Address V r L '3!' contractor's Name Telephone Number Some Improvement Contractor License#(if applicable) :onstruction Supervisor's License#(if applicable) X•PP R E S S PERMIT ]Workman's Compensation Insurance J U L ,I. Check one: ❑ I am a sole proprietor TOWN OF BARNSTABLE. I am the Homeowner ❑ I have Worker's Compensation Insurance Lsurance Company Name orkman's Comp. Policy# opy 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) �I,1] Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *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 ArUquire NATURE: PFILESTORMSIbuilding permit formslEXPRESS.doc sed 070110 j The Commonwealth of Massach useits Department of Industrial Accidents 1 Office of Investig ations t j// 600 Washington Street oil Boston,MA 02hT1 _ www.mrrssgov/pia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Busi33ess/Organiration4ndividual): �\ y� < Address.--as, City/State/Zip: YVS �1 'rU Phone E' l an employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors 6. New construction a sole proprietor or partner- listed on the attached sheet. t 7•. ❑modeling and have no employees These sub-contractors have 8. ❑-Demolition working for me in any capacity. workers' comp. insurance, g ❑Building addition workers' comp. insurance. 5. .❑ We are a corporation and its ired.] officers have exercised their IO•❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL . 1 I.❑ Plumbing repairs or additions lf. [No workers'camp. c. 152, §1(4), and we have no12,❑ Roof repairsance required] t employees.(No workers' comp. insurance required.] 13.❑ Other - *Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy information. t Homeowners who submit this afbdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such xContractors that check this box must attached an additional sheet showing the name of the sub-contracton and their workers'comp.policy information. I am.an employer that is providing workers compensation insurance for information. my erirpinyees. Below is the policy and job site Insurance Company Name: .Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/Stator/ ip: 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of*. Invesiigations of the DIA for.insurance coverage verification. l do herebyl {��un r the pains and penalties of perjury that the information provided above is true and correct ii ature:�F� r M1� qq Date: ' 2 Ztl 6/ P Official use only. Do not w'rite in this area;to be completed by city or town bffzciaL 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 • J 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 Iegal 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." } i MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhbld 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-contractor(s)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 Tequired. 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.ih 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 (Le. a dog license or permit to burn 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 Sheet Boston,-MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MA.SSAFE 'P av 4 <1 1 '71 7 -7-7d n Towu of Barnstable P�of�t�y - ti� o Replatory Services Tbamm F. Geiler,Director �.bg Building Division Tom Perry,Building Commissioner 200 Mifq- trcct, Flyanni.s,MA 02601 wwsv.town-b arnstable_ma.us Office: 508-862-403 8 Fax. 508-790-6230 HOMEoYMER LICy,\,sE=h=om Please Print DATE Z•' Z 1 `Z,c^> f JoB LocAllox: Q�`^ 1 C . 'L krl v) �S number treat village •'�iO],.fFAWNER": � e�. �Y 1M r �', (, � ?�l,� �� 10 • mine h e work phone CURRENT MAMING ADDRESS state MP eade The current=msption for"n=Cowngs"was cxtendcd to include;ovmcr-occupied dwmllings of aix mait s or less and to allow homcovmers to engage an individual for hire who does not possess a license,provided that the owner acts as Supervisor. DEnMTON OF BOMEOWNTR t .r Persons)who owns a paxccl of land on which he/she rmsides or intends to reside,on-V h*thcreis, or is mtmded to- be, a one or two-family dwelling, attached or det3.rhed struetarrs accessory to such use and/or farm structtnrs. A person who coast-gr-ts more than 6ne home in a two-year period shall not be considered a homeaWncr. Such 'homcowncr"shall snbmif to the Building Official on a form acceptable to die Building Official, that he/she shall be rc=cnisible for all such work pedimmcd tinder the butldine permit (Section 109:1.1) The-nndersigncd`homeowner"a mmT--rc responsibility for compliance with.the Statr Building Code and otl= applicable codes, bylaws,rules and r"91 7a"CMS. The=dcrsigncd"homeownee'certifies that he/she,understands the Town of Bamstable Building Depar-iment_ r m spcction pmccdmcs and rc-Yirm: nffnh and that he/she will comply with said proc=hn s and Si tisre of f • h Appmval ofBuild ng,Offfcial Note: Three-family dwellings containing 35,000 cubic feet or larger v U be required to comply viith tbd ' State Building Code Section 127.0 Counts-+ibm Control_ . HO1l�o Wt�.R'S FXEMf?ION . ' .The Code stzles that Any bomcowecrpa*mming work for which a btnIdatg patent is required shall be axc rqt from the proyimmu f this=don,(Seetian 109.1.1-L=u-ing of cant metion Superrisors),provided that if the homoowna eagagu a pm, (s)for has to do such 'or c,that suCch Hamccwna•shall act As n:pa-Xsor." 1�2aay homeasmas who use this t=rmption er e unawars that they errs ssstmsng the rmponst'bilides of a'= -v err(see Appendix Q, uks&Kegula lions for;Secasing C—Imcdoa Supe Visors,Section 2.1-5) This lack of awar=c=Men msuhs in serious prob]aas,particularly Oct the hm cowna•hires unlicensed pcgrm 1n this ease,our Bonn ca.ot prnmeacd agaatst the unlicensed P=Cn as it%could with i licensed pervisor. The homenwna actatg as 5uperrisor is ultimately respottsib]a To=assure that the homeawna is 5LUY aware of JjACrrrspotuabt7iticc.Marty emnmunitics mquir,as part of the pan it application, t the homeowner=ti y that be sAc un6=bmds the rrsponnbtli tics of a Supervisor. On rbc]2st page of this issue is a,form tsar dy used by 41 w' • r 1 - . 1 , n r° y Town of Barnstable 0 • Regulatory Sex-vices i Bl Tt7J1 MA UL j p �'� $ Tharnas F. Geller Director ` Building Dfvis on Tom perry,Building Commissioner 200 Main 5troct•,Hyaffii4 3 A 02601 www.to w n.b a rns tab I e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Prop erty Owrier,Mus t Complete and Sign 'This Section ' If Using A Builder is, A.' M V , as Owner of the*subject property hereby authorize to act on M7 behatf in aIImattnis relative to wprk authorised by this bu2diug permit application for (address of Job) VVV sgnatlue of Omer l •. Da Punt Name If Pro �pea Owneris applying for pernmt pleas e com fete.the Homeowners License Exemption Po= ou :the revere side.