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Home My WebLink About0387 OAKLAND ROAD a6`l Chk �arr_L '�,- a '71ou , r l 1. r We Town of:Barnstable ' *PernAt Expires 6 months r 11 o issue dot Regulatory Services Fee BARNSTABLE, ,m$ Thomas F.Geiler,Director Building Division `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 APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2 7/ O Il Property Address 3 Ir n,4Kr -A A!� • ��, 00 %#A! 1 JS /`l/�•' d ZGo/ &i esidential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address d lD tit.i_ VI S Contractor's Name a Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License# if applicable) PERMIT ❑Workman's Compensation Insurance Check one: k n �ti AUG '2 3 '2013 ❑ I am a sole proprietor [�I am the Homeowner ❑ I have Worker's Compensation Insurance ® N OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) N. ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris'will betaken to 4, ❑Re-roof(hurricane nailed)(not stripping. Going over-; existing layers of roof) [•�•Re-side Fe,"! '8** '-.Ss N'/s • & to( ?A.,H [•OReplacement Windows/doors/sliders.U-Value 2,4 (maximum.35)#of windows Z #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. • A . ..ilk . i SIGNATURE. C:\Users\decollik\AppData\Local\Microsoft\Window`s\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 • r, y 1. ?7ne Commonwealth of Massachusetts Department of Industrial Acciddents Dice of Investigations 600 Washington Street Boston,MA 0-7111 rvnnv.mass.goWdia Workers' Compensation Insurance Affidavit: Bnilders/Confi—Actor Iectncians/Rumbers Applicant Information Please Print Legibly e Name a sinesslOrpnizationffix1hidnai): Address: 2 dq '2 City/StatelZip: ctr,,, S ,4 di-k4l Phone ik Are you an employer?Check the appropriate boa: T of project r . 4- I am a general contractor and I Type p J ( �� 1.❑ I am a employer with ❑ g 6- ❑New construction. employees(full andlor 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 g_ ❑Demolition working for me in any capacity. employees and have wodcers' 9. ❑Building addition jrro workers' comp.insurance camp.insurance. )required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or addittons 3- 1 am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 110 Roof repairs insurance required.]l c.152, §1(4),and we.ha,%Te no employees.[No workers' 13.❑Other comp-insurance required-] •Any applicant that checks box#1 must also fill out the section below showing their wotkets'compensation policy infornkadom Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mnst submit a new affidsvit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the.sub-coo=c:tors and state whether or not those entities have employees. If the sub-contractors have empioyees,they must pmvide their workers'comp.policy number. I aln au ellrployer that is prvvidirrg.itrorke-rs'compL—rtsadon insurance far lriy*ertrpdvym& Below is the podicp and job site informatrolL Insurance Company Name: t Policy 4 or Self-ins.Lie.4: 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 andlor 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nnder tkf pains and penalties eperjuty that the information pro tided above is tnw and correct lure: Z y Date: Phc ne# �'�l d 7'-- C ---------- official use ondyt Do not writs in this area,to be c utpleted by city or town official I City or Town: PermitUcense# Issuing Authority(circle one): 1.1Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.10ther Contact Person: Phone#: _ 6 J THE h p Town.of Barnstable r w * MARNSTABr.B. : Regulatory Services y MASS. 16g9. Thomas F.Geiler,Director QED NIA A 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:� /�3 I JOB LOCATION: 3jr? d�K��MY ¢" '+� - tI V&.4A of S number ( + street +� �* village "HOMEOWNER": O1BQ&\ h 1A0;11 y�I 7? -"I?S7 name horn hone# work phone# CURRENT MAILING ADDRESS: SA/Y C city/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 retirements and that he/she will comply with said procedures and requirements. Signature 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 10941.1 -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. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EX PRESS.doc 8 Revised 061313 t , Building Department ComplainVInquuy Report " Date: Rec'd by: . Assessor's No:Z 7�' Complaint Name: Location �� Address: M/P s Originator Name Streee 1 Village: State: Zip:__ Telephone:D/C Complaint F7 , Description: Inquiry Description: For Office Use Only Inspector's Action/Comments Date: Inspector. CV follow up Action G Additional Info.Attached COPY Di oibudon: White-Deparunent File Yeffovv-Inspector ' Pink-Inspector(Renua to Ofce 3fanager)