HomeMy WebLinkAbout0247 OCEAN AVENUE � 4 � Ocean fl,vt--
0
� own of Barnstable # l l }oF1�r� �' *Permit
P� ~O "Expires 6 month from issue date
Regulatory .Services Fee
i IARNSTARLE. -
v MASS. Thomas F. Geiler,Director
1639•
plfD MA't A
Building'Division
Tom Perry, CBO, Building Commissioner.
200 Main Street,Hyannis,MA 02601'
l 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 3C6— t !® � _
Property Address O G IE�14 N V 45- 17 y,4 IV411 S .
Residential Value of Work ` S dam• Minfmurn fee of$25.00 for work under$6000.00 ,P
Owner's Name&Address W 1 + 5 14 A AIM N PA-C 140 P,00
Contractor's Name �j �� Telephone Number/
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) N IA'
❑Workman's Compensation Insurance X.PRESSPERMIT
Check one:
❑ I am a sole proprietor i MAR 19,2010
I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABL .
Insurance Company Name
Workman's Comp.Policy# }'
Copy of Insurance Compliance Certificate must accompany each,permit, r
Permit Request(check box)
r
a
❑ Re-roof(stripping old shingles).All construction.debris will be taken to
❑Re-roof(riot stripping. Going over existing layers of roof)
Re-side
of doors
Replacement Windows/doors/sliders. U-Value (maximum 44)#of windows .3,_
*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. j
SIGNATURE: ...'
Q:\WPFILES\FORMSUilding p t s\EXPRESS.doc
Revised 090809
The Commonwealth of Alfassachusetts
Department oflndustrial Accideti.ts
Office of1'nvestigations ,
600 Washin-ion Street
..Boston, MA 02111
_ J�1
jviviv,niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le i� bly
Name (Business/Organization/Individual): TAG XPk.
Address: t�"d , 17 V P4412 GD > S T-
City/State/Zip: 5 0 . 17��R FI eFG> M-ALLA`, d S
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a em Io er with• 4. 0 I am a geneial contractor and 1 . °
P Y 6. ❑ New construction
employees (full and/or part-time).*` - h ave hired.,the sub-contractor s
2.❑ I am a sole proprietor.,or partner-, listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g. Demolition
workingfor me in an capacity. employees and have workers'
Y P Y• 9. 0 Building addition
[No workers' comp. insurance, comp.insurance.$ -
required.]
5. We are a corporation and•i[s .10.0 Electrical repairs or addition
3.®,I am a homeowner doing all work ,officers have exercised their . 11.❑ Plumbing repairs or addition
myself. [No workers'_comp, right of exemption per MGL 12 E]Roof repairs
insurance required.) t c. 152, §1(4),and we have no
er
employees. [No workers' 13.Dot'.
comp.insurance required.]
*Any applicant that checks box it] must also,fill out'tbe section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
]Contractors that check this box must attached an additional sheet'showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am.an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.'
Insurance Company Name: —
Policy#.or Self-ins.Lic # '`_ Expiration Dater
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 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK.ORDER and a fin
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"Io hereby'certi 'under the pains and p ties of perjury that the information provided above is true and'correct.
� pp -:,-19 .
i
Si ature: � v Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
. t
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
Contact Person: Phone#:
' Instructions
Information and
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 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,constriction or repair work on such dwelling house
or on the ground's or biiil'ding appurtenarit'ihereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or,local lice"rising agency shall withhold the issuance or
renewal of a license or permit to opeti ate-a business or to construct buildings in the commonwealth for any
O
applicant tvho 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-contractors)name(s), address(es)and phone number(s)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 permit/license number which will be used as a.reference number. In addition, an applicant
that must submit multiple permitflicense 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 bu
siness 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:
k The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
rv�1 f 7
Town of Barnstable !
FTHE 1pk ,
" Regulatory Services
o �
* r,+at e,
r Thomas F. Geiler,Director
aAxrts
nsAss.
109. ��� Building Division
PTED �a Torn Perry,Building Commissioner'
200 Main Street, Hyannis,MA 02601 4,
www.town.barnstable.ma.us
Office: 508-862 4038 " s Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
u 41 C IV h /+ y� y�a Nam/ s
JOB LOCATION: "/ 'T
number street �J Y\villaage
"HOMEOWNER": 2�14 /V � --PAC,v PJi J� �! , 7 1 V 6-;" z�.>00
name home phone# ork phone#!
CURRENT MAILING ADDRESS:
5v , 17 5RFi/,G Z Nl14 .' O *S7�2
r
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 buildin> 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
equirernents.
A � `
Signa 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
1 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 supervisorr(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
w 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 hdshe 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:\WPFILFS\FORMs\homee-xempt.DOC
�YHE r Town of Barnstable
Regulatory Services
aaaxsrnaLE. Thomas F. Geiler,Director t
9 ems. $, t .
Fo 3;;� 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
Property Owner Must
Complete-and Sign This` Section
If Using 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.
*IKE r Town of Barnstable *Permit tc)
o �
Expires961onUrs from issue date
Regulatory Services Fee
Thomas F. Geiler, Director
AIFDjihA'�a �� Building DivisionIV
5 2009 Tom Perry,CBO, Building Commissioner
7_01A/N®1z SAR 200 Main Street, Hyannis,MA 02601
�S7-A,8L,E 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 77�b
Property Address �.� P C CA Ill A V i�—_ y A. AIM 5
Residential Value of Work !,I5L-G,or. Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address N �• + 5 tq-44,Y✓) Pl4 0 iaA"OF
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) /V LA
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
® I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(riot stripping. Going over existing layers of roof)
® Re-side D �F 4' F (;_AAA-6� F
Replacement Windows. 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.
Home Imp;�ye e Contra rs License& Construct Supervisors License is required.
SIGNATURE:
Q:\WPFILES\FORMS\Expr s RESSPERMIT.DOC
Revise06O4O9
Caf
The Commonwealth of Massachusetts
IS
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
s• �� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): D�� N �. 'F �7 k A PIN 64 C/.0 pip&
Address: Sd 9.,'A A A&,P 4 F 5 T
City/State/Zip: SO
VIP FP 1C/ PG hone#: 1 6 6 S 0
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or pa time).* have hired the sub-contractors 6. ❑New construction
rt
2.❑ I am a sole proprietor of partner listed on the attached sheet. T.�Remodeling
ship and have no employees These sub-contractors have g_"❑Demolition
workingfor me in an capacity. employees and have workers'
Y P t3'• $ 9. ❑Building addition
[No workers'.comp.insurance comp.insurance. 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp_ right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit 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-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.M 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 tip 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$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 c under the pains and penalties of perjury that the information provided above is true and correct.
Si ature: \ Date:
Phone#: 0(4 13 t>a 6 S —3a
Official use.only. Do not write in this area,to be completed by city or town official
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
Contact Person: Phone#:
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 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 building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states 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 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-contractors)name(s),address(es)and.phone number(s)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 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
(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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lnvestigations.
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
d'
4L
s"ETati Town-of Barnstable
Regulatory Services
9 ' $ Thomas F.Geiler,Director
1619.
1 a 16 Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using 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.
P
Q:FO RMIS:O WNERPERMISSION
yWP�� tgy��
Town of Barnstable
THE M`
Regulatory Services
Thomas F.Geiler,Director
aAxxsr.+=r.E. .
1639.. ��� Building Division
PrfD µfa�
Tom Perry,Building Commissioner
_-.-.. .. ..... ._ ..-...200 Mairi=Street,—Hyannis;MA 026D1 _.._. . .. _.____......
www.town.barnstable-ma.us
Office: 50 8-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEKMON
p Please Print
DATE:
JOB LOCATION: ; ,/"'1 Cf.C E A-0 Jove., If A
number street village
"HOMEOWNER": -°N Aiq k' (d{1 J� 6 a
name home phone# work phone#
CURRENT MAILING ADDRESS: 5 Vo A 0-LD 4- E 971
Sd. >Ef 9Fi FGD AtA • D'137 3
cityhown 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."homeownee'certifies that-he/she understands the.Town of Barivstable.Buildipg Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
r ` ements. y
Signa f 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 U exempt from the provisions
of this section(Section 109.1.1 -Cleansing 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 art unaware that they are assuming the respmsibilities of a supervisor(sec 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 persona. 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 responnbilities,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 fomJcertifrcation.for use in your community.
Q:forms:homocxcmpt i
;20AO125/
®PTV4 PERMIT Town of Barnstable *Permit#
O Ezpire months from issue date
08 Regulatory Services Fee
ToThomas F.Geiler,Director
039. Aim STABLE Building Division
rED MA't
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.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 ?j 4
Property Address O� '1 7 P 00A, 14 10`tv/1,(S
Od Residential Value of Work /&CT. Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address 'Y O N N t S 1M r-7 dU Fg G lB 14F
4. 0137
Contractor's Name Telephone Number ! ��
Home Improvement Contractor License#(if applicable) N/A
❑Workman's Compensation Insurance' e
Check one:
❑ I am a sole proprietor
�C I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name r
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit 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 S l �3' _�V/ 00 Pa wf rs
❑ Replacement Windows/doors/sliders.U-Value . (maximum.35)
*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 is required.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
ZHE Town of Barnstable
�
~o� Regulatory Services
RAMST,Bt,E, ; Thomas F..Geiler,Director
16,19. ,�� Building.Division
'°rEv Tom Perry,Building Commissioner
206 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 —b• $
JOB LOCATION: ;I NN S
number streets ` z h village\
"HOMEOWNER": �IQ�/V ?i9C,too K !�l3 )��5 �, 1 66 5_=3 V"q
name home phone# or one#
CURRENT MAILING ADDRESS: 570 S 0,4 A tiL d#F
city/town OF 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
suvervisor.
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
firemen � � �
Si ature f 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 your community.
Q:\WPFILES\FORMS\homeexempt.DOC
r
Town of Barnstable
anxNSTnsLe.
Regulatory Services
a�Eo s Thomas F.Geiler,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
Properly Owner Must
Complete and Sign This Section
If Using 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
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' a 600 Washington Street
Boston,MA 02111
w„ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): tU ( VA 07d
Address: 90 SyC.+AeoA Sr.
City/State/Zip:
50,"PFOfFi MA . Phone#: ! 3, -3O 1-9
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with . 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.El I am a sole proprietor or partner listed on the attached sheet. 7. .0 Remodeling
ship and have no employees These sub-contractors have g. Demolition
workingfor me in an capacity. employees and have workers'
y p �'•
[No workers'comp.insurance comp. insurance.$ 9. ❑Building addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.9 1 am a homeowner doing all work officers have exercised their l i.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.X Other W!N(7B lr!
comp.insurance required.] s'! �✓G
"Any applicant.that checks box#1 must"also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: `
Policy#or Self-ins. Lic. #: 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 a 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$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 tify under the pains and alties o perjury that tilet information provided above is true and correct.
Si afore: N ( / Date:'
Phone#: 13 6 �O s 3.9
Official use only. Do not write in this area,to be completed by city or town official
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
Contact Person: ' Phone#:
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 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 building appurtenant thereto shall not because of such employment be deemed to be.an employer."
MGL chapter 152, §25C(6)also.states 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 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 perfonrnance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please full out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s)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 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
(i.e.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: f
The Commonwealth of Massachusetts
De artment of Industrial Accidents `
P _
Office of Investigations
600 Washington Street
Boston, MA 02111
TO. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
f
►IE j Town of Barnstable *Permit# OQ 10
Expires 6 ths from issue date
1 Regulatory Services Fee
s►� Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner PERMIT
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us O C T 2 7 2006
Office: 508-862-4038 Fax: 508-790-6230
TOWN OF SARNSTAKE
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
0 �.
Map/parcel Number —30L — lot
Property Address CC-0: 4 IV V NA10 C
[Residential Value of Worktl®B. I Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address JO 14 /V GAR-VA.; A , 1 d-
rtl E a i3?!S
Contractor's Name Telephone Number }jO��
Home Improvement Contractor License#(if applicable)-
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit 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)
21 Re-side
❑ Replacement Windows. 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.
Home Improvement Contractors License is required.
SIGNATURE: �" t
Q:Fonns:expmirg
Revise071405
,yam The Commonwealth of Massachusetts
` l \ ; Department of Industrial Accidents
t Office of Investigations
600 Washington Street
l'Ut Boston, MA 02111
i
a� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ao l+-&J �: ��lc /o,/z E-
Address:
- M►4 e 1373 /
City/State/Zip: Sd D �/z��GL D L Phone #: C i-5)
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. # ❑Remodeling
ship and have no employ
ees ees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. g, ❑Building addition
o workers' comp.insurance 5. ❑ We are a corporation and its
P
� n
10. Electrical repairs or additions
required.] officers have exercised them
❑ P
3. I am a homeowner doing all work right of exemption per MGL 11.[�Plumbing repairs or additions
yself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp.insurance require
d.]
]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information,
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below.is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Dater
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 and/or 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 der the pains and penalties--of ple�rjury that the information provided above is true and correct,
F.V� jB `17-
Signature: // Date:
Phone#: 1 'O
Official use only. Do not write in this area,to be completed by city or town official
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
Contact Person: Phone#:
Town..of.Barnstable=:
Expir 6 months from,rssue date
Repulatary Services F
9 Mass.i6Jq. Thomas F.Geiler,Director
�p �0
r-0 A Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 PERMIT
Office: 508-862-4038 -PFZ���
Fax: 508-790-6230 nn, -� 1 o ZOOS
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint TOWN OF BARNSTA51-r-
6 -
Map/parcel Number cr �
C77
Property Address ;V 7 ,
10 Residential Value of Work
Owner's.Name&.Address. 0 N' N� �' S k��-yAv
Sa. 1DEE2Gi r--e-b-0
Contractor's.Name �D NF Telephone.Number C4 13) 44 C—3 e y?
Home Improvement Contractor License#(if applicable)
Construction Supervisor's.License.#(if applicable) ,
❑Workman's.Compensation Insurance A
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
❑. I have Worker's Compensation Insurance.
Insurance Company Name
Workman's.Comp.Policy.#
Permit Request(check box) s
Re-roof(stripping old shingles) All construction debris will be taken to rD
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. 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.
Home Improvemen ontractors License is required.
Signature '
Q:Forms:expmtrg
Revised 121901
THE Town of Barnstable
CF lq�
Regulatory Services
sAxtvsri►HtE Thomas F.Geiler,Director
t,A
94, a639. .•�& Building Division
DIED N1A�
Tom Perry,Building Commissioner
200 Main Street�Hyannis,Na 02601
)ffice: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE ] /
JOB LOCATION:. 4�-LV7 B C F R N A V F
number sireet / village
�IOMEowNEx" 36 rf v 1 - -S#4A-11.y ?At le.A£�(�l�3�66s-��� �if►��-3o s 9
name home phone# work phone#
CURRENT MAnJNG ADDRESS: So S rl �GO/� F 57,
5t,* , )FFAFi tG ) MA, e r 373
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 foi all such work performed under'the buildingpermit. (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
f'oquirements.
1 Si f 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 responbilities,many communities require,as part of the pemrit application,
si
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 forni/catification for use in your community.