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Home My WebLink About0370 OCEAN STREET 7 O O cep S� c 00 o - �oFrt+r Town of Barnstable *Permit# ti 0 Erpires 6 months-front is-rite dare Regulatory Services Fee * B.ARY57•ABLE, ' v 1619 � Thomas F. Geiler, Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 62601 www,town.barnstab le.ma.us Officer 508-862-4038 Fax: 50 8-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY /Vol Valid without Red X-Pres•r Imprint Map/parcel Number Property Address �G 0 ccoyyl �i'.9r1.,r✓ls" LzAf 02.6crI [Residential Value of Work X6-9UU Minimum fee of$35,00 for work under W00.00 Owner's Name & Address (IK , y��y.5- // Contractor's Name 10# Telephone Number 32�e) 77/-pz ji/ Home Improvement Contractor License# if applicable) Construction Supervisor's License#(if applicable) -75000 ❑Workman's Compensation Insurance NC�� Check one: E:0�1 am a sole proprietor TOWN OF BARNSTIABLE ❑ I am the Homeowner - ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must aecornpany each permit. Permit Request (check box) . Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed) (not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#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 of the Home Improvement Contractors License & Construction Supervisors License is r ired. l� SIGNATURE: i Q:\WFILESIFORMSIbuilding permit formslEXPRCSS.doc The Cammoirweallb ofMassachitserts --- — -- Department of IndlisfrialAcciderrz's �- Oct ofliave'sridntions J 600 1 aShilagtan Street 'ABoston, A,14 02III }t.,ww rrrass.govldin 'Workers' Compensation Insurance Aff&iiit: Buildel•s/Con:ti•.zctors./LlectriciansMiimbers Applicant Information Please Print Leobly Name. (Business,'Orguui7o6on.Qndividttal): 9,v 0 Address: 241 Sb� , City/,St&te/Zip: L iy�Kui lI e A44 67 2-G3 Z Pbotle #:. 3Z)F 711-e Z'/l Are you an emp.layer'°'Clsecls the appropriate:boa:.: Type of project(reId, L❑ I lira a employer iirith 4. ❑ I am a geaeral contractor and I ermloyeex(fu.11 and/orpart=time).* have hosed the sub-contractors 6- ❑mew construc Z,g I an,a sole proprietor or partner- listed on the attached sheet_ 7. Remodeling shi and have no employeese These sub-contractors have p8. ❑.Deuw.lition working :for me in any capacity. eimployees and have ivorkers' [No workers' coiup.irtsurtnce comp_in4urance..1 . 9. ❑.Building addit 5. We area corporation.and its 10.0 Eleclriral.repsadditions required:] ❑ 3.❑ :I am a.homeowner doing all work afcers have exercised their 11_❑Plumbing reprs myself [No tvarkers' comp. right of c::emption per PMOL 12.0 Roof repairs insurance:retluit d.]r c. 152, §1(4); and vve have no employees-Wo workers' 11❑ Other catvP.:insurance-required.] 'Any applicant:thstchecks box#1.must also fill-otit the section belong shcrmng heirworkera'compensa.b.an policy infonmtiam t Honieowmers who submit this affidat,it imitating they are doing all-work and then hirn autside contruclurs must sub;mi't.a new a$zdw0t indicating snc1L Contractors tbst check ibis box must attacbed=sdditiowtt:sbe.ei shoving the name of tbe;sub-cDntrscinrs su.d stain wbether or not chose entitaes have e loyees. Ifthe ernplvyees,.they.omst provide their workers'comp.policy number. I ant in eslpboyer that is providing workers':c0171p2r1;5'fth:01.1 illsramrr.ce for ItV eltrplaye,es. -Helow is the policy and job site 2ff fd r'1ft ah'011. Insurance Compmy Name: Policy#or..Self--ins_Lic.-A: E:,cpiration Date: Job Site Address.- City/State/Zip: Attach a copy of.the workers' cumpeirsation policy declaration page(&hoiidng the policy r—cumber and eapu•:at on date}. Failure to secure coverage as required under Secti-on 25.A of MGL c.. 1.52 can lead to the imposition of criiuinal penalties of a fine up to$1,500..00 and/or one-year iruprisonment,as well as ciVril penatties in the form of a STOP 'WORK ORDER and a fine of up to$250.0o a day against the vioLator_ Be advised that a cope of this statement may be f0marded to the Office of Investigations of the D.IA for insurance coverage verification. I fro lt,erm_y nerd 1 rider the pants and partat " s f perjury that the it fortttatlav:r prt;i idid.a bone is trcra.and correct. Simature.: Dote: - —/G Phone#: {Jul � -oz Qffi-cial use only. Do not write fit this area,to be completed by city'or town qfficfal City or Town: PerrnitfLicense# Issuing Authwity(cii-cle one): 1.Board of Health 3.Building Department 3. Cirrrfroi n Cleric 4. Electrical Inspector S.Plumbing Inspector 6. Othe.r C"nntactPerson: Phone H of THEM. t f - • BARNSPABLE, • . " i6J9�: Town of Barnstable �� - Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us fie` Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section ff Using A Builder T /lio,k AlacskS as Owner of the subject property hereby authorize Sj+�7 -OW/k`— to act on my behalf, in all matters relative to work authorized by this bLuldingperrnit application for: 970 0&5Ao 5 �7 J r(Add Ses of job). . a - Signature of Owner Date dlci Ati�sf s Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the . reverse side. Q:IWPFILESIFORMSIbuilding permit forms1EXPRESS.doc 3 Pot r y Town of Barnstable °�' Regulatory Services �A °`jg((assBLE'$x Thomas F. Ceiler, Director, —Cjo ,679• A1� r10 Building Division Tom Perry, Building Commissioner. 200 Main Street,. Hyannis, MA 02601 wtivw.town.b a rns to b l e.m a.us Office: 98-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:—( JOB LOCATION:_ number street village "HOMEOWNER" name home phone N work phone# CURRENT MAILNG ADDRESS: 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 requirements and that he/she will comply with said procedures and requirements. r Signature of Homeowner Approval of 8 uilding 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 caret amend and adopt such a form/certification for use in your community. QAWPFILESIFORMSIbuilding permit formslEXPRESS.doe Revised 072110 • � Y` � '� s :.� � �l'3U y�,�,4'trt(°f""„pi�,��,//�3/T�1�y v-i•.r —.,_,. r ''. ,<. Q � a��r" .�` •#i*� tt ons pv ". -,:wit- Massachusetts- Department of pub hllc Safety Board of Building Regulations and Standards Co�?,,tituction Supervisor. .-icense License: CS 78000 Restricted to: 00 " p SCOTT H QUILTER . PO BOX 727 " W HYANNISPORT, MA 02672 3 Expiration: 2/3/2012 (b mnissi°Oe r Tr#: 21477 i G6itll ,. tit ctsrttrtt fiNY, n Y, Mir 'K', e