HomeMy WebLinkAbout0011 PAINE AVENUE Ale-
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oF1HE Town of Barnstable *Permit#xt100 0/ IS
EzP' 6 man frn sue daMN
Regulatory Services Fee U
. RAJINETAM4 �
Thomas F. Geiler,Director
Building.Division -
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis,MA 02'01.
r www.town:barnstable.ma us
Office: 508-862-4038 Fax:.5108490-6230
EXPRESS PERMIT APPLICATION. RESIDENTIAL ONLY
Q(� Not Valid without Red X-Press Imprint
Map/parcel Number_ O l /
Property Address r AlmV �1t'( * O�i N �j
Residential . Value of Work Minimum fee of$35.00"for work under$6000:00
Owner's Name&Address C 1-3 (10-. )O ''r
Contractor's Name c5L T je p °-Tole hone Number 'y
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
® R.
`❑Workman's Compensation S PER
Insurance -_ 'T
Check one:.
❑ I am a sole proprietor FE9.2 9
[� I am the Homeowner
❑ I have Worker's Compensation Insurance.
Insurance Company Name v TOWN OF BARNSTABLE
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompanyeach permit. ,
Permit Request(check box)
® Re-roof(stripping old shingles) All construction debris.will be taken cs,,
Re-roof(not stripping. Going-over existing layers of roof)
❑ 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.c.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
r ,' ed ,
IGNATURE:
1WPFMM\F0RMSIbm7ding permit formslEXPRESS.doc
.wised 070110
fia
r The Commonwealth of Massachusetts
Department of lndustrial Accidents:
:Office of Investigations
600 Washington Street, •
Boston,MA 02111
www.mas's.gov%dia
Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C�( _[ ) -20) 1
Address: 1 l'� �t-JC,
City/State/Zip: " r,4 ti
Are you an employer?Check the appropriate box: Type of project(required).
1.❑ I am a e to er with 4.'❑ I am 4 general contractor,and I
Y 6. ❑New construction
employees(full and/or part-time).* have hired the sib-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, ❑Demolitlon
workingfor me in an capacity. employees and have workers'
Y p tY 9."❑Building addition
[No workers' comp.insurance comp,insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q ] officers have exercised their 11. Plumbin repairs or additions
3.�]�lam a homeowner doing all work`. A. _. ❑ , g P
myself. [No workers' comp right of exemption per MGL 12.❑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 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 foamy employees.,.Below is the policy and job site a
information. .-
Insurance Company Name:
Policy#or Self-ins.Lic:#: X 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 2.SA of MGL c. 152 can lead to the imposition of criminal penalties of.a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a$TOP VORK ORDER and a fine' `
of up to$250.00 a day against the violator: Be advised hat a copy of.ths statement may be forwarded fo the Office of
Investigations of the DIA for insurance coverage verification.:
I do hereby certify un r the pains ared pe' flies of perjury that the information provided above is true and correct
Signafore: 7 Date:
-` Phone#: � _ • —,
..
r
cial use only. -Do not write inthis area,to be completed:by city.or town official or Town: _ Permit/License#
ing 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#:
u
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 permittlicense 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 pemuts 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 fay:number:.
The Commonwealth of Massachusetts
Department of Industdal Accidents
Office of Investigad6us
600 Washington* Street
Boston,MA 42 111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax#617-727-7749
www.mass..gov/dia
i
�t Town of Barnstable
�., Regulatory. S• ervices
wex MIX. :
MASS �• Thomas F.Geiler,Director
1639.
Ec ram+' Building Division e
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us "s
Office: 508-862-4038 Fax: 508-790-6230
Property,Owner
Must'- IN
,.
Complete and. Sign This'Section
If Using A Builder.-
as Owner of the subject r o e
.; p..p riY
hereby authorize to act on my behalf,
- q
in all matters relative to work authorized by this building permit
(Address of job)
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled before fence is installed and pools are not to be:
utilized until all final inspections are performed and accepted
Signature of Owner Signature of Applicant
Print Name Print Name :.
Date
Q:FORMS:O WNERPERMISSIONP00LS
r
1HE Town of Barnstable y, 1F
Regulatory Services
BABNSPABLE, « Thomas F.Geiler,Director
16.39. .�� Building Division
ATED MA't�
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:__
JOB LOCATION:
`number ^ street village
"HOMEOWNER": �]_G,}-A q 72 0 Z. L✓
name home phone# work phone#
CURRENT MAILING ADDRESS:. 11 ?_o-)W C
)aC-1Ey�I N1`5 �W► C5�2FA'
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwelling 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
requiremp9ts +
ignature of Home er
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 caret amend and adopt such a forn/certification for use in your community.
I
Q:forms:homeexempt i
i
YOU WISH TO OPEN A BUSINESS? ►
Fof Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does•not give you permission'to operate.) Business Certificates are available at the Town Clerk's Office, 1'° FL., 367
Main Street, Hyannis, MA.02601 (Town Hall] y
ns•ra. ,x cx•P d B'i NI!N.a6 ""- - - DATE- `✓C ".j 7`V7 'i
'junn�ta mgaa 0 Fill in pleas 1 e:
as , am APPLICANTS YOUR NAME: R)Cyl(� R-C)AFT, G.)�1 6
s$s;:,.:<••:4q . +. BUSINESS
��'�• ;• ., • . YOUR HOME ADDRESS;�
c.n N ti, c.,1 CQ.61MI
TELEPHONE #- Home Telephone Number .. -
NAME OF NEW BUSINESS �'��.._IjQj �>
1.TYPE OF BUSINESS: �E,.►Cp�L �,
IS THIS A HOME OCCUPATION.. YES
Have you been given approval-fro.rn the building:divisod? YE5 NO
ADDRESSOF BUSINESS Y� �)`� ;�,�, r� t, MAP/PARCELNU.MBER
When starting a new business there are several things you must do in order-to be in compliance with the rules and regulations of the Town of '
Barnstable. This form is intended to assist.you-in obtaining the information you may need. You MUST, GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street). to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM NER'S OFFICE
This individ al h s en i0b d-of a permit requirements t pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
A 'thpri Sig re** COMPLY MAY RESULT IN FINES.
COMMENTS:
2. BOARD OF HEALTH
This individual has been informed of the permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS: .
3: CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature—
COMMENTS:
COMMENTS:
Town of Barnstable
THE
Regulatory Services
OF 1p�
ti. Thomas F. Geiler,Director
yP ��
Y Y
Building Division
+ BAM ABLE, '
y MAC g Tom Perry,Building Commissioner
1639. �0
a�E p Mp(a 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 a� : 08-790-6230
Approved.
Fee: Iq
Permit#:
HOME OCCUPATION REGISTRATION
Date:
L�LL
Name: Phone#:
Address: ��� �.C _ Village: e'Al�)N N>S
Name of Business:
Type of Business: ery :9fi'1Map/Lot: a`
INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the
activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual
alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit, located
within that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there
is no outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration, smoke, dust or other particular
matter,odors, electrical disturbance,heat,glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials, or flammable or explosive materials, in excess
of normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation., and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There is no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit.
1,the undersigned, have d nd agre th the above re ictions for my home occupation I am registering.
_ PP
Applicant: y Date: Q
Homeoc.doc Rev.5/30/03