HomeMy WebLinkAbout0057 RUDDER ROAD i
7-7- IH P�
°FTC Tom, Town.of Barnstable *Permit#� ol
F-Vires 6 months from issue date "
Regulatory Services e f �
snarrsrnac.E,
MASS. Richard V.Scali,Director
16
ATED�jp
Building Division . -
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 PERAUT APPLICATION - RESIDENTIAL ONLY
B i Not Valid without Red X-Press Imprint A
Map/parcel Number
Property Address 57 19unuer RoctJ A,�JIAJAI
n/Residential Value of Work$ ',Cg0O Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address _
m
g�_7 ��
Contractor's Name—' eean -.J Telephone Number 771f-p2(a-0_S6ng
Home Improvement Contractor License#(if applicable) 1 CA I Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
C ck one:
[ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance t '
Insurance Company Name
N OF�ARNST Workman's Comp.Policy#` ABLE
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Rest(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 46 0,0 '+" I
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#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: Prbperty Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE: _.-
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313 '
�s Ca;rn�x�rntth rrf�assueTrrrst .
Depaphnent of frrdmstrcrd Accidexrts
- 19Kce Of IMIMAkadons
600 Was1%rigtom Street
$ostor4 MA Q2,11'1
wwm massgarldirr
'workers' Campensati€an Insurance davit:$iiilders/Cantra:ctarsMetfricians/Numbers
ApydicmA Infarmation. Please Priat LegiMy
Name cBtmiresdOrganizationrfnaividuan_ Sean -TW beC± {b(u
Addre.SS7
city/stateizip= �v1 Jai Asa 77 Y
__fie yoti atf employer?Check the appropriate boz:�__.__�� L at
4_ T atns.. contractor and I µ ltt'al�(r
1._El I am a employer with 6_ constructionNewconstructione rloyees(full andlor part-time)* have hired the sub-contractors.
I am a sole proprietor or partner listed on the attached sheet 7_ RPm odeling
ship and have no employees These sub-ooat mctors have g_ ❑Demolitioa
w forme in an c d r_ employees and have workers'
o�tng Y � t5 _ $ 4_ ❑Building addition
[1 6 world'C4EIIp_inmirance comp_insu ari
[ e&] 5.. We am a corporation and its 10-0 Electrical repairs or additions
of ha- exercised �Plumbinum exercise ter 1 L airs or additions
3_❑ I am a homerxwner doing all-work g�P ,
myself[No workers'rOatg_ right of exemption per MCL 12_.0 Roof repairs
insurance required.]t c-152,§1(4} and we have no
employees-[Na workers' 1 _.0 Other ,
comp_insurance rsgmre _]
Y PliaEaYthatchecksbox##urns#alsofilloutthesectionheloty e'shu ingthdrvrodecomipensadoupoiiryi�rmztioa�
�Homeowners who submit this affidavit in&cstmE they are doing sII wart[and that hire outside contractars Est submit anew affidwit indics#ng mch—
tractors that check this boat nrmt sitached an additional sheet showing the Warne of the Mb-omifI3dun ind ststg vrhether or nm thane enthies have
,mviayees_ Ifamsubcontractorshire employees,they=1 piavidetheirworkers'comg_Policy number-
lam art employer that is pro-iding workers'congmnsatian irmirarro!r for trig employceets Belau is fhepo cy an.dl:oh site
in,for ma6gm
Insurance CompanyName: '
Polrcyf#orSelf tits Ian; ExptrattonDate:
Job Site Address: Cttyr'Stat zip:
Attach acopy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MCL c. 152 can lead to the imposition of r•rirninal penalties of a
Sine up to S 1,500.00 andlor one-year imprisonra t,as well as civil penalties in ihe form of a STOP WORK ORDER-and a fine.
ofup to$250.00 a,day against the.violator_ Be advised that a copy of this ststemient maybe forwarded to the Office of
Immgogations of the DIA fur inaamrnce coverage verification-
I do hereby c;et hfy tinder tkepizins and penatlies afperjury that the irrfonntatiunprmidedabmw is b-im and correct
Sign tune _ Date- G/�?o b L
Phone M
Off kiat use only. Eka not write in this area,to he campleted by cil j or town o•ficiaL
City or Town: PermitUce ise-9
fssu Ax thcwity(circle one):-
1.Board of Health 2.Binding Department 3.Cityf own Cleric 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone t#_
6 ,
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto 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 Iocal 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 nay
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 numbers)along with their cen 1ificate(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 Departinent of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the aif davit 111e affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Deparmnenf 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. Sell 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 permitliicease number which will be used as a reference number. In addition,an applicant
that must submit multiple pemnitllicense applii ations in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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 hike 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 Comm onwYealth of Massachusetts
Department of Industrkal A,ccidmts
Mce of favestiotio-m
6-QU Washingm Street
Boston.,MA G2111
T f-,L A 617 727--4900 W 406 or I--& IASWE
Revised 4-24-07 Fax#61 727-7-149
vv-ww.mass-gav/dia
oFTKE
R }
} BARNSrABLK R
9$ ' � Town of Barnstable
Regulatory Services
g rY
Richard V.Scali,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
Property Owner Must _
-Complete and Sign This Section
If Using A Builder
as Owner of the subject property
1
J P P rty
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
_�-7 12uddi-r- Pood
.(Address of Job)
Signature of Owner Date
.Print Name
a ,
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
QAWPHLESTORMS\building permit forms\EXPRESS.doc
Revised 061313
Town of Barnstable
Regulatory Services
P�ppTHE Tp�y Richard V.Scali,Director
Building Division
snxxsr"iE Tom Perry,Building Commissioner
MASS.
�e34. ��� 200 Main Street, Hyannis,MA 02601
Arloy a 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":
name home phone# work phone#
CURRENT MAILING 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 Rermit. (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.
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 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\building permit forms\EXPRESS.doc
Revised 061313
Office of Consumer Affairs do)anSln2Ss ll:^ vala son License-or registration valid for indiv ul use only
EliME IMPMOVEMENT CONTRACTOR : before the expiration.date.,If found return to:
egistrabow- 1651„35.. ' Type: Office of Consumer Affairs and Business Regulation
xpiration 1/7/2016 DBA 10 Park Plaza-Suite 5170
Boston,MA,02116
SEAN THIBERT HOME IMPROVEMENTS.
F o s x
SEAN THIBET "
184 JOHN �OSEPH RD
HARWICH MA 02645 Undeeseca etary Not valid without signature
NiassacS^usettS -DePartre
crlt of Pi:hl�r. T4Pt1� •..tl - , .. .
ulations and Standards
Board of Building Regisc,r
Constructioin Super,, -
License: CS-100782. '
SEAN T TI;I�ERT .� _.. ;. '- < -; •
44 1NDRICK
Ha
l with MA 0265
a .
Expiration Nti
.681291201 .
Commissioner