HomeMy WebLinkAbout0023 SCHOOL STREET 33 �,i� S+.
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Town of Barnstable *Permit 4C �l
I � da
Expires 6 fr m issuete _
Regulatory Services Fee
MAM -2 Z�,? Thomas F.Geiler,Director
i639' s`0�
Building Division
,r 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
Property Address .23
`Residential. = Minimum fee of$35.00 for work under$6000.00
Value of Work
/Owner's Name&Address J4,4l t'f-C
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑WoAman's Compensation Insurance
Check one:
❑ I am a sole proprietor
4X lam the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany 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)
de .
#of doors E
Replacement Windows/doors/sliders.:U-Value (maximum.35)#of windows '
❑ :Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and'inspecfions required.
Separate Electrical&#ire Permits required.
*YJhere 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 ofthe Home Improvement Contractors License&Construction Supervisors License.is
required:
SIGNATURE:
nilAma Hermit fhrms\F.XPRFSS.doC
The Commonwealth of Massachusetts
a Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 0211.1
5• J' www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le Ably
Name(Business/organizatiowhidividual): .
f
Address: S'L°�O cl/ S o7zz. 2,0
�
01G
City/State/Zip: �«/i.S Phone.#: 7
Are you an employer? Check the appropriate box: Type of project(required):.
. I am a general contractor'and I
1.❑ I am a emplo 4
yer with � 6. 0 New construction .
.employees (full and/or part:#me).* have hired the strb-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
employe es and have workers'
workingfbr me in an capacity.
Y9. ❑.Building addition I
[No workers' comp, insurance comp. insurance. •
required] 5. ❑.We are a corporation and its 10.❑Electrical repairs or additions
3 I am a homeowner doing all work. officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs
152, 1 4 ,and we have no
insurance required]t c. § 13.❑ Other
employees. [No workers'
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.
tContractors 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 thepolicy 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 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 certi nder the pains and penalties.of perjury that the information provided above/is true and correct
Si afore Date: G6 Z' lei
Phone#: 2-0 /d a h4 e__-
Official use only. Do.not write in this area, to be completed by,city.or town offciaL
City or,Town: Permit/License#
Issuing Authority(circle one):
A.Board of Health 2.Building Department.3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
Information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fortheir 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 _
- --- fore _. .
receiver or trustee of an individual,partnership,association or offer 16gil 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."
Additional[y,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-contiactor(s)name(s),address(es)and phone number(s)along with their certificates)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 then
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 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:
They Commonwealth of Massachusetts
Department of>zkdustriai Accidents
Office of Investigations
60.0 Washington Street
Boaton, MA 02111
Tel.##617-727-4900 ext 406 or 1•-M MASSAFI;
Revised 11-22-06
Fax##617-727-7749
www.mass.govfdia
. tKEr� .
Town. of Barnstable
Regulatory Services
MxwsTnsc Thomas F.Geiler,Director
Mass.
1639. Building Division
EDMA'tA ,, _
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
f
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
CAD-ATE: -0 V 2
ct:JOB'LOCAT ON: J q/ �T A� f `S
enumber street. village
�i n n q village prey
«H, - WNER": V�"1�YCL S �(9 /�I f��. �u a ! /1 "f/ 17.� s ./ l b
l��M-EO.. nie�> home phone# work phone#
CURRENT MAILING'ADDRESSi -3 SC480/ ?l~.
city/to setatt; 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
require ents.
Si tune-of Homeo wner'-
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 thisexemption 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:forms:homeexempt.
THE�, Town of Barnstable .a
° Regulatory Services
Mass, g Thomas F.Geiler,Director
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
t
Property Owner Must
Complete and Sign This Section
If Using A Builder
I
as Owner of the subject to e
p p riY
hereby authorize to act on my behalf,
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 or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner. Signature of Applicant
Print Name Print Name
Date
Q-FORMS:OWNERPEFMISSIONPOOLS 6/2012