Loading...
HomeMy WebLinkAbout0320 SCUDDER AVENUE �o S�d�ee-�t/�- 76 Town of Barnstable *Permit# Q� Expires 6 months from issue date Regulatory Services Fee . w+Rtvs ABIX. 16 �' Thomas F.Geiler,Director m����� PERMIT, �� I1A IT'. Building Division �- Tom Perry,CBO, Building Commissioner APR 17 2012 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 TOWN OF B M230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY p Not Valid without RedX--Press Imprint Map/parcel Number l ° Property Address 3 CJ 5C ujj,-(—P- u`e— . C. KResidential Value of Work i 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Cky` S iq v-,�j Contractor's Name . . ,�: 5 e.^—S 1 Telephone Number Home Improvement Contractor License#(if applicable) ��1�_l FZ Construction Supervisor's License#(if applicable)- �J Si(Cl.f ❑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#_ �L. �. ( _ Z —b l 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) Re-side ❑Fence over 6' #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: Pro rty Owner must sign Property Owner Letter of Permission. A py of the Home Improvement Contractors License&Construction Supervisors License is r uired. SIGNATURE: i l Q:\WPFILES\FORMS\building ermitforms\EXPRESS.doc Revised 051811 i The Commanweahr of Massachusetts IJke whnent of Industrial Accidents UV 09we gflnvicestiga ions 600 Washington Street Boston,MA 02111 n m mas&govldia Workers' Compensation Insurance Affidavit:Builders/Couft2ctmvEkctricians/Plambers Amilicant Information Please Print U6b Nam( on&dividnal)- I ^� 1/ �� IZ Address: Ci /state;/ ' - C fv SPhow#7 Are you an employer?Check the appropriate Im. Type of project(required): ❑ I am a employer with 4. ma general contractor and I fo /nil and/or 6- New cam . etnp gees( part-time).* ve hired the sate-ccm�clors 2.❑ I am a sole proprietor or partner- fisted on the attached sheet. 7. ❑Remodeling ship and have no employees. These sub-contracts have 8. Demolition watking for me in any capacity. employee and have workers' [No worlom'comp.susurance comp insura X&I 9. ❑.Building addition required-] 5. ❑ We are a corporation and its _ 10.❑Electrical repairs or additions 3-0 I aur a hotneoumer doing aft work officers have exercised their I LE]Plumbing repairs or additions. myself[No workers',comp- right of exemption per MGL 12.❑Roof insurance rewired..}L - � c.152, §1(4),and we have no - employees.[No workers' 13.0 Other Mt cu tlt- comp-insurance required.] � Y aPP lhst checks Los#1 mast also fill out the section below showing theirwoakete ca®pe�aa Policy � Hnmoeowmers erswhin submit this affidavit indicating they are doing all wank and then hire outside contractors must submit a new affidavit indicating such. ZContracton 9m check this boor must attached sn add]tiDnsl sheet showing ing the name of the sub-cautuicnxg,and On w employees. Ifthe sub'-c toicturs bin id homer arnot three eatiries have . employees,They�provide their workers'romp.policy attttrber. I am an employer that isprovMing morkers'.co insurance for my snrplfyVdL Below is the p ncy MW job sit;. informatim Insurance Company Name: r tA.70 Polity#or Self ins.L:ic.#: � 5 -3G�32 - /'aZ Expiration Date: Job Site Address: 1 '161v"'5 city/stat izip: f`�Z``16 Attach a copy of workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secime 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 WORD ORDER and a fine' of up to$250-00 a day against th a�a tor- Be advised that a copy of this statement may be forwarded to the Office of Investigations of the I]IA for" nce coverage verification. Ida hereby cartior a • s andpenallies ofperjnrY that the ieformadon,prow&d M W and correct Signature.- Date: /c Phone F-9 Z—O , (3ffi al use only. Do not strife in this arer,to be completed by city or town afic&I City or Town: Permitff kense# Inning Authority(time.one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other. Contact Person: Phone 9• %' 6 RARNSTABIX 039. Town of Barnstable prFD MA'S� r Regulatory Services Thomas F.Geiler,Director Buildings Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us 9 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I S , as Owner of the subject property ' hereby authorize �z S lj to act on my behalf, in all matters relative to work authorized by this'building permit application for: c v (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. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Revised 051811 Q i ME Town of Barnstable Regulatory Services 9 $' Thomas F.Geiler,Director �p 659. 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: y 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 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. 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 051811 i TDIRE-1 OP ID: SC ACOR�' DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/13/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 508-771-1632 NAME: Northwood Ins.Agency,Inc. 508-393-2955 PHONE FAx 540 Main Street,Suite 9 A/C No Ext: AIC No Hyannis, MA 02601 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Liberty Mutual Insurance Co. INSURED TDI Realty Group Inc. INSURERB:WESTERN WORLD INSURANCE CO P 0 Box 796 Hyannisport, MA 02647 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD UBR POLICY NUMBER MM DD POLICY LTR /YYYY MM/DD/YYYY - LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY NPP8014950 01/16/12 01/16/13 DAMAGE T RE PREMISES Ea occurrence $ 50,000 CLAIMS-MADE Fx_1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 JECT POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $._ EXCESS LIAR CLAIMS-MADE AGGREGATE $ L= I RETENTION$ $ WORKERS COMPENSATION X I WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LI T ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC1-31S-365323-012 03/05/12 03/05/13 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $. 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 230 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I Board of Buildinu, Re-uLitions and Standards Construction Supervisor License License: CS 98149 TATE ISENSTADT PO BOX 796 HYANNISPORT, MA 02647 y. Expiration: 3/24/2013 ( nnmissi uicr Tr#: 10982 e of Co L "ices Rr.gulxtion. ,HCi44E IMPROVEMENT C;ONTFv-CTOR r '-istration. : .5, 997 Type' Expiration 5�29'ti013.'` Pii .a-fe Corpo T REALTY GRQ, M.- TA T E ISENSTAD F: y 55 LAKE AVE. I IYr�NN1S PORT,MA Undersecretary r 1712 09:26a LLOYD 7722326026 P.1 t icr.,sc or Ccgcsit3tip:; fcr indit`iovl- o:tij` _,� J�i� �oisznzonsuF.alf ef'. -�.�.,•� c '_.caciftrcr Al , ' 'v f n, ^ f'ie e f3U0n date. 1.-round return!0: rQrc i HChiE{ts1FROVc Y. '' �.t -TOR 1T -'i'•T Cifice of Ccrsun..�AiCairs and Business;:egruiation aistrstion:. 5 97 Tyae 10'Park P;nza-Suiteal?C . .Y'W E;cPiru ion: 5/2Pi2013 private Corp"-_ �•:oston,,`Ls 02116 :- ,::: � D I`REALTY GROUP !1C TATE ISEVSTACT m 55 LAKE AVER--y�rr. - - -- ---- - - HYANNIS PORT,{4A 0264' t,,,dcrsecretrrY }got valid without signature - f Town of Barnstable *Permit# ' Expires 6 months from issue date s Regulatory Services Fee lop Thomas F.Geiler,Director j Building Division _ @S Tom Perry,CBO, Building Commissioner " 7 200 Main Street,Hyannis,MA 02601 182006 www.town.barnstable.ma.us Office: V8662-4038 Fax: 508-790-6230 QF' PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 1 Property Address ,)2 W 2 ,Residential Value of Work oC Qa S2,0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address C��e,�S ?A j 2t C C N CA 302.0 .SC UAQc­R AV(-- hVIV6A•5 -- 44,+ 0 -?ro0 � d Contractor's Name ` i-F> . /� � Telephone Numbers 09-t�- /y V3 Home Improvement Contractor License#(if applicable) L1 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 GO [Y i 41 E i_ C r V J Y4,N A) t- Workman's Comp.Policy# x, P S 9 33 - Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) gL Re-roof(stripping old shingles) All construction debris will be taken to t, �7�� U j� .� �'j 5,p ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. 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. copy o the Home Improv ent Contractors License is required. SIGNATURE. Q:Forms:expmtrg - Revise061306 1 ne t,ommonweacrn uj lvlussucnuseun Department oflndustriad Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Y c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Bluilders/Contractors/Electricians/Pluimmbers Applicant Information Please Print Legibly Name (Business/organization/Individual): `f0&,,?,4f D &U /Z 1/y ''J � 'r✓ Address: / !wr.1 7 City/State/Zip: )t�1,¢V&f,5 , .f/" Phone#: 2"-2 Are you an employer? Check the appropriate bog: 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 t 7 ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 120 Roof repairs insurance required.] t 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 $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: `--�J/y(� �—rz A, �' Policy#or Self-ins.Lic. #:_ y ?'� - Expiration Date: Job Site Address:3 Z0 S CAi-n D C� City/State/Zip: ,-44 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$1,50Q.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 i under the ains and penalties of perjury that the information provided above is,true and correct: Si atur Date: 02- �- Phone#: ) O 9 aC `7 3 -e ®facial 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 I 6. Other Contact Person: Phone r: 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 rnorze 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 they 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-contractor(s)name(s),address(es)and phone numbers)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 resumed 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 IRI out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permittlicense 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: 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 Faxx 617-727-779 Revised 5-25-05 www.mass.s'ov/ciia Town of Barnstable s •'�FTHt�� . Regulatory Services 9B $ Thomas F.Geller,Director Building Division. Tom Perry, Building Commissioner 200 Mafia Street, . t, $yannis,MA`02601 www.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Scction If Using.A Builder I, `I'a as.Owner of the subject property hereby authorize #h 02�,,�, �� r�;,�•� arhoi un", , to act on my behalf, in all matters relative to work authorized by this building permit application for. s, Zo AA- (Address of Job �tare of Owner Date PO&VIi t I eL, v7 Pnnt Name Q:F0WS:0WNERFERMLSSION 43 r ; # a d'+^��'� + r rttyxw - f �w^,� - .. Ell— ' ,+P y ,�y�k1 a if tiw v'x3� + �ici .'x4't�'� t 'P{ ry. �t'i�4..$`k4✓� �� '� A� i -'� .. S<i i. k3,s %� ""Dt p i.st�-gFr "`•mMuk i a�i'"., q� 5b }1 ,y a m s+w�am v"�+a r 77 f a I 3r; .� a�e�y�, c°tbv � x. ` r 'at' ,� 'a ai t �'ir •of F.,a,„.,_.v,�_..,._... 4 4 ie t "' ,y� f'�i ✓J7� VGt;p2�Y�1�7nalP�GLZ / �i i�2<ZGdL2C�N + . ... ry Board of Building Regulations and Standards ' • . <: :p�Y .&;xr=a HOME IMPROVEMENT CONTRACTOR Registration: 142802 �xpiratlon 5120/2008 z � DBlug " Type i { CUERVO BUILDING:+REMODELING JIJ •. PABLO MARTIN" 49 SMITH ST HYANNIS,MA 026011 Deputy Administrator I i * >r.A it ^• ` ...� a:s�.:� ,wa w.r� '•.�'%wri+H��,."k Msew,{`R`w'wN ""�,T'.' _ p} .nS•W i F ^'4� �1'�u�T''.1Gv `LSS. xY`�1�� � �,y+��� Yam.• 'YIVw."... yd.TIA f , r: C) oFIKE,� Town Of Barnstable. *Permit# Qti E.vpi<s gmonths from issue date BA M"T BLE, ` Regulatory Services Fee h`^ ? Thomas F. Geiler, Director plF4^�'`A Building Division TOWN gA;1�15 1_ L Tom Perry, CBO, Building.Commissioner 200 Main Street, Hyannis, MA.02601 www.town.barnstab l e.ma,us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Reif X P,ress Imprint Map/parcel Number Property Address 16 Residential Value of Work 2,000 Minimum fee of$25.00 for worlc under$6000.00 Owner's Name&Address. jJ A►" Contractor's Name ( AIC T( e,S "�' `� Telephone Number 50 --?2—OfOr Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Y� ❑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# �L ��, 1.S "' �W 23 a,t 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 0► ❑ Re-roof(not stripping. Going over existing layers of rood Re-side ❑ Replacement Wndows.0J-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: 4PRERM wner must sign Property Owner Letter of Permission. Horno.vement Contractors License & Construct Supervisors License'is reijuired. SIGNATURE: Q:\WPFtI ES\FORMS\ExpressIT.DOC Revise060409 f - fJ The Commonwealth of Massachusetts - Department of Industrial Accidents 1� Office of Investigations 600 Washington Street r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): f(�j_ �ea� j Address: r City/State/Zip: Phone #: 5L 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 part-time).* have hired the sub-contractors 6. ❑ New construction 2.Y I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling hip and have no employees These sub-contractors have g_ ❑ Demolition workingfor me in an capacity. employees and have workers' Y p Y• 9. ❑ Building addition [No workers' comp. insurance comp, insurance.1 required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ lam a homeowner doing all work officers have exercised their 1 LE] Plumbing repairs or additions myself. o workers' com right of exemption per MGL Y � P• 12.❑ Roof repairs insurance required.] t c. 152, §1(4),..and we have no. � employees. [No workers' 13.❑ OtherS!,�,�� 6,41e comp. insurance required.] *Any applicant that checks box 41 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 any employees. Below is the policy and job site . information. Insurance Company Name: �r Policy#or Self-ins. Lie.#:_ (,. sf.. 31 c _3 6 5- 3;_,3 b 1 Expiration Date: (� Job Site Address: ��� (, =fi e City/State/Zip: ,a:.w�s�6/6f14D2e 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 DI r insurance coverage verification. I do hereby certify the pains and penalties of perjury that the information provided bov is true and correct. Si nature: Date: G Phone#: 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, constriction 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-contractor(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: 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 i �1HE,�,ti Town of Barnstable R Regulatory Services 9 ATE& Thomas F. Geiler,Director 1639. Building� Division En►�• g Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b a rnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �tl45564�► - , 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. 320 (Address of Job) 2 67/ Sign a ' e of Owner Da e Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&O WNERPERMIS SION oft►+E rqy, Town of Barnstable o Regulatory Services snxrtsTnsc Thomas F.Geiler,Director Mss. 9q, 039. �.� Building Division AtE p�,I A 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": 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 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. 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\bomeexempt.DOC