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HomeMy WebLinkAbout0000 SEA STREET �, �,.� c _ _ _- - — , Ft Town of Barnstable *Permit# Expires 6 monW from lasae date MASS Regulatory Services Fee ®�' Thomas F.Gellert'Director �'�Eo�►.+' Building Division _ PERMI Tom Perry, Building Commissioner RCS 200 Main Street,.Hyannis,MA 02601 JUL 7 - 2005 Office: 508-8624038 Fax: 508-790-6230 TOWN OF BARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY !!// /Not Valid without Red kPress Imprint Map/parcel Number 3�(o T ®lam Property Address 3 eq On 1 +14 --n r► ❑Residential Value of Work /�� 3 oo,. ob Minimum fee of.$25.00 for work under$6000.00 Owner's Name&Address SAG S, f 7) 'L Goa r\ Sea. 0 41+- rI n' (Y-)Oy'-" Contractors-Namte . ::Co bb Ynfi-e/ ?)A) Telephone Number �50� 6 0— OD7 Home Improvement Contractor License#(if applicable) 1 � Construction Supervisor's License#(if applicable)_ ❑Workman's Compensation Insurance Ik one: am a sole proprietor ❑ I an the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 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 ❑Re roof(not stripping. Going over existing layers of roof) ❑ Re-side M KePlacemeat Windows. U-Value (maximum.44)- *Where required: Issuance of this pernrit does not exemptcompIiance with other tows department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature QForms:expmtrg Re vuNi3004 • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name (Business/Oraanization/Individu l): I b©yA� Address: roL.r,c- City/State/Zip: A fw h Phone#: S 1� ct a- a-?y 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 loyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[1 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 12.❑ Roof repairs insurance required.].# employees. [No workers' 13.0 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. TContractors 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: 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$1,50Q.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 certify under the pains and penalties of perjury that the information provided ab77, ' and correct: Signafore: Date: Phone#' U . --� y 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. it /Town Clerk 4 Electr ical Inspector, 5.Plumbing Inspector ctor 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, 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 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would Ile 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 5-26-05 www.mass.gov/dia °FTMEr�,, Town of Barnstable Regulatory Services vMAN. '� Thomas F.Geiler,Director q'ArFp �a`� 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 Property Owner Must Complete and Sign This Section If Using ABuilder L & t7aA W 4G q:P0yl ,as Owner of the subject property hereby authorize "L'O Ld ,fir f> to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Address of Job) Aat-a.�lf W P2eaorL '� l "��r Signature of Owner Date Print Name w Q:FORM&OWNERPERMISSION 71. 76...,../& a� aaeac�u�ael! BOARD OF BUILDING REGULATIONS License CONSTRUCTION SUPERVISOR ` Number: CS 055029 Expires 06/14/2006 Tr.no: 2903.0 ' Restricted 00=r •`� TODD R MACDONALD PO BOX 544 G- YARMOUTHPORT MA 02675 Commissioner License License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02108 Vot valid without signature ✓rae V�arvnzoouis� a�../f/laaaac�ivael�a Board of Building Regulations and Standards ' HOME IMPROVEMENT CONTRACTOR Registration: 111195 Expiration:-10/7/2005 Type: .Individual TODD R.MacDONALD, TODD MacDONALD 17 WAGON RD. l�d YARMOUTH,-MA 02675 Administrator