Loading...
HomeMy WebLinkAbout0240 SEA STREET � �� ��� s��-�-�� Application number....j .. Q.....:2..7.�1..� Fee................... ....... ... ... .. ... ............. ...... . rslASUL OCT ?!7 �� j Building Inspectors Initials....... .:'.. MASS ,r ............... 1639. DateIssued....................... ........ ................................ Map/Parcel...... . ...7....f.. ... ................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOV ES/WEATHERIZATION PROPERTY INFORMATION Address of Project: I Y O 5,!`R . sr N yA NN/.5 NUMBER STREET VILLAGE Owner's Name: V'1A/c C/A/ T 00 PS Phone Number Q&O - 7 q`f" 33 Email Address: 1/R ,I;Cc M tq> C D m C i3S7.NFTCell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 4F1-. to make application for a building permit in accordance with 780 CMR Owner Signature: �Jl,�cy-c�T Date: /0- /7°;?D/? —V TYPE OF WORK Siding E Windows(no header change)ff 0 Insulation/Weatherization Doors(no header change)# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to ,13 A INNS TA,6 4 F 7-170 N S F E i j' $P'l3 T/d CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. r APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location (s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: V/A/C.5/V7- /Y yO PS Telephone Number 'R66- 7 9Y- 33 8-� Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures;specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature K/ Date /® -17- 2 O/g' APPLICANT'S SIGNATURE Signature ��.--�, �j'�� Date /D-/7,AD/g' All permit applications are subject to a building official's approval prior to issuance. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION off ."�3�7 �T Map-.100171V Parcel 3 T 0 9 Application # Health Division Date Issued Conservation Division ���)� Application Fee "Jv Planning Dept. Permit Fee n('� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis 1 Project Street Address SST R LrEr" Village y/g/V N 4 Owner VIA/CENT RVORU Address AyD SEAS S /5/W/9XW45 Telephone SG O' 8 7?-O T 7 7 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation %o V—Construction Type w000 Lot Size e• /a.3 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Q Two Family ❑ Multi-Family (# units) Age of Existing Structure gy Historic House: ❑Yes N No On Old Kin -s Highway❑Ye 21 No Basement Type: X Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) 'y Basement Unfinished Area (s4.ft) 7$_4 Number of Baths: Full: existing new Half: existing nee Number of Bedrooms: existing _new awe �°- Total Room Count (not including baths): existing 7 new First Floor Room Count-' T Heat Type and Fuel: ❑ Gas I2LOil ❑ Electric ❑ Other ` Central Air: ❑Yes A No Fireplaces: Existing XNew Existing wood/coal stove: ❑Yes No Detached garage: X existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name V/A/C E Pi r R UO Ps Telephone Number Q60 - 7; ' O 7 77 Address AYD 56,4 57- License# t NYAM A116 AAA D G00 Home Improvement Contractor# 10 ° VAA G C oM Jq) Co MCe95T.NE7" Worker's Compensation # ' ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,,(�ARNST�44�E T/QANSFE�P STi4T�ON SIGNATURE /.�- 7 DATE FOR OFFICIAL USE ONLY APPLICATION# t __DATE_ISSUED___ MAPLPARCEL.NO. w 3 ADDRESS VILLAGE OWNER •A : 4 - _ Y IN DATE OF INSPECTION: FRAME FIREPLACE ELECTRICAL: ROUGH FINAL Y ' PLUMBING: ROUGH FINAL GAS.:. _____-ROUGH _ FINAL .. v, r FINAL BUILDING'° DATE CLOSED OUT ASSOCIATION PLAN NO. 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/orgm&.ation/Individual): ✓/NC E At /4 VO IOs Address:_2 YO SEA 3 rAT E try` City/State/Zip: IIyRNNIS MA 024ol Phone#: 8,&O-$72,OY77 Are you an employer?Check the appropriate box: Type of project(required): 1.El 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.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees. These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.msura„ce.t 9. ❑Building addition required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 32 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 insurance required.]t c. 152,§1(4),and we have no 13.® Other pEG.� employees. [No workers' comp.insurance required:] *Any applicant that checks box#I 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-contactors 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 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$1,5W.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 above is true and correct Signature: Date: //`/.` 3k D/ Phone#: QLv D- $7 7-4 777 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. 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 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Qffitce of luvestigatians 600 Washington Street Boston,MA 02111 Tel#617-727-4900 ext 406 or 1-877-MASWE Fax#617-727-7749 Revised 4-24-07 Www.mass.gov/dia Town of Barnstable Regulatory Services swsc� * Thomas F.Geiler,Director MASS � P 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 JOB LOCATION: .Z 4 0 SEER 5 ri?EET number sheet village -HolvMWNW: VjV G E NT' /Q u 0 P5 8'G $72-0 777 name home phone# work phone# CURRENT MAILING ADDRESS: N D .S EA S T R E FT b[yr9NN�S Nl A 952A / cityhMn state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow 1 homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINMON 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 requirementsand that he/she will comply with said procedures and requirements': t, 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. C:\Users\decoUWAppData\Lom Mansoft\wmdows\Temporary InternetFBes\Content.Outlook\QRE6=NOURESS.doc Revised 053012 o Town of Barnstable Regulatory Services g Thomas F.Geiler,Director 163g. Building Division Tom Perry,Building Commissioner 200 Main Sheet,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-4038 Fax: 508-790-6230 Pro� e Owner,Must >, p rtY Complete and Sign This Section If Using A Builder as Owner of the subject property 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:0WNERPERhMS10NPWL•S 62012 r TOV Of "ARINSTA"LL P. 3: 37 " � 5"x9—/4"x 1 —1/2" PT 12'6 2"x 12" 1 ' O.C. .� 2'6" Breather Block, Ledger screws - �1/8" Lead Flashing Joist H ngers z, c� w Railing 42" � Height N Balusters 4" 14' 0.0 3, 5„ Post 4"x4" low 10" Sauna tubes 4' Dee 4 —10 4 —10 4 —10 STAIR-5/ 7-1/2" RISE 10-1/2" Carrier Beam 15' TREAD 3-2"x12"x15' c. s 9F Y r r t 14 ak r irdamrmxwaxuuti ,,,w'^' of s k� F TOWN OF BARNSTABLE SEINER RENTAL RECORD FIxrURE RATE Ci NAME AND ADDRESS OF SEWER CONNECTION BILL TO - NAME AND ADDRESS TYPE OF BUILDING REMARKS 1101°S same FO - 240 Sea St Mondor, M. M. Hyarn-ds, MA 02601 Map #307194000 corm 6/23/83 PLUMBING FIXTURES YEAR TOTAL CHARGE YEAR TOTAL CHARGE YEAR TOTAL CHARGE YEAR TOTAL G _ water closet. 1 I I + sink 1 tub 1 i lav 1 " 1 TOTAL FIXTURES • C'� ��OYda���'� �' ems. S'�` ~ • LT i ti 0� r'o ASS.LOT #194 GAR. 0 p PORCH �#2401 s 0101 RES. ZONE.• 'RB" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C" Bank Use Only TOWN: HY�IS — REGISTRY OWNER: VINCENT & CA1�OL RUOPS DEED REF: 7264 240 _ _BUYER: REFINAN�F' _ — _ DATE: 142_ PLAN REF: NO PLAN _ _SCALE:1"= 40'___FT. I HEREBY CERTIFY TO 5LAWMU_'MOR_TG CO_ —FIRST AMERICA TITLE INSURANCE CO. $y 3�t�, ----------N----------------THAT THE BUILDING F , �- YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS '., PA't)t. SHOWN AND THAT ITS POSITION DOES —_-- CONFORM E '` �.'L� !,,^W �`�sw� CONSULTANTS NT TO THE ZONING LAW SETBACK REQUIREMENTS OF THE ti.., '�O 3 j 143 ROUTE 149 TOWN OF BAR111STABLE--_____ —_AND THAT MARSTONS MILLS, MA. 02648 IT DOES_ NOT__ LIE WITHIN THE SPECIAL FLOOD HAZARD '` �'�` S f-r', '� �Fti_£,_f ,-- ,�.� TEL; 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED_ 2_9Z__ �� c�_ FAX 420-5553 CMEU unit —Panel 250001 0006 D A I2I THIS PLAN NOT MADE FROM AN INSTRUMENT Q421 KJH METH PLS SURVEY NOT TO BE USED FOR FENCES ETC. J V Town.of Barnstable .kY " *Permit m ' , ,. . a Expires 6 onths from issue date Regulatory:Services. Fee + snxivsznei E ., k Thomas F.Geiler,Director pet Building Division 1�A}� 40t.Per'ry,CBO, Building Commissioner -��� 20,10 200`Main Street,Hyannis;MA 02601 r , 4 0p BA�`" www.tawn barnstable.ma us Office:.508-862-4038 ST,gBL Fax: 508-790-6230 EXPRESS PEIT APPLICATION -` RESIDENTIAL ONLY t Not Valid without Red X-Press Imprint r' A Map/parcel Number 3 0 7/ �{ Y l Property Address © k [�Residential Value of Work pC? . Minimum fee of$25 00 for work under$6000.00 Owner's Name&Address V IAIC t=ltf r L9 f6 As,:, ° , y r v"141,c 64L /y,0 CT -'6662Y g' �� 7 � J3 3`8� Contractor's Name Sri,� � � � ' `Telephone Number a- y, ` Home Improvement Contractor`License#(if applicable) ',W Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance , s Check one:El a Y C 4 I am a sole proprietor,' " I am the Homeowner ' # ^ '• °I have Worker's Compensation Insurance E' p x n s LL. Insurance-Conl an Name p Y Workman's Comp.Policy Copy.of Insurance Compliance Certificate must accompany each permit... Permit Request(check box) y Re-roof(stripping old shingles) All construction debris will be-taken to' rl?A^/.S 7^L4 57,9?'10 l'}. ❑Re-roof(not stripping. Going over existing layers of roof) Y ' ® Re-side na t + #of doors Re lacementWlndows/doors/sliders'U-Value''`�y P (maximum:44)#'of windows P , , *Where required Issuance of this permit does not exempt compliance with other town department regulations,Le:Historic,Conservation,etc,: -. a***Note Property Ownerfi°must sign Property Owner Letter of Perm►ssion A:copy of the Home Improvement Contractors License&Construction Supervisors License is ' SIGNATURE: F } 4 - +t• r. F t x t f.- •: .P 4+'" � „� . ,k:+ i w• C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGUSQOIEXPRESS.doc s ` Reviged 090809 e + }; ' c' ,v Town of Barnstable Regulatory Services EL a MASS. 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: �'�/`I' 2010 JOB LOCATION: A If d $E/9 5 NYA,NN/6 number street village "HOMEOWNER' V INC ENT 600)0.5 $(a o-7 74-33 2' 06®`2,53- 8 30 q name home phone# work phone# CURRENT MAILING ADDRESS: 140 U o A A 4 i .Q Md /?jp 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 ofthe 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. C:\Users\decollik\AppDataTocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 1 The Commonwealth of Massachusetts y Department of Industrial Accidents . ' Office of Investigations 600 Wdshington Street �= Boston, MA 02111 `y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber.s Applicant Information Please Print Legibly Name (Business/Organization/Indivi dual): tP/iVC.E�/1 r Address: y 0 U 19A 4-c 0 AA City/State/Zip: c.T' Phone #: $10 7 9 Y 3 3 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 6. ❑New construction * have hired the sub-contractors.. employees(full and/or part-time). -- - - --_.-_- ❑ listed on the attached sheet:. 7. 0 Remodeling 2. I am a sole proprietor or partner- ` These sub-contractors have g, 0 Demolition ship and have no employees working for me in.any capacity. employees and have workers' 9F1 Building addition No workers' comp. insurance comp.insurance.1 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 I I.❑ Plumbing repairs or additions 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_S7r✓ini� r comp.insurance required.] G 0.If!: ONC *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 wheth_er 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 the policy and job site information Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Dater 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 ofMGL 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date 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 S. 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 with 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 publicwork 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 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 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.refemnce 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 0,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 4 617-727-7749 Revised 4-24-07 www.mass.gov/dia I �oFt►�1� Town of Barnstable Permit# oW N QfPiRAAO�StTAOesue date 9s�xxABLE,p Regulatory Services ? E 0 1639, �0 Thomas F.Geiler,Director �AlfD1A0`A Building Division Peter F.DiMatteo; Building Commissioner` DIVISION 200 Main Street, Hyannis,MA 02601 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 410 a4 , OU i i residential Value of Work 45 00 G 0 Owner's Name&Address V I✓t C qv,)A gy�.S + K y O PS Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: X-PRESS PERMIT am a sole proprietor \ I am the Homeowner f ' ❑ I have Worker's Compensation Insurance F E B 2 ,1 2002 Insurance Company Name TOWN OF BARNSTABLE Workman's Comp.Policy# Permit Request(check box) P.Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows.. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg Revised121901