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Home My WebLink About0085 SMITH STREET r Town of Barnstable *Permit a J 0 % GExpires 6 mon from issue Regulatory Services Fee • BAxNsrmr.A • MAS& Thomas F.Geiler,Director 165 Building Division 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 �84W Property Address o esidential Value of Work$ y:�� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name % ® �. Telephone Number Home Improvement Contractor.License#(if applicable) (A 4?0 Z_ Email: CAI M 85f ZS0 YA HQ0 ® � Construe ' n Supervisor's License#(if applicable) 16 / orkman' ,� 7s Compensation Insurance Ch�ec ne. 2 1 am a sole proprietor ❑ I am the Homeowner ff.Y�ave Worker's Compensation Insurance �r a ?®13 Insurance Company Name AIM ro %Jr HA Workman's Comp.Policy# / KI Cl /00 �—�� 1610-96._Z01.� RNSTA I,�� ° Copy of Insurance Compliance Certificate must accompany each permit. o Permit Request(check box) ® Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to \se a_W4 0141 1 S D n SA%— ❑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: Property Owner must sign Property Owner Letter of Permission. py of the Home Improvement Contractors License&Construction Supervisors License is iz SIGNATUREP4r Q MPFILESTORMS\building permit formsTMRESS.doc Revised 060513 A t ft The€ommompmfth of MassachUsdit Deptrntt v f1udn &fed Accidents - Office 004 Agafie rs Britoil,MA 0211 tm .masxgotldia Workers'Campensatiun Insurance Affidavit':BmIders/ConsractorsMectrici2n&Oumbers _APPHcant Informatian Please Print Legibly Name(B an/fndividnal7: . Address: J!2 39 Citgl tateJZip: Ca ne .. ��P' "3 Are you an employer?eheck the appropriate box: Tppe of project(required): L❑ I am a employer with 4. ❑I am a dal contractor and I 6- ❑New cmwEr sctiou mrloyees(fall and/or partAime)* havehiredthe sub-conftwiom 2_ I am a sole gragrietor orpattner- listed on the attached sheet: 7. ❑Remo g strip and haze m employees These mb-contractors have 8. ❑Demolition woddng forme in.any capacity_ employees and have worms-9- ❑Building addition . [No worlmrs'comp.insurance comp.,nsura,ae f' require&] 5_ ❑ We are a corporatioa and its 10.E Electrical repairs or additions. 3_❑ I am a homeowner doing all work officers have exercised their 11g repairs or additions myself[No worloers'comp. right of exemption per MGL 11[59o-ofrepairs insurance reqmimd.]I c_152,§l(4} and we have ua. employees_[No workers' 13_❑Other COMP-insurance rBT3iMd] �lfay,cpptnaatthatcheacsbmz#lomitalsof�outthese�teoaheIowsheRiaSa�eaoro�cess*cmape�ia�pv iaf�r f Homeawaers arho submit ibis afdavit m&catiug they are daigg anorak sad men bi m autsitLe comtxactaa omit subotit s gem alb davit such_ tCaat<acma it 63eck this bmc most attached m addi5eual sheet dwRing the name of the sob-caufts a sad stare vdmtler argot tbase ea ides lave employees. Ifthe sok ruaivadcts LaFe emPjcF -% 3`Est provide their warkets'comp.paters aumbes lam an employer thatisprov ng workem'comperuntion insurance for my enq7tnyees. Belau is diepaHcy and job silo F inaformatiam pp Insurance CompanyNime: A t �A 1^O-rU>Ar(- I ty Su g—A, ;C-,L Policy#or Self-ins-LiC 4. I 6?t) Expiration Date-IO r'�.'_3 /.3 Job Site Addis: CityfSiatelTp: yJmm Attach a copy of the mmikers'compensation policy declaration page(showing the policy n&Ur and expiration dated Failure to securecov-erage as regairedunder Sectim25A o€MGL c. 152 can lead to the imposition ofcliminal,penalties of a fine up to$1,500.00 and/or one-pearimprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Eke of up to$250-00 a day against the violator. Be advised that a copy of this statemeurt mzy be finwarded to the Office of ' Investigations of fhe DIAL€or n,a a,ce coverage verification- . I do daereby eider thepains anrd enaliies ofper,jury ihatthe information prmi&d above is hue and correct Date: l'® 01 Phone i# 0 '4 O, FdaI use only. Da not writs fn this area,to be cmmpldtad by city or town ofjrciat City or Town: PermitUcense 9 Issuing Authority(circle one): L Board of Health 2.BuRding Department 3.CitflI'own Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.OdFer Contact Person: Phone#: "e 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 ofhire, 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 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,b checkin the boxes that I to our situation and;if PY g apply Y necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLCM 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 toverage. .Also be sure to sign and date the affidavit The affidavit should be retained 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 pennitllicense 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 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 Gomm wealth of Massachusetts Department of 1ndustdal Accidents Office of Iavestigations 600 Washi4on Street Boston,IAA 02111 Tt<L#617-727-49W at 406 or 1-977 MASSAAFE Revised 424-07 Fax#617-727-7749 www.mass govldia ; . � Town of Barnstable ti °* Regulatory Services ! RL RN.CILRTR • MASS Thomas F.Geiler,Director 059. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 . _... www.town.barnstable.ma.us Y - Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section _a If Using A Builder I, ,as Owner of the subject property hereb7 authorize Raiwo to act on my behalf, in all matters relative to work authoiized by this building pettnit (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. S&Ltlep' f Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOIS 62012 Town of Barnstable Regulatory Services naves.rkl s Thomas F.Geiler,Director MAM Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 50 8-862-403 8 Fax: 50 8-790-6230 — HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: b city/town state zip code The current exemption for"homeowners"was extended to include owner-occuRiied 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 pen-nit (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 helshe 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 jRules&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\decollildAppData\Load\Microsoft\wmdows\Temporary Internet Files\ContentOutlook\QRE6ZUBNOTRFSS.doe Revised 053012 OfficeCon> me ffaire&CBu�inessn' n License or registration:valid for individul use only 1 before the expiration date..If found return to:. HOME.IMPROVEMENT.CONTRACTOR s Re istration Type: Office of Cons6mer Affairs and Business.Regulation •`; gi 142802 T 5/20/2014 DBA 10 Park Plaza-Suite 5170 Expiration E Boston,MA02.116 .. C YO BUILDING+REM 0DEL'ING PABLO•MARTINEZ�. - r i 49 SMITH ST `•''HYANNIS' MA 02601 — ' UndersecretaE -.;r. Not valid with t signature i . 74 �•`'•__ .. ... ___... ......................... _... .. 1. .. Massachusetts- Department of PubliC.Safct� ,Bo trd of Building; Re-ul ttions find Standards COii ru6t,1' Supervisor Liczanse License: CS 103617 - Restricted,to;` 00 I PABLO MARTINEZ_'h` j 49 SMITH ST;. r HYANNIS, MA 0260.1` ; Expiration: ,11/17/2013` Cununisvio�iet`' Tr#: 103617 r • r r � � r ! t I.