Loading...
HomeMy WebLinkAbout0147 STRAIGHTWAY `17 S'�,aur�ht any IKE Town of Barnstable *Permit 4c�?D 13 079/ Expires 6 mont fr m iss ate Regulatory Services Fee �xivszeaie, Maas.. Richard V. Scali,Interim Director IT �D MA'I A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �7S97. Not Valid without Red X,Press Imprint Map/parcel Number Property Address -------BResidential Value of Work$ y Minimum fee of$35.00 for work under$6000.00 v Owner's Name&Address- 70V),n ��4 3v b s c tr IA ��- �v-.4— �c,,n s .,� ©a10-D i Contractor's Name 7 3(3--)r, 9z>e C_✓ S U Telephone Number E 3 b 7—�2) t Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) l� ❑Workman's Compensation Insurance Check one: O C T 9 I am a sole proprietor _ 2013 I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF 13ARNSTABLE 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) —�] Re-side . q i LLE . ---�] Replacement Windows/doors/sliders.U-Value -- `v""' (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. A copy of the.Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit fo 0 Revised 061313 : l � i The CoIF morrnwaUh of Massachusetts Dedaranent of Indksfrial Accideras Ojoke t7,f-Investigations ' 600 Was,&Wgton My-eeJ Boston,MA 02LII wnm ynusmgoWdia Workers' Compensation InsuranceAffidavit:Builders/Contractors/Flectricians/Plumbers Applicant Information Please Print Legibly Name{BvsiDeaslOantz�ian,+individnal�: ��n 'Adaress: City/StatelZip: tAN not2 pad- Phone 4- 5+7 L3 7--Z-/ 6 Z Are you an employer?Check the appropriate box: Type of project(ralaired): 1.❑ I am a employer with 4- ❑ I am a genial c�mtractor and I 6. ❑New oansfruetion employees(full and/or part-time.} * have pined the sub-conftwtors 2-❑ I am a sole proprietor or partner-, listed on the attached sheet 7- ❑Remodeling strip and have no employees niese sub-contractors have g- ❑Demolition W0A3ng forme in any capacity- employees and have woticers'- g- ❑Building addition [No workers' comp-insurance comp-tat required-] 5. ❑ We area corporation and its 10-❑Electrical repairs or additions �❑ officers have exercised their I am a hameowntrr doing all work 11_❑Plumbing repairs or additions myself [No workers'comp- right of exemption per MGL 12 insurance r d].T c_ 152, §1(4} and.we hnre no ❑Roof repairs 13.0 other employees-[No ' comp-insurance required.} I f i j• *Amy appUcmn that checks boot#1 must also fill out the section below showing their walkers'compensation policy infnranatiaa Homeowners wba sabmit this affidavit mdica&g tbey are doing all mcA sad then hue outside coatiacmrs mast submit a new ald.9vk meIiret ng sorb- kcnahmctors that check this bank mast attached as additional sheet show the name of the sob-c=ftxtmrs and state whether ornot these entities have employees. Ifthe sob-contsaaors lave empIcyees,they must provide their workers'comp.policy number I am an employer that isprvuidirrg workers'compeatsadon insurance for my employees Belau is thepuiicy and job site injormaadgm _ Insurance Company Name: Policy 9 or Self-ins:Uc 9: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the-mmikers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL t, 152 can lead to the imposition ofc minal penalties of a fine up to S 1,500.0D and/or one year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250-00 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 Irereliy cot under th its andpenalfiss of that the information pratzded above is tnw and correct Phony 02ici.al use only. IM not write in this area,to be completed by do or town qfficiaL City or Town: PermitUcense# Issuing Authority,(circle one): r 1.Board of Health 2.Building Deparh#ent I Cityfrowu Cleric 4.Electrical Inspector 3.Plumbing Inspector 6.Other Contact Person: Phone#: 6 a Y�; ly Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employeeds,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 permitilicense 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 relaxed 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 lice 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 Depai4ment of Industrial Accidents Office of luvestigaflGns 600 Washington Street Boston,MA 02111 T61.#617-727-4M ext 406 or 1-MLMASWE Fax#617-727-7749 Revised 4-24-07 W _mass`govfdia ti Town of Barnstable Regulatory Services snRNsrwsrt. ' Thomas F.Geller,Director Mnss. M . i639. �.0� Building Division ED M1A't Tom Perry,Building Co mmissioner issioner - .200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us , Office: 508-862-4038 _ Fax: 50&790-623Q:.. 1 HOMEOWNER LICENSE EXEMPTION " Please Print DATE: I v� Q JOB LOCATION:_ I `1 � �1h�" �y ` tr, �l -- number — street .village, Sid- 3b��21 bZ d �� `zr 6 Z "HOMEOWNER' tires work hone# name {{ ' ,.home phone# wo_P�_ CURRENTMAILINGADDRESS:_= o 9-M i rvyKa C 1A,,47 ` city/town ; r-- 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. 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 uirements and that he/she will comply with said procedures and requirements. �Signa eo er. Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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\decoflik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 t 1 °F SFiE Tp� Town of Barnstable Regulatory Services yBAMSTABLK MASS, g Thomas F. Geiler,Director �p 1639. $ . 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 Se tion 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 building permit. /aa of Job) *Pool fences anhe responsibility of the applicant. Pools are not to be filledfore fence is installed and all final inspections are peccepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORM&OWNERPERMSSIONPOOLS 62012