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Home My WebLink About0157 STRAIGHTWAY /S7 U � �F\q -�i DIME Town of Barnstable *Permit# Expires 6 nths from issue date i3' ^ Regulatory Services Fee g , + a • a + • BARNHABLE MASS. Richard V.Scali,Director 039. �0 AlfD MA't A Tom Perrry, Division . CBOTg Building 1ComissioneAPRESS RM U 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us AUG 2 7 2014 Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDE "JMu— Not Valid without Red X-Press Imprint f STABLE Map/parcel Number Property Address 154 SW41604--emif Residential Value of Work$ /Of VVV Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address l Y7 51 - 0diI6 Contractor's Name 141 IQ Lv y Telephone Number S'vf- a3 — &_'F7 a Home Improvement Contractor License#(if applicable) /7:7 a G Sr Email: i f#41 D&4 y e4L c ci CoKe"I •�,e Construction Supervisor's License#(if applicable) GS— O'7�6 35 3 ❑Workman's Compensation Insurance ChSpk one: , I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) L%TRe-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. ' *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi d. SIGNATURE:' Q:\WPFILES\FORMS\building pe it fo XPRESS.doc Revised 06 13 13 s 1 - G4i Ile Comtrt'orrmmkh of Massachusetts Detvurftnent of llirdmft ial Accidents Ojywe of 1m estigations 600 Washington&reef Boston,,MA 02111 www.truss govldia , Workers' Compensa.fim hmurance Affidavit:BuilderslContractorsfE ectri.ciansXlvmbers Applicant Information Please Print Legibly Name($nirew/Orgmizafiontfndividual): Address. '�� City/Statrjzip: C':f/'.'` _"j ILAL d4l)- Phone 9: -'�_67 �- Are you an employer?Check the appropriate box: Type af. o ect r 4- I stxr a contractor and � i ��- L❑ I am a employer with ❑ t� 6_ ❑N 0U ' �fnployees(full and/or part-time).* have hied the sub ciors 2.,[ I am a sole proprietor or partner- listed on the attached sheet. 7+ delin1= ship and have no employees 'These sub-contractors have 8_.❑Demolition working for me in any capacity employees and have workers' 9_-❑Building addition [No world' comp:insurance comp-insurance., required_] 5. ❑ We area corporation and its 10_0 Electrical repairs or additions 3111 am a homeowner doing all work, officers have exercised their 11..❑Plumbing repairs or additions. myself. [No workers cep- right of e�wn ptioa per MGL 12..0 Roof repairs in�xanre required-]I c.152, §1(4),and we have no employees_[No workers' 13_.❑Other comp_insurance required_]; "Airy appliamt that checks boa#1 toast also fill out the section below showing their woadcers''compensation policy infbMilfia o- T Homeowners vrho submit this affidavit and csting they asa doing all wo k s'ad rhea hie outside contractars n submit anew affidavit indicating mch lCoutcactors that cheek this boa mast attached as additional sheet showing the name of the sab-m a and state whether or not these amities have employe-n. Ifthe lab-contractors hate employees,they nnhst provide their warps'comp.policy nianber_ I am an employer that is prm idLag workers'compensation insurance for my emplayem Bdow is the po8cy andlob site informad9n. , Insurance Company blame: _ Policy 9 or Self-ins.Lic.4: Expiration Date: Job Site Address: City1'State/Zip: Attach a copy of the workers'compensation policy declaration page(shasiing the policy number and expiation date). Failure to secure coverage as requireduuder 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 yearimprisonment,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 Imiestigations of the:DIA for insurance,coverage verification_ I do hereby cerh;fy tinder tFrepai rid penaliCies ofperjuty that the information provided about is tnm and correct„ , Si tore: Date: Phone i#: G► icti l use only. Da not write in this area,to be completed by chip or town official City or Town: PerraitUcense 9 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitlTown Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: 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 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 -eceiver 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 IocaI 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 lay applicant who has not produced acceptable evidence of compliance with the insurance.coverage requ.ired." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political si.ibdivisions 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 ofinsurance coverage. Also be sure to sign and date the affidavit 71ne 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 ilz (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 ( .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 Commonwealth of Massachusetts Department of Industrial Accidents office of lavestigations 600 Washington Street Boston,MA 02111 Tel.A 617-727-4900 ext 406 or 1-377-MAS E Revised 4 2407 Fax# 617-727-7749 Www.mass gov/dia • aniuvsrnBts, MASS. ,�� Town of Barnstable ArED��p Regulatory Services Richard V. Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b a rns to b le.m a.us Office: 508-862-403 8 'Fax: 508-790-6230 Property Owner Must Complete and Sign This Section, If Using A Builder I, as Owner of the subject property � ff hereby authorize /" �� tG�r�2� "'��"� to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) 7i e of Owner Date Print.Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMSIbuilding permit forms\EXPRESS.doc Revised 061313 Town of Barnstable , Regulatory Services P�oFTr+e r�g,� Richard V.Scali,Director Building Division w sAxxsTAsr.E, " Tom Perry,Building Commissioner P MASS. 039. 200 Main Street, Hyannis,MA 02601 ArEo �s 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\building permit forms\EXPRESS.doc Revised 061313 artmet, of Public safety ssachusetts D�egula`•°s and Standu"`is ry Ma of Bu�ldin9 R Board super**` Construction .p76� n License'�`-`' L D� FCIDR 55 SA �yE TV1A '*tw CENT iration 0610205 �Jssionet = �. CJ/ee cp�c+�,coaxcvecclll a�C��llec6;ccc�cc�e ;. - _ License or registration valid for individuT use onty lY Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:x — ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation - istration 177265 Type' 10 Park Plaza-Suite 5170 , xpuation: Individual Boston,MA 02116 F.MICHAEL DWYER` � . t F.MICHAEL DWYER . t 55 SACHEM DRIVE t CENTERVILLE,MA 02632 "Undersecretary Not valid w►tho' signature