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Home My WebLink About0036 TANAGER ROAD Town of Barnstable Permit# o Expires 6 months from issue date Regulatory Services Fee( �� BA"STABLE, Thomas F. Geiler, Director n v ntnss. 1639. e.,� Building Division plfD MA't Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barristable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number1f� n Property Address � � 1 � �^ /Residential Value of Work ( a() ,0V Minimum fee of$2.S.00 for work under$6000.00 Owner's Name&Address [ 'i G e( ( 3 Tana. er „ ci Contractor's Name JO c_ d Ul/C S Telephone Numbert 1�� Home Improvement Contractor License# (if applicable) ❑Workman' ompensation Insurance C ck one: I am a sole proprietor - RE S PERMIT ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance AUG 2 9 ZOOS Insurance Company Name YWNTABLE Workman's Comp. Policy 0 Copy of Insurance Compliance Certificate must be on file. Permit R;/P!el,ODfc(strippmg chek box) /old shingles) All construction debris will be taken to as��S 74 C t �� ❑ Re-roof(not stripping. Going over existing layers of roof) . ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maxirnum..44) *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.OwnerLetter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:1WPF,ILES\FORMS\building permit forrns\EXPRESS.doe Board of Building Regulations and Standards ~ HOME IMPROVEMENT CONTRACTOR License or registration valid-for individul use only � beforc the expiration date. If found return to: t RegiStratto i ,13g"o19 . Board 0f Building Regulations and Standards Expiration 7/28/2009 Tr# 131937 One A_ihburton Place Rm 1301 Type:- 'BA Boston,llla.02108 t 'ERS HOPv1E-RENOVATIbNS POWERS t xz a =R RD ILLE,MA 02632 Arlmmistrator - - Not valid without signature • a The Corrrrrsonwealth of Mass achusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Bostort, MA 02111 www.mass.gov/dia Workers' Compensation Insurance A.fflda-vit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Le 'bl Name (Businc:3d o ni7Ation/individual): 0fr d✓ l s Address: 130 u e/ Rol o City/State/Zip: 6n rvo 1 e Oh Od-WPhone.#: Are you an employer? Check the appropriate b,oYc 'type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction s (fulland/or part_ime).* have hiredthe sbb-contractors 2. tnloyer a sole proprietor rietor or artier- listed on the attached sheet 7. ❑Remodeling p p p These sub-contractors have 8 . ship and have no employees . ❑Demoliti on worlang for ma in any capacity. employees and have WDtkerS' 9. ❑Building addition camp. No workers' camp.-insivanee ncc.t or 5. ❑ We are a corporation and its 10-❑Electrical repairs or additiar r � j officers have exercised their 1 L❑Plumbing repairs or addiiiM 3.❑ I am a homeowner doing all work myself: [No workers' comp. right of exemption per MGL 12 ❑Roof repairs incnrance r t c_ 152, §1(4), and we have no �� employees. [No workers' 13.❑ Other fiL rurancc required] *Any applicant that chccla box#1 must also fill out the erection below sbowing tbcir woricaa'mmpa soon policy information. t Homeowner%who submit this ej5davit indicating lbcy arc doingall work and than hire outride eantracfnrs must submit anew af5aavitindiratin9 wch- --=tractors that cbmv this box must atfachcd an additional chc ct showing the name of the sub-contractors and Ktaf whether or not thosd entities have t employers. if the sub-mntractms have rmpkyccs,.they must provi&their workers'camp-policy numbcr- Iam an employer that is providing workers compensation insurance for my employees. B'elaw is the policy and job vile informadon. Insurance Company lame= Policy#or Self-ins.Lic..#: Expiration Date: fob site Address: Citylstdclzip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date; Failure to secure covcrage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of. fine tip to$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a f of up to S250.00 a day against the violator. Be advised that a copy of this statLmerit mgy lie forwarded to the Office of Investigations of the MA for 7_nsruamr,coverage verification.. I do hereby ceo 1mdqqthc pats pen f perjury that the informations provided `�ave�' rand correct Zi Si c: Date: V — Phone# �z O Rein!use only. Do not write in this area, ro be completed by city or town official City or Town: Permit/Licewe# Issuing Authority(circle one): I.Board of Health 2.Building Department. 3. City/Town Clerk 4.Electrical Inspector 5.Plambing Inspector 6. Other I �opzHetp� Town of Barnstable Regulatory Services ■ r l.Al NSTA13 MASS. Thomas P. Geiler,Director v$ i63q. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnsta ble.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Z , as Owner of the subject property hereby authorize. O to act on my behalf, in all.matters relative to work authorized by this building,permit application for: t (Address off ob) Signature of Owner Date T�>� t, Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. I Town of Barnstable Of'(HE Regulatory Services b f Tbomas F.Geiler,Director " SARW5IXBLE. . v MASS.. Building Division D µA'i p`o b Tom Perry,Building Conunissioner . 200 Main Street, Hyannis, MA 02601 m ww.town.berrnstable.rna:us Office: 508-862-4038 Fax: 5.08-790-6230 HOMEOWNER LICENSE EXEMPTION ,Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": WNER": 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 fo 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. Signatumof Homeowner r Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or largei will be.required to comply with the State Building Code Section 127.0 Constriction 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 parson(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 res s ftc'su is 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 l Supervisor. The homeowner acting as Supernsor is u]timate yres p onsiblc. 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 hc/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.