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Home My WebLink About0138 THIRD AVENUE (HYANNIS) /38 .,,w�f� ./�.e-x---a-- J J I The CummanN•caltlt of Atassacllusctts 'j -�• !' ' Department q Industrial Accidents �, '"•�i ,M -�� OIlleeaf/oees�fgallaas ' „`. it .: •a' 600 !i mliingtnn Street Bustoa.11firss. 02111 _ �• Workers' Compensation Insurance Affidavit location- LU ❑ 1 am a homeow r performing alYwork myself. ' ❑ 1 am a sole proprietor and have no one working in any capacity rl I am an emplover providint workers compensation for my employees working on this job. city phone o insurance policy to ' r ------*- •----••—' ___. :..,..-., .. .*,.r-.....,-,�.�---•• . . � . ... . . ed below who t ❑ 1 am a sole propnetor,general contractor, meown crtrle one and have hired the contactors list the following workers' compensation poiic comp.inv address: phone#• noiicy At m anv na e• address- .n nhone 4— imance co. • .. polder# . .. ;Attach additid' ai•shee!if aeeessary• y '�"�""- ' • rr tam'¢ 1 �.0 Failure to secure coverage as required under Section 3A of AfGL 152 can lead to the imposition of aimiaai pettaldn of s fine up to Si300.ti0 am one can'imprisonment as sell as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day Winn mts I understand tits copy of this statement mad•be forwarded to the Ounce of inves!%atior of the D1A for coverage swifieatioa. 1 do hereby 1/1p its a 0 un•that the information provided above is true and comet Sitmazu � ° �"" _ rc Print name Phone# atiicial,use only do not write in this area to be completed by city or town ofneial city or town: permit/llecuse fl r1guildinn Department DUa Hoard asiag • OSelectmen's Ounce ' check if immediate response is required (3ileaitb Department phone 0: contact person: nOtber�_ 4 Information and Instruction: Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for employees. As quoted from the "law", an emplgvee is defined as every person in the service of another under anv contract of hire, express or implied. oral or written. An enrph rer is defined as an individual, partnership, association. corporation or other legal entity, or any two or n the forecoin-, engaacd 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 owner of a dweilins: 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; or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic MGL charter 152 cction 25 also states that ever},state or local licensing agency shall withhold the issuance or rene+val of a license or permit to operate a business or to construct buildings in the commonwealth foram• applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. 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 chaps: been presented to the contracting authority. r �w�.+�. '. .....w...��. - .. 't�i:f.►: . \T J.:L _• ,.y... :�'n.r';IN.M.;yA:,�V •.r• .yam :Y:r,:i� - .J'�".' •.._. Applicants Please 'I11 in the workers' compensation affidavit completely, by checking the box that applies to your situation an supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tile 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 requi: to obrain a workers' compensation policy, please call the Department at the number listed below. Qn• or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottorr the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. F be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returnf the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any quest: please do not hesitate to give us a call. , r�,...-w.�.,... ...r.�.n.m►••. •� «��i.r. .:�.�•��w :•ram .:1' :•l.•�: :�:�.. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts ' Department of Industrial Accidents w ' Office of investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 nhone #: (617) 727-4900 cst. 406, 409 or 375 e Town of Barnstable E AM Environmental Department of Health Safety and Envinmental Sernces Building Division 367 Main Street,HYatmis MA 0=1 Ralph Crosses Off= 509-790-6227 Building Coffin' F= 508-775-3344 For office use only Permit no. Date AFFIDAVIT HOME n"ROVEMENT CONTRACTOR LAW SUPPLEMENT TO PE Wn APPLICATION MGL c 142A requires that the"Roonstrucdon,alterations,renovation,nepa�modernization,conversion, coon of an addition to any pm- owner Op 4ncd impravemenL.mmcm-4 demolition. or consau which atz ad}acent building containing at least one but not more than four dwelling waits er to stainti0�+ along with other to such residence or building be done by registered eonuac7ors,with cer requirements. Type of Work: ' Address of Work: •,' Owner.Name: q Date of Permit Application: I hereby certify that: Registration is not required for the following rcason(s): Work excluded by law ob under S1,000 Building not cw=-0oeupied Owner pulling am permit Notice is hereby given that: CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING WrM ��LESS TO THE FOR APPLICABLE HOME IMPROV w01rr WORK DO ARBrrRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a penult as the agent of the owner: � ;i/ w r Regisuation No. Date ConuacYorname�,41 ,s OR ' .. _ .. .... .. .. ... n.... 1 .........t• .t. ..r .r .t .......... .._ ......... r .. 1. .. .. .\.. ... "f TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. . DATE .. ..a: . JOB. LOCATION /3,F . 'Number Street address ection of town "HOMEOWNER" Name Home phone Work phone . PRESENT MAILING ADDRESS City town State Zip co The current exemption for "homeowners" was extended to include owner-occu• dwellings of six units or less and to allow such homeowners to engage an dividual for hire who does not possess a license, provided that the owner acts as supervisor* DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to side, on which there is, or is intended to be, a one to six family dwellii attached or detached structures accessory to such use and/or farm structu: A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner"• shall submit to the Building Of on a form acgeptable to the Building Official, that he/she shall be respor. for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the Building Code -aad other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requireme:and that he/she will compai3it6said proced es d irements. HOMEOWNER'S SIGNATURE APPROVAL OF. BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be reuirE to comply with State Building Code Section 127. 01 Construction Control. q HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for whch.ta build permit is required shall be exempt from the provisions of this section (Section 109.1. 1 - Licensing of Construction Supervisors) ; provided tha Home Owner engages a persons) for hire to do such work, that such Home shall act. as supervisor. " Many Home Owners who use this exemption are unaware that they are assum the responsibilities of a supervisor ,(see Appendix Q, Rules and Regulat for lice tion Su ervisors Section 2.15 . This lack of aw using Construc p , ) often results in serious problems, particularly when the Home Owner hir unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Rome"Owner as supervisor is ultimately responsible. . .�. To ensure that the Home Owner is fully aware of his/her responsibilitie, communities require, as part of the permit application, that the Home 0. certify that he/she understands the responsibilities of a supervisor. c ' last page of this issue is a form currently used by several towns. You care to amend and adopt such a form/certification for use in your commu: Map (�(�, Parcel `�J Permit# / ' Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) l9 j Date Issued Board of Health(3rd floor)(8:15 -9:30/ 1:00-4:45) 17 •-2 Fee Engineering Dept. (3rd floor) House# 3$ p3 S sNE r BARNSTABLE. MASS ing 19 , TOWN OF BARNSTABLE _ Building Permit Application f{ P 'ect St I A � � ` l I� V 143 rd IUS3 VillageP1 N, Omer .9as ,o�` s ,e,y,N e f/1�,�lAddress '/,3 A �L � Telephone -5 a 9;7— 7 l o_ Y,5 5 Permit Request ft'l�,L y"V nJ First Floor 11 f/� square feet T , Second Floor square feet 6 Estimated Project Cost $ ��__ 6 y -- Zoning District Flood Plain Water Protection Lot Size U a 4."o — 2 e d x!F a Grandfathered ? Zoning Board of Appeals Authorization Recorded /Current Use Proposed Use Construction Type %Commercial Residential I-' Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure rya Basement Type: Finished Historic House Unfinished j Old King's Highway Number of Baths 3 No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel T<<`?it�c Central Air ----- Fireplaces Garage: Detached Other Detached Structures: Pool Attached / Barn None Sheds Other Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. / ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO / 4 /d P,-7— n SIGNATU DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) POR OFFICIAL USE ONLY P MIT NO. D.TE ISSUED f P/PARCEL NO. ADDRESS ' VILLAGE r` OWNER + DATE OF INSPECTION: ' FOUNDATION FRAME i INSULATION FIREPLACE• ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO.