The URL can be used to link to this page

Home My WebLink About0030 WATSON STREET T y�P�_ ��--�� f l 1 f �FIHE Tp� 'Town 6f arns a le *Permit# t �p Expires 6 mop tlis jrom issue date Regulatory Services Fee r r RAantsrA Thomas F. Geiler,Director HASS. Oka 69 r Building Division CRVy,CBO, Building Commissioner ; ^, FEB d 00'Main Street, Hyannis, MA 02601 1...; 9 2008 ,�^ www.town.barnstable.ma.us r,i Office: 508-862-4039 -tAR� S�-Fax: 50P90-62'30 EXPRESS APPLICATION - RESIDENTIAL ONE` Not Valid without Red X-Press Imprint Map/parcel Number Property Addressca residential Value of Work�,_q--�Q, UU Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number_)�4— w lV J14 Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. -A copy of the Home Improvement Contractors License is required. i SIGNATURE: Q:Forms:bu ildingpermits/express . Revisel12807 ` The Commonwealth of Massachusetts ` Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111, wl•dw.mass.gov/dia ' Workers`Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amplicant Information Ti ase Print Le M Name(Business/Organization/Individual):. Address: City/State/Zip: Are you an employer?Check the appropriate bog: :Type of project(required):, 1.❑ I am a employer with 4. El am a general contractor and I 'employees (full and/or part-time). *, have hired the sub-contractors 6. ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition' 'working for me in any capacity. employee$and have workers' [No workers' comp,insurance comp.insurance. $• 9. ❑Building addition required] 5. ❑ We are a corporation and its 10.❑•Electrical repairs or additions officers have exercised their 3. am a homeowner doing till work . 11.❑PhmibMg repairs or additions myself.[No workers' comp, right of exemption per MGL 12.❑Roof repairs insurance.required.]f c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeownera•who submit this affidavit indicating they are doing all work and t5en hire outside contractors must submit a new affidavit indicating'such #Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether ornot those entities have enrployees. If the sub-contractors have employees,they must providt;their workers'comp.policy number. 14m an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Nmne: Policy#or Self-ins.Lic.# Expiration Date: Job Site Address•. City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 fine of up to$250.00 a day against the 'olator. Be advised that a copy of this statement maybe forwarded to tbe•Office of, Investi atio of the INA o oe c v e verification. ' I do hereby under e p ' s an Bien 'es of perjury that the information provided above is true and correct. Si ature Date; Phone#: Official use only. Do not write in this area, to be completed by city or town•.official City or Town: ' Permit/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: T"Era'ti Town of Barnstable o� • a Regulatory Services • BARNSTABLK v MASS. $ Thomas F.Geiler,Director i639 �� ArE�►r+A''" 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 Section If Using A Builder �S as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner Date Print Name If PropertyOOwner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION Town of Barnstable �Op SHE r, i y�P o� Regulatory Services • Thomas F. Geiler,Director r • BARNSTABLE, 9 MASS. qp 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 HOMEOWNER LICENSE EXEMPTION fi C� Please Print DATE: I�/ b V JOB LOCATION: :72t 611 'nnumber? street lLvillage „HOMEOWNER": NIC�^�%1 �( K T Ll name „home phone# work phone# CURRENT MAILING ADDRESS: IN A t ' 'ty/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 minim i spec 'orocedures and requirements and that he/she will comply with said procedures and uire a ts. gnatu f 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:f6t7ns:homeexempt PERMIT PAYMENT RECEIPT i TOWN OF BARNSTABLE BUILDING DEPARTMENT, 200 MAIN STREET HYANNIS, MA 02601 DATE: 08/04/06 TIME: 08:50 -----------------TOTALS----------------- PERMIT $ PAID 25.00 ANT TENDERED: 25.00 ANT APPLIED: 25.00 CHANGE: .00 APPLICATION NUMBER: 20062288 PAYMENT METH: CHECK PAYMENT REF: 606 dF Town of Barnstable *Permit# ,�z UcCe =PRESS Expires 6 months j>nissue date Regulatory Services Fee C; AUG — 4 63 & Thomas F.Geiler,Director Building Division -OWN OF BAD 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 �j Not Valid without Red X-Press Imprint Map/parcel Number Property Address ? Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ,` `PVT-I-A� N)JCZ5N—( Contractor's Name 1 , \ Telephone Number I V Home Improvement Contractor License#(if applicable) ► Construction Supervisor's License#(if applicable) 0 A ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor 0--ILam the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prope wn must sign Property Owner Letter of Permission. Ho Improv ent Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 The Commonwealth of'Massachusetts Department oflndustrial Accidents Office of Investigations { a 600 Washington Street Boston,AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADPlicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 1�6b� ' City/State/Zip: Phone#: � � 90 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 New construction have hired the sub-contractors traction employees(full and/or part-time).* I 2.❑ I am a sole proprietor or partner- listed on the attached sheet it 7• f —modeling I ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in any capacity. workers' comp.insurance. g p tY• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its equired,] officers have exercised their 10,❑ Electrical repairs or additions `3�O I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. (No workers' 13.❑ Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside c ontmctors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy.declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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-year imprisonment, as well as civil penalties in the farm of a STOP WORK ORD7ER 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 Investigations of the DIA for insurance coverage verification. I da hereby at:unde-fepa'!ns Wppeties of perjury that the information provided above is true and correct Sim i afore: f Date: U ' `�— c Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 'I.Building Department. 3.City/Town Clerk a.Electrical inspector 5.Plumbing Inspeeter 6. Other ' - I Contact Person: Rhone#: 3