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Home My WebLink About0006 BUTLER AVENUE U � 9 r 2 Town of Barnstable *Permit# a Expires 6 months from issue date Regulatory Services Fee oS , o Y Q Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner X-PRESS PERM11'200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us APR 0 7 2006 "�8 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL O TLLY BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number 12—6(O3 -0 Property Address 4 e--r ✓Q_ , residential Value of Work � Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �e�S+4 ell L'e_ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's 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. 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 Ownenentontra erty ner Letter of Permission. OHome proveor Li e is required. SIGNATURE: Q:Fomis:expmtrg Revise071405 The Commonwealth of'Massachusetts Department of Industrial Accidents /27 Office of Investigations _ t 600 Washington Street Boston, MA 02111 M 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L.e 'bl Name (Business/Organization/Individual): Address: v 2✓ City/State/Zip: CW,4Mt(f , M S Z Phone#: .50!K • ? S 140 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 employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ Remodeling ship and have no employees These sub-contractors have Sm. ❑ Demolition working for me in any capacity.' workers' comp.insurance. 9. ❑ Building addition o work ' insurance 5. ❑ We are a corporation and its � workers' Gump. 10.❑ Electrical repairs or additions - required.] officers have exercised their 3. 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.❑ Roof repairs insurance required.] t employees. [No workers' ✓ comp.insurance required.] I3.❑ Other *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 contractors 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 for my employees. Below is the policy and,gob 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 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 Investigations of the DIA for insurance coverage verification. I do herebyaA 47 .1 the p ns nal 'es f perjury that the information provided above is trace and correct Signature: - Date: n 0 6 Phone#: 0 k of • 4S-1 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 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector ., 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to 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 represantatives 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 maintenan6e, construction or repair work on such dwelling house or on the grounds orbuilding appurtenant thereto shall not because of such employmentbe deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold theissuance 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-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 a4wised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be scare 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 a 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 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 related 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 of idavit 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 Investigations 600 Washington Street Boston, MA 02111 Tel. L 617-727-4900 ext 406 or 1 o77-MASSA'E s ah ; 617-727-7749 Revised 5-26-05 www.mass.govitia