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", ,,�,,, � , . , - 1;� ,�t:, , � "" ,­% , , - ��,,­_ � " ,,,,,_ ,.�,,�',,,,,,,�;�,,� ,'�_!��:,:, , , , , , , , �, , ,�:� , -�,,:,,�,'�',,�,:"�-�,�i�,�:��,,'�,,,,�,,,,�:;��l .,,,,.��.,,,,,�,�� "! -��,­'.�,:�:'., ��,""�.�� �` J':',,��,',,;i�,�,�:,,_�,,­, 11�1!�, , , "I ,i iiiiiiiiiii�',,��,-���",;�"I'�,,�'��"".�,������:"���,-_,�,;,�,:�,� ly'.-l!"� . ,:".",,,,e�� ���,,�� � , ��., ,'� ��:',�fl;��,���,f�!��",;",L�,,���'',-���, . , -- ��l �J�?l,� f44_ ' l �o� Town of Barnstable, *Permit# Regulatory Services Fee 6 months from issue date s s r • =ARNSTABIX r Richard V.Scali,Director gb 3 'elED MA't A �+�� Building Division ps/74Q Tom Perry,CBO,Building Commissioner I►i� 200 Main Street,Hyannis,MA 02601 �'oWfV SE . � �?015 www.town.bamstable.ma.us r U ��BOAR Office: 508-862-4038 'mttyo EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number / Property Address Residential Value of Work$ 30� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �� . ,X% A~/fk®/74!� Contractor's Name Telephone Number ('j Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: Vam a sole proprietor am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name1� 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 betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side � � 200Sc1�3. Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows I q #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 required. SIGNATURE: Q:\WPFILES\FORMS\building permit s\E RESS.doc Revised 040215 Town of Barnstable Regulatory Services �t t � Richard V.Scali,Director f °^ Building Division r * snarMAKY, * Tom Perry,Building Commissioner ass. 200 Main Street, Hyannis,MA 02601 �En Imo'' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230. HOMEOWNER LICENSE EXEMPTION A Please Print DATE: l—I7—/S/ JOB LOCATION: number street village "HOMEOWNER":.. 916W 3X—a3 0-72 4/7-�S3`/- �i 7% name �L }_ home phone# work phone# . CURRENT MAILING ADDRESS: 77 / 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 su ep rvisor. 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 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 fomu\EXPRESS.doc Revised 040215 ' 1 • BARNBTABLE, + MAS& Town of Barnstable Regulatory Services g rY Richard V.Scali,Director Building Division Thomas Perry,CBO 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 a er of the subject property hereby authorize /� to act on ray behalf, in all matters relative to work authorize this building permit application for: Address of Job) Signature of O er Date j� Print Nam If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 r Ile ComIHOM'veaIth r�,f-Vassachusetts Depa `hytent cr,f ludusbial Acciderrtr - Offwe-of lnvestrgations. 600 Washington jh eet Boston,41A O2111 ` impi ninssgovIdia Work-ers' Campensation Insurance Affidavit:Blcdlders/CantractorslElecEricians/Plumbers Applicant Information Please Print LeQib Flame(IIusiness ganizatianflndividnal /�/C I�T/T/� / -IV4A) Address: -CG�n� yU1 y city/s�ret G�tir �`�l�-� Phones 6l74�3 7 l Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4 ❑I am a general contractor and I 6- ❑New constructioU employees(full andfor part-time)* have hired the sub-contractors 2.❑ I am a sole proprietor arpartner- listed on the attached sleet 7..❑Remodeling ship and have no employees. ,' These sub-cant rac#ors have $. ❑Demolition wod-ing for me in any capacity employees and hxLa workers' 9. ❑Building addition LNo worken'Comp.insure nce '. Comb-insurance-1 eq ired-j 5. ❑ Nile are a corporation and its lt}❑Electrical repairs or additions 3. am a homeommer doing all work officers.have e=cised their 1L❑Plumbing repairs or additions myself[No workers'comp- right of exemption per MGL 17.❑Roofrepaim innzance required-]1 C.152,§1(4h and we have no. employees.(No workers' 13.❑other comp-insurance required.] AiLyya"H-aCthacchecksbox9lmostalsoMoutthesectionbelowshmiugtheirwoterecumpem%&npoHryinf r=zdmL Ho—who submit dais ai`iid2l'g=ff=tM_gp they axe d=.—ZH war m4 then hira outside conhvctors xst submit a new affidavit mdic=ng surb FCartnctaisYhxt checkthis bw[most attached an additional sheet showing there of the sub-comdixtoa and state whether Or nott-hnse entitiesbave employees.Ifthesub-coat maoEshave empIayees,they must pmri&their wurkr&c=p.policy number. I ant arr e[[iploy[rr float fs pro>tiding ivarirers'con�e[[satio[[insurance for nr*enrp£ay�ees $eto[v is thePUHcy and job rrter information. Insurance Company i�ame: Policy-,4*-or Self-ins.I.ic-Ilk MxpirationDate: Job Site Address: City/Statelzip: Attach a copy of the workers'compensation.polky declaration page(showing the policy number and ezxpiration date). Failure to secure coverage as required under Section 25A of MGL c�152 can lead to the imposition of criminal penalties of a fine up to$UOD.00 andlor on�impfisonrn-A as well as civil penalties,in the form of a STOP WORK ORDER and a rMe of up to$250-00 a dap a4ainst the violator. Be advised that a copy of this statement maybe forwarded to the Office of Imvestigations ofthe DIA for iasu=ce,coverage verification. Ida hereby certffyr nerd tlrs i[s andpen 's ofpedwy f iatthe informa6wi-pmided abm e s tnm mid correct si>mahze: Date: Yh 714(( Phone i OBE at we miry. Do not wrfte in tfris Brea,ter be ca'[npfeted by city artotcn 4ffrciat City or Ttawa: PerudtUcense;9 BSU*Authority(circle one): L Board of HeaIth I ceding Department 3.CitytTowa Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ormation and lastrn.ctions ; Massachusetts General Laws chapter 152 regoaes all employers-to provide worb='comPensation for their en:[PIoyees. pm-suantto this sty,an onployee is defied as. _.every person in the service of another under any contact of hire, express or implied,oral or wri t em" An employer is defined as"an individual,partnership,associafian,corporation or other legal errtby,or any two or more of the foregoing=ga is a joint enterprise,and including the legal representatives of a deceased employer,or the � receiver or trustee of an individual,partnership,association or other legal entity,employing employees- However me owner of a.dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who empIoys persons to do maintenance,construction or repair work.on such dwelling house or on the grounds or building app thereto shall not because of sachL employment be deemed in be an employer" MGL cbapter 152,§25C(6)also states that"every state or lout licensing agency shall withhold$Le issuance or renewal of a license or permit tooperate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.covearage required." Additionally,M(M chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall to ruin an contract for the erf=anee of ubhc wmicuntil ac ceptable evidence of compliance with the fimu-a,ce•. enter any P P regqui mments of this chapter have been presented to the contracting aufhoi*" A.pp4ca-rb PIease fill out the workers'compensation affidavit completely,by checld g the boxes that apply to your sifnaiion and,if necessary,supply sub-contractors)name(s), address(es)and phone numbers) along with their certEcate(s)of „nmarce. Lim.itEdLiability Companies(LLC)or LimitedLiabilityPatta ships(LLP)withno employees other than me members or partners,are not required to carry workers'compensation insorance- If as LLC or L LP does hate employees,a.policy is required. Be advised that this affidayitmaybe submitted to the Department of Industrial Accidents for confrtmation of insarrance coverage. Also be sure to sign and date;.he affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Shouldyou have any questions regarding the law or ifyou are requited to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-fi surance license number on the appropriate line. City or Town Officials t Please be sine that the affidavit.is complete and prk&A 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 store to fill in the pen�o.itllicense number which will be used as a reference number. In addition,an applicant that must submiL multiple pemitllicamse applications in.any given year,need only submit one affidavit indicating current policy inl6mation(if necessary)and under`clob Site Addess"tie applicant should write"all locations jn (city or. ;own)--A copy of the affidavit that has been officially stamped or maimed by the city or tnwn maybe provided to the applicant as proof that a valid affidavit is on file for ftmse 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.yenLrse (i.e. a ens dog lice or permit to bum leaves etc.)said person is NOT req�ed to complete this affidavit The Office of Inons 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 Departmenfs address,telephone and fax Tmmber: Co=loaweala of Ma,Mchusdb-, Degarb.nmt of 1ndusf dal Agent% Of d TILVe&tigafl=.!i �Q4 man S ,(-,d Boston,MA Q11F TeL#617' -4 QgL 406 car 1-977 MA SAS Fax 9 617`27 7M Revised 4-24-07 w w 7.masV_ggfdia oFTME la,, Town of Barnstable *Permit# P� Expires 6 months from issue ate BARNSUBM Regulatory Services Fee 6 9 MASS. g cb i6 9,. .0 Thomas F.Geiler,Director A'EDN'°rp Building Division X,P Tom Perry, Building Commissioner ��� * 200 Main Street, Hyannis,MA 02601 �' M Ivy z, Office: 508-862-403 8 - q y 19 Fax: 508-790-6230 TOWN Of 1 ���2 fit— EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY BA&AIST Not Valid without Red X-Press Imprint L; #/parcel Number •operty Address residential Value of Work /DU wner's Name&Address mtractor's Name mot/ �Csf�.�,fi e/� Telephone Number ome Improvement Contractor License#(if applicable) instruction Supervisor's License#(if applicable) ]WAkman's Compensation Insurance Chepk one: .[ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance surance Company Name orkman's Comp.Policy# .rmit Request(check box) [3/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) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. gnature -orms:expmtrg vised121901