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Home My WebLink About0129 HAYES ROAD (, 4 q �`411 "W, AT V MOM 6 A OWN" 14 fig Akf MV Mail,111 �5 vp �15 row, —MM MWRI-i-N g YMAi4i 1� k1MI NINE Milli "'M 32 am P,Niii 5 5f -All t v USE PRO 3,140 1 "Ali , -10"I R M"L , ?!,.. 11M,i- r f I r WE Town of Barnstable *Permit# `i lib 705 7q� r O Expires 6 monttes front issue date AASN51ABl. Regulatory Services Fee� ;. MASS. $ Thomas F.Geiler,Director r�b+��' Building Division I Tom Perry,CBO, Building Commissioner . 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us I Office: 508-862-4038 Fax: 508-790-6230 i EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number .2 [)ci 5 i Property Address 1 � 1 1 c` Ve�,r-; Gm4-e y i I Ie m A o o- (e t-�a �J Residential Value of Work ' , 00�y� ° Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �r al 16 Pi }��^teai Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) 0 C°l Construction Supervisor's License#(if applicable) El)fell- ❑Workman's Compensation Insurance E � S T Check one: �s=�;:.�°m' " � f. "�i, ❑ 1 am a sole proprietor 1 am the Homeowner S E P 14 2007 ❑ I have Worker's Compensation Insurance Insurance Company Name TOWN OF BARNSTA5 Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Pen-nit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i:e.rHistorie,.Conservation,etc. ***Note: Property'Owner must sign Property Owner Letter of Permission. ome Improvement C ract s License is required. CiU i,6 SIGNATURE: Q:Forms:expmtrg f. Revise071405 The Commonwealth of Massachusetts Department of Industrial Accidents € Office of Investigations 600 Washington Street Boston, AM 02111 , www.mass.gov/dza Workers' Compensation Tnsurance.Affidavit .Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. Address: rg\,/ ��(2 City/State/Zipah�O If, Mn 0aWo Phone.#: q-2 Lg a3 Are you an employer? Check the appropriate box: -Type of project(required): 1.❑ I am a employer with 4. T am a general contractor and T employees (full and/arpart.time).* have hired the nb-contractors 6. ❑.New construction . 2.❑ I am a.'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me,in any capacity. employees and have workers' ' co insurance.$• 9. 0Building addition [No workers comp. insurance comp. XmyseZ requied.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing allwork officers have exercised their 11.0 Plumbing repairs or additions [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance,required.] t c. 152, §1(4),and we have no employees, [No workers' .•13.❑ Other comp. insurance required.] . *Any applicant that checks box#I 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 contractor;must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providb their workers'comp.policy number. , I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Sdf-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. Ido hereby certify under the pains•and penalties ofperjury that the information provided above is true and correct: Simature: p Date: 9 - 1�_, 07 _ Phone #: a Official use only. Do not write in this area,'tb 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 CIerk 4. Electrical Inspector S.Plumbing Inspector . 6. Other Contact Person: Phone#: ppTHE rp� Town of Barnstable Regulatory Services IARNSTABM .' Thomas F. Geiler, Director Muss. 019. �� Building Division Arlo r. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ` Please Print DATE: q ` / O JOB LOCATION: Vi J number rr ga (( �_p str et �f p l a vi�llaagge "HOMEOWNER": w l I K� Pj 1W P C 0 (e r9, 0 3 6 / name . home hone# /� work phone# f CURRENT MAILING ADDRESS: C 6 A ► vl rD La t.— 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 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 and that he/she will comply with said procedures and requir ents. Sign ture 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 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.