HomeMy WebLinkAbout0068 KATHERINE ROAD 00
Town of Barnstable *Permit#
Expires 6 mo s issue date
X-PRESS PERMIT Regulatory Services Fee
Thomas F.Geiler,Director
AUG - 8 2006 Building Division �l
TOWN OF BARNSTABLEom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
t -
Property Address o ��-�'V 1 Pal'l✓12
Residential Value of Work ,Wb Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address YNa(lt Z( Kee
Contractor's Name l��e Telephone Number Tog -39-9
Home Improvement Contractor License#(if applicable)
i>Jense # ireable{ app - -- — - - -
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
RI 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) ,
URe-roof(stripping old shingles) All construction debris will be taken to _r-,4C w 1L J.�u A,`Q
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
[Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: lssuance 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.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
I ne t,ommonweacrn of lrlusyucnuseeca
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA OZIII
•� www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunabers
Applicant Information Please Print Leeggibly
Name (Business/organiZation/Individual):_ ka e .
Address: `E ��(�S�,�Ju,`�-e �rn�le,
City/State/Zip: . (,c s�/I�D U`�'��CN� 90# OAS Aone#:
Are you.an employer? Check the-appropriate boa: 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. $ 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9, ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical r airs 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 12.0 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 wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tcontractors that cbeck 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 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 hereby certify under the p ins andpenalties ofperjury that the information provided above is true and correct
Signature: Date: �o
Phone#: 5_64�- 1 —j9d-�5/
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.I3uildina Department 3.City/Town Clerk 4.Electrical Inspector S.Plu mbing Inspector
6. Other
Contact Person:
Phone
.r.
FINE, Town of Barnstable
ti
Regulatory Services
' BARNSTABLE, ` Thomas F.Geiler,Director
Building Division
lFD MA'S a
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.tow n.b arnstabl e.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, , 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
Q:FORM&O WNERPERMIS SION
Town of Barnstable
pFTME)per
Regulatory Services
BARN6t,ABLE ; Thomas F.Geiler,Director
MASS.
s639 �0i Building Division
�PrfD MP't Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.1barnstable.ma.us
508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
.ATE: - dL42 c1:o0 b /� I
�B LOCATION: e� P/t� n Q �C l 2 dl 9 LA 6��
number street village
HOMEOWNER! 1 z1^ Kee
name ccyy��/I// •
home phone# work phone#
,TRRENT MAU2NG ADDRESS: 1c7_ 06(1��Q-C uir\
ou e 7�
city/town state zip code
Me current exemption for"homeowners"was extended to include owner-occupied.dwellings of six units..or less and
:o allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
>uperyisor.
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 of 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
resvonsible 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
req ' ements, i
Si a e of Homeown
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 persons)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:forms:homeexempt
I�