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Home My WebLink About0015 LAKE DRIVE � � ' x ' �' � ., �. �FO. .. - 0 �. ' ♦ � � • -. .� �. y .. e F �- y - �. . iy i o � ' ., ;' ' ti ;.. .. ,. t � .. y .: r �. ,. � .. ,. ., . � .. - THE r Town of Barnstable *Permit# G� j p Expires 6 nnondrs front issue date Regulatory Services Fee * BARNSTABLE, v� 639. `�� Thomas F.Geiler,Director AT r A ' Building Division Tom 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 . Property Address ��°,',��Q /% A e I V Z �j [Residential Value of Work �(j Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 4- ��i4 c.l ilk Contractor's Name Telephone Number q"/z— Z4 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a.sole proprietor OCT I am the Homeowner _ LUU9. I have Worker's Compensation Insurance p TOwN OF BqRNSTgg�� Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) f Re-roof(stripping old shingles) All construction debris will be taken to /1/0 0IV41✓ . ❑Re-roof(not stripping. Going over existing layers of roof) Re-side #of doors ° Replacement Windows/doors/sliders.U-Value (max.imum.44)#of windows (� *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. , IL SIGNATURE: </ C:\Users\decollik\AppData\Local\Ivticrosoft\Windows\Temporary Internet Files\Con ten t.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 4 The Con ntoniveallli.of Massadiusetts Department .._ 1 Office of Investigations E- 6,00 Washington Street Boston,MA.0211'1 .•F N,'4tli'.r�la�S.gl7v1 if Workers' CompensatiGn.Insurance Af'fidmit: Builders/Conchae-tors:/ElectjicL-ins/Plumbers Ap licaut Information Please Print Legiull, Name(Business/Orgau zatiolidudivid€tal)_ JA QJ 3 a- L K) AJ r- / Address: /_6 A D/C i Ciiy{IStat Zip: �vl�f`�R V'� LLCM G�6.upilone /g- —g�y0 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 employees(full and/or part-time),*a 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. employees and have workers' .[No workers'comp_insurance comp-insurance I _ ❑Building addition required..] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions. 3. I am a homeo-amer doing.all work. officers have exercised their 11.❑Plumbing repairs or additions my lv1 self: No workers'ca' right of exemption per CL c. 152,s1 4,and we have.no 12❑Roof repair-. iststtrartce required.]i � �' � 13:❑$Jt11er employees.[No workers' comp.insurance,required-] 'miry applicant thM checks box C musti also fill oufdte section below showing their r eA—ers'compensation policy information. f€omeowrmers who submit this affidafint indicating they are doing all work and ffien.]sire outside coutracrors roust submit a tees-aff€dsvit indicating such. !contractor.,that check this lrox trust attached an additional sheet showrau-the omn:vf the sub-contactors and state'whether or not those entities have employees. If the wht rontracrorshace-employees,they must pm de their trorktus':comp.policy dumber. .I:Arr!All ernplayer tlant ispY0l+iclatrg itror'.�Stia`S'L"Onap'ertSAta ra irr5rlYAnC@,for�rrtt'etttptrr}�ees. Beloty is�thepolact!and job site alf�oYrlrRtlArr.: Insurance.Company'-Name: Policy;P+or Self-ins.Lie-:.4: Expiration.Date: Job Site.Address: cityfstateiZip: Attach a copy of the:worke-rs'compensation policy declaration page(slionring the policy number and expiration date). I:allure to secure co v erage as required reader Section 25A of MGL.c.. 152 can lead to the imposition of criminal penalties of a fine gip to$1,500M and'or one-year imprisonment,as well as civil penalties in the form of a STQPE''€7RK ORDER and a lint_ of up t4 V2150.00 a day against:the violator. Be advised that a copy of thin statement may be fora,,.,arded to the Office of Investigations of the DU for in urance:coveragee verification- I rlv pert b f under the p 'ras Arad penalties of p 'it, At t7a€aatf�rrrtrala�aaa prat araert colas,/e^is to Apad c.rwrect Simature.: Date: Phone#: Official is se onty. II�not+tYite ifs tltas Aa erl�to lie rornyteteri bt=ciYt or knot n o��aal City or Taws: � PeriniffLicense#. Issuing Authority (circle one): L Boars!of Health `2.Building Department 3.CittfFbrr=n Clerk 4.Electrical Ins-pector 5.Plumbing Inspector ' 6.Other Contact Person: Phone#. �FTME_ Town of Barnstable Regulatory Services &'RMASSS. E Thomas F.Geiler,Director i639 v�A . ,0g' lf039.tA Building Division Tom Perry,Building Commissioner 20.0 Main Street, Hyannis,MA.02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print ADATE:/ j s^�JOB LOCATION: r�5- / numbdr street �village . "HOMEOWNER":_ 1 RNI c�].�� name home phone# work phone# o< f�,C1-�I CURRENT MAILING ADDRESS: L , )Zb ._ 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 f proce es and r uirements d that shill comply with said procedures and requirements. a / 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 foniVicertification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809