HomeMy WebLinkAbout0040 LAUREL ROAD :yo n
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Town of Barns a e *Permit#
Expires 6 months from' ue dat
Regulatory Services Fee
sMASS.
`g Thomas F.Geiler,Director OK ylll I�?
pTFD MP't e
eL
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 D z,,,.,'e- j
®Residential Value of Work
_19,40 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) 3�s Ong P ' IT
Construction Supervisor's License#(if applicable) C J S L-S Z-� 4 2�13
❑Workman's Compensation Insurance
Check one: BLE
I am a sole proprietor TOWN OF BARNSJTA—
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
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 be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side #of doors
# windows
Replacement Windows/doors/sliders.U-Value '� (maximum.35) of —1--
❑ 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
re ed
SIGNATURE:
n��mcrr RC\Fr1RMR\hnil1
ina permit forms S.doC
i
?axe Comnron wealth a,f Massachin lts
Z artm,ent of Inciu &ial ccidenft
Office of Investigations
600 Washwgton Street
Boston,Md 011.1 .
?MIV. as&go v/dia
Workers' Compensation Easvrance Affidavit B ildersfC.ontractors/Decfric.ans/Phimbers
Apphcant Information Pease Print LIeaffi
Name 4B
hQnllmr3iviclnai): i'f'S+ 2 4u
Address:
02 Z
City/Stat&Zip: �(v Phone 4-
Are you an employer?Check the appropriate box Type of project(rewwred):
. ❑ I am a general contractor and I
l_❑ I am a employer with 6_ ❑New consfrwtion
employees(fun andlorpart-time)-* have hired the sub-cent ackn-s
listed on the attached sheet 7. ❑Remodeling
2.�� I am a sole grnprie3oi orpartnec- .
ship.and have no employees These sub-contractors have S. ❑Demolition
wcddn,g for me in any capacity. employeesand have workers' § ❑Building addition
o. amp-g'C insuranceCQrrYp_mcnraru�$
ice' ��S' 5. ❑ We are a corporation and its 1D.❑Electrical reFsiss or additions
rewired_]
t�
3-❑ I am a homeowner doing all work ce s have exercised ffitir 1 I.❑Plumbing repairs or additions
myself[No workers'comp_ rightof exemption per NfGL 12.❑Rflof repairs
i nmra ce required,]T c.152,s§I(4)6 and we have no
] 13.❑other
employees-�o workers'
comp.insuranm required.].
'Any appficza tfiat dmc3m box n mast also u oat the section below sbawiug dheir vole&compensation poricY infbnnsdon-
II Ijameovnmm who submit Ibis affidsvd iud cat kg fty azedomg sU v at and tfien hoe outside contscmn amst sabre&anew affidavit indicating such.
1.oni cmm that f-hea this boa:mu a xttwlwd an mmitianat sheet showbg the r=2e of the s6-C mnmcbm smd Mte whether OF IIOt'IbDSE S b8S 2
empjaYee, Ifthemb-contlacia have emplcyeeii they=unpmvidetbw wrote s'rmp.policynumber
lam all emp€o�,or tliatis providing worke-rs'cc ngmsadon in=ramce for r2ay Mgla}{egs� Bda"is the po icy dadjob srfe
• inforrl�rrdtc�n .
h sumce Company Nam:
Policy#or.Self-ins-Lic.# Farpiration Date_
Job Site Ade�ss: Gi#yfStatelZip=
Attad k a copy of the workers'compensation policy declaration page(showing the policy mmbec and espAration 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 S 1,50D-OD and/or one-year imprisonmenk as well as civil penalties is the€aim of a STOP WORK ORDER and a fine
of up to$250-00 a day against the viob itar. Be advised that a copy of this sbdement may be forwarded to the Office of
bnestigations of ire DIA for insurance coverage venfca ion- '
I do hereby ce--riA #Its ins andpenaUhrs afpet q that the infurnsa#irta provided above is d w and correct
Si Date_ `� 3
Phone 9-
fa cial its+tr and}: Do not writs ih Ifi&aced,Ev be WINFIderd by cio or laical 401ciA .
tw Tom. Perud-alcense#
Issuii4 Authority(cffele one):
1..Board.-of De:ltih 2.Building Department 3.Q.tyfrown Cleric L Electrical Inspector 5.Phunbiug.Inspector
6. tI er..
Phone#: . ..
ME
• sexxsTnst.E.
1639. ,�� Town of Barnstable
.. . 'DrEa Mai"
Regulatory Services
Thomas F.Geiler,Director
i r
Building Division
Thomas Perry, CBO
Building Commissioner
200 Main-Street,, Hyannis,MA 02601
www.town.barnstable.ma'.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Ownea Must -
Complete and Sign This Section
If Using A Builder
u-) ; as Owner of the subject property
hereby authorize I&S1 I &7111R1-*,% to act on my behalf,
in. all matters relative to work authorized by this building permit application for:
(Address of Job)
/.)
i 6 l
Signature of wn Date
Print Name
If Property Owner is'applying for permit,please complete the Homeowners License Exemption Form on,the
reverse side.
Q:IWPFILESIFORMS\building permit fbnnslEXPkESS"doc _
a
°FIME T° Town of Barnstable
P °T Regulatory Services
BARNSTABLFE ' Thomas F. Geiler,Director
iDrf16.3 Building Divis'on
Tom Perry,Building Co missionec
200 Main Street, Hyannis MA 02601
www.town.barnsta le.ma.us
Office:. 508-862-403 8 Fax: 508-790-623 0
OMEOWNER LICENS EXEMPTION
Please Pri
DATE:
JOB LOCATION:
number st et village
"HOiAEOWNER":
name home one work phone#
CURRENT MAILING ADDRESS:
7
7
city/town state zip code
The current exemption for"homeowners"was extended to ' clu owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not osses a license,provided that the owner acts as supervisor.
DEFIN TION O HOMEOWNER
Person(s)who owns a parcel of land on which he/she resi es or inte ds to reside,on which there is, or is intended to be, a one or two-
family dwelling,attached or detached structures accesso to such us and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a ho eowner. Suc "homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be es onsibI for 11 such work performed under the buildin permit. (Section
109.1.1)
The undersigned "homeowner" assumes responsibili for compliance wi the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned "homeowner"certifies that he/she nderstands the Town o Barnstable Building Department minimum inspection
procedures and.requirements and that he/she will co ply with said procedur s and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 5,000 cubic feet or larger wi I be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTIO
The Code states that: "Any homeowner performing ork for which a building permit is r quired shall be exempt from the provisions of this section(Section
109.1.1-Licensing of construction Supervisors);provided that i the homeowner engages a person( for hire to do such work,that such Homeowner shall act as
supervisor."
Many homeowners who use this exemption are unaw re that they are assuming the r onsibilities of a supervisor(see Appendix Q,Rules&Regulations for
Licensing Construction Supervisors,Section 2.15) This lack of a areness often results in serious problems,particularly when the homeowner hires unlicensed persons.
In this case,our Board cannot proceed against the unlicensed per n 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/ber ponsbilities,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. t!
Massachusetts -Department of Puijk- safety
Bo:rd of&+i!d;ng regulations and Star-lards �e
tOffice of Consumer Affairs&Busibess Regulation
Carp ruction Supervisor
OME IMPROVEMENT CONTRACTOR
License C�-08259 _ egistration: 141496 Type:
a 441 xpi ratio n 4/26l3014, DBA
RASE:J CON('RO" r
7 DANA RD CON O REMODELING
FORESTDAVE
BASIL_CONGRO
7 DANA RD. L
xpr.ratiGn 1 FORESTDALE, MA 026413_. s y` Undersecretary I
GtamrPrisioner /2013 ..
i V�• _
r
License or registration valid for indrvidul use only,
before the expiration date. If found return to: .
Office,of Consumer Affairs and Business Regulation
i 10 Park Plaza-Suite 5170
Boston,MA 021.16
i of v` id "t.ho: ,:signature
i
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