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0153 NOTTINGHAM DRIVE
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I-, , - i, , LL of jk 1 ,,L�` _1,11�11_� "'I"L,','�'r,'I" ;1'21� ��.,.;,i,t �,']. ,.��,�,,,L ,, 1,L __ - : , , ,, �, A., A,. , ,�, , � , 11c I -, T,�", ,,A�f,�''-"4v . , , . . �', ,: , " ,it 1 �";;""�,,� :"",�""4�,,,,�"�',,'�",.:�,'�,",',',',,,,'-��� ::�� �:'�": _ .�,�:, "il"- i . - �_ !_ :,c,,, _,,� , _ _ __ � .._,�L_,� -�, � -, �, _ � - -.1-1 11.� � .' ' . r r 1 �t Town of Barnstable *Permit#doos oD D f Expires 6 months from issue date °� 1`tegulatory Services Fee arxtvsTnsi R 2 Thomas F.Geiler,Director g 2008 Ar Building Division SARN' A Perry,CBO, Building Commissioner 00 Main Street,Hyannis,MA 02601 www.townbamstable.ma.us Office: 508-862-4038 Fax: 5087-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ��2. 0AS Q Property Address 1Qt+� WJ� . y L� .'Residential Value of Worl �t Qb0•D Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number (yfo2 2 ly l 2. Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Chec_k one. am a sole proprietor I 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) ❑ 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/doors/sliders.U-Value (maximum.,3�<•#4 *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 is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers Applicant Information Please Print Legibly Dame(Business/Organizaiion/Individual): Address: City/State/Zip: Phone-#: Are you an employer? Check the appropriate bog: 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 stab-contractors 2.❑ I am a•sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contactors have g, E]Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers'comp.-insurance comp.insurance.x d.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3. Iequire am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myselL[No workers' comp. right 6f 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 chaelm box#1 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 contractors must submit anew affidavit indicating such. tContractors 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 pravidt 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 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 crinih al penalties of a fine tip 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 ce ;fy under the pains d penalties of perjury that the information provided above is true and correct. Si ature• Date: Phone# Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense#. d Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructio'n.s Massachusetts General Laws chapter 152 requires all employers to provide workers' mpensation for their employees: Pursuant to this statute,an employee is defined as"...every person in the service of other under any contract of hue, express or implied,oral or written." An employer is defined as an individual,partnership,association,corporation other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal represen fives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal en employing employees. However the owner of a dwelling house havig not more than three apartments and who r sides therein,or the occupant of the dwelling house of another who a loys persons to do maintenance,cons ction or repair work on such dwelling house or on the grounds or building app nant thereto shall not because of sue employment be deemed to be an employer." MGL chapter 152, §25C(�also states t every state or local licens g agency shall withhold the issuance or renewal of a license or permit to oper to a business or to construe buildings in the commonwealth for any applicant who has not produced accep le evidence of comglia a with_the insurance coverage required." Additionally,MGL chapter 152, §25C(7)s tes"Neither the comet wealth nor any of its political subdivisions shall enter into any contract for.the performance o ublic work until a table evidence of compliance with the insurance requirements of this chapter have been presen d to the con authority." Applicants Please fill out the workers'compensation affidavit mpletel ,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address s)and hone number(s)along with their certificates)of insurance. Limited Liability Companies*(LLC)or L' 'ted L ability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'co ensation insurance. If an LLC or LLP does have employees, a policy is required Be advised that this .t may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the rmittor license is being requested,not the Department of Industrial Accidents. Should you have any questions reg the law or if you are required to obtain a workers' compensation policy,please call the Department at the r listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly.\apa epartment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Invens has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will bea reference number. In addition,an applicant that must submit multiple permiVUcense applications in any givneed only submit one,affidavit indicating current policy information(if necessary)and under"Job Silre Address writ should write"all locations in (city or town)."A copy of the affidavit that has been officiuy stampedk by the city or town may be provided to the applicant as proof that a valid affidavit is on file fo{future permce es. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining license or pt re ted to any business or commercial venture (ie.a dog license or permit to bum leaves etc.)said person is Nuired complete this affidavit.The Office of Investigations would like to thank yu in advancer coop ation and should you have any questions, please do not,hesitate to give us a call The Department's address,telephone-and fax n er. The egpCa onelth a of Massachus Dartm nt of Industrial Accidents OM a of Investigations 600 ashington Street Bo n,-MA 02111 W. #617-727-4900 ext 4-06 or 1=$77-MASSAIVE t Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia r- Town of Barnstable �pFSHE tp�� y� o� Regulatory Services swxtvsrAsr>v. r Thomas F.Geiler,Director y Mnss.. $ �p 1639. �� Building Division lFD �p Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: . d �� �/� JOB LOCATION: �b J ��/Q t 1 I I1GM. Yvan - 0;1 It "he number 1 street F village .HOMEOWNER': �'��1� If ��lJ"17�s`�� (01 Z name /� 1 home phone# work phone# CURRENT MAILING ADDRESS: eh C2s tV oiiial 04 4, 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 t`6-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 requireme 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 pen-nit 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 homeowneris 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. L•. oF1HET� Town of Barnstable ti 0 Regulatory Services ELAAMSTAB Thomas F.Geiler,Director i639• ��� plF639 a 'Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner ust Com lete and Sign T is Section f Using A Bu' der as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by s building permit application for: (Address of Job) -Signature of Owner Date Print Name If Property Owner is yin or pe it p ease complete the Homeowners License Exemption Form o( the reverse side. (1•Pni?AAQ-OWNPR PPR MPQQJ0M