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Home My WebLink About0004 SOUTH EAST LANE .. i� ,., 9'.. '.. A. � ... � � _. � r. ,. i i f -. , .. ., � h ,. .. :. _ .. :S u b .4. _ .'� a .. � - .- .. . ,' �� s G� ^ � 4 .. - '. .. 'vl ,. � �. .. �. �. ` 6 '. -� .. -, , ,.;� oFT�t Town of Barnstable c� Expires 6 month om 'sue date Regulatory Services Fee sntexsreata, asnss. 16g9. 0. Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �" So U 'jam t\\ $ I L C S LL r r� ❑ Residential Value of Work 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) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ,44KESS P Check one: * ' ❑ I am a sole proprietor A U r F. ?(11 I am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABL Insurance Company Name' Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) A ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side #of doors Replacement Windows/doors/sliders.U-Value_�3 (maximum .44)#of windows �p *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. R A copy of the Home Improvemen Contractors License& Construction Supervisors License is �,. required D SIGNATURE: Q:IWPFILESTORMSIbuilding permi formslEXPRESS.doc Revised 070110 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/Electricians/Plumbers Applicant Information * ( Please Print Legibly Name (Business/Organization/Individual): d�IR..t kL�� I`�G wS_�, °v'a Address: City/State/Zip: Phone M S ' Are you an employer?Check the appropriate box: Type of project(required): ` general contractor and I 1.El I am a employer with 4. 9 I am a g 6. ❑ New construction employees full and/orpart-time).* have hired the sub-contractors ( 2. I am a sole proprietor r partner- listed on the attached sheet. 7. ❑Remodeling ❑ p p o pa er ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' ,Y9. Building addition comp. insurance. ❑ g [No workers comp. insurance P required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 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 who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 pains and penal ' s of perjury that the information provided above is true and correct. Si atur — Date:' Phone#: 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.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual): ,i 14 rAd—d:r:e:s:F ?,D City/State/p �S' °T��6� � Phone#: 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).* have hired the sub-contractors 6. ❑ New construction 2.19 I am a sole proprietor or partner- listed on the attached sheet. 7. Memodelig ship and have no employees 'These sub-contractors have, g, emolition working for me in any.capacity. employees and have workers' [No workers'comp.insurance comp,insurance.# 9. ❑Building addition required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t a 152, §1(4),and we have no employees. [No workers' 13.0 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 who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 provide 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 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 nd r the pains and penalties of perjury that the information provided above is true and correct Si afore: ,•-D�^ f Phone Fc fficial use only. Do not write in this area, to be completed by city or town official ity or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 14.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person.- Phone#: Town of Barnstable mop THE Tp� - y�P Regulatory Services BARNSTABLE, : Thomas F.Geiler,Director Mass. 1659• ,��A Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 50,8-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: — f t JOB LOCATION n inber street village "HOMEOWNER": r name ome phone# work phone# CURRENT MAILING ADDRESS 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. PP � Y � , The undersigned"homeowner"certifies that he/she understands the Town of Barns table table Building Department minimum inspection procedures and requirements.and that he/she will comply with said procedures and re ' ements. 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 super�isor." 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 IHErati Town of Barnstable Regulatory Services w saxxsresLE, v ass Thomas F.Geiler,Director pTFo - 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 Must_ Complete and Sign This Se t'on If Using A Builder L Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to wor uthorized by this b ding permit application for: (Address ) y Signature of Owner ate Print Name If Property Owner is pplying for permit please complete the Homeowners Liee e Exemption Form. on the reverse side. QSORM&O WNERPERMISSION