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HomeMy WebLinkAbout0019 SOUTH EAST LANE . :_ ;Souk. � = ter.. _ 'h -. ...: r �. ... - � .-, - - - _. s u. .. - .. _ T, �. � , � � � Y _ _ r 7, � � .. o � �� F •,., '. .. � ,III " � .. .. .. 4 F Town of Barnstable *PermitC# -0 t'S a�5�v . O Expires 6 m ,t/s fr t iss.e e Regulatory Services FeeBARNSTABLE MASS , 1639•i639 Richard V.Scali,Director �� Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 . EXPRESS PERMIT APPLICATION - .RESIDENTIAL ONLY P 8 O Not Valid without Red X-Press Imprint Map/parcel Number , Property Address 9 So4-7%CcuF( L A9e CC,- /evhvr ❑Residential Value of Work$ 9'0 d ©0 Minimum fee of$35.00 for work under$6000.00 t Owner's Name&Address R l to &^j Contractor's Name kcwew- Co X Telephone Number S®k` ZY b SO 2 Home Improvement Contractor License#(if applicable) 3 3/�S Email: rU CO x J ct Q Co.L4 C_QJ Construction Supervisor's License#(if applicable) CS '"023 ❑Workman's Compensation Insurance ��� Check one: SS ;5,I am a sole proprietor PEU11 k ❑ I am the Homeowner N®1' 6 ❑ I have Worker's Compensation Insurance V 2015 Insurance Company Name TO WN OF BA R N S TA B LE _ 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) ,r Re-side ❑ Replacement Windows/doors/sliders.U-Value- (maximum.32)#of windows #of doors: ❑ 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 require SIGNATURE: w QAWPHLESTORMSUilding permit fonns\EXPRESS.doc ` Revised 040215 fll � r ?lie CQmmarr>'veak3i of 1Flassticlrusetts Department o, IndushialA.ccidents Offi-ce of fmWstigalions 600 Wasiiirigdon Street- L . Baston,E CIA 02111 4 wivistinaxLgrrvfiiirt ' '"Takers' Compensation Insurance Affidavit:B.uildersiContradursl'EIectricians/Plu nbers Applicant InfGnnatian Please Print Leib Name(Busi�anizafionandividad): PC Q c® Address: souk CQ57&tfe a e,i7—e.,—L, Citylsta&zip: e���v,' lP c'JS: 9,16 3 Phone SAS= �3 �So Are you an employer?Check the appragriate baz Type of project(required}: 1.❑ I am a employer with - 4. ❑I am'a general contractor and I T ❑I pr jectcons r equir employees(full andfor part-time)-* have hired.the sub-contractors 6. 2. I am a sole proprietor or partner- listed on the attached sheet: 7- 0 Remodeling ship and have no employees. These sub-contractors have 8. ❑Demolition wa tking for me in any capacity: employees and have workers' [No nnorSaers'comp.it surance comp.insurance-, 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeovmer doing all work officers have exercised their 11_❑Plumbing repairs or additions myself[No workers'comp- right of exemption per MGL 12-❑Roafrepairs insurance required,]T c.132,§1(41 and we have no , employees.[No workers' 13 Other"rC f i - comp-insurance required_] #Any a"ficant that cbedcs box AlurnsI also fill cut the section belowshowi g their wotisers'compertsa&npolicyinfrmat-sal I Fi m ownem who submit this affidndt indicating they are doing an wat and then}tire outside coattactars mast submit a new affidarst indicating sadL fCanttactors that check This boar mast attached m additional sheet showing the name of the sub-contractors Md state whether at not those entities have emplayeas.Ifthe subtaatractumhace employees,theymust p nide their workers'comp.policy number. I atrt aru smpioyer tJlaf is pro�zdir ytiarkers'conlpertsatioe i��srirarrce for Orr}*enrpIaj es. Below is the poicy aril job sfte intformadon. Insurance Company Name: Policy,or Self-ins-Lic- Fnipiratioa Date: Job Site Address: h e 7 LR. CitylState)Zipr:_ald cs -" o 6 �- Attach a copy of the workers'compensahonpolicy 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$UOD.0D andf'or onee-yearimprisomn-A,as we11 as civil peualties.in the form of a STOP WORK ORDER and a fine of up to.$230-D0 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofdle DIA€or insurance coverage vufrcation I do Ieer1r.by Ceti the 'its ands rlaNes ofFedwy that the informadan pt mined abmv is bare and correct ' Sitmature: Date: Phone sO /3�" G c7 d�� U,,oacial use only. Do not at.rke in this area,to be completed by city or town official, City or Town: PermtitUcense 4 f Issuing Authority(circle one): 1.Board of Staple 2.Building Department 3.Citylrown Clerk 4:Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Iastruefions Massachusetts General Laws chapter 152 reqaiirs all employers to provide workers'compensation for their employees. Punsnantto this stHJMte,an.Errzplayre is dewed as_"_.every Person in the service of another under any contract of hie, express or implied,oral or written." I An Mplay8'is defined as"an individual,par(nersbip,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,padnersiip,association or other legal entity,employing employees. However the owner of a dvveIIm g house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or oa the grounds or brie appurt euautthtmt o shaR not because of such employment be deemed to be.an employer." MGL chapter 152,§25C(6)also sides that"every state or local licensing agency shaII withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the incnran ce.coverage required" Additionally,MCrL chapter 152, §25C(7)states"Neither the Comm onweallh nor any of its political subdivisions shall enter into any contract for the performance of public work until nt it acceptable evidence of compliance with the insurance:. ce._ req uir en ents of this chapter have been presenind to the contracting autTioaty" Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your sitnation and,if necessary,supply sub-contractors)name(s), addresses)and phone n=ber(s) along via their certificafe(s) of in ounce. Limited Liability Companies CLLC)or Limited LiabilityPartamships(LIP)withno employees other than the members or partners,are not required to taffy workers' compensation ias¢rance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of incrrranc-e coverage. Also be sure to sign and date the affidavit- The affidavit should be retuned to fine city or town that the application for the permit or license is being requested,not the Department of hadngti al Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please caIl the Department at the number listE below: Self-msu-ed companies should enter their s elf-in s rrar,ce license number on the appropriate line. City or Town Officials . t _ Please be sole that the affidavit is complete and prinEed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sine to fill in the pen iWlicense number which will be used as a reference number. In addition,an applicant that mint submit multiple permitJlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (cry or town)_"A copy of the 7afffidavit that has been officially stamped or maimed by tame city or town may be provided to the - applicant as proof that a valid affidavit is on file for future permitr or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le. a dog license or permit to burn leaves etc.)said person is NOT reqaired to complete this affidavit The Office of Invesstigaations would hke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a ca.IL The Department's address,telephone and fax number: The CG.=MM t1a of Masnchussft s , Dtpartru t of Iadu&friak Agents �of�vesfig�tzo� Goo,wasbi OGIL Stet ' Bostoij�,MA Gil I I Tf,-L 4 617'27-4900 Qxt 4-06 ar 1­9 SAF7 Fax 9 617-727 7M Revised 424-07 snas,- goglctia anxxsrnsis. « ' ' ,��' Town of Barnstable " Regulatory Services Richard V.Scali,Director Building Division _ Thomas Perry,CBO 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 Section. If Using A Builder " as Owner of the subject property hereby authorize �0 Q� CCU to act on my behalf, in all matters relative to work authorized by this building permit application for: q S E LaNe , Ceti V1, f 12 fYJ (Address of Job) Signature f er -Date . . Print Name t, If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILES\FORMS\building permit forms\EXPRESS.doC Revised 040215 ; Town of Barnstable Regulatory Services �oF r°if� Richard V.Scali,Director Building Division 1 HARNSTA13M Tom Perry;Building Commissioner tKnss 1639. `0� 200 Main Street, Hyannis,MA 02601 pTED � www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home 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. 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 requirements. Signature of Homeowner i 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 form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doo Revised 040215 Massachusetts -Department of Public Safety Board of Building Ile' fA f)ops,and Standard ' '•l.3 11 ` '.. EOWStructirin Superwistir License: CS-07 5 388 ROGER T COX 19 SOUTHEAST CENTERVILLE ILIA � ��- Expiration Commissioner '03112/2016 �L Office of Consumer Affairs&Business Regulation . ., f,icense or registration valid for individul use only I,� HOME IMPROVEMENT CONTRACTOR .'before the expiration date. If found return to: Registration;_. 133775 Type: "Office of Consumer Affairs and Business Regulation k-M ,, Expiration 8/7/2017 Individual -10 Park Plaza-Suite 5170 Roger T.Cox Boston,MA 02116 Roger Cox ' 19 Southeast Lane Centerville,MA 02632 Undersecretary of valid without signature t Town of Barnstable ��1NE Tp� do Regulatory Services Thomas F.Geiler,Director * BAMSTABLE. v� MASS. q Building Division ATEp �a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 n ` Fax: 508-790-623( PERMIT# FEE: $ SHED REGISTRATION 2 120 square feet or less `� sd L�-�IfC� -Z-4 ti CC-�� ie-v- U;Jle Location of shed(address) Village r y(Cr nJ (moo iu S'a Property owner's name Telephone number Size of Shed Map/Parcel# / 1 b-17, ©Q,�-r Signature Date Hya is M n reet ater nt oric striet`�`— O K' g's hw Historic strict Co ris iction. Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg ( n REV:042506 b� ea 4 1 MA 1 9 ° 44 ye MAP 189 o ' 4 p4 \ \ c 1\ --------------- AP 89 P 189 0 # MA 89 0 0 # 13 MAP I E 9 14 4 # 31 / /MAP 01.2 8 MAP 189 # 4 \Desktop\Conservation.dgn 5/19/2006 3:41:21 PM