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HomeMy WebLinkAbout0093 TERN LANE A S n ' � a of t►+E r Town of Barnstable t Perm-it# Y-3— Evpires 6 montlu frau issue date Regulatory Services Fee Y * BARNSTABLE, " v MASS. Thomas F. Geiler, Director j �p 1639. (7� rFDMA'tA Building Division Tom:Perry, CBO, Building Commissioner ® �- 71z016�?4L 200 Main Street, Hyannis,MA 02601 www.town.bamstable.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--_ s 7/ //�f /�!'3: ' aZU� -- Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address C �, ?%t �� Contractor's Name Telephone Number I Ionic Improvement Contractor License#(if applicable)__/�� � Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance 'ya r � z Check one: JUL � � �po� ❑ I am a sole proprietor UI am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp. Policy#— k Copy of"Insurance Compliance Certificate must be on file. Permit Request(check box) / [�e-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U=Value (maximum .44). *Where required: Issuance of this pennit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:'WPFII..GS`.PORMS',.building permit Pons\EXPRESS.doc Revised 100608 f The Commonwealth of Massachusetts .Department of Industrial Accidents Office of Investigations 600 Washington Street �< Boston,MA 02111 wrdw.mass.gov%dia Workers'Compensation Insur'ance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant information Please Print Legibly. Name (Business/Organization/Individual): �zW&.,W eg u � d2�_ Address: n�.� Z ,V ::;er City/State/Zip: Phone.#: `�vZl - Are.you an employer? Check the appropriate box: .Type of project(required):. 1.❑ I am a employer with _ 4. [] I am a general contractor and I • * , .have hired the sub-contractors 6. []New construction . employees(full and/or part-time). 7 01 Remodelin 2.[] I am a•sole proprietor or partner- listed on the-attached sheet. 62 g ship and have no employees These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' 9• Q B��g addition comp, insurance,$ [No workers comp.insurance 10.❑Electrical repairs or additions required.] 5. [] We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL . 12,0 Roof repairs insurance.required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp,insurance required.] *Any applicant that checks box#1 must also fill o.ut 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. . lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy and job site information. Insurance Company Name:--� 06 — Policy#or Self-ins.Lic• Expiration Date: -Job Site Address: , /,�, 11� City/State/Zip:ar ��/- 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 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 maybe forwarded to the Office of. Investigations of the DIA for insurance coverage verification. I do hereby certify un r the pains-and penalties of perjury that the information provided above is true and correct.. Si attue: / Dater — Phone# Official use only. Do not wrife 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#: Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of brie, express or implied,oral or written." An employer is defined as "an individual,partnership,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,partnership,association or other legal entity,employing employees. However the owner of a dwelling 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.on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall 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 insurance coverage required." Additionally,MGL chapter..152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented•to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number 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. 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 sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 (city'or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits 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 (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. Cox mollwe aJ.t6 of Musachuset S DQpart mmit of lnd-u t al Acc &uts (.office of fuvest gatious 600 Washington Street Bostw,.lulA 02111 TO. 617-727-4900 ext 406 or 1-977-MASSAFE Fax##6.17-727-7749 Revised 11-22-06 ' www.mais.gov/dia I SHEra,� Town of Barnstable .� Regulatory Services vBM MA&L � Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: S08-790-6230 Property Owner Must Complete and Sign This Section If using A Builder as Owner of the subject property hereby authorize ,:2X&2,0 Z�ldk to act on my behalf, in all matters relative to work authorized by this building permit application for:. (Address of Job) Signature of Owner ate Print Name If Property Owner is applying for permit please complete the. Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Town of Barnstable ��Op THE r�y Regulatory Services , BARNSTABLE, : Thomas F.Geiler,Director MASS. 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 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 Approval of Building Official � t 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/certifi cation.for use in your community. Q:forms:homeexempt C.) . Iry�I=-• P. _ 8 6 °MM. CERTIFICATE OF LIABILITY INSURANCE Opio Xo LOATe1MWDOMIY, H DAVA 07/21/06 � �oDUCSR -,4W lS CERTJFICATE!6 l4lS 6ED Ag A MATTER OF INFORMATION ONLY AND CONFERS NO R113HYS UPON THE CEIRTIFICATE tinrtl�'MOC t Zas. �etavy e 2'nu. HOLDEFt TMS CERTIFICATE DOES N OT AVENA,E XTEIVD OJi $05 West Wain 9tre*t ALTER THE COVERAGE AFFORDED BY THE,AOUCJE.S ReLGW, Hyarmis >lJ;,A 02601 Phone i 508-795-1632 3'Eura 808-393-2585 INSURERS AFFORDING COVERAGE � _ NAIC# IIs6WAED j INSURER A: Travelers Xneurmce Co. !INBU M 0: rxaoelara snauaaswe ea.p"y ��_..._• David Cox, c. }I•NSUrZR c, _ a Xsimout>�60�1 02654 !INN ISURER D: SURER E: COVERAGES THE PUL CIE$OF iNSURWCB Lt3'ff LQW HAVE SEEN ISSUE!]Tp THE INSURE?NAMED ABOVE FOR 7Hfl POLICY P2Ri0O fNQIGATEg.NOTWITH87AHQINO AN'Y RBOUIi� TMBNT,T 04 CONN N OP ANY CONTRACT OR OTHLR pOCUMSNT W T;h RaspecT TQ W WCH m)S CHATIFmATe MAY BE issueo OR MAY KmAw.W INDURISKOR AFFQR e0 SY TKQ PCOCIEB t>WFUSPID H8R81N IS 8U83HC'•TO ALL THE TERMS,EXCLUSIONS ANO CONDITIONS OF SUCH ?OLICI@8.At3!2tT$LMV9!MOWN Y r1AVS NSEN REDUCED BY PAID CLAWS. LTA N9 �TYPIb IN.4URaNC t}OLICYNiJM50 ' DD" DATE M, D `- uwuTB {08NLf;l11LIAfiIwY l EAC4OCCURRSNCE 41000000 _ J► a t il RpgITY 61f0-1ti81Dt795 03/St/09 03/i4/09 FRHAHSa5fZ9caawrera S 50000 ^'-CLAI#18�AlAD 1 UR MEOVP�pwe�l . s 5000 $ � O1,T:tae J' P6R8UNAt 8 AOV INJIMV $ 1000000 GENERALA0CM"TE 32011000 } ,GEN.b 8 "}JMIT APPUM9 PtR: PRODUCTS-COMMIX AGO $2 0000 C 0 Po'LICY 'A 0" LOC CELI 2000000 AUTOMOBILE LIABILMY _ CLIAIHtN8G81NOLELIMIT S 4 ANY AUTO CEO G=W41MI) ( ALL OWNIIO AUTOS i BODILY+NdURY t ' SCM@DUt•HO AU^'OS � (Per paean! ►AED AVT08 • BOOILV)NJURY. S NON-OWN6G AUTOS Ira aeadonll PROPERTY DAMAGE i I ��— (Pa ooafdoM) i OARAQ2 UASIU►' -� f AUTO ONLY.6A ACCIMNT S ANY AUTO ROTHERTHnN EA ACC S 06 ONLY: AOt3 S� EXONISIUMOR66LALIADiLITY EA014OCCURRINCF. ; OCCUR 171 CLAIMS MADE AGGREGATE S 1 ; DEDUCTIBLE ; RET6NTION ; WORKERS GCMFlINEATION AND TORv LINITe EA EMPLOYERS'LIABILITY 8 6�CM91OX742207 07/IS/07 07/15/0;3 B.L.&ACNACGIQe1tT'- 1100000 � �RICEP�A/N�T RxACLUp&D9 ECUTIVC r ...,-....,...+ _ { n�yy��C.I�Pily eunda� 6=991OX742208 07/15/08 07/15/09 C.L.0159AS8•EAEMPLOYEe 1100000� f ePE VpR10V114I0N8 bdow 4.L•71sEASE•POLICY LIMA: i 00000 OTM i E E I DEI{CRIPTIDM OF ERATIONB i L CATIONS iV LE8 i EXOLUSIONS ADDED BY E40ORSEUMT I SPECIAL PROVISiC.NB I CERTIFICATE HOLDER CANCELLATION _ _ .• � SH0VLO.ANY OFTHI:ANOVS 6a8CW88D POL{C>!da QA OANO@LLEC berDaE tikC f:XPtRATION DATE THEREOF.THE 188U1NO INSURER WILL ENDEAVORTO MAIL 10 DAYS WRITTEN +;{ TOWN QS SAR111J9'fiA9LE NOTICE TO THE CERTIFICATE MOLDLR NAMED TO THU LIFT.W FU1LUR4 TO DO 90 SHALL sui 1ding Dept• IMPOS6 NO OSLIGATION OR LIAWUTV OF ANY KIND UPON TH8 MUR A ITS AOVITS OR 367 HLXN STREET RY'ADir IM KA 02601 f LPR89eNTATNEB. AU ACOPO 26(1001/08) 0 ACORD CORPORATION 198E o/ze -�omvrw�zcuealtl o�✓�oeoac�a.,�a`et7a i _... _ ,...''.._ ., - Board of Building Regulations and Standards License or registration valid for individul use only 5 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:.. 100497 Board of Building Regulations and Standards One Ashburton Place Rm 1301 ; Expiration 6/18/2010 Try 268012 i r: Boston,Ma.02108, Type Pnyate Cprporation i DAVID COX INC.` David Cox 19 LAVENDER LN r W.YARMOUTH,MA 02673 Administrator_ Not valid without s' nature _ - �� kuar of m ing egu anon and tandards q a �,onstructton Supervisor License li c ? r License: CS 63537 Birthdatii. 01 5/1953 'i �.._.A � Ex�piratt"15/2009 T4' 6313 It ,y Restnt:tion DAVID R COX `' (51 S YARMOUTH tMA 02664 -` Commrss�oner j r e 60 of TE r Town of Barnstable *Permit# H Expires 6 roonrhs jroun issue date t .5 00 Regulatory Services Fee v mmsrABM MASS, Thomas F.Geiler,Director X-PRESS PERMIT �A 1679. A�0 lfo 3+ Building Division Peter F.DiMatteo, Building Commissioner A U G 2 1 2001 367 Main Street, Hyannis,MA 02601w TOWN OF BARNSTABLE Office: 508-862-4038 Fax: 5087790-6230 t EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ' Property Address 9-3 emA/ 1riy (A 0 Z(I 3 :I24esidential Value of Wor"k yl of n d�a , Owner's Name&Address •[ t jZ_� /��1�T'J�/C y�(-Q�� 93 ERA L,4AIE 0-1-5—/tYTEIZ 4 J r4 ©2_(3 Z. Contractor's Name a�a/U J /1 i C/ (7 i L n/'?, Telephone Number Home Improvement Contractor License#(if applicable) U DQ Construction Supervisor's License#(if applicable) 4 ❑Workman's Compensation Insurance Check one: P I am a sole proprietor r ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy It Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) U�Ie-side d Sm �f SAT c-jjjw . 31/ 1 AAwsm 1 rT,11vCF • �f U•�Ae7-OA,34 Replacement Windows. U-Value (maw •`4) ❑ Other(specify)ZA AtD 6A Id � 10� l41 N]'1 iNST-LL *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg:rev-070601