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T Town of Barnstable .*Permit#
Expires 6 months from issue date
Regulatory Services Fee _
* auuvsrnBi.E, � •
�
'16 9. Richard V.Scali,Director
3 ♦��6b,SAP+p .
Building Division �"Tom Perry,CBO,Building Commissioner
Main Street,.Hyannis,MA 02601 P
www.town.barnstable.ma.us 5' �� �
Office: 508-862-4038 T EP 23 ? : 508-7 6230
EXPRESS PERMIT APPLICATION - RESIDE Y
Not Valid without Red X-Press Imprint 'ABLE
Map/parcel Number
Property AddressDET'
Res 40'
idential Value of Work$ `Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address t�
Contractor's Name �_ �) L K— Telephone Number v a5 7 /
Home Improvement Contractor License#(if applicable) I Email: F
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Chec
am a sole proprietor
i
❑, I am the Homeowner s
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Re ue eck box) '
Re-roof(hurricane nailed)(stripping old'Shingles) All construction debris will be taken to 6le
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ 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 y of the Home Improvement Contractors License&Construction Supervisors License is .
fired.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC
Revised 040215
The Comrtromveakh of-Vassachusetts .,
De parameart of Industrial Accidents
�'- - Offw.e ofInvestigations
600 Waslriugion Street
_..__ 13aston,MA 02111
ivoi tst mas&govfdia ,.
'"corkers' Compensation Insurance Affidavit:Bgilder-s/Contracturs/EIectr cianslPlumbers
APPEcant Information Please.Print f egibIy
Nam(Busm ganizatianflndividual� /
Address: ��� /
Cityftatelig ! ( 4g
Phone / yr
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 6. ❑New construction
eoyees(full andlor part-time).* have lured the sub-contractors
2.[Pe am a sale proprietor or partner- Listed on the attached sheet 7- UY&mOdel ug
ship and have no employees. These sub-contractors have g_ ❑Demolition
wading for me in any capacity_ employees and have workers' g- ❑Building addition
[No workers'camp.insurance comp.insuranm
required-] 5. ❑ We are a corporation and its , 10.❑Electrical repairs:or additions
3.❑ I am.a homeoumer doing all work officers have exercised their 11-❑Plumbing repairs ofadditions
myself [No workers'comp- . right of exemption per MGL 12.❑Roofrepa=-
insurance required.]T c.152,§1(41 andwe have no
employees_[No wod=s' i3 Ua ti'm�
camp-insurance required.] '-
*Any applicant 4hat checks box AF1 must also filloutthe sectionbelaw shnuaing their workeus'compensation policy information_
I Hameovmmn who submit this affidairif Mdiczt1UJ dey are doing RU watt sa4 then hire outside contactats mast Submit a new afisdavit indicating such
Fcontnctors that aea this boa mast attached an additinual sheet shouciag the name of the sub-cu=dots and state whether ar not those entities ha e
employees. I€thesubtantmctarshave employees,theym=pmuide Yheir workers'comp.policy number-
I ant an enfpZger that ispratadbW ivarkers'congwisa an hwurauce,€or tr:y earplolwax Below is d ie paticy and job site
inforasatrbn. .
Insurance Company Name:
Policy#or Self-itch.Lic_# Expiration Bate:
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 imprisonmenk as well as cital penalties.in the farm of a STOP WORK ORDER and a fine
of up to$250_DO 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 veriffca#ion.
I da Hereby cerffy u er the its anMnas erjuy fhatf ie information pratzded abm d if bw and correct
Simature_ I)ate.
Phone#
Officild use anly. Do not write in this area,to be completed by city arfonm of j`dat
City or To-nn: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City]Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
M�zachusetts Geheaal Laws chapter 152 regt all employers to provide workers'compensation for their employees.
pM-ST�this Suite,an.errrploynC is defined as."-.every person is the service of another under aay contract of hie,
Y
express or hnplied,oral or wnttr "
An ernployEr is defined as"aa individual,partnership,association,corporation or other legal=t ty,or any two or more
of the foregoing engaged ia a join ea
t enterprise,and including the legal representatives of a deceased employe,or the
receiver or trmstee of an iadividnal,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments anal who resides therein,or the occupant of the -
dweMag house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or oa the gromids or building apprr mama thereto shall not because of such employment be deemed to be an employer."
MGL 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 rap
applicant who has not produced accepta-ble evidence of compliance,with the insurance:coverage regrdred,"
Additionally,MCrL chapter 152, §25CM states"Neither the commonwealth nor`any of its political subdivisions shall
enter into any contract for the'performancc ofpublic work until acceptable evidence of compliance with the iuSUr an cE.
r ents of this chapter have been presented to the contracting a�hoTit}:"
PZ TiTPm ,
A-pplicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your sitnation and,if
necessary,supply sub-coutractor(s)name(s), addresses)and phone numbers) along with their cent fcate(s)of
incrrrance. Limited LiabMty Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insra-mce. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidayit maybe submitted to the Department of Industrial
Accidents for confirmation of fits rran ce coverage. Also be sure to sign and date the affidavit The affidavit should
be returaed to the city or town that the application for the permit or license is being requested,not the DePar(m.eut of
Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'
compensation policy,please call the Department at the number listed below Self-insured companies should eEter their
s elf-in.suance license number on the appropriate line.
City or Town Officials .
t
Please be sine that the affidavit is complete and priced leg-11y. 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,pen it ceuse number which will be used as a reference number. In addition, an applicant
that must submit multiple pezraitllicense applit-at nns in any given year,need only submit one affidavit m&catmg current
p olicy inlfbmation(if necessary)and under"lob S i L-ATess"the applicant should•rite"aIl locations in (cam'ar
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 futare permz s 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 Yenture
(i.e. a dog license or permit to burn Ieaves 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 gaestions,
please do not hesitate to give us a call.
The Departm.enfs address,telephone and fax number:
Th,e Commonwealth-of Massachusj--M
Depart rent cif l iak Aocidenti
(5w,WasI hoo-u stmd
Bastml.,MA G21.11
` f,1 4 617 727-4 Qxt 4-06 or I-977-MASSAFF
Fax 4 617-727 7M
Revised 4-24-07 ww .mass-govldia
f
ti
* sAENSTABM
9� 16 9. ,e� Town of Barnstable
A
rEp ,
r
Regulatory Services
Richard 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 s w
If Using A Builder
I, �( � t✓/ , as Owner of the subject property
hereby authorize �)C fI er to act on�my behalf, p .
in all matters relative to work authorized by this building permit application for:
4) 6-f 17Laih
(Address of Job) 4�
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the ' >
reverse side.
QAWPFILES\FORMS\building permit formsEXPRESS.doc
Revised 040215
Town of Barnstable
Regulatory Services "
oFtKE rqy Richard V.Scali,Director
Building Division
CAB •' Tom Perry,Building Commissioner
MASS.
v 0.59. 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
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.doe
Revised 040215
r �
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-078000
.4= :Y.T FI, -
SCOTT_ff QUB,Tgk -
PO BC*X-727 -
West HyannisporF
_ •,J,.�;...',�t.Ce�. Al Expiration
_CoFnmisswneT 02/03/2016
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991in )of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing information visit: www.Mass.Gov/DPS
i lOffice of Consumer Affairs &Business Regulation- Mass.Gov Page 1 of 1
The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR)
' e
Consumer Affairs and Business Regulation
Home Consumer Rights and Resources Home Improvement Contracting
HIC Registration Complaints
ly
Registration# 132691
Home Improvement Contractor
Registrant Registration Home Page
Name SCOTT QUILTER
Address 247 STRAWBERRY HILL RD.
City, State Zip CENTERVILLE, MA 02632
Expiration Date 03/23/2017
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
Back To Search
https:Hservices.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=32921 10/2/2015
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