HomeMy WebLinkAbout0018 NICKERSON DRIVE r
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�TME Town of Barnstable Permit
6 3 y ?O
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Regulatory Services Fa.pires6mmnaufromiasu,jdate
HARNSTAaf� . Fee
MASS
659. A�b� Thomas F.Geiler,Director
Building Divisions
Torn Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
Www-town.barnstable.ma.us
Office: 508-862-4038
EXPRESS PER APPLICATION - RESIDENTIAL.ONLY 508-790-6230
MIT
Not Vafid without Red X-Press LnpriaY
Map/parcel Number
Property Addresso-I
❑Residential Value of Work Minimum fee of$35.00 for work under$6000.00
owner's Name&Address_ !_����<�U,-,4 C—c IdA ¢M
:ontractor's Name_ ?� /i�
5 Telephone Number 6-0S 7 7/
-ome Improvement Contractor License#(if applicable) /1/6 V
Onstruction Supervisor's License#(if applicable) S3
]Workman's Compensation Insurance
Chec ne:
LT . "ESS
I am a sole proprietor
❑ I am the Homeowner `,
��,
❑ I have Worker's Compensation Insurance
urance Company Name TOV/N OF BARNSTA81
rkman's Comp. Policy# E
ry of Insurance Compliance Certificate must accompany each permit.
nit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
gie-roof(not stripping, Going over_L existing layers of roof)
[Y"-Re-side I[)i.-mel-
❑ Replacement Windows/doors/sliders. U-Value ` #of doors
(maximum..44)#of windows
*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 nTiie mprov ontractors License&Construction Supervisors License is
requi
tTURE;
Fit
•
The Commonwealth afMassachusetts
Department of Industrial Accidents
O{
Office of Investigations
d J� .
g�,-v 600 Washington Street
• v v
4 a/ Boston MA 02111 -
www.mws gov/d"ia
Workers' Compensation Insurance Affidavit: Btulders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLdbly
Name (B�ness/Organization/Individual):
Address >]/'
City/State/Zip: �e��✓i/��/� 05C,5-1, Phone #: • S Gk- 771/910
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑ l am a employer with 4. ❑ I am a general contractor and I
el
ployees (full and/or part-time),* have hired the sub-contractors 6 0 New construction2. m a sole proprietor or partrier- listed on the attached sheet t �•. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑•Demolition
working forme in any capacity. workers' comp.insurance. g, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
IO required.] officers have exercised their •❑E
lectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL H.l.❑ umbing repairs or additions
myself. [No workers'comp. c. 152, §](4), and we have no ]Z,❑ Rpof repairs
insurance required] t employees.[No workers'
comp. insurance required.] 13.❑ Other
*Any applicant that checks box#1 must also fRI out the section below showing theirworlcers'compensation policy information,
t Homeowners who submit this affidi vit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such,
lContractim that check this box must attached an additional sheet showing the name of the sub-contractors and theirworicen'comp,policy information.
I am.an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site
informolon.
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 maybe forwarded to the Office of
Investigations of the DIA for,insurance coverage.verification.
(do hereby certify under and p ury that the information provided above is true and correct
ii ature� Date;
'hone#:
O-TICW use only. Do not write in this area;to be completed by city or town bfftciaj '
City or Town: - Permit/License#
Issuing Authority(circle one):
J
Information and Instructions
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 hire,
express or implied, oral or written."
An einployer 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 Iegal 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." .
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 any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C()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 a�davit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)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 Iaw or ifyou are required to*obtain a workers'
oompensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lime:
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 iii the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill io 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 Iicenses. 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 burn 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations'
600 Washington Street
Boston,.MA 021 I 1
Lp
.fib . . .. ._
Town of Barn-stable.
• RegvZatory Services
_Sig R& �$ Thomas F. Geiler,Director `
Building I)ivisiOII
Tom Perry,Building Commissioner
200 Main Strect,'Hya=is;MA 0260,
www.town.barnstable.ma.us
Office: 508-862-403 8
Fax: `508-790-6230
Property Owher-M is t v
Complete and Sign Tliis Section
If Using A BuVde
I, F� C�OrIO 0 C�ICD�'Yl�t�` Owner of the St jert;propertY
bEleby authorize �'�.¢1^��S D O to act on =7 behalf
,
in all matters relative to work authorized by this bmlding permit appliratrnn for.
{Ad ss of Job) -
Sim trP of Owner ' ��. ��
Date
• Pent Name
If Property Owneris aPP1Yrng forpermitplease 'coraplete. the
Homeowners License Exemption Form on :the reverse`side, -
y,
Town of Barnstable
Tt•tt:rho .
,. Regulatory Services
uxNsuar� Thomas F. GeDer,Director
xASIM ,
�b 16.79. .*� BzWdiIIDivision
D Tom Perry,Building Commissioner
_ 200 Maid_ trcct;_Ayannis, MA 02601
www-tawn_b zrns•table.ma_us
Offcc: 508-862-403 8 Fax: 508-790-5230
HOMEO�NE.R LICF3dSE EXEMPTION
Please Print
DATE
JOB LOCATION:
numbs stns! village
'7-10MEOWNER":
nine borne phone work phone#
CLJR RENr MAILING ADDRESS:
aty/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellines of six units or less and
to allow homwwners to engage an individual for hire who does not possess a license,provided that the owner acts as
supea-yisor. '.
DEFRiMON OF EOMEOWITR
Person(s) who owns a parcel of land on which helshe resides or intends to reside,an which there is, or is intended to-
be, a one or two-fa:m7y dwr]� attaehr d or detached structures accessory to such use aad/or fay structures A
person who constrgr-ts more than one home in a two-year period shall not be considered a h0meownrs. Such
"homeowner"shall s311nit to the Building Offers/on a fo=acceptable to the Building Official, that he/she shall be
r=ozisible for sli such work perfo=ned*undcrthc buDding pezmit. (Section 109:1.1)
The iodersigned`homeowner"assumes responsibdity for compliance with the State Budding Code and other
applicable codes, bylaws,rules and regulations.
The tmdcrsigncd'homeowner"certifies thaOrJshe,understands the Town of Barnstable BoldingDepzr-t ant
=sp6Cd=procedures and requiremcnf3 and that he/she will comply with said procedures and
requirements.
5ignztureofHametiwvna
Approval ofBurlding,Of5cw
Note: Tbree-family dwellings containing 3 5,000 cubic fact or larger veU be requirzd to comply with the '
3tato Budding Code Section 127.0 Construction Control.
HOME07NER'S FCC NOMON -
-The Cede states that: "Aay bomenwncr perArtrmrg work for which a braiding parnit is required sw be exempt f•o n the proyisions
f this Sccd n(Sectidn 109.1.1-Licensing of=asttveti=Supervisors);proyidcd that if the bmr=v cr eagages a pcsan(s)fhr biro to do such
m9c,that such Hameawvner shall act as supervisor"
l�my homeawnas who use this txtarpticm aro unaware that they are xmn7sng the responstlulitics of a supervisor(see Appendix Q,
Iles do Regina lions for Liecass 2g Cmdruei;oo Supervisors,Section 2.1.5) This lack of awz==Men resuirs in serious problems,particularly
1=the homeowncr hires mlieta p=== In this case,our Board cannot pnmeed against the=licensed person as it would with i licensed
�avisor. The:haaienwna ac>atg as 5upervisar is ultanately tnpansible. '
T.,.,,.,..,.rr,�e f1,�hnr,,.•„o..,.r;e fi,ifv vww��fi,;dh.r,:..,.,,..l.:i;«-. ...�...-'---�------ ----,_rs _. .. ..
Massachusetts- Department of Public S--&O I
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 6653
Restricted.to 00.
`1 i tit
CHARLES.G'PALTSIOS '
183 LONG VIEW DRi'!�'.
CENTERVILLE; MA-02632
-- - ism Expiration:'9/221201F1.
('o�rmissiuner - Tr#: 2790
�ie o2nvyuvrzvear csi a ��Z Azaa c.�iccGe6
Office of Consumer Affairs&Bpsines.Mcg ila[id, License or registration valid for individ 'I use only .
HOME IMPROVEMENT CONTRACTOR P
before the expiration date.-If found return to:
•
Registration 4114644 Business Regulation
Office of Consumer Affairs and tip
10;Park Plaza-Suite 5170
Exp1rattion4 10/8/2011 Tr/x 288141 Boston,MA 02116
Type 1, DBAf`?
'C.PALTSIOS BLDG 8A_REMODELING
CHARLES PALTSIOS
183 LONGVIEW DR
CENTERVILLE MA 02632 r' Undersecretary Not vali without sigriaturew .
i