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HomeMy WebLinkAbout0490 PUTNAM AVENUE t/i! r 06116613 0p1HE T Town of Barnstable *Permit# OExpires 6 inontk fronn issue date Regulatory Services Fee ; • BA ENSMBLE, 16 Thomas F.Geiler,Director � lenl�wt S PERMIT Building Division O J.ANil Tom Perry,CBO, Building Commissioner. ` �G1 r a 200 Main Street, Hyannis, MA 02601. OV"'l j OF BARN(3TAS www.town.barnstable.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 `{orb fi'S V\a01 ❑ Residential Value of Work Minimum fee of$35.00 for work under$6000.00 . Owner's Name &Address &\y L�� Contractor's Name m i z- \A t cy,�/,J Telephone Number Lt Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) `A b. if f;"kman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner E'1 have Worker's Compensation Insurance l Insurance Company Name Vi Workman's Comp. Policy# � C t V Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) 0-'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 (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 mustsi n Property Owner Letter of.Permission. A copy of t Home prov ent ontractors License& Construction Supervisors License is re ired. SIGNATURE: /f a , NOTICE r NOTICE TO V _ TO EMPLOYEES EMPLOYEES. The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7016215012010 01/10/2010 - 01/10/201.1 POLICY NUMBER EFFECTIVE DATES P O Box 494 Leonard Insurance Agency Inc Osterville, MA 02655 (508).428-6921 NAME OF INSURANCE AGENT ADDRESS PHONE Mark Herbst 35 Peep Toad Road Centerville, MA 02632 EMPLOYER ADDRESS 01/11/2010 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related iqjury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS Tn RR. PnQTIP.II RV T'MPT :nV1P.R J`` Massuchu�ctts_ �1�iI1 Board of BcParrtment ofp Buildin"Re,r ublic Safe( Construction Su •t"Lltions.rnd Lice pervis Stand:lyds License: CS 48546 or License Restricted to: 00 MARK D HERBST. «� 35P •� �,• EET TOAD RD h , > CENTERVILLE MA 02632E . f'unimissiune, .. Expiration: 1/27/201 - - 2 Tr#: 13699 T Office of Consumer Affairs&B siness Regulation License or registration-valid for individul use only HOME IMPROVEME NT CONTRACTOR before the expiration date. If found return to: Registration:;0,126480 Type: Office of Consumer Affairs and Busmess_Regulation Expiration 6/8�2012 'Individual 10 Park Plaza-Suite 5170 -� Boston,MA 02116 MA K HERBST j r �{ MARK H E R B S T 35 PEEP TO CENTERVILLE;-MA 02632 Undersecretary. Not valid wi o t signature a , The`Commonwealth of Massachusetts i Department of Industrial Accidents Office of Investigations ;IIIIIJ 600 Washington Street - Boston, MA 02111 c ry www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (��K Address: ? (J City/State/Zip: Vyl Or, Phone #: `-1 "ol©(0,59 l ib Are you an employer?Check the appropriate box: Type of.project(required): l_I L t am a employer with 5 4. El am a general contractor and I * have hued the sub-contractors 6: ❑New construction employees(full and/or part-time). . 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ? ❑Remodeling. ship and have no employees These sub-contractors have 8. ❑ Demolition_ working for me in any capacity. workers'. comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work . right of exemption per MGL I LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4),and we have no 12.[}Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑Other *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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: 1W\. YNk 5-1 Q A- 1 Policy#or Self-ins. Lie, #: a,!N\ c� Expiration Date: 1 Job Site Address: LA4C) ���� C19\� 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 cove ge verification. I do hereby certify u the ins an nalties f ry that the information provided above is true and correct. Signature: Date: /'7 Phone#: _;2 d /.y a C ' to 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 I City/Town Clerk 4. Electrical Inspector'5.Plumbing Inspector 6.Other. Contact Person: Phone#: 3 1 r Information and Instructions Ma sachusetts 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 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. 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(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-contractor(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 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. e The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia f IRME Town of Barnstable . Regulatory Services • s,�xxsresr�. .. t,uss $ Thomas F. Geiler,Director Eo; �Ib Building Division Tom Perry, Building Commissioner 200 Main Strect, Hyannis,MA 02601 www.town.barns.table.ma.us Office: 508-862--4038 Fax:. 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder V� , as Owner of the subject.property hereby authorize (� �' .�b S' to act on my behalf, in all matters relative to work authorized by this building permit application for (Address of job W,rL - '/ f mature of Owner Date C ✓��' Print Name If Property Owner is applying for pem-it please complete. the Homeowners License Exemption Form on the reverse side. , Town of Barnstable �Of rp�� o Regulatory Services srAB Thomas F. Geiler,Director BARNm HAS-S. �6.19. ,�� Building Division prEn I,ta�" Tom Perry, Building Commissioner 200 Main.Street, Hyannis,MA..02601 www.town.barnstable.ma.us Office: 509-862-403 8 . Fax: 508-790-6230 HOhdEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: _- number street village "HOMEOWNER name home phone# work phone# CURRENT MAILING ADDRESS: city/town state ap 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. DEFINMON OF HOMEONVNER 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.constrycts more than one home in a two-yeas 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 rr,;r,;rnum 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 containing35,000 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.homcowner performing work for which a building permit is required shall be excrript from the provisions of this section.(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such wofk,that su.h Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc 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/hcrresponsibilitics,many communities require,as part of the permit application, that the homeowner certify that belshe 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 suchl-fonn/certification for use in your community, w;,',:� .H...r;{-�- [ «H �i6'�Ss•tW`W'f'(.'i�F�.,�:•Ve{.nt �'.-:�w4. r„!„IY1t-,b � 'cyF'� - -.�sk°� ' his-".j � •y 31.` "�ti���.�d'r' :..,.F�!4..:""Tc.p4:.4'^ .re `Op THE Tp�� •. Town of B arnstable _ BARNSTARLE. Regulatory Services ` - - 9 MASS..._.._ .. y...r pIFDMP�s• Building Division ________ 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Notice Type of Inspection _f ( 7E Location q4 O 7WK& Y1V1?---, T Permit Number ----- Owner Builder One notice to remain on job site, one notice on file in Building Department-:-- The following items need correcting: t U.57 65 !d o2 'f Yuen ri&5 4,-L..C—L:7e t'U IV Ce-ZC Taw 5 ; -7 fPlease call: 508 862-403' for re-inspe)ctioon. Inspected by Date I cl {yy'/�.n� '�! y� .::::. ::: A1i��l:::: ?::i:': 'y '�::i::i: 1. 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