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Home My WebLink About0039 CENTERVILLE AVENUE«I c v t } } I> r , V� w Town of Barnstable II �>5 Expires 6 monda from issue date a i Regulatory Services Fee • fA8;V5TA8ts, • h�b� Thomas F. Geiler,Director / Building Division Tom.Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 • Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Yafid wit -bout Red X Press Imprint Map/parcel Number Property Address C,L lr t ��c. �• 1 l. �,�' �1 4 1✓ �...v { -t Residential Value of Work 1, 00® Minimum fee of$35.00 for work under$600 0.00 Owner's Name&Address f,"A fv`i 1'i COY_, �Y1 la► Q`� contractor's Name Telephone Number -------------- Some Improvement Contractor License#(if applicable) ;onstruction Supervisor's License#(if applicable) ]Workman's Compensation Insurance )UL i ' n{a ❑Check one: TOWN OF BARNSTABLE I am a sole proprietor � I am the Homeowner ] I have Worker's Compensation Insurance surance Company Name orkman's Comp. Policy# ►py of Insurance Compliance Certificate must accompany each permit. rmit Request(check box) Re-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 (maxi #of doors mum :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 the Home Improvement Contractors License&Construction Supervisors License is required. R JATURE: YVX f i The Commonwealth of Massachusetts I I Department of Industrial Accidents f Office of Invesfigations fill; 600 Washington Street • u,n, Boston, MA D2I�1 t I- Www.rnassgovhfid Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Le�My Name (Business/Organization/IndividuaI): ` �, 0\6' C Address: . (�1 1 C.L e I I a- C ty/State/Zip:_C(-�LXtR V 1 LL t- (Y1 Phone #: .. : U k-1 r2a an employer?Check the appropriate box: Type of project(required): a employer with - 4. ❑I am a general contractor and Iloyees (full and/or part-time).* have hired the sub-contractors• 0 New construction a sole proprietor or partner- listed on the attached sheet t ?. ❑Remodeling andhave no employees These sub-contractors have S. ❑-Demolition king formeinanycapacity. workers' comp. insurance. 9. ❑Building addition workers' comp.insurance 5. ❑ We are a corporation and its ired.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption.per MGL 11.❑ Plumbing repairs or additions lf.[No workers'comp: c. 152, §1(4), and we have no12.�.Roof repairsance required] t employees.[No workers' comp.insurance required.] 13.❑ Other *Any applicant that ehedcs box#1 must also fill but the section below showing their workers'compensation policy informatioa.+ 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 shoat showing the name of the sub-contractors and their workers'comp.polity information. I am an employer that is providing workers'compensation insurance for trry erirpinyees. Below is the policy and job site information. 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. trda hereby Certify under pains and penahY6 of perjury that the information provided above is true and correct >t //__ Date. \ 'hone#: t� Official use only. Do not write in this area;to be completed by city or town of`rcidL City or Town: Permit/License# Issuing Authority(circle one): V_ C� ' 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 an such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean 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 affidavit 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 maybe submitted to the Department of Industrial Accidents for conformation of insurance s'coverage. Also be sure to g ign 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 i fyou 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 rioted p p 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 in the perinit/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 beeui 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. e0 Offi ce ffi a of Investigations would like to thank you in advance for your cooperation and should you have an estions �. please do not hesitate to give us a call. . y 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 T 7 17 /r rf ��n I n�w •w i _ _-_ _ _ _ _ -- .t Town of Barnstable " Regulatory Services Thomas F. Geiler,Director Building Division Tom Perry,Bnildfn Commissianer 200 Main-Street, Ayanais,MA 02601 www.town_b arastable.ma.us O1 ff-r-c_ 508-862-4038 Fax. 508-790-6230 ,i HOMEON1dER LICEA'SE EXEhdIrI70N { Q Plesse Print DATE JOB LOCATION: b ok G E N E I-01 („L*�- A V C- number street vrllage OMEOWNER" k-I --I-I LM�I` Ic— nMMr home phone# work phone# uzIT hiAMINQ ADDRESS; 'M C) l.� L, U tn� f.rT,(C9 e-;br { erty/ta— state zip code The current extmlption for homeowners"was extended to include,owner-occupied dwt-.11iaps of six units or less and to allow h0B=-WMer3 to engage an individual for lure who does not possess a Iiccnse,providcd;th.at the owner acts as supervisor. - ti - . DEFTN o?Y OF HOMEOWNTER Pcrson(s)who owns a parcel of land on which helshe resides or infcnds to=—dc, an which there is, or is intended to- be, a one or two-family dwrl?n, attached or detached sfructorrs accessory to such use an for faom shuctcars. A person who canstrgCts more than one home in a two-year period shall not be considered a ho=owncr, ,Such "homcowncr"shall subnut to the BtnldEag Ofcial on a form acceptable to 6r-Building Official, that he/she shall be resnoasible for all such work yrxfarmed'undcr the bw7ding pcnnit (Section 109.1.1) The undersigned`homeowner"a¢mrrnes responsibility for compliamcc with the State Budding Code and other. applicable codes, bylaws,riles and regulations. The undersigned`homeowner"certifies tha.t.hdshe understands the Town ofBarmtable ROding Department nrinirmzm inspcetion procedures a d requi=xn=f3 and that he/she wEl comply with said procedm-=and requircmcn l ignatisre nf,Ham cr Approval ofBurld ng,Official Note: Three-faintly dwellings containing 3 5,000 cubic feet or larger wM be rcgrured to comply with the ' `3t do Banding Code Section 127.0 Canstructkm Control. H0Alx0WMM S EXEMPTION _ The Code states that: "Any hgareowocr pc&nnr rg work for which a bm'Idmg perrmt is rzquuzd shall be exempt from the proyisigns t this ration(Section I D9.1.1-L;cauing of eonshvetion Superyisors),provided that if the hmneowncr engages a persom(s)for hoe to do such or,that such Hamrawn a shell ad as supervisor." 1�aay homer wners who use this•rzrmption are tmrwue that they are Lauminx the responsrbtlities of a sups visor(sec Appendix Q lies&Fr6lz lions for �r=ia9 Construeb®Snperwismz,Section 2.1-5) This lack of awarmess bfk n molts in serious problems,par•iculaly tar the hmacowncr hires unlirrnsed pasmas. ba this case,-our Board cannot proceed agxfiul the ualieeased person as it would with s liearscd acr .Yisor. The hamoowoa acting as SnpcYisor it ultbrutdy responsible Tn run..,-flat tr,,.hnmrn" _4 AMV r r • � T � Town of Barnstable 0 r Regulatory Services '� YABNST�m^ i _ `6$ Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Streck Hyamaisr MA 02601 ' wwsvaown_barnstable.n-ia.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Mus t _ Complete and Sign This Section If U "sin A Builder as Owner of the suhJ'ect.P, roperty hereby authori>P to act on my behalf, to a1I matters relative to wprk authorized by this building Pem-Tf'applicattoii for. (.Address of Job) f Signature of Owner R Date • i�rinr Name . If R!Dperbr Owner is applying for p emit pleas e c oiu fete. the Homeowners License Exemption Poem oiz ff e. reverse side.