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Home My WebLink About0114 LAKESIDE DRIVE EAST ..,gi...a .Pa...�,r. t :�:�� T� , ,.�--.-.. , ..:,.• ..'.r i� rye :,'�j.. x�v 'c.- .�� q�, .,vb( ..+,. .M, i. 1r'�h .a.. ...' t� .^.....:7.4 .� :A ,.. .. ,!S' k. ,i,Y a•t � i:• �..t k 'fi'• t d;y c�' t ��Qy .�....,. ..,:� r.-.. ,. ,. .., �.i .. .., � s.• r ..�,,. ,�,.., .ry• QI„,.,,.� a+P -,s°��vK .� "kY':-'tr .s;qa t, �` .� as'F'� # r y .+ n re e o 0 . r • it I� v i , f.: a Y 3 4 a o , ° , )C. - Town of Barnstable.. *Permit ` 0 PERMI Expires onths from' e date ; Regulatory Services .,, Fee i639' 2013 . 'y . Richard V.Scali,Interim Director rED Mfd A :. TO Building Division P BARN !', 5�� E 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 12� , Not valid without Red X-Press Imprint Map/parcel Number 0 " Property Address L i�2ziCL ot- -le ❑Residential Value Hof Work$ 7 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address _ ' Contractor's Names Telephone Number M6 Home Improvement Contractor License 1 applicable) 6 Va 'Email: �u E Construction Supervisor's License#(if applicable) lC�l ❑Workman's Compensation Insurance , Ch�Ck one: [� I am a sole proprietor t ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) n ❑ Re-roof(hurricane nailed)(stripping old shingles)'All cq}struction debris will be taken to— Sn i s ❑ge-roof(hurricane nailed)(not strippg`.Going over existing layers of roof] E j Re-side replacement Windows/doors/sliders.6-,Value f3' Q (maximum.35)#of windows ` #of doors: ❑ Smoke/Carbon Monoxide detectors 4 flopr.�lans marked with,red S and inspections required. Separate Electrical'&Fire Permits requi;'d. *Where required: Issuance of this permit does not exempt compliance with other town,department regulations,i.e.Historic,Conservation,etc. **-Note: roperty Owner must,sign Property Owner Letter Qt Permission. k copy of the Home Improvenient.Contractors LiFFnse&'Constrpction Supervisors License is required `£ i' SIGNATURE: t T:\KEVIN D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 Massachusetts -� �—_' -- Boaro of Oepa,tne Building.Regulat. nt of Public Construction Super,i ons and StanSafety License: Cg_ isor dards 101696180 DIV r Hya�GANRD- MA: 026Q1 ;+ ' j _ F co mmissioner �xptration _._ 08/23/261 i /ae�oarnnzaazcrrecaltli a�C�/ a�ortic�cr� j License gr I�b,� d atlon y�jjd for ind►vidul use only office of Consumer Affairs&Business Regulation beprp the a piration date. If found return to: ¢ME-IMPROVEME. NT.CONTRACTOR ,,t e. E)ffice.of Cgnsumer Affairs and})usiness Regulation f egistration 159982 yP ; 10 Park Plaza-Suit 5170 , q xpiration 6/13/2014 DBA , Boston, 02116 TiMOTHY,P JOHNSON CONSTRUCTION TIMOTHY JOHN$ON�� L 180 MEGAN.RD + HYANNIS,14A.02601 Undersecretary '. Not li wi hoot signature i Tate Comrrromtwdth off Massachuseffs Deparhnen t of lyrdkstrW Accidents Oj ke oflIt{Fnfiga one s 600 Washington&reef Boston,,AM 02111 wnm mass gmAdia Workers' Compensation Insmmuce Affidavit:Builders/Contractors/ElectricianstNumbers Applicant Information Please Print Legibly Name(WsineWOrganinfimbdividnat7: J`\n -1 City/Statr/Zip: ±1�). fLis �) Phone ' 77 t D,�6 Are you an employer?Cieck the apimpriate box: Type of pr oi ect(requ ired): L❑ El a em to er with 4• ❑ 1 am a go ❑6_ New oonstnrctifln al contractor and Ioyees(full and/or part-time)* have hired the sub-conttractors2. a sole proprietor orpartner listed on the attached sheet: y- E�emodeltng These sob-contractors have ship and have no employees 8. ❑Demolition. working for me in any capacity. employees and have wtttkers' 9. ❑Building addition [No work' comp.insurance comp.insurarlce_f 5. ❑ Vile are a corporaticnand its 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 1 L_❑Plumbing repairs or additions myself[No workers'comp. right of exTimption per MGL 11 M Roof repairs insurance required]F c.152, §1(4),and we have no employees.[No workers' 13..❑Other comp.insurance req*ed.]. "Any appb c=that checks boa#I mast also fill out the section below showing their wor keta'compensatiGn policy information T Homeowners who sabmit this affidavit indicating they are doing all wm k and then hire outside contractors>rmst sabmA a nL affidXVh indirnt#ng sash_ =Contractors that cbeck this box most attached an additional sheet showing the name of tie sub-eontzacmzs and state whether or not those entities have Employees. if the salt-contraaurs have employees,they must provide their workers'comp.policy number. lam an employer that is prmithkg workers'cottrjmiundon insurance far my employees. Beloit is Ste policy cold job site information. Insurance Company Name: Policy;9 or Self-ins-Ilc.9: FxpintionDate: Job Site Address: City/State/Zip: Attach acopy of the workers'compensation policy declaration page(shriving the policy number And expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in dLe form of a STOP WORK ORDER and a fine. of up.fia$25 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Im�estigati o DIA for insurance coverage verification_ I do hereby ce ender tha pains andpenalties ofperjury that the information pratzded a l is true and correct Si tore: Date: I Phone#: Qj cial u se only. Do not trrite 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 S.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 hvo 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 Iocal 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 auy 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-contractors)name(s),address(es)and phone number(s)along with their certiificatc(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 Gomparjes 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 pernritllimase 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 Ior 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 Conmonwealth of Massachusetts Department of Industrial Accidents Office of kvestigafioas 600 Washington Street Bastou,MA 02111 Tel.#617-727-4900 W 406 or 1-$ MASSAFB Revised 4-24-07 Fax# 617-727-7749 www.mass_gov/dia IKE * BAMSTAKE, r " A, Town of Barnstable` EDN1°� Regulatory.Services i Richard V.Scali,Interim Director Building Division- Thomas Perry,CBO Building Commissioner . 200 Main Street, Hyamis,.MA 02601 www.town.barnstable.ma..us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must, p Complete and Sign This Section "If Using A Builder as Owner of the sub' ect ro er l P p ty hereby authorize 10iVN to act on my behalf, , in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of ner Date ° Print Name , If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN Muilding Changes\EXPRESS PERNHT\EXPRESS.doc Revised 061313