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Home My WebLink About0334 LAKESIDE DRIVE WEST 71 ..ix. o V y a a ee ., LL V is 1. x11 � _.�� y � 1 � - ` :��• xQ'•.. a 0 l 1_( ��2 BIKE Town.of Barnstable *Permit# Expires 6 months rom issue da e Services Fee ' • anaxseABM • �"' 9 MASS.039. $ Richard V. cai Director �p i639. �0 rEo �a �JUN 3 1014Building Division . Tom Perry,CBO,Building Commissioner TOWN®FB/qR�Y� treet,Hyannis,MA 02601 , bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT "PLiCATION - RESIDENTIAL_ ONLY ;1Z� I,,�v j k f Not Valid without Red X-Press Imprint Map/parcel Number //Property ��Y � � /✓r• �/ �POli �� Residential Value of Work$ � Qd. - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name I,-z ti � �i n Telephone Number Sabr SD Home Improvement Contractor License#(if applicable) /2 7W 4o' Email: �LDv�i�i��► //�� l ,G/fOD'� CDori Construction Supervisor's License#(if applicable) 6 7.2 35_� ❑Workman's Compensation Insurance Check one: t IA-I am a sole proprietor ❑ 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) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value (maximum.35)#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 copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\E)KESS.doc Revised 061313 J w : .. - _. (92e cpornirrconcuea11211?,a�C%/Ga�aac�ic�eCt' Office of Consumer Affairs&Busi ess Regulation License or registration valid for mdividul use only OME IMPROVEMENT CONTRAC 1 before the expiration date. If found return to: TOR i' egistration: 127006 Type Office of Consumer Affairs and Business Regulation xpiration , 8119/2014� DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 -- -a j ) COUG LIN PROPERTY MAINTENANCE �. BRIAN COUGHLIN r 82 PRUDENCE LANE ,y, I COTUIT, MA 02635 66 Undersecretary Not,valid without ature lam Massach uset#s -DepartMent of P Board of.Buildin g Re ublic Safety gulations and S Construction Superviso tandards r License: CS-072354 BRLANP COUGI 82 PR UD - LN ;. Cotuit MA 02635= Commissioner Expiration 06/14/2014 T w Comvroymwa h ofMassachuse Deparhtrmt of liu said Accidents Office o,f lrnlfffigativrrs - 600 T3'tas-hutgtan&-reef Boston:,.M,102111 wn*w.mmmgmldia Workers' CompensatiunInsurance Affidavit:Builders/Coiatractors/EiectriciansMumbers Applicant Information / Please Print.Le.Lnh;. Name - "- oaffiidividnal): Address ��- �✓�GYtG� �� City/Stat&Zip: � 1,4 dllo Phone 2w Are you an employer?Check the appropriate bo= Type of o ect r uire _ 4_ I am s confractor and i 3'� pT' J �'� �" l_❑ I am a employer with ❑ 6_ ❑New con f nu oa employees{full aad/orpart-:ime}* havehiredthe sub—contractors. 2-[ I am a sole proprietor or partner- listed on the attached sheet 7_ ❑Remodeling ship and have no employees These sub-oontractors have S_ ❑Demolition w for me in an c ci ,_ employees and have workers' offing y � � c insurance., ❑Building addition , [No workers'C'onlp_insurance omP 5. 0 We are a corporation and its MCI Electrical repairs or additions officers have exercised their 11_ Plumbing airs or additions 3_❑ I am a homeowner doing all work. ❑ g� , myself [No workers'comp- right of exemption per MGL 12..❑Roof repairs insurance requiredI1 c_15Z§1(4',and we haVe no employees_[No workers' Other comp-insurance required-j *Any sppEcat that checks boa-91 anti also fill out the suction below showing ihei woders'compemadou po&y infntmatica 1 SameowneM who submit this sftidavh M&CBting they are damg sH wcx k sod then hag outside contrscmrs mast submit a m affidavit inert-tmg ma t0muRctors that rhxtc this Irmo must sttsdhed=additinzW sheet showbg the nsme of the mAb-a and suds whether txnot thosa entities hive employees- d€the sob-contractors hive employees,the}most provide their—&-mrs'comp.pahcy'Lumber. ;tam arz employer iliac is prm id&g tt�orke-rs'congm?uution insurance for my empIayem Edmv rs the policy an.d,job site in;formaliarr. Insurance GompanyName: ' Policy 4 or Self-iris_Luc-4: Expiration Date: Job Site Address: Gity/Statelzip: At#ach a copy of the workers'compensation policy declaration page(showhig the policy number and expiration date). Failure to secure coverage as requiredunder Sectioaf 25A of MUL c. 152 can lead to the imposition of rri+mifeal penalties of a ' fine up to$1,500.06 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a$ns of up.to$250.00 a day against the violator_ Be advised stint a copy of this statement maybe forwarded to the Office of Investigations of the DIA liar insurance,coverage veritication_ I do hereby aerttfy under tlrspains dpanaWas ofpet�ury thatthe irrforraation provider/aabonne is.hue and correct Sitmattme: Date_ & —2 Phone G QjEcial use only. Do not sprite in this area,to be completed by cio or town officiaL City or Town: Permi#UCense# Fssuin Authority(circle one): 1.Board of Health 2.BuiI&ng Department 3.CitylTown Clerk 4.Electrical Inspector 15.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. 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 airy 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 witli 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 numbers)along with their certi-ficate(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-inmrance license number on the appropriate line. City or Town Officials Please be are 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 bum 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 Commanwealth of Massachusetts Department of Indnstdal Accidents Office of frtvestigatEam 600 waashinzoa stztet Boston,IAA 02111 Tel.#617-727-49-00 W 4D6 or 1-9 MASS FB Revised 4-24-07 Fax#617-727-7 749 vv-vmmassgav/diaa r oF�rOk , B"NSMBLE. + ' Town of Barnstable pTED N1A't A Regulatory Services 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 If Using A Builder as Owner of the subject property hereby a thorize KJ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signa of Owner a 4 f Print 11ame If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the # reverse side. QAWHFILESTORWbuilding permit forms'ZYPRESS.doc Revised 061313 Town of Barnstable Regulatory Services ��oFtHe ratyy Richard V.Scali,Director Building Division *.. BAMSTABM ' Tom Perry,Building Commissioner KASS, 1 e39. �� 200 Main Street, Hyannis,MA 02601 prFo �p 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 formlcertification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313