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oF� r Town of Barnstable *Permtt#
ti0 Expires 6 months rom•sue date
Regulatory Services Fee
* anarasensr.E,
9�A MASS. $ Thomas F. Geiler,Director639- b `_ / '` Lr
lA
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 Valid without Red X-Press Imprint
3>0 Map/parcel Number_ _j
Cj L11 I
Property Address L ( /[_._.l �L� U�11 K U .
[o/Residential Value of Work D D Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 4AI(I—L-1 JVJ ✓�'� Z_Zf 7—7—
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance r ��R �fA � �
3 P m t� h '3
" - .b- t.
Check one: �.$�. Yil
❑ I am a sole proprietor
�L_l.: 1' :
❑ I am the.Homeowner - ..n(1 11U
❑ I have Worker's Compensation Insurance
)VVN fit. i / NSTABLE
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
a
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
0 Re-side
#of doors
❑ .Replacement Windows/doors/sliders: U-Value (maximum .35)#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
r required.-
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms EXPRESS.doC
Revised 072110
f
The Comthonwealth of Massachusetis,
Department of Industrial Accidents
x�� Office of Investigations '
600'Washington Street
Boston, MA 02111,
Y www.mass.gov/dia
.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lef,
Name (Business/Organization/Individual): 2 Z
Address: �` y�t� �a cs ✓k�
City/State/Zip: -AA914t)'1J1 S Phone #: G.1 7 St 2
Are you an employer? Check the appropriate box: -Type of project(required):
7.❑ I am a employer with 4. ❑ I am a,general contractor.and'1 New construction
employees (full and/or part-time).* have hired the sub-contractors '
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 71 Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity, workers' comp.'insurance. 9. Building addition .
o workers' comp. insurance 5.:❑ We are a corporation and its` ;
equired.]
officers have exercised their 10.❑Electrical repairs'or additions
3. I am a homeowner doing all work right of exemption per MGL. 1 l.E] Plumbing repairs or additions
myself.[No workers' comp., c. 152, §1(4), and we have no 12•Q Roof repairs
insurance required.] t employees. [No workers' 13:0Other
comp. insurance required.]
*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 anld 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,andjob 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.aSTOP WORK.ORDER and a fine
of up to$250.00 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:
l
I do-hereby certify under the pains andppenaltt ie"s of perjury that the information provided above is true and correct
Sisrrtature Date:.. �Jc? L +ZGt. Z L� j_o
Y
Phone#:
[6.
icial use only. Do not write in this area, to be completed by city or town offcciaZ
or Town: Permit/License#.
ing Authority(circle one):
oard of Health 2. Building,Department 3. City/Town Clerka 4. Electrical Inspector 5:Plumbing Inspector ..
ther.act Person:
Phone#:
F
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 employers defined as"an individual, partnership, association, corporation or other legal entity,or any two or more
of the forego irig�engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustNf an individual, partnership, association or other legal entity,employing employees. However the
owner of a dwellingo ouse having not more than thr; apartments and who resides therein, or the occupant of the
dwelling house of an o er who employs persons to d maintenance, construction or repair work on such dwelling house
or on the grounds or,buil rig appurtenant thereto sha not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)als states that"every stat or local licensing agency shall withhold the issuance or
renewal of a license or permit t operate a business r to construct buildings in the commonwealth for any
applicant who has not produced a eptable evident of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C )states"Neith r the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomlan of public w rk until acceptable evidence of compliance with the insurance
requirements of this chapter have.been pre rated to the ontracting authority."
Applicants
Please fill out the workers' compensation affidavi co letely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s), addres es and phone number(s)along with their certificate(s) of.
insurance. Limited Liability Companies (LLC)or Li ' ed Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' ompensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this of 'vit m+ay be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Alsa b sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for th pe it or license is being requested, not the Department of
Industrial Accidents. Should you have any questions re rdin the law or if you are required to obtain a workers'
compensation policy,please call the Department at the n mber li ed 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 le ibly. The Depa ent has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of nvestigations has t contact you regarding the applicant.
Please be sure to fill in the permit/license number which wi 1 be used as a referent number. In addition,an applicant
that must submit multiple permit/license applications in any iven year, need.only su tit one affidavit indicating current
policy information(if necessary)and under"Job Site Addre "the applicant should writ "all locations in (city or
town)."A copy of the affidavit that has been officially stamp d or marked by the city or to may be provided to the
applicant as proof that a valid affidavit is on file for future pe its or licenses. A new affidavit ust be filled out each
year. Where a home owner or citizen is obtaining a license or ermit not related to any business or mmercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is T required to complete this affidavit.
The Office of Investigations would like to.thank you.in advance or your cooperation and should you have a y questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of assachusetts
Department of Industri Accidents
Office of Investig tions
600 Washington S reet
Boston, MA 02111.
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
''I Revised 5-26-05 www.mass.gov/dia
Town of Barnstable _
Of r
Rep-Oatory Services
Thomas F. Geiler,Director
Building Division
PrED '�k Tom Perry,Building Commissioner
200 Mam Slreef_Hyannis, MA.02601 ,.
Rev.town.barnstable_ma.us
Office: 508-862-4038 Fax:.:508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: R. y* 1'U' • .. .,q '
JOB LOCATION: t ° (/L I� C� L tQ �Iv Iy L J
number street villa e
"HOMEOWNER": C.y`i--L-! rq ►^�, ` �ZZ t r:. G�(.,7 ��i °I Z.-
name home phone# work phone#
CURRENT MAILING ADDRESS: S 7 =iac _5 i / J 6W l 0I(LE 1q
If
city/town state rip code
The current exemption for"homeowners"was extended-to include owner-occupied dwellings of six'units.or,leSS and`.
to allow homeowners to cagage.an individual for hire wbD does not possess a license,provided that the owner acts as
supervisor_
DEFINITION'OF HOMEOwI\'ER
Persons)who owns a parcel of land on which be/she resides or iatcnd.'to reside, on which there is, or iS intended to•-
be, a one or two-family dwelling, attachcd or detached structures accessory to such use and/or farm structures. A
person who constrgcts 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'Offici.al, that he/she shall be
responsible for all such work performed under the building permit .(Section 109.1.1),
a
The undersigned"homeowner"assumes responsibility for compliancewith the State Building Code and•other,
applicable codes, bylaws,rules and regulations.
The undersigned "homeowner"certifies tbat.he/she understands the Town of Barnstable Building Department:,
rninirnum-inspection procedures and requirements and that he/sbc will comply with said procedures and
rr-guir�ements.
�/�-�'� � • it , - .
Signature of Homcowna
'{ n �;
Approval of Building Official .
Note: Three--'family dwellings containing 35,000 cubic feet or,larger will be required to cbmp.ly with the
State Building Code Section 127.0 Constiuction Control. r
HOMEOWNER'S EXEMPTION.
The Code states that "Any bomeowncr performing work for which abuildin`g pcinvt is required shall be exempt from the provisions
of this scction,(Scetion 109.1.1 Licensing of construction Supervisors);provided that if ncC hbmcozpner cngagcs a pc son(s)for hire tq do.such
work,that such Homcownct shall aches supa-visor."
Many homcowncts who.usc this exemption arc unawarz that they arc assuming thelresponsrbilitics of a supervisor(sec Appendix Q,
Rules&Rcgvladons for Licensing Construction Supa-Yisors,-Section 2:15) This lack.of awareness often"rosults in serious prgb)ems,particularly
when the homeowner hires unlicrnsed persons-'In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. Tnr homcowncr acting as Supervisor is ultimately responsible.
To cns-urc that the homeowner is fuIly aware of his/ho-responsb0itics,many communities require, as part of the permit application,
that the homcowmer certify that he/she understands the responnbi)itics of a Supervisor. On the)Nast page of this issue is a form currcnt)yused by
several towns. You may care t amend and adopt such a formAcertification for use in your Community.
Q:fornu:homcczcmpt .
' R
THE Town of Barnstable
0
� r
Regulatory Services
` 1AR]t6TASL.E, f
4 Thomas
v g F. Geller,Director
°rEocc� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office; 508-862-4038 Fax: 508-790-6230
Property Owte Must
4V`
Complete and Sign. his Section
If Us in A ilder
as Owner of the subject property
hereby authorize to act on my behalf,
M all matters relltlVC to work authorized by adding permit application for.
(Address of ob)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete. the
Homeowners License Exemption Form on the reverse side.
Q:FORM5:0WNERPERMISSION