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HomeMy WebLinkAbout0020 STANLEY WAY 3 � _. N c ..a �� � - — � .�• . �. �� ,. _. {: ,.. r ,`_. .. ., _ _, , ,.,, a -;r ,r �� � � { , � � ,, � � I y n_ +.. ., u f,; c �1 ', - - 1 y arm 1012s/1 J oFt ra,, Town of Barnstable *Permit� Expires 6 months from issue date w ^ Regulatory Services Fee • snatvsrnsM v Mass.1639• Richard V. Scali,Interim Director $ ATED MA't a Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL; ONLY of Valid without Red X-Press Imprint Map/parcel Number ` - Property Address o h (� �� 617 ky//(� r -� ❑Residential CValue of Work$-'4 OlJO. D6) Minimum fee of$35.00 for work under$6000.00 `Owner's Name&Address 40 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) PERMIT n Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor TOWN ®F �p�(�STP►BLE E;1<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)-ErRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ()(/MP Or, /p q y ❑ 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:_ QAWPFILESTORMSUildingpermit forms\EXPRESS.doc Revised 061313 i The Commonwealth cif Massachusetts Detvaranent of IYdnsft ial Accidents Ojoke of-nvesfigations 600 Washington Street F Boston,3L4 02111 wtviv.7nasmgov/dlfa Workers' Compensation Insurance 4ffidavit:B.uilders/Contractors/Electricians[Mttmbers Applicant Information Please Print Legibly Name giusme organizationffndividnat): Address: ao �h 6-w Wa-V City/Statz/Zip: �/1`fCld P 1y1 :3 Z Phone� Sd ',/UZ r Are you an employer? Check the appropriate box: Type of o'ect r uire 4. I am a contractor and I 3`l� � 3 (� �- 1.❑ I am a employer with � 6- ❑New won employees{hill and/or part4ime * have hired the sub-conawtors. 2_❑ I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling ship and haze no employees These sub-contractors have g_ ❑Demolition working for me in anycapacity employees and have workers' 9_ [:]Building addition (No workms' comp.in umnce comp_insurance-1 ed) 5. We are a corporation and its iG_❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I L.❑Plumbing repairs or additions V myself. [No workers'cpmp- right of exemption per MGL 12..❑Roof repairs insurance required_]b c_ 152, §1(4),and we have no employees_[No workem' 13_❑other comp_insurance required-j *Any appticnt that checks boa#1 most also fill out the section below showing their woaken'compensadou policy information_ T Homeowners who submit this affidavit imiicsting they up-doing aR wink and then hire outside cootraetors nmsi submit anew.affidavit induating snch- 0onx ants thst check this boat must sttacheri an additional sheet showing the name of the state-ooamactairs and stahE whether or not those eafities have i mplayen. Ifthe suTo-cont roars hale employees,they must provide their workers'comp,policy number. I am an employer that is prat idng tvorkers'compensation insurance for my*employees. Beloty is Ste policy and job site informadon. . Insurance Company Name: Policy 9.or Self-ins-Inc.9:. Expiation Date: Job Site Address: Citv,/StatelZip: Attach a ropy 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 G. 152 can lead to the imposititm ofcr;mi,aal penalties of a fine up to$1,50G_00 and/or one-year imprisoIIzrnt,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 Iirvestigations of the DIA liar insurance coverage vecification- I do Hereby c;erhfy' tinder the pains and penalties o,j`petjury that the information provided above is hue and correct Signature: 2��fC/J' r -Date: !) 1.2 Phone a#: � 7&0 �y2� ©,f ciat use only. Do not irrite in this area,to be completed by civ or town officiat City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.CitylTown 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 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 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 ally 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.o your situation and,if necessary,supply sub-coatractor(s)name(s), address(es)and phone number(s)along with their certufcatc-(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. 'nt 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. Sells 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 permitilicense number which will be used as a reference number. la add ltiou,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 ill (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 hike 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 Commonwealth of Ma.ssachusett Department of 1l dustdal Accidents Office Oz Iavcst gattaus 600 Washington Street Boston,MA G2111 TeL#617-727-4900 w 4-06 or 1-977-I aSSAFE Revised 4-24-07 Fax# 617 727-7 49 www.mass-gav/dia fTHE� Town of Barnstable Regulatory Services '�$^R'km Thomas F.Geiler,Director BuiIding Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION � � -- Please Print DATE: JOB LOCATION:(/ ( /L&!�j number street village "HOMEOWA'ER": YI , LU�i name / , -homephoone# work phone# CURRENT MAILING ADDRESS:_ ! D sqqa "V 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. DEFINTHON 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 BuiIding 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 proced es and requirements and that he/she will comply with said procedures and requirements. Signature of_omeowner - Approval of Building Official - Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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 homeowwner 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 form/certification for use in your community. C:\Users\decollikV,ppData\Loca]\Microsoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 FmE T Town of Barnstable 0 Regulatory Services ganxx $IEg Thomas F. Geiler,Director 0.59. k Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnsta6le.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must i Complete and Sign This Section I£Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012