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':�,�, ,�",,­I 11;I,- ,-,.�,I :�,-,,,,�.�,",1�,1 I,�:,,,,I!�:,'_�_,'�,�,,..,;.,,���_,_,,�"�L,,I 1Z'­-I�'',,_'�",�-.:I,H1I1 1��I,_,,�I­,,.,---,,,,_,_I,_V�, - , Syr t ,.{ { iR H4 ih >i �+ p { 4 0 { ' b � a X 'q f sx�� tx Town of Barnstable * # er�� U of Permit Expires 6 months from issue date Regulatory Services Fee C �'S— 'r ReuHcr�x_rx s' — 659.1 . � Thomas F.Geiler,Director P2RMI639 �� TBuilding Division D 17c 1T om Perry,CBO, Building Commissioner Z 200 Main Street,H yannis,MA 02601 , TOWN of 8aRNST tww.town.barnstable.ma:.us Office: 508-862-4038 A L Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X.--Press Imprint Map/parcel Number S 1 a -1 Property Address `4 ,� , Lf �41 j116 c-J t / PX-e-s`i�dential Value.of WorTc v/ )�� J\) Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address f 7L,)L f J Contractor's Name S Telephone Number Home Improvement Contractor License#(if applicable)_ J ) Construction Supervisor's License#(if applicable) '❑Workman's Compensation Insurance Check one: ❑ ixlrasoie proprietor 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) e-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) " ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .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 re tired. &Construction Supervisors License is SIGNATURE: �AWPFILESIFORMS\building permit fnrmslEXPRESS.doc f Revised 070110 77Ye Com w o nwed&O�f Afassfi'C�ime& Office of Imtit56gfifions 600 WashingAw Street Bost�-M#2111 WWW.MU1 gf)v/diff Warkers"Compensation Insw-ance Afdav Bu'dders/Contractors/EkchicianslPb mbers; Awhcant Ili.ormation Please Print i*ffi.lv Namc City/State/: Are yan as employer?Check the appropriate box Type.of �'ect r F1 am a p j (required): L❑ I am a employer taPith ❑ cantraar and7 I t4 New motion employees f©ll andlorpart-ftime� have hired the sub-�actm ❑ 2_❑ I am a sale prrpietor orgarb=- listed cm the attached shfttr 'i. ❑Remodeling ship and have no employees These sob-ccntrac a:s have $ ❑DernD woricing forme in-any capacity. employees andhave.ovadcM' 4. Buildingaddition WQrfa=*COMP-iMMrRUCe comp- 1 ❑ 5. ❑ We are a coTorxtioa and its 10-❑Electrical repairs Cr additiims . 3. I am a b=ezwner doing all w+thrlc afbcen have e$eveised their 1 l_b2of g mP�oramyself[No Wo kars'camp- fightof esemptham per NIGL 12. repairs insurancerequired,]; c. 252„§l{4�,and we have no employees.[No wod'' a 13-0 Other comp-ksrtranm required.] j w ;Any appb=that checks boa#1 nuw also fill.o©t the section below abashing then warrseW cmp Pormy infimmudan. ✓ .Ea>neo -bo submm this affidavit mdid—g they ale doing 2UWCd sad then hoe outside camuarjors sans.submit anew affidavit indicating sect: Icantractms tbatrhear this mast attached am additiam sheet showing the name of the sb-secs and stale whetber ar nottbuse des have employes. Iftbe s*—nmams bane mwlme-%theymustpm vide tin aiadMV CMp.policy mmiber. I am an employer that is prmvidfng ruorirers'camperrs�sn iffm7 eg for MY Bg&w is thep Uey and job sit, �} Inmuanm Company Name: Y04. 1 . . Policy#ar Self-ins-Litw 4,16 Job Site Address: �� \1_ sg �J CityfState��ip:�IJY11 Aek�-,1)^f) Bch a copy of the worlfers'compensate m pormy declarat im page(showing the policy umber and aspiration date)' Fail'=to secure coverage as required under Seam 25A of MGL c 152 can lead"to the*Position of criminal penalties of a fine up to$1,500 0Q a Wor one-year imprison 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 may be forwarded to the Office of lavestigatiams of the DIA for Insurance cGVMm a ver am Ida hrrekt cer#a and er thepain rind penahrks rrj`perft"&&t he;vf0 =barn protdrfsd abanrs is tr ee and correct $ Date, f Phone#: Q,Lei d use rrrrfy. Do not Writa in lids area,to be COMP W by city+or town offieiai CYO or'To PerndtUcense# issuing Authority(cfl de am): . 1.Board:of Health 3.Bmldmg Department 3.Otylf'own Clem 4 Electrical Inspe for 5.PirSmbFng Inq vector b.Other contact Person• Phone#: Town of Barnstable Regulatory Services WansrMar.E, ; ..Thomas F Geiler,Director MAW. p i' Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstabie.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number / street .j ' t /�� q village "HOMEOWNER": / -�/ r.lO l��/ 1.r �7 Y/�M,6 yname home ph?one.# work phone�76 � `� �� ` CURRENT MAILING ADDRESS: 5>r) I�7 6 ('�( Cow kn 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. Thetundersigned"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 requireme Signature of Homeowner �k f 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 perfomUng 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 form/certification for use in your community. aFE Ta,, Town of Barnstable - Regulatory'Services XLF y MASS Thomas F.Geiler,Director � 1639. 6 7 A ED niw Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-4038 j i Fax: 508-790-6230 Property Owner �/e Complete and Sign Th If Using A Buil I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters.relative to work.authorize this building permit application for: (Addres of Job) Signature of Owner D Print Nam_ e. If Pro e ' Owneris. aPP Yr g Per l n for mit lease complete the P �' P P � Homeowners License Exemption Form on the reverse side. I