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Home My WebLink About0019 BEARSE ROAD to s2 �-7 Town of Barnstable *Permit# Expires 6 nths frsue date Regulatory Services Fee 9 Thomas F.Geiler,Director 639. Building Division Tom Perry,CBO, Building Commissioner, 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION. - RESIDENTUL ONLY ¢� Not Valid'without Red X-Press Imprint Map/parcel Number p � r Property Address B e—v4a5 i>;c &Residential Value of Work /;�g (US ! b y Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 5--�e p h ri _.J ew h n l3(l S S Contractor's Name rW,:-_nV1 1yC-LISOfv Telephone Number 508 35-� ?� Home Improvement Contractor License#(if applicable) 1 Construction Supervisor's License#(if applicable) C ¢ �Za ❑Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors [� Replacement Windows/doors/sliders..U-Valued (maximum.35)#of windows _. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervi ors License is ' �rqired. JU SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 L tl The Commonnwalth of Massachusetts Department of Industrial Accidents - Office ofinvestigadons 600 Washington Street = Boston,MA 02111 nm"ttmass.gov/dia Workers' Cumpelnsation Insurance Affidavit:Builders/C,ontractursT-k-ctr nsdPlu nbers- Applit�ant Inform,atlon \\ ( Please Print LegibhT �3ille(BuSmesst�Organtzalionldndividual}_ �uJD'S`-� � l��,�.. � Address: to '7 14-SC rer/ L.Zty!Jt$:I,Gf � LJ-f GVt. t u V L-✓^6 J $* :J 09 -35 3 4 9 Are YOU an employer?Check the appropriate box: Type of project(required): 1-❑ I am a employer with 4.. ❑ I am a general contractor and I to full and/or part-time).* have hired the sub-coutra�ctors 6- ❑New ce�nstsuctiou employees( ' part-rim ) 2. I am a sole proprietor or partner- listed on the attached sheet. ?- ❑Remodeling ship and have no employees. Thee sub-contraeturs have g- ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance-1 9- ❑Building addition required_] 5- ❑ We are a corporation and its 10-❑Electrical repairs or additions 3-❑ I am a homeowner doing all.work officers have exercised weir 11-❑Plumbing repairs or additions myself.[No workers'comp. fight of exemption per MGL 12.❑Roof repairs insurance required_]t C. 152, §1(4�and we have no / employees.[No workers' 13.[gOther,2 J&62 Re comp.mumance required-] 'piny applisauC dhar checks hoar#1 amst also fill or the section below showing dh�s woffkerC ca®Pm p�Y��bo who submit this affidavit mdwztmg'they are doing all woo}aDd then hoe outsi&counacdon amzi snbozrtt a new affidavit indicating such iconnactoas that check this boa must attached an addwonal sheet show the name of'the sub-contractm and state wbether ornot those entrttes have eavloyees. Ifihesubtozcitactons have employee%they mtsi provide their workers'comp.policy nuber. I am an employer that is prvvideng workers compensateon.insur ran ce for my employees. Below is the policy grad job.rite information. Lance Company Nance: Policy#or Self-ins-Lic.4: Expiration Date: Job Site Address: CitVIStatetzim Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiation date). Failure to serene coverage as required under Sech4m 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 imprisonmeut;as well as civil penalties in the form of.a STOP WORK ORDER and a tine ofup to$250.00 a dap against the-violator Be advised that a copy of this statement may be fmvmded to the Office of Im mstigations of the DIA for insurance coverage verificatia[L I do hereby cextifj�outer thepains anal :/tees of perjury that the information proWded aborna is bee and correct Si true: ` Date: 0. D '2-0(' Phone a- t),fjfcial use only. Do not write in tltrs area,to 6e completed by city or town official 4 City or Town: PermitUcense 4 Issuing Authority(circle.one):: 1.Board of Health 2.Budding Department 3.Cityl Town Clerk 4..Eiectrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• 6 c1 C; o�try a � • BARNSfABLK 9� i639' g Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building Division - h Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.nia.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 �� Z5 B -. hereby authorize J to act on my behalf, in all matters relative to work authorized by this building permit application for: i (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the reverse side. QAWHILESTORNObuilding permit formsTYPRESS.doc Revised.051811 Q -I BIKE Town of Barnstable Regulatory Services IMANSTMI4 " Thomas P.Geiler,Director 9 MAN. a ra`` Building Division Tom Perry,Building�Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 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, attachedor 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 ag"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. Q:\WPFILES\FORMS\building permit formS\EXPRESS.doC Revised 051811 Affai � _ Office of Consumer rs&Business Regulation License or registration valid for individul use only � HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 4152971 Type: Office of Consumer Affairs and Business Regulation Expiration: J�b/23/2012 Individual 10 Park Plaza-Suite 5170 t Boston,MA 02116 R LPH W NELSOri. .: _: RUDOLPH NELSO�1 107 QUAKER MEETIN HOUSE / 1 n %� SANDWICH,MA 02563 � Undersecretary Not valid without signature N°lasslichusetts- Department of Public Safet} Board of Buildin!, Regulations and Standards Construction Supervisor License License: CS 93070 • � F,. RUDOLPH W NELSON , PO BOX`1141 .� SANDWICH; MA'02563 Expiration: 9/2212013 ('onmiiscinner. Tr#: 2399 I