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Home My WebLink About0060 HARVARD STREET Town of Barnstable *Permit# Obo �°6 2( Expires 6 months from issue date Regulatory Services ee l�ruxxsTnsLe; Thomas F. Geiler, Director 9`b b� 8 2008 Building Division `rFo r wt° (� �' Tom Perry, CBO, Building Commissioner 'I1' OF BARNSTABLE 200 Main Street, Hyannis, MA 02601 www.tovm.bamstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Numbers Property Address &rt y e S , [ Residential Value of Work . 00 --- Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name 1�S `� Telephone Number �5"-4�� ` —8c 19 Home Improvement Contractor License#(if applicable) ❑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 be on file. Permit Request(check box) / (� Re-roof(stripping old shingles) All construction debris will be taken toi�� ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum..44) *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 is required. SIGNATURE: Q:\Vr/PFILESTOR-MMuilding permit forms\EXPRESS.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Name(Business/Organization/IndMdua): 6 • Address: �'�" � CitylStatelZip: Are your an employer? Check the appropriate bar: 'Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the mib-contractors listed on the attached sheet 7. ❑Remodeling 2❑ I am a sole proprietor or partoer- ship and have no employees These sub-contractors have g,.0 Demolition employees and have workers' working for mein any capacity. $ 9. ❑Building addition . [No workers' comp.insurance COMP'1DZurance. S. 0 We arc a corporation and its 10.0-Electrical repass or additions rcgnirml] officers have exercised their 11.0 Plumbing repairs or additions 3 I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs incrtralSce required-]t P. 152, §1(4), and we have no - employees. [No workers' 13.0 Other cow,in once regTII 41 *Any applicant that chxks box#I must also fill out the section below showing their wari=-s'enn?c soon policy information- t Hmnmwncn who wbnit this a$davit indimting they arc doing all work and thm hire outside contractors must submit anew a�davitindiratin9 such Tcontraetms that chxk this box nuut attathcd an additional sheet showing thc name of the sub-cantractorm and str6e whether or not thasb rntifies have cmployccs. If the sub-eonhactors have employees,.fliey mint providh thcv work='comp.policy number.. Iam an employer that is providing workers'compensation insurance for my employees. Selaw is the policy andjob site information. Insurance Company Dame: Policy#.or Self-ins.Lie.# Expiration Date: fob Site Address: Citylstatcdzip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requircd under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine Tip to$1,500.00 and/or one-year imoprisonincnt; as well as civil penalties in the form of a STOP WORK ORDER and a fit of up to$250.00 a day against the violater. Be advised that a copy of this statcmerit may be forwarded to the Office of Investigations of the DIA for insr ranee coverage verification. I do hereby certi;fy der the pains-and penaltie�Irr " Chad the information provided above u e and correct Date • Si c: Phone# O j7dal use only. Do not write in this area, tb be completed by city or town officiaL City or Town: Permit/License# Isvidng Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other i-,,,,far-t- Phone 9: Town of Barnstable Regulatory Services 'Thomas F.Geiler,Director s&axsr&BI E. .s, MASS Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnst2ble.ma.us Office: 508-862-4039 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: O 0 number street llage "HOMEOWNER": 4amc home phone# work phone# CURRENT MAILING ADDRESS: ,4 o 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. . DEFINITrON 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) for compliance with the State Building Code and other The undersigned"homeowner'assumes responsibility applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department um inspection procedures and requirements and that he/she will comply with said procedures and re ments. e � Signature o omcowner 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 perforrrdng work for which a building permit is required shall be exempt from the provisions of this section(Section iog.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a pmon(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption sit 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 Ktith 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. f oFtHEt° . Town of Barnstable Regulatory Services BARNSTesM Thomas F. Geiler,Director y Mnas. 16 q �� 3 Al�o �a 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 Owner Must Complete and Sign This Section If Using A. Builder j (J Cf S r ✓ i , as Owner of the subject property hereby authorize to act on my behalf, in an.matters relative to work authorized by this building permit application for: Address of job) _ e Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on .the reverse side.