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Home My WebLink About0054 KELLEY ROAD ke-l/o L E F4 ta_ 1+ Town of Barnstable *Kermit# 1tes 6 months from issue date Regulatory Services ee��o� �- M MASS, Richard V.Scali,Director r o��, O �ii� 1639 �� Building Division ��/0� Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601f��`�� www.town.barnstable.ma.us • �C Office: 508-862-4038 Fax: 508-790 6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �j',-� 6 S Property Address 5q- e lle�z kOa J NUa✓hn t S M A . O ZG O , [residential Value of Work$ 2,200 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address SUh ✓ ✓✓t a i yt S9- P11CF autd avla~;s MC 9zKol Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: . Construction,Supervisor's 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 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) [❑ R -side Replacement Windows/doors/sliders.U-Value Z OOv (maximum.32)#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: Q:\WPFILES\FORMS\building permit forms\EXP SS.doc , 06/20/16 The Comwomvea c,f-assadr Deparbnerit of fludwsbialAcciddaats Qffire 0' 600 Was1tiuigtm&r e _ Baston,MA 02111 tP innniasmgovIdia Workers' Cum]pensaffan Insm-ance Af Eda'it:BixRdeIS C=h-actursMect icLmL-VPlumbers APPHcant W6 mnfian q IPlease Print Y Naffie = Su ntD✓ 3P�/L"taeiv, A7C'Xt p Address- ke l CitgfSfatMg*_ o1401 Phone 509 Are you an employer?: erk the appropriate box: Type of project{regui eq: 1.❑ I ant a employer vd& 4 ❑I am a general contractor and I 6_ ❑Ides oanstra�ction employees(fall andfor pact-fiime * have hired ffie sub-comma oar 2.❑ I am a sole proprietor or partner- listed on,the attached sheet I- ❑Remodeling. sh�p and have no employees . Mese sub-contractors have g_ ❑Demolition worming forme in any capacity- employees aadhavewodmrs' 9..Q Building addition.[N g,wo 'pomp,i"Misa_a re camp-insurance# regtured I I ❑ We are a carpozaticn and its UQ❑Elechical repairs or a,d�ons 3:Ell am a homeov;mer doing all Mork officers have exercised their IL❑Plumbsngregairs or additions myself[No work='temp. iigbt of emem;don per lk GL 13.❑Roof repairs c.15 1 and we have no incawancgreq ;mod i 2s [ 13-❑Other $-cam iZC'b • employee es.�To workers' per- 'A.aygTffcza d=tcheftbosisl—st also i outthesectioabeiowshuvingdieirwaske compeasatianpoRcyinf=zdan_ &nme wnem Who submit dais afddariE indbcath�g the}*axedaiog elf Wal and.rheabite o;=decmxwui=mnSt submit anew affidaviCmdies is sad TCa s ezt chadf this box mast w t r-ll as additi®21 sheet showing the name of the sub c�amdacta�and stare Whether or not those entitieshm • emp9oyees.Ifthesoh-caatmctflshave ezagToF�,�Y�stgmvidertl�s sradr�'gyp.gali�aumisez . lam an hz=zraaca f br mya emp&y zee Eetoiv is Ae paTicy and job sfte iri,�orrrrafiora. Insurance Company Name: Policy 4,or Self-im Lic.4 E�piratioa Date: Job Site Address: CitylStatelytg: Attach a-pnpy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Fa&m to serum coverage as required under Section 25A o€M-W_m 152 tan lead to the impos ili Qf crinsimal penalises of a fine up to$1.50D OD andfor orie-yearimprisonmenk as well as rivil penalties in the form of a STOP WORK ORDERand a fine of up to 0M a dap against the violator Be whised that a copy of this statement may be forwarded to the Office of Invesfigations o€the D3A.for insurance coverage vedfic a iem.. Ida ker-e.Jry cartFfy under gone paQts andpwaKu afget jury thatthe infarmmtavupro1-i&d abate is true grid correct - Ph4ne k- Co - 027dd use wily. Do oat avrke in thb area,to be cvmpTeted by c:iip artatvn ojokiaL - City or Town: PerrutfT;cense;g ximg Anfhearity(drde one): L Board of$eahk 1 lwTXmg Department 3.Mylrawn Clerk 4.Elecfrical hupector 5.Plumbing Inspector 6.Other Confta Person: Phone#: o�rmation and Las coons . . t Massachusetts G=)3=3l Laws ChSp�152 rejm=all employers to grvvide wor=s'oompeasafion.far f=Ir employ=. parsum3ttD fhis ,an Mayne is defined M, .svery person in the service of another raider any c nftact ofbi�r, eXirMss or i mpHA oral or " �. An emplayEr is d efi ed as lair individual,partnership,association;coaporafion or othea legal em ify,or any two or more of the:foregoing engaged iQ a joint entzp ise,and inchEmgg the legal rff2m faizves of a deceased employer,or the receiver or trastee of an individual,par<neasbip,association or otherlegal entity,employing employees. However the owner of a.dwrH;aghouse havingnotmam than three aparhnerds andwho residesffierein,or the occ¢pant oftize - dwelling house of ano5fer who employs persons to do ice,causf ud on or repair work an such dwelling house or on the grounds or b hang a�purEsnartf thereto shall not because of such employment be deemed to be an emzployea_" MGL chapter 152,§25C(6)also sites that"every state or local licensing agency shall withhold the issaance or renewal of a Hcense or permit to operate a busbress or to construct buildhip in the commonwealth for any applicant who hms notproduced acceptable evidence of compHauce,with the insurance.coverage rmgaired_" AddiiionaIly.MGZ chapter ISL,§25C(7}sues"Neii3er the commgnwealth nor jay Of its political subdivisions shall e m,D any contract forthe p�nw ofpubho,wolku�I acceptable evidsace of comp requirements the insurance. e nts of this chapter have been preserctcd io the contra m a afhomty." Applies , Please fill Dirt the workeas' compensation affidavit completely,by rheCkg the bones that apply to.your situation anct,if necessary,supply sub-conira� s)name(s)• addres (es)�dphone bez(s)aIongwithiheir cetiifrcate(s)of insurance. LimitEd Liability Companies(LLC}or Lnmtr-dLiabihfy Parfamslups(LIT)withno employees other than the members or partneas,are not regtmmd to carry wo]±ers'compensation insmumce- If an LLC or LLP does have employees,a policy isregnnrd. Be advised that:tiusaffida-vit may bembmittedto the Department of Industrial Accidents for confirmation ofiom=mce coverage. Also be sure to sign and date the affidavit The affidavit should be mtnmed to the city or town that the application for the permit or license is being requested,not the Department of ; Inri,-st al A=dmts. Mouldyou have any questions regardm g the Iaw or ifyou are requiredto obtain a worio rs' =npensaticm policy;plmsm call ffic Depax-troent at&a number listed below. Self-msmed companies sb¢nldem'urtheir s elf-ins =cz license nnmber an fhe approgriai--line. City or Town Officials t _ Please be soza that the affidavit is complete and pri3trdIegIly. The Department has pm4ided a space at the bott= of the affidavit for you to fill out in the event the Office ofIuvesti gB&=has to contact you g the applicant Please:be sine to$71 is the pe r/a icrose m nber which wili be used as a reference number•. Iu-addition,an applicant that must submit mIultiple penoit/ ceoce applit:afi ms in any given.year,need only sabmit one affidavit indicafmg=Ent policy information Cif necessazy)and under`Job Site Address"the applicant should write"all locations in (citY or town)-"A copy of the-affidavit that has been.officially stamped or maiim;d by the city or town maybe provided to the applicant as prooTthat a valid affidavit is on file for future pemi.�or license& A new affidavhmust be filled Dirt each vaofnro year."Niece a home owner or citizen is obtaining a license or permitnotrelaied to any bns�s or commercial (ie:-a dog license or peanit to bum leavcs etc_)said person is NOT rcgdkrd to complete this affidavit The Office ofZnves�figations would like to thank you is advance for your cooperation and should you have any gaesfions, please do not hesitaiz to glue vs a call- The Dej�arfmmfs address,telephone and fax n=ber_ • went of Izid�.1 As�c�ts OEM=of T-vedkatio= f A TWawou B MA 02111 Ta 4 617 -4900 m t4fl6 or I-M-MA4 FA Fax#617` 27'749 revised 4-24-07 gav Town of Barnstable y. Regulatory Services Richard V.Scali,Director ' Building Division &VRNffrAB1X Paul Roma,Building Commissioner e39. �� 200 Main Street, Hyannis,MA 02601 Fp www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: Please Print � 2 . 2 - /6 JOB LOCATION: I(e Iles fi�p a / number /� village "HOMEOWNER": sL,y1 r y✓ &Ae - name fi J home phone# work phone# CURRENT MAILING ADDRESS: %[e/lAy gold Hyo v, �S /4,4 —?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. 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 HomeoyKer 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 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. ` Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 Town of Barnstable Regulatory Services PIAM ` Richard V.Scal4 Director - Nua 16 Building Division. Paul Roma,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 as Owner of the subject property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application for: (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:FORMS:OWNERPERMISSIONPOOLS