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HomeMy WebLinkAbout0034 LINCOLN ROAD C�p ZA-) -------------------- i �_ �- � �'/ f Town of Barnstable Permit# Regulatory ServicesF-V ge 6monthsjrom issue date sntuasrwstE • KAM �$' Thomas F.Geiler,Director . s6;q.- �FD MA'1 A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-403 8. Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 1 Property Address iUC'O Vt✓t t-S [Residential. Value of Work e0d Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number Home Improvement Contractor.License#(if applicable) ®®®® Construction Supervisor's License#(if applicable) -PRESS PERMIT ❑Workman's mpensation Insurance JUN - 7 2012 fa�am one: a sole proprietor . m the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check,box) - Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over % existing layers of roof) ❑ Re-side #of doors ❑ Replacement.Windows/doors/sliders.U-Value (maximum.35)#of windows y.. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is : required. SIGNAT v c� � Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Revised 05,1811 The C'ommonweakh of Massachusetts Deparonent of lnda;strial Ac+ciden& 09we of Investigations 600 F wJWngton.Street Boston,MA 02111 n�ry v lmass gov�dia Workers'Compensation Insurance Affidavit:Bmlders/ContracbarslElectrncians/Phrmbers ApiplicantInibrmation Please Print Lmhly �I�TIe=($usmelO�gan�tian/lndividOaU=_ 1/b � r9g�C �/a —rsrz Y �/�rS Phone t ta- — . Are you an employer?Check the appropriate box: T of project 4. I am a contractor and i . Type p I (required): 1.❑ I am a employer with ❑ dal 6. ❑New constniction. employees(full andlor part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partum- listed on the attached sheet. T- ❑Remodeling ship and have no employees. These sub-contractors have g_ ❑Demolition w for me in any c employees zmd have workers' �ttY- 1 9. ❑Building addition o`vorlmrs'comp.insurance comp.insurance- d. 15. ❑ We.are a corporation and its 10-E]Electrical repairs or additions (33 am a h m I eowner doing all:vac officers have exercised dm f 11.❑Plumbing repairs or additions myself [No workers'comp- Tight of exemption per MGL 12."of repairs insurance required.]t c.152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required] *Any applicant that checks boa#1.anal also fill out the section below showing their woQkere c©mtpemsation policy infarinstioa FYameowneix who submit this affilava indicating they are doing all work.mud Ikea hire outside contractors mast submit a new afdsw indicating such fContcactors that cbeck this boa must attached am additional sheet showing the name of the sub-conUxAm and state whew ornot those entities hsve emphryees. If the snb-caatm an have employees,they must provide their works'comp.policy number. I am an empIoysr that is pnn dW g workers'compensa an.insurance for my emptgyeeL Below is the policy rind job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/StatetZim Attach a copy of the workers'compensation policy declaratim page(shoring the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250-00 a day against the idolater Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herby ceW&jmdqr thepains and pana of peduty that the information pro ided above is hue and correct /�P- Phone- #--Official use ant}. Do not►Trite in this area to be completed by tfy or town afficiaL City or Town. PermitUcense# Issuing Authority(circle one): 1.Board of Heallfi.2.Building Department 3.Cityfrown Clerk 4.,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• 6 Town of Barnstable Regulatory Services 9 MI'E'$' Thomas F.Geiler,Director 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 /// HOMEOWNER LICENSE EXEMPTION Please Print DATE: ,joB w—c_TTIO--N:--!n,, G//Izr 4,1 number street village name home phone# work phone# ,CURRENT K1JLINGADDRESS_34 � W Cd O /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 roce es and require and P����.�-.,_�•_ill_comply with said procedures and requirements. i`atum—of Ho eo 7 r 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 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 dF� ,•� 'Town of Barnstable '°lFo Ma's" Regulatory Services Thomas F. Geiler,Director Building-Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: '508-862-4038 �� _ Fax: 508-790-6230 , �r Property Owner Must Complete and Sign This Section.; If U/ABBuffer e subject property 1 hereby authorize to act on my behalf, in all matters relative to work authorVbythiilding permit application for: (Address f Job Signature o Ow r Dat - Print Name If Property Owner is applying for permit,-please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORWbuilding permit formsEXPRESS.doc Revised 051811