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HomeMy WebLinkAbout0138 LINCOLN ROAD ,, I Town of Barnstable *Permit c( e pF � Permit# O� Expires 6 months from issue date Regulatory Services Fee s s * BARNWABL$ MAS9 1 ¢ �e� Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number lr 1f1/C (f L, Y�� r Property Address 3t �� �L,) ❑Residential [Value of Work... _ 1DO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address J St'tt Pc FT-oU Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) X-PRESS PERMIT Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance MAY 3 0 2013 Check one: ❑ I a sole proprietor c the Homeowner TOWN OF BARNSTABLE ❑ I have Workers Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request-(check box) L-0`Re roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ,a fM01#�La K� ❑Re-roof(hurricane nailed)(not stripping. Going over existing-layers of roof) F[q'Ie ide #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ 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: _ QAWPFILES\FORMS\bui ing permit formslEXPRESS. Revised 053012 The Commonwealth of Massachuseft - Depart7nent oflndustrrl'al Accidents Office of Investigrttions 600 Washmgton Street Boslon,.CIA 92111" nwwv.rn gov/dia Workers' C0MPe33Ls2fion Insurance—,davit: Builders/Contractors/E.k-ctricians/Phtmbers �Apphcant Information Please Print Legibh CAcitizess: r-City/-State/Zip-�1 l Phone 4- S o� q Z Z. `Are you an employer?Check the Approptiate box.: Type of project(required): 1.ElI am a employer with 4- ❑ I am a general contractor and I employees(fall and/orwime).* have hind the sub-conhact"s G. []New ccnstrucfioo 2_❑ I am a sole proprietor orpartnea- listed on the attached sheet. 7. ❑Remodeling strip.and have no employees These sub-contractors have 8_ ❑Demolition worlring .for me in any capacity. employees and have modcus' jN0[itorkerS' comp.insurance COIDp_incuxarup, �- ❑Btuldmg addition egrrised] 5..❑ We are.a corporation.and.its 10.❑Electrical repairs or additions 7 .1 am.a homeowner doing all whale ����exercised their 11_❑Plumbing repairs or additions myself [No workers'comp- right of exemption per IYIGL 12.❑Roof repairs insurance required.]T c. 132, §1(4). and we have no employees.[No workers' 1.1.❑'Other comp.insurance required.} 'Any applicant tbst checks box#1 must also fill out the section below shearing their workers'compensation policy infornrstioa t Homeowners who submit this af5davit indicating they ace doing aU work and then bae outside cons mcwn mast submit a new affidavit indicating such iCaattacurs that check this boa must attached am additional sheet showing the nmme of the sub-cunracwts and state whetbu or not ftse entities bane employees. If the sub-contizacis have employees,they in=pmvide their werkers'comp.policy number. I am an employer that is provi Yng workers'conlpa nolon insurance for my eniployea& Mow is the pv&.31 aid job site information. Insurance Company Name: Policy 9 or'self-ins.uc.;9: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers'compensation policy,declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Seclibn 25A of MGL.c_ 152'can lead to the imposition of criminal penalties of a fine up to$1,500..00 andfor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against the violate r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of ffie DIA for insurance coverage ueritifiatida: I do hereby certify under thepains aadpeanahYes of 'ury that the infortraairon provided abfiw is true and correct 1 5i �-3d- }?ltorre#: a 26 2, ©jftial ase only. Do not w to in this area,to be completed by do or tong ofeiat City or Tor%'n: PermitfLicense )[sluing Authority(drde one): 1..Board of Health 2.Building Department 3.City/I own Cleric d Electrical hispector 5.Numbing Lupector . 6.Gther Contac t Person: Phone#: 6 �oFVEr Town of Barnstable �90 Regulatory Services BARNSTABLE, " Thomas F.Geiler, Director 1639. �s``� Building Division Tom Perry,Building Commissioner 206 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DA�. y.� �• -JCJ l r/ y�' JOB LO-CA-T-ION:--, 13R L( P�CO�� 1ZP "/ IV/� ;number a /� � street -� '-g: / v l/aget�, "HOMEOWNER,,: .� � J(4tXCf 6A� �®O - �l��"�j�(� h name -v home phone# work-phone- CURRENT MAILING ADDRESS: -- zGV 1 city/t wn `'� 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 at he/she understands the Town of Barnstable Building Department minimum inspection procedure ndrequire ri d that he e will comply with said procedures and requirements. . — l Signature f Homeo er 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 I 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 caret amend and adopt such a form/certification for use in your community. , Q:\WPFILES\FORMS\building permit forms\EXPRESS,doc Revised 070110 F THE 1p� + lARNSrABLE, + 9� MASS.: ,�� Town of Barnstable i0reo 1,,�r°' Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis, MA 0260.1 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner ust Complete and Sign 's Section If Using A wilder h s Owner of the sub)ect property hereby authorize to act on my behalf, in all matters relative to work authorized by this uilding permit application for: (Address o job) i r Signature of Owner Date I Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on..the reverse side. Q:IWPFILEST0RMSIbui1ding permit forms\EXPRESS.doc Revised 070110