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Home My WebLink About0063 LOCUST STREET r r FYI r Town of Barnstable b e it# SOT Expires 6 months from issue date ' Regulatory Services Fee 3S-,. i 11IANSTJAT24 MASS 9cb 1659. Thomas P. Geiler,Director -PRESS ERMIT prEa Mp'4 k , Building Division Tom Perry, CBO, Building Commissioner MAR 2 ® 2012 200 Main Street, Hyannis,MA 02601 www.town:barnstable,ma.us - Office: 508-862-4038 TOWN OF B' Fax:��8-N 230 _ EXPRESS PERYET APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7 V Property Address v �— . 5 ` Residential Value of Wor a Minimum fee of$35.00 for work under$6000.00 � p • Owner's Name&Address r ( V Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) 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. t Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going-over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value �. (maximum.44)#of windows _ *When 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 r uired. IGNATURE: IWPFILESIFORftuilding p it formslEXPRESS.doa :wised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 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/Individual): C J-e Address: L Ic C L . Ci /State/Zi : 0 (, Phone#: - �l 1067 tY P Are you an employer? Check the appropriate box: Type of project(required):; L❑ I am a employer with 4..,❑ I am a general contractor and I employees(full and/or part-time).*. have hired the stab-contractors 6. New construction . 2.❑ I am a'sole proprietor or partner listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have & ❑Demolition workingfor me in an capacity, employees and have workers' Y P tY 9. ❑Building addition [No workers' comp.insurance, comp.insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3. I am a homeowner doing all-work l l.❑Plumbing repairs or additions myself. [No workers' comp. i right of exemption per MGL '12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[V Other_ ; _j �Ie le comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they'are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. .Below is the policy and job site information. Insurance Company Name:., Policy#or Self-ins.Lic.#: 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 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$250.00 a day against the violator. 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 hereby ce c unde a pains-and penalties of perjury that the information provided above is true a d correct. Si ature: Date: J Phone#: Ll Ski 'Official use only. Do_not write in this area,to be completed.by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person.in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house,of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold`the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced,acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract fok the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. . City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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 marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related io any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number:. -The Commonwealth of Massaehuwtts Department of Industrial Accidents Office of I avestigatim 600 Washington' Street Boston,MA 02111 Tel. #617-727-4900 ext 406 o.r1-877-MASSAFE Revised 11-22-06 Fax.## 617-727-7749 N www.mass.gov/dia 'VKE Town of Barnstable Regulatory Services t Baxsznars, * Thomas F.Geiler,Director r MASS. E1639. 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: c� O t aO 1 oZ Q JOB LOCATION: S .� C number street vill ge n —�� — „HOMEOWNER": �f e I `C '" 1V �di� �� ? —L/l D_p name (/ home hone# wbrk phone# CURRENT MAILING ADDRESS: - Lp �,j ,�c �M oaG3 city/town � Ystate 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 n rLmum' ection procedures and requirements and that he/she will comply with said procedures and re e Signature. 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 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 personas 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, I that the homeowner certify that he/she urderstands 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 fomdcertification for use in your community. Q:forms:homeexempt �1 Town.of Barnstable Regulatory Services U+ss. �, Thomai F.Geller,Director 0.19. �m nr +' 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 4 a -, Property Owner Must Complete and Sign This Section Y' 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 (Address of job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final "in' are performed and accepted. Signature of Owner Signature of Applicant Print Name ,. _ Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS THE roytio Town of Barnstable *Permit# •5�c r7 Expires 6 months from issue date snvsraetE Regulatory Services Fee s, 0D 9MAS& Thomas F. Geiler,Director Building Division Xpp� Peter F.DiMatteo, Building Commissioner �� 200 Main Street, Hyannis,MA 02601 IAAI Office: 508-862-4038 TO 1 r 2002 Fax: 508-790-6230 V/N OP EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY BA&/VS Not Valid without Red X-Press Imprint Map/parcel Number d. VV Property Address ❑(Residential Value of Work (go. er U Dwner's Name&Address �� ' ' C:�G-/�• contractor's NameTelephone Numb Some Improvement Contractor License#(if applicable) construction Supervisor's License#(if applicable) Ywl"orkman's Compensation Insurance heck one: ❑ I am a sole proprietor ❑ I am the Homeowner [lY I have Worker's Compensation Insurance nsurance Company Name Vorkman's Comp.Policy# [1 7 3 7 ! y lJ 0 '1 'ermit Request(check box) ►["RRe-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ignature :Forms:expmtrg wised121901