HomeMy WebLinkAbout0002 LOUISBURG SQUARE 7 ciy �� R
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/FL11E,r. Town of Barnstable *Permit
Expires 6 months fryr -issue date
Regulatory Services Fee
• 13ARNSAS. * °�
MA S.
•�� }67q. .�� 3 Thomas F. Geiler, Director
�
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Building Division
ST,9e`� Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barris table.ma.us
Office:. 508-862-4038 Fax: 508-790-6230
EX-P-RESS-P-E-RATIT—ARPLICA-T-T-O-N -RESIDEN-T-IAL-ONIrY
Not Valid without Red X-Press Imprint Map/parcel Number d 79 0( �0 0 s q uo"Vel
Property Address --r/w�`7 Z c� z .r�3 v S e• v'» Jam.
Residential Value of Work "D Minimum fee of$25.00 for work under$6000.00
Owner's Name & Address Jijg V
Contractor's Name _ hl� J, �.� � � Telephone Number J G Va_s't;Z -a 71
I loins Improvement Contractor.License#(if applicable)__ f02 Y1
Construction Supervisor's License#(if applicable)
❑Workman's Compensatio.n.Insurance
Check one:
® .I.am a sole proprietor
❑ I am the homeowner
1 have Worker's Compensation Insurance
Insurance Company Name I � . 1 C r u z �-t ,��. tvn a
r y
Worl<man's Comp. Policy ft Z t7Q t. X 0 a 0 /
Copy of Insurance Compliance Certificate must be on file.
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
Replacement Windows/doors/sliders. U-Value&Js (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.HomeJmprovement Contractors License is required.
SIGNATURE::
Q: WPFILESTORMSbuilding permit Fon,MEXPRESS floc
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HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
Registration, before the expiration date. If found return to:
102149 - Board of Buildin
IFExpiration: 6l30/2010 Tr# 268765 g Regulations and Standards
One Ashb
r,4 Type Ihdividual �0n Place Rm 1301
Boston,Ma,02108
JOHN JOHNSON
John Johnson
PO Box 118 160 hurch-S-'
W.Barnstable,MA 02,66 8
_ Administrator
Not v id without signature
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The Commonwealth of Massachusetts
De artmerzt oflndustrial Accidents
Office of Investigations
d 600 Washington Street.
Boston,MA 02111'
www.mass.govI is '
Workers'Compensation Insurance Affidavit: Builders/Contractors/Ele.etricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): c QI�w' �U w✓a w
Address: �d y C �•
City/State/Zip: 14" n r��<l ec Phone.#: 5 0 V. 3 6 Z. .2 ?7/
Axe.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
* have hired the sub-contractors
6, ❑New construction .
•employees(full and/or part-time). 7, Remodeling
2.� I am a'sole-proprietor or partner- listed on the'attached sheet. ❑ g
' . ship and have no employees These sub-contractors have g, []Demolition:
working for me in any capacity. employees and have workers' 9 0 Building addition
comp.insurance•$
[Nq workers comp.insurance 10.❑Electrical repairs or additions
required.] 5. (] We are a corporation and its
'3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance. d.ixe
re q n t c. 152, §1(4), and we have no
] employees. [No workers' 13•0 Other
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.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
employees. If the sub-contractors have.employees,they must provide their workers'comp.policy number.
I am 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 penaldes.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 maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct.
Si afore: Date:
Phone#: J6V - c, t. -�2..�7(
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#:
a
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defiued 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
to do maintenance construction or repair work on such dwelling house
e o employs ersons P
house of another wh
dwelling L. )?
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
construct buildings in the commonwealth for any
f a license or permit to'o erate a business or to - g.
renewal o P
P „
e evidence.of compliance with the insurance coverage_required.
duced�acce tabl v
a licant who has not ro P
PP P P
Additionally,MGL ehapter.152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of_public work until acceptable evidence of cornpliznce 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-contractor(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 '.Gown 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 permittlicense 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 may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must filled out each
year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture
(i.e. a dog license or peradt to bum 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:.
�commonww of I UI Sachus_eas
Df,Parto�at ofdta1 A.ccxc eu.ts
Offtce of lavcstigatpas
604 WaA nat06 S.tre�t
• Bostan,-ILIA Q�111
Te,1.#6,17-727 4900 ext 406 Qr 1 r977-MASSAFE
Fax##(517427-7749
Revised 11-22-06
www.rrt=.gov/dia
SHe Tay Town. of Barn-stable
' Regulatory Services
�s hUS& Thomas F. Geiler,Director
1619.
n MAt 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 ABuilder
I, Z'_ -� Owner of the subject property
hereby authorize kX1 to act on my behalf,
in all matters relativ o work a 4hoiized by this building permit application for:
(Address of Job)
Signature of Owner Date
Ll K ye.
Print.Name
If Property Owner is applying for permit please complete the -
Homeowners License Exemption Form on the reverse side.
!1•F(1D ARC.11T1R.i1;DDCD1„(TC CTl11.1
y���oF z�r���•
Town of Barnstable
Regulatory Services
(; swxtvszesre Thomas F. Geiler,Director
MAss.
ses9 ,�� Building Division
Tom Perry,Building Commissioner
200 Main-Street, Hyannis,MA 02661
vrww.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village-
"HOMEOWNER .
name home phone# work phone#
CURRENT MAILING ADDRESS:
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 OYHOMEOWNER
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
er"shall submit to the Building Official on a form acceptable to the Buildin Official that he/she shall be
"homeowner" g p Building.Official,
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 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 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 helshe 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:forms:homeexempt