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Home My WebLink About0016 OAK STREET /K7 � Sr- oFt r Town of Barnstable Permit# Expires 6 mouths from issue date Regulatory Services Fee * saxxsrnar.E. 9� 1639. Thomas F.Geiler,Director ATEp�.IA Building Division Tom Perry,CBO, Building Commissioner 200_Main Street,Hyannis,MA 02601 www.town.bamstable.nia.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number `0 �� Not Valid without Red X-Press Imprint / ( )) '' Property Address 047 residential Value of Work$ Z, ! J Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address i G�<<d p� P•., Contractor's Name G/j>�� ,i`/cf Telephone Number Home Improvement Contractor License#(if applicable) /14 Email: Construction Supervisor's License#(if applicable) A1,Q o )(--PRESS PERMIT ❑Workman's Compensation Insurance Check one: JUL 29 2��3 ❑ I am a sole proprietor [rI am 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) ff-Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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,is 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: cl�,eo& Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 060513 r The Commonwealth ofMassachuse#s Deparhnent of Iil`dustrial Accidents Office of-Investigations 600 Mashington,meet Boston,MA 02111 wtvmYnass_govfdia Workers' Campensatian Insurance kffidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiy Name(BusinesBlOrganization/Individnal): 1`4 -1 Address-. / 3.3U lr B " S City/StatelZ p: Se-c wj h e zG 31 Phone 47 S G �'� ! - Z,F N Are you an employer?Check the appropriate box Type of o'ect(required): 4. I am a contractor and I }Pe � 3 �� - L❑ I am a employer with ❑ 6- ❑New construction employees(full and/or part-time).* have hired the sub-contractors. 2_❑ I am a sole proprietor or partner- listed on the attached sheet ?- ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition. working forme in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.t required'.] 5. ❑ We area corporation.and its 10_❑Electrical repairs or additions 3.YI am a homeowner doing all work officers have exercised their I L.❑Plumbing repairs or additions myself [No workers'comp- right:of exemption per MGL 12..❑Roof repairs insurance required.]b c. 152, §1(4),and we have no employees [No workers' 13_[ 0ther eest e comp-insurance requires.] *Amy appUcant that checks boat#1 oust also fill out the:section below showing their worker'compensation policy iaf nuteon- T Homeowner who submit this affidavit mffcating they are doing all work and then hire outside contractors mast submit a new affrdawt indicating such. +Contractors thst check this ba x must attached an additional sheet showing the name of the sub-ors and state whether or not those entities bave employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproi Ong workers'compensation insurance for my employees Belau is Ste policy and,job site informal lL Insurance Company Name: Policy#or Self-ins.Lic. : Expiration Date: Job Site Address: City,`State/Zap: 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 verificcation- I do herebv certify iender tItapains andpffnalties ofperjury that the information pratrded abmre is hue and correct Si tame: Date: z 9 �3 Phone#: f—z 8 Orcial use only. Do not}Trite in this area,to be completed by city or town officioL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CiWrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 r, r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 an of its political subdivisi a Y P � § ( ) y p ors shall enter into any contract for 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-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 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 may be 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 to 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 Massachusetts Department of Industrial Accidents Office of lvestigations 600 Washington Street Boston,MA 02111 Tel.A 617-727-4900 ext 406 or 1-377-MASWE Revised 4-24-07 Fax# 617-727-7749 w .mass_gov/dia t BIKE�b Town of Barnstable Regulatory Services 9sn Mkrwsr�$ Thomas F.Geiler,Director 39.,,.�• 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 DATE: ��9/ Please Print JOB LOCATION: number street village ..HOMEOWNER"=-nt GG� i� J\�i /� S''c? F� s'�"Z 8'"N q Al name L home phone# work phone# CURRENT MAILING ADDRESS: 3 / ��►^l S�j6 r_—w,r J',, r +Q Q�a/ 3 I 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 proced and requireme t and that he/she will comply with said procedures and requirements. 0 Si ature 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 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. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 Town of Barnstable •> ti Regulatory Services s" rE bUss. Thomas F.Geiler,Director rass. 'prfo;� ``� 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 Co plete and Sign This Section If Using A Builder as Owne of the subject property hereby authorize to act on my behalf, in all matters relative to work authorizeVthisbuil permit.-) 0✓�� (Address o 0 *Pool fences and alarms e the respons. ility of the applicant. Pools are not to be filled or u ' ' ed before fence is 'nstalled and all final inspections are perfor d and accepted. Signature of Own Signature of Apphcan Print Name. Print Name 7zz �.3 Date Q:FORM&OWNERPERMISSIONPOOLS 612012