The URL can be used to link to this page

Home My WebLink About0045 PINENEEDLE LANE III Town of Barnstable *Permit# FApims 6 months from issue date Regulatory Services Fee W, o • �atvsrnsi.�, • Thomas F.Geiler,Director 1619. Building Division X®PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.townbarnstable.ma.us S E P 2 3 2013 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENEA � X_ RARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number Property Address s _ P1 e , - Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ( ��"��C l Cam " ti'W�L+-y - J Contractor's Name Telephone Number75�� Home Improvement Contractor License#(if applicable) Email: C H y L00 21 'ncaS6 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 A-C 1 �® r S Workman's Comp.Policy# p c'J 2=2, 9 f 1-D Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Q El Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to e�>�5 0 f n P- d-lu, kLRe-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ® Replacement Windows/doors/sliders.U-Value I,S— (maximum.35)#of windows #of doors: 2_ ❑ 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. Q:\wPMESTORMS\building permit forms\EXPRESS.doc Revised 060513 i ?ate CoMrtr01m akh oaf vassachrrsdft Depar&zent o,f lain ftid Accidents - - QKwe o,f Inm gations 690 Washha zgton Street Boston,M,4 02M wwwanasmgovIdia Workers' Compensafian Insurance Affidavit:BiulderslContractors/EAectricianslPlumbers Applicant Tnfa.-.., tin,. /1 Please Print Lezibly m Name(Busew/drganization&&idnao: C C ' Address: eA�& Aig CityfStatefZip: Phone 4- U --I Are you am employer?Check appropriate box: Type of. o ect(required): I srni a contractor and I 3'i� � 3 �� L❑ I am a employer with 6. Ne�v.construcfion employees(full andlorpart-time}* have b��sub-contractors 2_ I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling drip and have no employees These sub-contractors have g- ❑Demolition woddng for me in any capacity. emp"and have workers' 9- ❑Building addition [No workers' comp.iumnanre comp-incnrarun f required] 5. ❑ We area corporation and its 10-0 Electrical repairs or additions 3.❑ I am a homeowner doing all wont officers have exercised their 1l-Q Plumbing repairs or additions, myself [No worlrers'comp- right of exemption per MGL 12 Roof repairs 152 c- , and we hm a no insurance mod,]Y �1(�' � ) employees-[No workers' 13_❑Other comp-insurance requued.] *Amy WHcant that checks box#1 trmst also fill out than section below showing then woadceie compensation policy iusamatim- 1 Homeowners who submit this a$davit indicating they axe doing sII tiro Bk sad then hue outside contractors toast submit anew affidxdt indicating inch_ ICanttactors that check this bank must sttached an additional sheet showing the acme of the scam txmrs aad state whether ormt those wrilies have mpluyees. If the sub-conttactots have employees,they smut provide tlwr workers'comp.policy amp 1 nm an employer that is prm�iding workers'congwLv rtion insurance for my emplayea. Below is die poM7 and jolt site ire,formation Insurance Company Name: Policy#or Self-ins-Uc. : //^^ Fxpi ation Date: Job Site Address: Phe4l� ! Cify/S tatelZip: 7)Zfa�, Attach a copy of the workers'compensation policy declaration page(showing the policy num and expiration date). Failure to secure coverage as required under Section 25A o€MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.Oa 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 violator- Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for iamnance coverage verification- I do hereby certify u r 'h pain t penatlias that the informidian provided above is tme and correct Si tore: Date: 91,23)13 Phone#: •� i j az too onI}: Do not write in this area,to be completed by city or town officint Chi or Town: Permit/License# f suin Authority(circle one): 1.Board of Health 2.Building Department 3.Oity1rown Qerk 4.Electrical Inspector 5.Plumbing Iuspeetor 6.Other I s 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 Iocal 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 way 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 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-contractors)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 cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required_ De 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 pemait/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 pro�Zded 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 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: The Commonwealth of Massachusetts Depaitmmt of Industrial Accidents E}ff ice of lmvestigadom 600 Washington Strcet Boston=Il4r.A.02111 Tel.#617-727-4900 W 406 or 1-977-MASSAFE Revised 4-24-07 Fax#617-727-7719 www.mass gov/dia i oFIME Town of Barnstable Regulatory Services rBLABS. � Thomas F.Geiler,Director �iOIE1 5µp. 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 LOCATION: !'"L I k)en(e,�5dle I,k8 r 1 L/0 V]V)1_,� number l street q village y "HOMEOWNER": name f� home phone# 2 work phone# CURRENT MAILING ADDRESS:_ ►'. !�O 53 f3 -tom M 1,L r Z(� cityltown state zip code The current exemption for"homeokymers"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 proce s and re irements 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&ReguIations 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\decolltk\AppData\Local\Ivficrosoft\Windows\Temporary Intemet Files\ContentOutIook\QRE6ZUBN\EXPRESS.doc Revised 053012 �ZVET Town of Barnstable Regulatory Services BARNSrABMMass.q Thomas P.Geiler,Director 9�p sbg . � r6 .(a 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 A Builder I, C4-ot L I v1, I , 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 or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:F0RMS:0WNERPERMLSSI0NP00LS 62012