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Home My WebLink About2140 MEETINGHOUSE WAY/RTE 149 UPC 12543 No.53LOFi ��,, � HASTINGS,UN i IN QLv JA �+ ! *' Town of Barnstable *Permit# �oolo�315� h u' Expires 6 months from issue'date 'J'•y Regulatory Services Fee ad Thomas F;Geller,Director Building Division O Tom Perry,CBO, Building Commissioner �"r 200 Main Street,Hyannis,MA 02601 ®PRESS PERM www.town.barnstable.ma.us office: 508-862-4038 DEC 1 S 200G' �� Of Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ml OF BARNSTABLE Not Valid without Red X Pre//ss Imprint( �� .p/parcel Number .1 >perty Address 1 y y'✓e L Residential Value of Work 3 0c> Minimum fee of$25.00 for work under$6000.00 rner's Name&Address 6121 C. 9-A S /44 . 19 w, ntractor's Name �.!/l�y�S � G�,r'S d �V-OA Iephone Number, �6 1 6 (p 1 Ime Improvement Contractor License#(if applicable) S� I 1V/ lWorkman's Compensation Insurance qhe ,q one: LT I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance :urance Company Name ;.z orktnan's Comp.Policy# ipy of Insurance Compliance Certificate must be on file. rmit Request(check box) ❑ Re-roof(stripping old shingles).All construction debris will be taken to ❑Re-roof(not stripping..Goingover existing-layers of roo fl 2"Re-side R-�,PlOuC)►erg LIV ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) °Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, op f the Home Imnrovernent Contractors License is requited. GNATURE: I Forms:expmtrg vise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,M-4 02111' www.mass.gov/dia ' Workers'Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers' Applicant Information Please Print Leizibly Name(Business/Organization/individual): . Address: pa a. A re City/State/Zip: �. - M e Are you an employer? Check the appropriate bog: .Type of project(required):• 1.❑ I am a employer with 4. ❑ I am a general contractor and I gimloyees(full and/or part-time).* • have hired the sub-contractors 6. ❑New construction . 2. I am a'sole proprietor or partner- listed on the'attached sheet. 7. E Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers'. 9. ElBuilding addition [No workers' comp,insurance comp, insurance.$ required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all-work . 11.❑Plumbing repairs or additions ' myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs. insurance.required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing then workers'compensation policy information. t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors mutt submit anew affidavit indicating such. *Contractors 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 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 maybe forwarded to the Office of Investigations of the WA for insurance coverage verification. � I do hereby certify un the ains and penal ' s of p ury that the information provided above is true an correct. Signati re: T Date: Phone#: `C T 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): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 1�lU�i�AA l,lf)11 A.HU 11IN l UkAIU113 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 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 conipl ance cyithtlie 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 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 fo 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 Mmarh=ltts Degarbazent of lanai Accidents Office of Investigations 640 Washington Street R6ston,.MA 02111 'Fe1. 617-727-4500 ext 406 or 1- 7-MASSAFE Faye#�617-727-7749 Revised 11-22-06 WWW.mas&g6vfdia ' a � 0 do rd of Ni g>RoGula[nliisnd 5 a "3:nJax .` H.WE ilV OVEPA PIT QN RACTOZ r _ V a 2007 CEDA. ORKS� - -- CN�IS o 10 OC".EAN N. Y _ 4 `d-oila° b it i i DARWORKS Box 1277 - So. Dennis -'MA-02660 Specializing in cedar exteriors 508.64.8.6117 ti - www.cedarworksOnline.com SSE'RVTNG CAP-E COD OPOSAL SUBMITTED TO d 1/A A /S PH� 5%D Z 7 210 DATE - aL �TRELT JOB NAME: pad 5-0 JOB LOCATION: CITY,STATE,ZIP DESCRIPTION'`: r `"_Z, lid r Gt- � o Re, `l e�rc-� i vY s CLA 1 s -< wt i 4ce_4e ��4 70 0 V If 60 0(0 ace_ yne. S . ) 74 r-ea W o--r S A, vu r oC i a-vi i&4s b 6 ' d ' /]O Lp 'Or I von WE PROPO E hereby to furnish material and labor—complete' accordance with above specifications,for the sum of: " $a)yiments /3 or J C , Dollars ($ ) to Ce made as follows. le ` . d All work to be completed in a substantial workmanlike manner according to specifi- cations submitted,per standard practices.All agreements contingent upon weather, Authorized accidents,or delays beyond our control.Owners to carry fire,tornado and other nec- Signature essary insurance.PLEASE NOTE:Cedarworks recommends removing all paint- NOTE —This proposal may b ithdrawn by us if ings,valuables and breakable items from walls,ceilings and any unstable area • _ r before work begins. not accepted within days. ACCEPTANCE OF PROPOSAL — The above prices,specifications and conditions are sati actory and are hereby accepted.You i are�oriz�e�d�dQ the vtorl�s�specified.P�ay�mQents will be made as outlined above. a = Pop- �'� N Dv �_I�1-►1( Dcbf ��v 3MOature � Date of Acceptance Signature L_