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HomeMy WebLinkAbout0000 SANDY NECK (2) 0�83 Doi 0 11I1 ® s UPC 12543 �a Now `�.�o► HASTINOS.WN e 'w+ly,lynPy,�i.M�d,•.. .rr"' ..>.-,w� ..,_. �..- �.��_6. ., N.0 n �:� , ,.. 7Z Town of Barnstable- � *Permit# 1116 -7 o Fxpbes 6 months from Issue date X-PRESS PERMIT Regulatory Services Fee las,o0 JAN 12 2006 Thomas F.Geiler,Director Building Division TOWN OF SARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ­Z4_36,93 Property Ad Lie gResidential ue of Work _!Za 9-0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address eS` C 12 4da2a \ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) _�flnttruction 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 be on file. Permit Request(check box)Re-roof(stripping old shingles) All construction debris will be taken to fiat 1� 1 1.a-4 -Pit ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. 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 Prope Owner Letter of Permission. Home Improvement C tr c icense is required. SIGNATURE: Q:Fmr w:expmtrg Revise071405 Department of Industrial Accidents02 ' • Office of Investigations, 600 Washington Street Boston,MA 02111 www.mas&gov/dia WorkeW Compensation Insurance Affidavit: Builders/Contractors/Electridanis/Plunabers Applicant Information Please Print LeLribly Name (Business/org na ;?ation/Individual): Address: c� �/1� �` f/Uc��► City/State/Zip: YVd Pone#: — 9 Z Are you an employer? Check the-appropriate box:. Type of projeet(required):. 1.❑ 1 am a-employer with 4. ❑ I am a general contractor and I ' 6. ❑New construction employees (f a-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 S. ❑ Demolition I orking for me in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' comp.insurance 5. ❑ We'are a corporation and its officers have exercised their 10.❑ Electrical repairs or.additions • required.] . . 3. I am a homeowner doing all work right of exemption per MGL 11•❑ Plumbing repass or additions myself:[No workers' comp. c. 152, §1(4), and we have no 12.®.Roof repairs insurance required.]t employees.[No workers- 13.❑ Other ' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below sbowmg their workers'compensation policy information: 1, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ` =Contracbars that cbeckthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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 SelMns.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 8TOP'WORK ORDER and a ffi e of .p 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 u e the pains and en of perjury that the information provided above is true and correct Si afore: Dater ® J Phone#: ^3 Official use only. Do not write in this area,to be completed by city.or town official City or Town: PermitUcense# 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#: St Information and Instructions V. Massachusetts General Laws chapter 152 requires all employers to provid��rekeTs�compensationt heircontract l ees' Pursuant to this statute, an employee is defined as ...every person m the s express or implied,6ral or written." to er is defined as:`:`andiwi�aa�.:PP�.:association,Farporation or other legal entity,or any two or more An emp y of the foregoing.engaged in a joint enterprise,and inchming the legal representatives of a deceased employer,or the receiver or trustee of an individual,pa rtnership,association or other legal entity, employing employees. Hovsrer: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 woikron such dwelling house shall not because of such employment be deemed to be an employer. or on the grounds or building appurtenant thereto "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 chapt states"Neither the commonwealth nor any of its-political subdivisions shall ..er 152, §25C(� enter into any contract for the performance of public work until acceptable'evidence of compliance with the insurance =equuements 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. supplysub-contractors)name(s),address(es)and phone nirmber(s)along with their certificate(s) of necessary, Lim insurance. Limited Liability Companies(LLC).or Limited Liability Partnerships(LLP)with no employees other than the ed to carry workers' compensation insurance. If an LLC or UP does have members or partners; are not requir employees, a policy is required. Be advised that this affidavit may submitted to the Department of Industrial Accidents for confiration of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should m be returned to the city or town that the application for the permit or license is being requested,not the Department of dustrial accidents. Should you have any questions regarding the law or if you are required to obtain a workers' In .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 pmrmiit(hcense 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 mom)."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 orliceuses..A new affidavitmust be filled out each e or permit not related to any business or commercial venture year.Where a home owner or citizen is obtaining a licens (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 file to thank you in advance for your cogperation and should you have any questions, please do not hesitate to give us a call. The Depar ment's address,telephone and.fax number: The Commonwealth of Massachusetts . . Department of IndasstrialAccidents . . .. .. OMce of Investigations ,• .600-Washingfon Street . Boston,MA 02111� Tel.#617-727-4900 ext 406 or•1-877-MASSAFE Fax#617-7274749 Revised 5-26.05 www.mass.govldia Application to: 0pr,PNPN'��PPNNS EP,�C? . .. _�.3.•....: P Odd King s Highway RegionalHisric District Committee in the Town of Barnstable for a CERTIFICATION.OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter_ 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo- graphs accompanying this application: TYPE OR PRINT LEGIBLY DATE .J:( 1©/6 ADDRESS OF PROPOSED WORK _ D .,,.d,� _ ��z,�C ASSESSORS MAP NO. 3 OWNER S �-C ,�— ASSESSORS LOT NO. ©�3.... HOME ADDRESS -� � I/W �:� WG�� dRc3_< �-T._.. TEL. N0. ��'.36� _�rf • AGENT OR CONTRACTOR ADDRESS TEL. NO. This application is for exemption of proposed exterior construction on the ground that: ❑ (1) It will not be visible from any way or public place. ❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work, showing location on lot, and, if an addition is involved, show. ing location of existing building. T� -� � �0.' 1 qj(Z (� O W l+A �' — ta�� cP Vlt ✓V� l��' 5 SIGNED Owner•Go Space below line for Committee use. . ntra.%TA 9ent Received by H.D.C. The Certificate is hereby5! pop I y Date Time C�l By Date Approved ❑ The categories of work entitled to exemptlon are listed on Disapproved ❑ the back of this form.