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Home My WebLink About0362 SANDY NECK ROAD (2) a omommommom � �worrno■■ommo� 1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ram. ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■!�■■A�!!�■ ■■■■■■■■■■■■■�■■■■■ I■■■■■■■■■■■■■■■■■■ �^ -%�1 A■■■■■■■■■■■■■■■■■■■ 1■■■■■■■■■■■■■■■■■■■■■R "■■■■■■■■■■■■ ■■■■■ I■■■■■■■■■■■■■■■■■■■■■ !! �!' !P!I■■■■■■■■■■■■■■■�■■■■■ i■■■■■■■■■■■■■■■■■■■■■�i■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ mmmmm ■■■■■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■� 3 ' i ■^■■■■■■■■■■■�■■ ■■■■■ I■■■■■■■■■■■■■■■■■■ ■■■ �■■■■■■■■■■�■■ ■ 1■■■■■■■■■■■■■■■■■■■■■■■■�i■■■■■■■■■■■■�■■ ■ PF ■■■ti��■�■■�■■t■■■■■■■�■■■■■■■■■■OWN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■F ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■l ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 47` q Application number ................................................ ,. EPT. i Fee .............................................................................. + KASS. Building Inspectors Initia s.....� 4 2020 TOWN OF BARNSTABLE Date Issued.............. .. 00 Map/Parcel.........3........... ......6.................................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 192 C'e�C� �Q �,) Cr1S �J� NUMBER STREET VILLAGE Owner's Name: C f Phone Number Email Address: :� to ,t,Qll Phone Number Project cost $ V oc)b Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK E Siding E-1 Windows (no header change) # Insulation/Weatherization 0 Doors (no header change) # Commercial Doors require an inspector's review 0 Rodf(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration (if applicable) # (attach copy) Construction Supervisor's License # _ (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............................................................ *For Tents Only* Date Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No _(If yes please attach floor plan with exits marked) Dimensions of each Tent X X , X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spy ead Sheet of each tent must be attached. Provide a site plan with the location (s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30'am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephony Number 609 �a.7.�� Cell or Work number � r I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand j the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. 1 Signature Date j 1 APPLICANT'S SIGNATURE Signature Date All permit applications are s ject to a building official's approval prior to issuance. r 1 Affidavit of Substantial Financial Interest .I, f l \; b� on oath depose and state as follows: 1. 1 am an applicant for a building permit for the property located at c536�� a3� 9 Map 33�2 , Parcel C�D . The address of the property is 2. 1 have %.legal or equitable interest in the real property which is the subject of the building permit,application which is identified in paragraph 1 above. 3. Within the last twelve months from today's date, which is , the following individuals or entities have had a 1% or greater legal or equitable interest in the real property which is the subject of the building permit application which is identified in paragraph 1 above: Na ` Address Nec �� 1 ` iC> ` u \�PMcL 4. Within the last twelve months, from today's date, which is I have had a 1%or greater legal or equitable interest in the following properties which have been the subject of a building permit application: Map/Parcel ' Address 5. Within this calendar year, I have submitted building permit applications for property in which I have a 1% or greater legal or equitable interest. 6. Within the last ten days, I have submitted C� building permit applications for property in which I have a 1% or greater legal or equitable interest. 7. Within this month, I have submitted C) building permit applications for property in which I have a 1%legal or equitable interest. I 8.•Within this month, I have received building permits for property in which I have a 1% legal or equitable interest. Signed under the pains and penalties of perjury, this Akday of 202D The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invadgations 600 Washington Street Boston,HA 02111 www.mass gov/hdia W) Workers' Compensation Insm*ance Affidavit:Bulders/Contractors/Elecfricians/Plumbers Applicant Information PIease Print Letribly Name(Business omnizatim/IndividuaI .'--Q6 v Address: a'C� City/State/Zip: Acakfv--, J- Co,— Phone Are you an employer?Check the appropria box: Type of project(regdred): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time)* have hired the sub-conizacEors 2.❑ I am a sole proprietor or partner- listed aa.the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.i mzanoe comp.msurance 2 �( �] 5. We are a corporation and its 10.0 Electrical repass or additions Nquir3.L I am a homeowner doing sIl work officers have exercised their 11.0 Phimbing repairs or additions ✓ myself[No workers' comp. right of exemption per Mt}L 12,0 Roof repairs insurance ]t r: 152,§1(4),and we have no ---------------—..-employees.[No-workers' 13.[]Other comp.insurance required.] --- *Aay applicant that chocks box#1 must also B11 met the section below showing their workers'compensation policy inforroatlon. •N t Homeowners who submit ibis affidavit indicating they are doing all work and than hire outside contractors mast submit a new,fidavit indicating such. tContraotors that check this box must attached an additional sheet showing the uame of the sub-coutradors and state v bother or notthose eatities have employee If the sub-contractors have employers,they must provide thoir workers'comp•policy number. Aram an employer that is providing workers'compensation insurance for my employees Below is the policy curd job site information. Insurance CompanyName: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address- citY/sttm/np' 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 MOLL c.152 can lead to the imposition of criminal pmialties 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 end 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 c Oilunder the painsi alties of po f wry thct the inforrrtadon provided above is true and correct Si . Data: Z ac) Z) Phone#: Ofj dd use only. Do not write in this area,to he completed by city or town o,0Tdal City or Town:. Permit)Ucense#. Issuing Authority(circle one): 1.Board of Health 2.Buildhrg Department 3.City/Town Clerk 4.EIectrical Inspector 5.PIumbing Inspector. 6.Other Contact Person: Phone k Town of Barnstable . IME Building Department Brian Florence,CBO' + BARNSTABLE, *MASS Building Commissid�ier �a g �p 16,39 % M� 200 Main Street,,Hyannis,MA 02601 r�D a www.townofbarnstable.us • .i Office: 508-862-4038 Fax: 508-790-6230 Own a r'S Liability Insurance Waiver Owner Name: CQ, Owner Address: Telephone: . E-Mail: Property L,ocation: . • r Permit#: I hereby certify that I am the owner of the property. I am aware that the licensee does not have the liability insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. QOV' , &7�' 0 C LA R -A^a'b b • Signature o Own Date