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HomeMy WebLinkAbout0110 BACON ROAD ACTIVE f - Q , CAPE COD ct INSULATION ' _7 7 �UJ ®® ' N77R CLASS 57AMl7SS SPRAT FOAM fYSP[ND[O 7V # s UWWN RAM 1-800-R6976-661Li 7 •1ri i Town of Barnstable s Regulatory Services Building Division 200 Main St ' Hyannis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that•CapeACod Insulation, Inc. performed & completed the insulation and weatlerization'work at the property listed below. Cape Cod Insulation did this in accordance'to the specificatidns. isted on the building permit application. All work has been inspected by ja certi.fied,Building Performance Institute (BPI) inspector. All work preformed meets or exceeds$Federal & State Requirements. • Property Owner Property Address Villa&e„ " aw( .fl[� J3u-6617 Insulation Installed: Fiberglass .Cellulose- R-Value Restricted Unrestricted Ceilings _ � (X) ( 3 ( ' � .. -. .(x ) Slopes ( ) (X ) Floors ( , ) ( ) ( ,.. ,•) Walls Xn c-t fs. ( X) 'Sincerely He y E C sidy J , President . :Cape Cod nsulation, Inc. - T F • t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application��q�# o Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Me Village Owner s ,���,/�' ��1G� Address S Telephone. `�/�,� Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 6 Construction Type a"V Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family JX Two Family ❑ Multi-Family(# units) , Age of Existing Structure Historic House: ❑Yes 2 No On Old King,',?Highway]Ygb..no. Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new A Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 4 xx za G/ /,t!f��ilD� Telephone Number L�o 5�— Address License # fd�9rP� Home Improvement Contractor# Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE s ' 4 3 4 FOR OFFICIAL USE ONLY i APPLICATION# =�' i S DATE ISSUED MAP/PARCEL NO. 4 ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME ' INSULATION i ; o FIREPLACE ELECTRICAL: ROUGH FINAL i> PLUMBING: ROUGH FINAL 'k GAS: ROUGH FINAL FINAL BUILDING ,} gF `i DATE CLOSED OUT ASSOCIATION PLAN NO. OWNER AUTHORIZATION FORM It 2MCQ) -�Skk (Owner's Name) owner of the property located at f 1 0, \�0 � C�� �11A NNE oQ(io l , (Property Address) (Property Address) hereby authorize oeC r� 1CC7L1'0AJ , (Subco actor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature - a( - a Date D UR Z:8 2012 _ 4 t -t ti � 1CC�� I �S 10 Park Plaza - Suite 5170 Boston;Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation' Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY 455 YARMOUTH RD. = - HYANNIS, MA!02601 Update Address and return card. Mark reason for change. [,I Address � I Renewal I' I Employment 'L `I Lost Card t r , )H.( sumo Arfaii jl3us'nc_ Kegul ttiun Lice tse or registration valid for i:; ivi(it! r.!, HOME I4P�f6(%`E�l(1��l7Nfp�a lu'� bei'ore the expiration date. If found return to: f7 ;� Registration: 153567 Type: (Rice of Consumer Affairs and Business Regulation ' Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 r' Boston,MA 02116 f' .t"6D INSULATION, INC ENRY CASSIDY 55 YARMOUTH RD. ' YANNIS,MA 02601 — -- -.._.._..._...... Undersecretary t alid ith t si ture I -)epartntent of Public Safety Bu:u d ilf BU41din" Re!�ulations and titagd'.11-Is'- 1 Construction Supervisor.License w Lican�•;: CS 100988 'HENRY CASSIDY 8 SHED ROW WEST �ARMOUTH, MA 02673 Expiration: 11/11/2013 ( vnuuv..I•r,v••r Tr#: 7620 No' 1605 P. 1 Client#:4597 CCINSUL ACORD,, CERTIFICATE OF UABILITY INSURANCE --- .DATE(MMIDUlYYYY) THIS CERTIFICATE IS ISSUED RM A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE/R HOISZ CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOY CONS 11TUTE A CONTRACT BETWEEN THE ISSUING INSURER(5),AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:It the certificate holder is an ADDITIONAL INSURI u,thn policy(ies)must be endorsed.IF SUBROGATION IS WAIVED,subJecf to the terms and conditions of the pollcy,certain policies may ruq I,d all endorsement.A statement Oh this certificate does not confer rights to the certificate holder in lieu of such endorsemenl(s). pRODUCER Rogers&Gray Ills.-So.Dennis NAME: Mar aret Youn 434 Route 134 • PHONE AIC E Exl:506'760-4602 FAk South Dennis MA 2` E-MAIL _ '1A/c"Noe 677.816.2'156 0g6s0_1aD1 508$96-7980 INBURERO)AFFORDING COVERADE WSUR6RA;Peerless Insuran Insurance NAICN wsuRED'y -- 16333 Cape Cod Insulatlon Inc INsuRERa:Evanston Insurance Company 455 Yarmouth Road INSURERC:Atlantic Charter Insurance --- Hyannis,MA 02601 INSURERD:Commerce Insurance Company 34754 + INSURER E: '—'- ---------------- COVERAGES 0 __ 1 INSURER F. -— CERTIFICATE NUMBER: PHIS IS TO REVISION D CERTIFY THAT THE POLICIES OF W$URANCE 1-15TED ry.CLOW HAVE BEEN ISSUED TO THE ME A VE FOR THE POLICY PERIOD INSURED NABO INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE ArFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.' EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN IYIAY' HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE ADOL SUER POLICY E D POLICYAID EC A GENERAL LIABILITY POLICY NUn+RcR MMIDDIYYYY MMIODNYYY LIMIT CBP8263063 S COMMERCIAL GENERAL LIABILITY ' 4/0112012 04/011201 EACH OCCURRENCE $1 00U 000 X ' pA�pc r 1 PREMI' S ENTED' _ CLAIMS-MADE ,�OCCUR ' S �occurrence 1100,001) y ME0 EXP(Any one pereon) $5 OOO _ PFR80NA4&ADV INJURY 11,000,000 GEN'LAGGREGATELIMITAPPLIE8P&R; GENERALA013REGATE $2,000,000 _ POLICY PRL� PRODUCTS.COMPIOPAGG $2 000 000 LOC p AUTOMOtIILE LIABILITY , 12MMBCKVm1K $ 4/01/2012 04/01/201, COMBINED BBINEDSINGLELIMIT ANY AUTO s 1 000 000 ALL ._ AUTOS NED x i SCHEDULED BODILY INJURY(Per Pcron) $ NON-OWNED AUTOS X HIRED AUTOS BODILY INJURY(Per auddent) S }( • •• .. AUTOS PROPERLY B X UMBRELLA UAB `• '— $ — DccuR XONJ453512 EXCB5y LIAR _ cLAINIs.MaDE a" ' 4/01/2012 04/01/201 EACH OCCURRENCE' $1 OOO OOO DEO X RETENTION '10000 - AGGREGATE - - $1 000 000 C WORkERB COMPENSATION -- AND EMPL�O�YERSp''LIA(yBIINUTY, WCA00525902 6/30/2012 06/30/201 x WC ST-ATU• OTIi. $ OFFICER MEMBER EXCI UO I��EGUTIVE�fY�/tN� - (Mendaiary in NH) , •� NIA - F.L.CAC14 ACCIOkNT 1 000 000 ' Il Yda, E.L.DISEAS DESCRI5CRI PTIOTIO N OF OPERATIONS Uclaw i E-EA EMPLOYE& $1000000 ""-- E.L.DISEASE POLICY LIMIT $1 OOOOOO DESCRIPTION OF OPERATIONS I LOCATIONS 1 VGNICLES(Allanh ACOR13 101,Addldonil R011 rks Sshgawp,k p10re epdC9 19 rOGUlf6(U "Workers Comp Inforrrlattorl Included Officers or Proprietors 1 Certificate Holder is InCiLided as an additiol al insured unaor General Liability when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION Cape Cod Illsulation,lnC i SHOUL0 ANY OF THE ABOVE DESCRIBED POLICIES ELL BB CANCI O BEFORE _ 3 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ,IN ACCORDANCE WITH THE'POLICY PROVISIONS. i AUTHORIZED REPReSENTATIVB - - ACORD 25(2010/05) (D188 -2010 ACORO CORPORATiQ 1 N,AI)fights reserved. S93649IM83848 of 1 The ACORD name and logo aru registered marks of ACORD ' MFY 1 he Comm 0l 0 AlfL1ssac.-h'Glseits Uepcirtment ,,! IJUstrial A(-XiCIents 0fji ( It t.stigcttions 5, 600 1 ;"'.t110WOn Street AA 02111 WIVIi 1 .1.b�UV�LIILI �r ► .t- (. I:et ',y cutul��.usatiun lutittr�utce. Builders/Contractors/Electrici ans/.1'It,rt..t►trrs lliitliraut lnft►►'tuati(►u � • , r flle kse Prilit Legibl.Y �,Itll, ;l;l S/ur��ttu.z tt[c:)rl/�rtCliVLltuaiJ: C. I'll a i 4 �It tau an elullluye('Y (.'ltecic the uPpropriate box; u `l'yhe 1'prujct't (rct[uu't'd) ' I .11ll.l c•l1lllll)yC�A W I.cll �„J , Luntractor and l have `' E New cunstru au)u rulplt)}t:t., (lull ant!/uI )ihl:-ttrni hire)UI . I�i .unu'actors listed oil , 7.. Remo eliup, the ant it .i .ilr,t.j ... i I :,R))rlC Of Of IMl'tllrr,th I- , These I) 11actors have ' S• Q Ueutt,luuail " ,I J Ilavc: nv Cloploycus working For emploi' .' .;..,I ii:tve worker's' comp. 9.- Building addition , nit ul ,uly capacity, [No workers' insutant (�—� cuuy) un I1aIII-r rr.tluirccl.J 5 We arr ;ttion and its 10, LJ $Ic ct[icitl rcl)airs ur uJduwns officer,II I,;. : ,rrcised their right of 11 ❑ Plurtlbinb re[MICS dr ziddltiuns �..._.� 1.un ct ht)ulc:uwllCr dumb all work exempli'm I, r NIGL e.'l52§(fit),and 12. Roof tel.latrs Nil Woi kti-s' ct)mp. we have lI,,,thilloyees. [No workers' ul,ut,uitc: rr.c tluccl - t 13: Otltcr•���.��'"�l�l�l yLJ-f I ' ylllli,t'I that checks box Itl rrnlSa alsi)fell otit the section below sh,),, •tl,:•t,workers'compensation policy infautation. . - ---_-- -- "' ::I.rn'.th„,ulunu this tlf(iduvit indicuting thr"y arc doing all NIJI ..,•I ""hire outside contractors must submit a ticw affiduvit m intli utiugsu h.- hal,hr.t'k tilts box must auacti ail Wdilional sheet showiu,tl or the sub-contractors and state whether or not those etl.w.u,tcRn�Iluvc t:n,l,loycce,lt[Icy MUSE Nrovidc their workets'c6i,q i..,i.. Iluntbor. tities have eulI)lulrrs ll l,urz rut employer that i.s'providirig workers'compensation i,r.,,:,ance j'or my employees.Below is thepoliey anti job site +,rlurnuUinn. //tom t�t�//' I�I•lu,;nc,•l iinllruly N iil'tlC: V' V�,;W'., dol �dl-ills. Lic. 16 —. �Xpll'allUi'1 Date..-� ill,' lthltr.5s City/Stlue/Grp: lu:r h a copy of cite wurl(ers' COI IIPeusatioII I]Wicy declaration pug, I.I,.,Irlug the policy number atld expiration tiat(j). It t">ci.wc")VcItk6C us rcyuircd under SCCLiQn 25A of MGL c. la;.,.,,i i ad to the iinposition of crintirtnl ptr'tzlltics of a fine up to )1,50U.Ut1,ultVol InIpI Isuunienl, as well as civil penalties in the form of a STOP W,ll(K ORDER and a fine of tip to$250.00 a(lay agaitist the vii)latur. Ijt::uhvisekI t tlua atatclncut u,zt e 1'ocwarded to the Office of lnvc5ti;..nl.•i-•,d the DIA fur insurance covoruge vcril'[cat[on. - !du here�!}1 c if urcder the I itis aril penalties of pz,y;rr v that the information provided above is true arid eorreet. ._. .. .... - Date: (!l,Iz<'ruf rue only l.)o rr<it write in trtis area, to be completer r I :it,or town official -- — - f�.. li t ily u' tuvvu: i'crtnit/License# IIssuing Aothol-ity (circle:one): - lii.Huard of Health 2. Btiildiu[ Dewil-Wicht 3.Cit,)i,,,Ill l;lr[k 4.Electrical lnshectur 5. 1'huubiu lus[r((lat'' b iI.(.►titer li l unturt 1'ct'sun: -- Phalle#; ,. Town of Barnstable *Permit# 5 � p F V&w 6 months jrow Janke date Regulatory Services Fee Thomas F.Geler,Director. s639 �0 Building Division Tom Perry, Balding Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 X-PRESS PERMIT Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY - 2005 Not Valid without Red X Press Imprint MapfparcelNumber 3010q® TOWN OF BARNSTABLB Property Address ,o t, i Residential Value of Work QL000 Minimum fee of$25.00 for work under$6000.00 Owner's Name&AddressR A l,3 �A LPW�t�U� S�L Z0004-,1 Contractor,-s_Name Telephone Number ---- —— ------ Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) % .R roof(stripping old shingles) All construction debris will be taken to jAgv,\6o-t' t�1 ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this pemrit does not exempt compliance with other tows department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home ovement Contractors icense is required. Signature Q:Forms:evn*5 Revise063004 The Commonwealth of Massachusetts r02Department of Industrial Accidents Office of investigations 600 Washington Street, 7`4 Floor Boston,Mass. 02111 Workers'Compensation Insurance.Affidavit:Building/Plumbin /Electrical Contractors MEW 449111 t l r s Tw M. ia4 -• address: ci state zip: i�-b© hone# Z� _a 3 work site location(full address): (�I am a homeowner.performing all work myself. Project Type: New Construction[]Remodel I am a sole ro etor and have ngoo+ne workin in an capacity. Buildiri Addition ice`,'S'`.:'.'1"i°'"ay ' i:• .^xdr',���4' '.j-... •tii':pFf3•,•? 's G } 4 "W-M r,�t'•.�v''"i,'iR "".yt.-• tiy..�ty x.�r•x:+ro',.'se•�•.�•°s:±R;=e��ea`•. 1�`V`r"y.n'r,Yb. I am an employer providing workers' compensation for my employees working on this job. company name: ` address: city phone#• Insurance co. Dolicy :AliQUIi~.' iX.4etiKa'+W&5� ;;vb:r'�hkbiy3 '#'i'n!°i..''u;e+$i• wer'ii.:a�, 'wS�YsE+.%; i'"Szu_r'i3:r;i5�',�•`:�4:1iee+".�' :�N3xJ:Fx�`yvlad:^C�"urY•%:.�5.'�E:urS: ':+ •,•a :;+2raaP+ 'tr.S:4wa''i/m'• ...h 0 I an a sole proprietor,general contractor;or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address- city: phone M insurance co. q"t�:i�':=5 "+:'...;:r�'•f'��r�a�i'!`ifv;�s.�u•:`a�i�,._+ . . . :PN':�r'��'i''�izi';��il�:'3'�i,+��l�iiri }'��`'. .x ;'r.'•,•, t��••�.». 'aa.. �� +'••r r':!' tfab;x;?;,;`v'.� .t§ �:�a'v'-�'...5�."�.'7Ft:i,a.`. ,w.:�.•fit'•,.+.va.,�u::'"�'. m�e.�"' �:7 .� . ..;,�>�,.. company name: address: city: phone#:. insurance co. policy# dl d 14 .�0 t �,�. ti.. i 4 ..." .u;} , ., ; y . . �., ae, al;='+a'�.:�:rP-• §.tT"".a: P.•r ...... . .• _.��..�3._.• �. r:',l^t."+� •ad .�6SS�.'x�+ 1 , ��.`�t�d�' efts.,t�'+"+��'° h.�E+�s�"+ `''�.c ": �a'` Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1;500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine df$100.00 a day against me. Lunde rstand that a copy of this statement maybe forwarded to the Office of Tnvestigations of the DIA for coverage verification. ' t do hereby certi under the pains and p Ities of perjury that the information provided above is true an correct. J Signature ✓ Date ( � S— Print name Phone# (official use only do not write in this area to be completed by city or town officialty or town: permit/license# ❑Building Departmentcheck if immediate re3 onse is r e aired ❑Licensing Board P q ❑Selectmen's Office❑Health Departmentontact person: phone#; ❑Otherevised Sept 2003). ash Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all-employers to provide:workers' compensation for their . employees. As quoted from the"law", an employee is defined as every person in the service of another under.any contract of hire,express or implied;oral or written. 4 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 section 25 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,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. .t r{dt 4, f tit +,'•tn�f,.. . :?: t4.,.2"=. {. J: .,'+�• .a�'` ,J •. gg �� eii tb k�✓�° a.., Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. �- 't 't +...�3w'{�+�;r• ?• - �`�R�7'?,�'er `:au :4�"�';f:_i'`8+.+sr:'.rE.•�"u3:�',°�?�:�lfF..�r=�%r.'�e�^'r;Lt'J�,x:1�.sti3' .liwh� iv City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for.you cooperation and should you have any questions, please do not hesitate to give us a call. !. w C"tF:"" :.1.• y- +. 2c' :•M't. a e, sJ re 1r`iabr+n7i,5, C{'. `. z �+w' g:.'! 'i';t r, t, A' C + 8w+ + T+r•F, .Tn r.�. Y.9+ 'h _ .� �,'y.' 6.` } ,`.r'.,1tx •F`.s:i'`i'k ti �,. 1LAA °. e �� .:ram. ;. ..t :tE}+ ,s'S#CM• ' •y+ ^� n •�3: :tiwu.: d164v A1MTihi./WM: IY.J.Y-•:~ .n ,The Department's address,telephone and fax number: The Commonwealth Of Massachusetts- Department of Industrial Accidents Office of Investigations 600 Washington Street,?h Floor Boston,Ma. 02111 fax#:(617)727-7749 phone#: (617)727-4900 ext.406 i NOTES RECEIPT DATE NO. 7024 RECEIVED FROM ADDRESS FOR . ., BY p2001 RMe Ms 8L808 S 1 I � j • *Permit T opt„Erg, Town of Barnstable E;rplres6,nunr6s/remiss„eQar� ti ✓ "P � 94 Regulatory Services Fee `s_ BARNSTABM.1• b � S& Thomas F.Geller,Director S� Fo Building Division X.PRESS PERMIT Peter F.DiNIatteo, Building Cumssussioner 367 Main Street, Hyannis,MA 02601w 0 C T 2 3 2001 Office: 308-862_038 TOWN OF BARNSTABLEo Fax: :08-+90-6230 _ RES�ENTIAL ONLY EIPRESS PERMIT APPLICATION vP d with without rentmprinr Map.,parce?Nurnoer 3 rf Properry Addresso Cc l �� Value of Work Residenrial Owner's Name g Address�� J LQr Telephone Numbe Contractor's Name Home Improvement Contractor License (if applicable) t Construction Supervisor's License=(if applicable) r > ❑Workman's Compensation Insurance > Check one: ❑ I am a sole proprietor I am the Homeonner ❑ I have Worker's Co n,ensarion Insurance Insurance Company Name Worlanan's Comp.Policy permit Request(check box) ❑ Re-roof(stripping old shingles) ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ' 44 ❑ Replacement Windo«-s. U-Value ( ) ❑ Other(specify) e c.i this permit does not exempt compliance with other town deparenen t regulations.i.e.Historic.Conservation.e: •Where required: luuaac :. i t Sisnature '��� Q:Furms:expmtrc:r��•-�1 i06t)! .