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".. �' .. °e.,'a-8..' .-._ '_ +g �.�.'.. *• '+°„..n r'ss ya�, .c�, - '�. t 4a -2 0.• Nws� a° *�'"k�, ' "'`,^ R�t". :'. 4^*• �''�� Y" �a�'"r '° a�'' nA ,"�Ys• a Y �s�,. _" + � .fir g h � ,. ,��, .. .. row',mi raaw�tt'iw' ':. h qW. . 1M Ci a "'Su'w"i re1, ,ats«'�"`a,r..u�'r,,,t�� ;;a,s,p� mo g 0 q. ,q :° .4.: x; ;:. m..., .�x. •dl* m,,aw�nw,�yag'Rma �W�'na��nr,.,'--�"m.� ,'."ua ^ snY @. � ,�: - :a �� a�?aiw0.i�m• „, : 2 m� . y .fin 6oww t, aS�Pw°ria"iu� �o ��� , c ,,ipaYpnd va". .,5 e. - i , i � ..- + .,'..;.. :, � ..z e, .`n:k c n�t a>•-^�J �ed9+.' n:. �,4 Syst �., PfRMI «r own of Barnstable -Permit#,;400 OC T 2 6 2006 Expires 6 months from issue date � ry Services Fee a t�i OVEN OF BAD fij.Geiler,Director �Eo: •+° Building Division Tom Perry,CBO, Building Commissioner « ERMIT 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us O C T 2 6 2006 Office: 508-862-4038 Fax: 508-790-6230 LARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint vlap/parcel Number�C2 ?roperty Address �� (�l /, S-7— I- t!a do h` ,$ 4 Gt S 5 6 Z C 0 / r /ffResidential Value of Work 7 t C7-"D Q ; (7U Mi 11mum fee of$25.00 for work under$6000.00 Owner's Name&Address XAZWA lu C_ � !L/ r o S A/aLd �S`7^ Ufa�n /,s M,20A d 2 �' y 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 f 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) Rom,Re-roof(stripping old shingles) All construction debris will be taken to ❑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 Property Owner Letter of Permission. Home Improvement Co tracto icense is required. SIGNATURE: - 9� Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts ^; Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111. f 3� www.mass.gov/dia Uz Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name(Business/Organization/Individual): � � e__p P � Address: 13 B f it C /e l 2 6/ D City/State/Zip: Phone SO — 7 7 Y �� 2 Ire you an employer? Check the appropriate box: Type of project(required): 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-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. # ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] o lt'I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] .ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. :m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: >licy#or Self-ins.Lic.#; Expiration Date: b Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). d1ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ie 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 'up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of .vestigations of the DIA for insurance coverage verification.. do hereby certify under the pains and//penalties perjury that the information provided above is true and correct'. mature: �'O �/ �7 Date: l P1 -2 6 c! ione#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2:Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: IPA r Town of Barnstable s�xsra �, �$ XAS& Regulatory Services Thomas F.Geiler,Director Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Dffice: 508-862-4038 Fax:. 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: o2 3 6 Y-0vt4 s Ik A o Z 6 0 T (Address of Job) Signature of Owner Date Print Name Q:Forms:expmtrg Revise071405