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Home My WebLink About0016 BLUE JAY DRIVE -3-: 31 -�s P,c Tow of Barnstable *PermitF. Regulatory Services e 4date zsfromi q • �►�ervuE;- �� aE NAM Richard V.Scali,Interim Director r Building Division Tom Perry,CBO,Building Commissioner ARNS1 A61-E 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Lnprint Map/parcel Number 6 v a l,�f C 'a O(C. ®/D - Property Address U ei 6 0 / Q].liesidential Value of Work$ 1 0 o G- o Minimum fee of$35.00 for work under$6000.00 Crooner's Name&Address�jr G 0 r .0 �v rt A� 6 5g14> err11 R. va6�g Contractor's Name ,7 (J h 1`, �, LV 0 r1C Telephone Number / Home Improvement Contractor License#(if applicable) 1 d / Email: L G P R U /.0 � C 0 C 9S-t e r Construction Supervisor's License#(if applicable) D -7 aorkman's Compensation Insurance Check one: ❑ I am a sole proprietor" ❑ I am the Homeowner ZIAhave Worker's Compensation Insurance r''� C>' ► CQti »•f rQgl� r Insurance Company Name G., y o� I c � � V Workman's Comp.Policy# 6 `U — .b J ?l I — 2 !/ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. •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. A copy of the Home Improve t Contractors License&Construction Supervisors License is .. req SIGNATURE: T:\KEVIN_D\Building Changes\E SS PERMMXPRESS.doc Revised 061313 Massachusetts Department of Public Safety. '� Board_of Buildrn 3 g;'Regulations�and Standards C�>nstructiori Supervisor ` License: CS-076126 i IN JOHN P LYONS 72 MGGINS CROW ° W YARMOUTH MA s �'�, .� `Jll„"rJ Expiration Commissioner 01/06/2016 I (92e Wanvrra ouaeaN a19ccddaclwdet(d License or registration valid for individul use only, Office of Consumer Affairs&Business Regulation i before the ex iration date. If found return to: ME IMPROVEMENT CONTRACTOR i ', p i office,of Consumer Affairs and Business Regulation egistration., 166189 Type-: ; xpiration =5/7/2016a LLC 10 Park Plaza-Suite 5170 T Boston MA 02116 Cedar Crest Properti@s LLG 1 �k John Lyons ` 72 Higgins Crowell Road West Yarmouth,MA 02673Y Undersecretary Not valid without 'g ature r _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston,MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aipolicant Information Please Print Le ibl Name(Business/Organization/Individual):• Q P/l�� rC� �'G f�� 1 S (.� Address: a W"o C� /.,I S. K 0 wt i' o Ci /State/Zi f P Y «+f `� Phone#: 7 4J-- 3S 3 3S Are you an employer?Check the appropriate bw. Type of project(required): 1.❑ I am a employer with 4. am a general contractor and I 4mployees(full and/or part-time).* �"L have hired the sub-contractors 6. New construction 2.lVJ l am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ' ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in capacity. employees and have workers' �Y � t3'• 9. ❑Building addition [No workers'comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 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 their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tr-ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not 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: V Y-r L A?) ►' C q w ( C I-o V Policy#or Self-ins.Lic..#: �j �.Z l/ ✓�j' — �, ) R-�Q ) 3 Expiration Date: � bJ/S / MJob Site Address: b � �i 8 l City/State/Zip: /`f r1 I j �q• �2 U Attach a copy of the workers'compensatio policy declaration page(showing the policy nu der 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 may be forwarded to the Office of Investigations of the DIA for insuranc coverage verification. I do hereby c nder /er'ns nil penalties of perjury that the information provided ove is ue and corred. Signature: V Date: Phone#: Official use only. Do not write in this area,to be completed by d&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#: b NOTICE,:. M NOTICE Z W !. A TO TO w EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 606 Washington Street, Boston,Massachusetts 02111 617-7274900 — http://www.mass.gov/difi.. As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) have provided for payment to our'injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 �— ADDRESS OF INSURANCE COMPANY (GZZUB-6B1 8281-3-1 4) 08-26-14 TO 08-26-15 POLICY NUMBER EFFECTIVE DATES SOUTHEASTERN INS AGCY 641 MAIN ST s HYANNI S . MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# CEDAR CREST PROPERTIES LLC 72 HIGGINS .CROWELL ROAD WEST YARMOUTH MA 02673 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to: furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the 'services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably • connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such.attention at the NAME OF HOSPITAL ADDRESS inn 1DU 1Dn0rVV" IQV Ul%4Dr nX7VID 9. Town of Barnstable Regulatory Services R Richard V.Scali,Interim Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I; �� G I I V ) l U L✓I-,- I'l C ,as Owner of the subject property hereby authorize G L U 1, -f to act on my behalf,' in all matters relative to work authorized by this building permit application for: c4hn1i 6 Uc (Address,ofjobj 11q 41 r Signature of Owner 15ate Print Name If Property Owner is applying for permit,please complete the homeowners License Exemption Form on the reverse side: T:\KEVIN_Muilding Changes\EXPRESS PERM MXPRESS.doc g Revised 061313