HomeMy WebLinkAbout0058 CASTLEWOOD CIRCLE 96 /�r��t ,ea� �
I
�► , Town of Bar-nstal)le *Y rmit#9� -7
Expires 6 monthsftont issue dale
Regulatory SerViCCS Fee .P
>i,.��r�B�. g y
MASS �' Thomas F. Geiler, Director
rFDr,pya Building Division
Tom Perry,CBO, Building Commissioner Pf
200 Main Street, Hyannis, MA 026{)l
Www.town.barnstab le.ma.us
Office: 508-862-4038 Tax: 508-790-6230
EXPRESSTERMIT APPLICATION - REMENTIAL ONLY
Not Valid without Red X-Press Inupri';1
Map/parcel Number o13 CX0
Property Address C i C; _ r
Residential Value of Work _ ,_ Minimum fee of$25.00 fOr work under$6000.00
Owner's Name& Address quo
U ' �h � 6,4.a
Contractor's NameT__-LAP-4 ---&a4 Number 77�: 1_
Home Improvement Contractor License h--(if applicable)_ 3k,�-9
r
Construction Supervisor's License#(if applicable)
❑Workman's Compensation.Insurance w� SS � 9T
Check one: •
2--ram a sole proprietor
❑ JUL 17 I am the homeowner
❑ I have Worker's Compensation Insurance a N 0� BARNSTABLE
TOW
Insurance Company Name _
Workman's Comp. Policy h
Copy of Insurance CompliancexCertiiica.-te must be on file.
Permit Request(check box)
FrRe-roof(stripping old shingle,) All constrtiction.debris will be taken to—Du rvv S eR___
❑ Re-roof(not stripping. Going 6ver. existing layers of roof)
EeRe-side -
❑ Replacement Windows. U-Value (maximum .44)
*Where required: Issuance of this permit dri11 es not exeurpl compliance with other town department sC.Oulations,i.e.Historic,Conservation,etc.
***Note: Property Owner trtust sign Property Owner Letter of Permission.
Ho I> m o ement Contractors License& Construct Supervi_,,ors License is required.
SIGNATURE:
Q:\WPFILES\t-ORMS\Express\EX RESSPERMIT.DO€:
Revise06O4O9
,per _; The Commonwealth of Massachusetts
Department of Industrial Aecidets
Off ce of Investigations _
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation nsurance Affidavit: Builders/Contractors/Electric ans/]Ptumbers
Please Print Leibl�
A licant Information i .
Name(Business/Organization/Individ al): E.,e
Address: i�f, 2t►�� �+-'
Ci /State/Zi : 14 Y AP'ty ;C rhvq Phone.#:_S7_ 5r� I q61
Are you an employer? Check the appropriate box: Type ofproject(required):
4. I am a general contractor and I; 6 n New construction
1.❑ I am a employer with have hired the sub-contractors
mployees(full and/or part-timel.* T. Remodeling
listed on the-attached sheet.
2.CJ 1 am a'sole proprietor or partner; These sub-contractors have g_'[�Demolition
ship and have no employees employees and have workers' 9 r❑Building addition
working for me in any capacity° mp $
[No workers'comp.insurance co insurance. 40..[]Electrical repairs or additions
5. E] We are a corporation and its
required.] officers have exercised their ( 1I.❑Plumbing repairs or additions
3.❑ I am a homeowner doing all w041k right of exemption per MGL i repairs
myself.(No workers'comp. p p I 12.❑Roof
c. 152,§1(4),and we have no
13.❑Other
insurance required]t employees.[No workers'
comp.insurance required.]
applicant that checks box#1 must also fill but the section below showing their workers'compenstion policy information.
*Any they-are are dour all work and then hire outside contractors must submit a new affidavit indicating such.
Homeowners who submit this affidavit indica g ey" g
tContractors that check this box must attached a4 additional sheet showing the name of the su o.tt warn er and state whether or not those entities have
employees. If the sub-contractors have employel,they must provide their workers comp.policy
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy grid job site
'
information. i
Insurance Company Name:_________
n
Eirafon Date:
Policy#or Self-ins.Lic.#:
U /State>Zip:
Job Site Address: 1
Attach a copy of the workers'comptsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required lender 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 risonment,as well as civil penalties in theorm be forwardedp:WOt the'OfficeRK of d a fine
of up to$250.00 a day against the vroltor. Be advised that a copy of this statemen may f
Investigations of the DIA for incuranctncoverage verification.
Ido hereby certify under the pains anYlpenalties of perjury that the information rovtded above is true and correct
Dale: Wgai
Signafore:
Phone#:
�-Lo —tyb
Offtcial use only. Do not write to this area,to be completed by city or town offcia[
.City or Town: Permit/License#
t
Issuing Authority(circle one):
1.Board of Health`2.Building Departnient 3.City/Town Clerk 4.Electrigw Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
Toy,, Town of Barnstable
Regulatory Services
9 $ Thomas F.Geiler,Director
a s Building Division.
Tom Perry,Building Commisgioner
200 Main Street,Hyannis,MA 02601
www.town_barnstable.maq us
Office: 508-962-403 8 Fax: 508-790-6230
Property Owner Mast
Section
Complete and Sign This
t
If Usin A Builder
J
g
I
as Owner of the sub�ectProperty, ��� 4kAe n' ��� r✓- J
hereby authorize clye),2 C_ (; ,4 to act on my behalf,
in all matters relative To work authorized by this badi.ng p rin t application for.
(Address of Job)
4
Signature of Owner Date
Pnnt Name
s
4
Y
a
If Property Owner is applying for permit 'lease complete the
Homeowners License Exemption Form 0
tie reverse side.
r
et;�ti�iR�gtid�fto�sauJ; sad�rls z;; .
HOME IMP tOVl`IIIIENT CONTi�f�1°cJR .t
CtegiBtf[rifi� '423659 ` " .
T4 281fvd°7 #
1Yy00= idtsai 4'
Card G.Graham {
n .
License or registration valid for in�lrvidul use onl w
y
before the expiration date. 1f found return to;
-Board of Building itegulations an One Ashburton P m lace R 1301nStandards`'
Boston,Ma.02108
a a.
i1
-- __r- ------
Not vabd withoptsignature
o; t y rid' a M � Y {vM� €�. .~ $,�, ,*gm -,
n,
f
Town of Barnstable
Regulatory Services
.� Thomas F.Geiler,Director i;t ..,
• antwsTaBie fie;, ,H ClF �a TABLE
9 MASS.a Building Division
n63y. �0
o�Eo► " Tom Perry,Building Commissioner 2Q06 Qr j 30 Pm
200 Main Street, Hyannis,MA 02601 � M
www.town.barnstable.ma.us
.�.
Office: 508-862-4038 S Fax: 508-790-623(
PERMIT" .� �� FEE: $
SHED REGISTRATION
120 square feet or less
Location of shed(address) Village
Property owner's name Telephone number
Size of Shed Map/Parcel# .
ignatur Date
Hyannis Main Street Waterfront Historic District? .
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature is required)
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE V1'ITHIN THE JURISDICTION OF ANY OF THE ABOVE 3
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM. MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shedreg
REV:042506 f
a
n _
273056 ------------------
-
- -
g .
E
-
ra#
jn
a' x mn
s 273204
ra
101
j
�I f
t
�C
ii
X cY
NOTE PARCEL LINES MAY NOT BE ACCURATE. The DISCLAIMER This ma is for planning t p D ng Purposes only. It
parcel lines on this map are only graphic representations of may not be adequate for legal boundary determination
or "' i 0 5 10 20 Feel
Assessors tax parcels. They are not true property regulatory interpretation.This map does not represent an
boundaries and do not represent accurate relationships to on-the-ground survey.
physical objects on the map such as building locations. �r 1 inch equals 20 feet
l