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Home My WebLink About0224 GREENWOOD AVENUE Of IKE T Town of Barnstable �{ Expires 6 months from issue dale aA , ,gLF :Regulatory Services Fee v� SAS& � Thomas F. Geiler, Director ATfo �a Building Division Tom.Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.baenstable.ma,us Office: 508-862-4038 Fax: 5.08-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not.Valid without Red X-Press Imprint Map/parcel Number Property Address _ Z .(?.f Ai t d 000 -+ [J esidential- Value of Work(? Minimum fee of$25.00 for work under$6000.00 ` Owner's Name&Address Z2 n -e.,✓ ev C C- 0 Ve Contractor's Narne 4sT,q«'��,�?-- ` Telephone Number. n� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) "C92, 2 (-, ❑Workman's Compensation.Insurance ESS PERMIT Chec one: .. am a sole proprietor �U� ' 2009 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTA14 Insurance Company Name � .UT L:&JV�4e_�C-P Workman's Comp. Policy H Copy of Insurance Compliance Certificate must be-on tile. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris.will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) [2/Re-side F Er 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. Hom provement Contractors License&Construct Supervisors License is required. SIGNATURE: QAWPFILESTORMS\Express\EXPRE PERdYiI .DOC Revise0606o9 The 0mtrion'wealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 •�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,.44 �1,'D k RAJ L'�_ Address:) k-r17 � w City/State/Zip:�'�,4 J.f c/ �� hA,- S Phone.#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a Y emP to er with 4. I am a general contractor and I 6. ❑New construction have hired the sub-contractors ployees(full and/or part-tim.e).* I am a sole proprietor or partner listed on the attached sheet. 7.. Q Remodeling ship and have no employees These sub-contractors have g. ' Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'-comp. insurance comp. insurance:$ required.] 5. We are a corporation and its 10.❑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 pi 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. lContractors 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:�/f/f}-U��((/� �1/�e4*,v C e P — Policy#or Self-ins.Lic.#: . AJ e— 9 7 Z Expiration Date: J�X,ZZO Job Site Address: Z Z a PAI-, .wOa V A,(J e City/State/Zip: 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 MGL c. 152 can lead to the imposition of criminEll 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 insurance coverage verification rdo hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Si afore:V Il Date: Phone 4: �z X,6 T 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 S.Plumbing Inspector 6. Other Contact Person: Phone#: r.. Information and InstrnctIons Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in.the service of another under any contract of hire, express or implied, oral or written." 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, §25C(6)also states that"every state or Iocal 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,MGL chapter 152, §25C(7) states"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«zth the insurance requirements of this chapter have been presented to the contracting authority.' Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-conftactor(s)sname(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . .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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Sile Address" the.applicant should write"all locations in__(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office oflnvestigations wouild like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Dcp ztment of Industrial Accidents Office of Iuvestigafi.ans 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.g4v/dia INET°�ti Town of Barnstable " Regulatory Services BAMWABLE, Thomas F.Geiler,Director , pTFD .�a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 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 �� b iA i to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) V� , Signature o net D to Print Name r :FORMS:O Q R'NERPERMISSION i Board of Building Regulations and Standards . Construction Supervisor License - Licensed CS 58266 i Exp�[ation 1l3012010 Tr# 13630. Restriction--1+ r } l MICHAEL J RENZI `=` $ 387 PHINNEYS LNG 4 �J Commissioner CENTERVILLE,MA 02632 Bo'a�o m mg eguCa�ods an tan ard��s� -� 1 License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration; 111859 Board of Building Regultions and Standards Expiration� a 2/4/2011 Tr# 279440 One Ashburton Place Rm 1301 Type Boston,Ma.02108 BA D MICHAEL RENZIC®NSTRUCTIO�N MICHAEL RE NZIT `J {{ ` 387 PHINNEY'S LN r CENTERVILLE,MA 02632 Administrator Not vali t t Signature i