HomeMy WebLinkAbout0182 HINCKLEY ROAD
Town of Barnstable *Permit#
"t Fapires 6 months from issue date
Regulatory Services Fee
• saxxsrnet.e,
Mass.0;9. Richard V.Scali,Director. 3�,
��
RFD MA'I A
Building Division
Tom Perry,CBO,Building Commissioner,'
200 Main Street,Hyannis;MA 02601
Www.town.barnstable.ma.us UK I
Office: 508-862-4038 � 10 l a/x,508 790=6230
EXPRESS PERMIT APPLICATION - RESIDENTI I ONLY
3
, O 0 Not-Valid without Red X-Press Imprint - 111V ° �
Map/parcel Number _e t '
Property Address �Z- V1XNC_tkk_V,,14-0,8'
[Residential Value of Work$ 2-0,0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address —repLttir C y e'-L k__
1�6 L�t�cae..�l Q.O..q� �/�,�e�e•�i�=d�� . " O2_fo0�
Contractor's Name Vi.wc? Telephone Number 5b R S o9'�6
Home Improvement Contractor License#(if applicable) /02$aj� ' Email: t 61-&L1 0,0-CW G(t) /a00-4 .6
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 H P.r 4V4=tCA_A IW$• �0
Workman's Comp.Policy# -U& 2,6 9013 1 l '
Copy of Insurance Compliance Certificate must accompany each permit.
* k
Permit Re u (check box) n /
1N -
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof),
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red,Sand 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 Improvement Contractors License&Construction Supervisors License is
required.
`SIGNAT
C:\Users\Decollik\AppDataU ocal\Microsoft\Windows\Temporary Intern t Files\Content.Outlook\ZPIOIDHR\EXPRESS.doc
Revised 040215
w BARNSPABM •
1 Town of Barnstable
QED MA'I A
Regulatory Services
Richard V.Scali,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
U i,�;UL— ,as Owner of the subject property
hereby authorize O to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
�►c'P�1 1 COJcLL-
Print Name ,
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc
Revised 040215
The Commonwealth of Massachusetts '
Department of Industrial Accidents
t Office of Investigations
' 600 Washington Street'
Boston,MA 02111
www.massgov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Na1]18(Business/Organization/Individual): ' � �
q404i
Address:
Por�o ,—
City/State/Zip: IPA Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. 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
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
These sub-contractors have
ship and have no employees. 8. Demolition
working for in an ca aci employees and have workers'
g Y p t - comp.insurance.:
9. Building addition
[No workers comp:insurance 10. Electrical repairs or additions
required.] 5. We are a corporation and its p
3. I am a homeowner doing all work officers have exercised their l 1. , 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.
:Contractors 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 numbei.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site .
information.
i'
Insurance Company Name: .
&.,V"
Policy#or Self-ins.Lic.#: . t Expiration Date: R
Job Site Address: 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 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 insurance coverage verification.
I do hereby certi der the pains and n of perjury that the information provided above is true and correct:
Si
e, t
Phone#
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 I Building Department 3:City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other.
Contact Person: Phone#:
Massachusetts Department of Public-Safety
4f Board of Building Regulations and Standards
License: CSSL-099167
Construction Supervisor Specialty .
OLIVER M KELLY
8 RHINE ROAD n4 �
YARM,OUTH POR f MAC
, err- i
�- UZ CA_ Expiration: -
Commissioner 09/284017
dX/te Uoowwno�w�ealtl?. al-,
.y
Office'of Consumer-Affairs and Business Regulation
}� 10 Park Plaza- Suite 5170
Boston,-Massachusetts 02116
Home Improvement Contractor Registration
Registration: 128957
-_ - Type- individual
Expiration:. 6/14/2017 Tr# 266936
Oliver Kelly .. _
Oliver Kelly
8 Rhine Rd = -
rm rt MA 267
oufh -o ._.
0 _5
Update Address and return card.Mark reason for change.
O 2ore-0sm Address [D Renewal C Employment Lost Card
billJf<r`r�t•»�niri�irca�/�a��'i���.:;arfiflcfl -- ----- - _._�__ . _ -
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egtstration: _:•j2g957 Type: Office of Consumer Affairs and Business Regulation
v Expiration _&14/20.1T; Individual 10 Park Plaza-Suite 5170
_ Boston,MA 02116
ar Kelly
ar Kelly -
line Rd. CQ caj,
nouthport,MA 02675 Undersecretary Not valld without signature
NWIR
CERTI
- - - - - -- - - - -- - - - -- n
RluFICATE 8 t SUED AS A MATTER OF imFoRw AT10NONLY AND CONFERS 10 F ITS W4161 THE CERTIFICATE HOLDER.TMS
CERTIFICATE DOES NOTARRRMAVI4IEL5"06 MUTi1VUVAVEW.EXTEND 4R ALTER THE COVERAGE:AFFORDED 8V THE;RDLICiES BELOW.
TK3 CE"FiCATE OF IN90MAfCE DOES INOT COIBMTUTE A NNTMACT BETW BEN THE it9SUfNO:0ISUFEftM MT%WIEED REFIFIERENFATiVE
h ORTAiff!II din etarilli it&beldti is im ADUrIOMAL INSIFHEID,d*ptfftd1,itil!terStt.Blpmr r?fad i1P'9fl�RDOATt�N'tS Yi"Ali1�D,!ulX tfi As
tba Ettrm aod,&mdIfitm tithe ptiEffie,tormiA pGliel-m Ray raquirtu mvil tent'f�taitfrrt, A:tEii tdtltlt ied tYrlA etrrUltttl!e,dbrEfi.tlR3s t: rlttr e1�iK3lu
tUi EtelllCfilri f§tildtt(�Iltid e!I':rwth taldtattrlidtti 4. !
PAdIC•
60M'E.IA GC A.GNTIL ENS ArxV 1 p"3m - r a
I�,Ift);
EIYA-MMIS,MA.02601 Aoo�Gs
221ralt rauRER IA—Fr C!1-D74C0YCRAGC HNCF
. INSUREE9 INSURER A:. iv.L'F.vl�►li;.t��71ldY'I:Fti+:d�n.L�b9/a�•S7'�
KT-I.LY RCKIM101KC INSURER 0
INSURER C::
INSURER D::
E HJUMER!?AD _
INSURER a:
�?1.7tI�IdfFIL'�&T.lvtrl 9?fiF5 d►F�uRQa Fr ___.-- -_
- 07KRAGM ceRTinIZATC NU1100h 111331SEN NUmalm. .. _......._
''AiflftlTGi�19iY'F.rtST'I.:tii!#ftIE�GFiFi`��fitliOC�rESO6iukiiA'IO�f�.YOYtf"�SSfliiiw9UpSGiNAi!�AliSrZFEpTAi:Athlla:YFsi�iG�+a°�'� �s>11FA59"NCi'Sd�'VtiG
AidYpiililAidlE.YT,'T6Fw.JYi GGwhTiEid'.Gi Ana eOia?,ph2ACp GPsi�A G�dlidii"ASPN riiiCftT TG�:eir�Tiro,eCp'P�ua7'idi(sY 6>ci 6�diGRi li'AY!DikT�d.'R.IiCdam`aiitM�
At'FCp5i0�V'CdvCP0iAA79pdtCGK"TiSrif945�FIC�1fY�3Ada'1'i1G'E6Adh�CAireGfOiad-AwGK4afGs;7iiid9&C.91Y�FOiiCiG4 LiY3�.'SodGtiNdlwYliu'zitf,¢4ip1W9die�i6GY .
NSA ----- - - - hG'f we i ,ltidiLw UFFGATC f1rdi&0"PeWtZ
LTA A. l0bevathirmsh f Oi#JYAwffj xmft5ft-w0 Li'ir7
GENERAL LIIV UIV Lt40£J:SIfE.4tEl'JCL' S
--tCAbRIERCMCZNCFiN.l.LLACLI.TY GGTd3t27itJTED S
CL mm kAM ®oovm PRENCES me EFj2me
j-- a!ESLF i�r ehm S
i,
GEtA.fiardrLG5.T0,LSf4 iFRLCSrfCRa
! !
' d3:d L: S
&IILJY ;�FATtT P$C aCOSLF S
AETsW0ra uLnnr v.Le3C Is-
-
: a
AWAL'Ta eaictfl
T4 s
:.4.L ow-lEt).ki M ( �mILY11JA,1Y1' -
T7er
— NAM AUMS 'P'er'$idr�f
i. lx'133N,aiARCD!AdT S ,• NWMR7fDAkPGE s .
Pei=t*tl
DIMSS LIAR CLAlAc4A;mr .GGREGATiC
ccausal:J.n: >:
Re�cNTFnn�s ;
A waONeRs cCUPENSATNSN"ll a�sT��urcpv aT
EIIfI!GO•Yms LL"uw trt►F UrP=601371.1v i comml1< �alY�1T :\. Ltoe'm
NiiPrwY�df6Fdtrip'i4AjTw�0.6:�Ia'.Una. !dy - i - C.LZADUAMCMENTit
Cf F dffi rdcU;L t:aEi d�Gt
�E:LaBCa`S'.-CA
!L7d.F`SaKCE. S 'SOf�fFt"i0
Ts3LiSfi'rTlCid 6rcr7uriTAdstsr� - 1 _-_DZCASC.-1a Y-LIN1 :6 SIl!'".
OCSIZAPTIag4r4R.'lilkTdali'SL'aCAfiONlIaVEIIfCLEvS#'.SiRICT9aR+a�OECUICOEM -
T7Esup6%r0l X%To•:►WeC7%T[SUAIDiKsUT,DTtiTIM.0;5MFICATEW-CMICAffl,=I*"A't.-R1KI CCWICfL'Wu--F..
%'AnT:kGrSLIIFECI.ATYi+INrl%'FiTROr PAR,"13ASgo;gmr,D-O cawmk-T
CEMI'le--ATE HOLDEtE CAINCELIiLlED@I
70%WC+ffBARNSTA.BLE SWULD.Anvari cAnonor—MAZEDPamesneCAITCrLLJ[D
aEFORE Ts1E eImmT3m DATE Tt1cmmmance IAUL 0e
357.tA1aL1ld 51' _ AGcaaDANce"TINTREaaLSY,a c
--
AAMORM"REFFISSE1TA41Y9C --_
9l5:atitiStdlS;.>,IA aD3t0I _ f
sd � DR 1aii$A�DiQCO1F All ulpRti 9EriACDD 2'41t�l TNACDHDafb tiW,,k)WAv&r-�ttFAI tlsl