HomeMy WebLinkAbout0194 HINCKLEY ROAD /9�e
PRIE s PERMIT a z
Town of Barnstable *Permit#
"'4• Expir nths from issue date
3 2012 Regulatory Services Fe
snaxszna . ;
amass $ Thomas F.Geiler,Director
BARNSTA®LE Building Division
. Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax:.508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number ✓ l� V `
Property Address
❑Residential Value of Work �- Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Ack L
Contractor's Name 6 Telephone Number' �� V /D6
Home Improvement Contractor License#(if applicable)' l t
Construction`Supervisor's License#(if applicable) l Y
❑Workman's Compensation Insurance.
Che one:
I am a sole proprietor,
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance.
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
�
Re-roof(hurricane nailed)•(stripping old shingles) All construction debris will betake n to�i`��d � LJifiq�
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors '
❑ Replacement Windows/doors/sliders.U-Value �(maximum.35)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation;etc.
- ***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the.Home Improvement Contractors License&Construction Supervisors License is
requi
SIGNATURE: -�
Q:\WPFILESTORMS\building permit formsTYPRESS.doC
Revised 051811
EMMANUEL HOME IMPROVEMENT PROPOSAL
P.O. Box 311
.vl Centerdle, MA 02632 1088
G
508-367-1679 Page No. of Pages
`
DESCRIPTION OF JOB
ARCHITECT DATE OF PLANS
PROPOSAL SUBMITTED TO: JOB
ADDRESS .
l� � N V l •\ /�`� CITY - STATE ZIP
` A _ PHONE - - - DATE
WE HEREBY,SUBMIT SPECIFICATIONS AND ESTIMATES FOR: -
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We hereby propose to furnish material and labor, complete in accordance with above specifications, .for the
sum of dollars ($ .4,,,:
with payment to be made as follows:
All material is guaranteed to be as specified.All work is to be completed in a workmanlike
manner'according to standard practices. Any alteration or deviation from specifications Authorized
involving extra costs will be executed upon written orders, and will become an extra - Signature
charge over and above the estimate.All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary Note:This proposal may be withdrawn by us if not accepted
insurance. Our workers are fully covered by Worker's Compensation Insurance. within days.
Acceptance of Proposal -The above prices, specifications and condi-
tions are satisfactory and are hereby accepted. You are authorized to.do
the work as specified. Payment will be made as outlined above. Signature e
o� I
Date of Acceptance: Signature
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Nlassuctiutiettc- ►t�i�ns..ind.Stand�t:,d
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Boa►-d Bu►Idinerv.isor Speciralty License
Construction Sup.. -
License: CS SL 99382
Restricted to: RF,ws.
HE
DR
286 STRAWBE MA HILL ROAD
CENTERVILLE,
Ham. won.
Expiration: 911412013
Tr# 2314
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The Commoniveakh of Massachwetts
Dtpaphnent ofIndustyial Acciden& _
Office ofInvestigat ors
600 Washington Street
Boston,CIA.02111
n%,w,.mas&gov/dk
Workers' Compensation Insurance Affidavit BMere/Contracturs/E tdrians(Flumbers
Apipbcant Information ; Please Print 'b!
Address:_ S
CitylStat (Zig: �V(( phone#
Are you an employer?Check the appropriate boa: T project(r'
4, am a.. }�of p ] d)=
I. I❑ I am a employer with ❑ genes contractor and 6_ ❑New construction
loyees(full and/or part-time).* havehiredthe sub-contractors
2. I am a sole proprietor or partner- listed an the attached sheet.. 7- ❑Remodeling
ship and have no employees.. These:sub-contractors have g_ El,Demolition
employees and have workers'
working for me in any capacity. 9_ ❑Budding addition
[No}workers'comp-insurance comp-insurance,.Y '
required] 5. ❑ We.are a corporation and its 16.0 Electrical repairs or additions
311 I am a homeowPner doing 1.all'work officers have exercised their 11_❑Plumbing repairs or additions
myself[No workers'comp- right of exemption per MGL : 12.❑Roof repairs
insuu-ance required.]1 c_.152,§1(4),and we have no
employees-[No workers' 13.❑Other
comp:insurance required_]
u appfic�t that checks boa#1 most also fill oar the section below showing they wmrtdere compensation ply information.
13 eoamers vrbo suborn this affidavit indicating they an doing all wart and then hire outside contractors mmst submit a new affidavit indicating such..
tCoauarturs that check t1 is boa must attached au additinnal'sheet showing the name of the sub-conitaicbon and stale whether oruat those entities bum
e®phmyees..If the:sub-contractors have employees,they must provide their workers'rump.policy number.
I afro an empli7jw Me&provid nog workers'congmusation.insurance for my employ�eaL Below is,Ae policy and,job sfte
information.
Insurance Company Name:
Policy#or Self--ins-lic.#: Expiration Date:
r
Job Site Address: CtyPStateiZip:
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 lip to$1,500-00 and/or one-year imprisonment.,as well as civil penalties in The foam 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 fonwrarded:to the Office of
1mvestigations of the DIA.for insurance coverage verification:. .
I do hereby cerh&under tk � sty that the information pro idid,above is true and correct
Signature: Date:
Phone
Official j%cial use-only.. Do not write in this arty to be completed by city or town official
dial
City or Ttawn : PtirmitlLicense#
Fssuting Authority(circle.one):
I..'Board of Health 2.wing Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector
6 Other . . ; . _
Contact Person: Phone 9:
6