HomeMy WebLinkAbout0005 HOLIDAY LANE
Town of Barnstable *Permit61Itgt� 1
Expires 6 mo rom issue d
Regulatory Services Fee :'
swnxsrasr.e,
163 - Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner .
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us - f
Office: 508-862-4038 Fax 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address "/ H O L I D Ay L. /,N F . W y AL�t,,�15 m A
y Residential Value of Work-2-j ocD, co Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address ► G�H��' . �A�j A 1�
34 E LL E L-P',WE CA3N[,�SToN 1 6 2q 2
Contractor's Name_VIND L-0 MA AR T 1 t3 P-Z- Telephone Number r)02) '.2j 39
Home Improvement Contractor License#(if applicable) 4- Q 2-
Construction Supervisor's License#(if applicable)
Workman's Compensation Insurance.. X-1'R ES S PERMIT
Check one:
_I am a sole proprietor
ElI am the Homeowner MAY 115 2012
❑ 1 have Worker's Compensation Insurance
Insurance Company Name `1'Pl\A/{\I f^1F R A RNSABLE
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 be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
%-Replacement Windows/doors/sliders:U-Value O.'Z.Q (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
uired.
SIGNATURE: V�"_Zk
C:\Users\decollikuppData\Local\Microsoft\Windowsl-emporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 072110
The Cornrnornvealth of Massachusetts
Depaphnent of IndustFial Aced feras
QKwe.of Investigations
600 Washington Street
Boston,AL402111
ivn tv.inass:govldia
Workers' Compensation Insurance davit:BuildersIContractors/Bl'ectrici,ans/P'lumbers
Applicant Information Please Pint Legibly
Name(Busiu anizatian&dividuel): PA LO M.ARTII3EZ
Addgess: 49 5 M ITN STR t7 °
Cif/SYatetzip: 01 i\N N 1 S NA A 0 2Lo 01 Plane#. 50 ° 214 , 11� --6
Are you an employer?Check the appropriate boat T of ro°ect
4. I am a d I
P (required):1.El Y am a employer with ❑ general contractor an
employees(full andforgait-time)-
* have hired the sub-contractors 6_ ❑New construction
2.X I am-a sole propmetor or partner- listed on th,e.aBtached sheet 7. ❑Remodeling
ship and have no employees 'Meese sub-contractors have S_ ❑Demolition
working for me in employees and have worms'
mY capacity. i 9. ❑Building addition
rs' .
[No worke comp-insurance comp_insurances.
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_Q Plumbing repairs or additions
right of on per MGL
self: o tvorToefas' � exemption p
rnI' � �P- 12.❑Roof repairs.
insurance requiaed,]1 c. 152,§1(4} and.we have:na
employees-[Na workers' 13.t Other ``U
comp.insurancerequired.]I 1�+�
'Any applicant that checks tox*#1 mast also falowthe secdonbelowshowing thekvmAerV eompensawnpohcyinfurmtaaa
i Homeu mews who submit this dEdava iudicaGag they are daing all worlt and then hire outside conaac=mm sub=anew affidavit indicating such
kanttactors that check tf®s box must attached.am additional sheet showing the name of the sub-comnamrs sad'stale whether or not those entities have
emphryees. If the sah-cann ctoas have employees,they Est provide theme warken'amp.policy number.
I ram an einptoyer that isprovidbW morli: 'couipensadan insurance for my emTloyees Belotw is the policy andlob site
inforrna am
Itui u ance.Company Name:
Policy 4 or Self-ins.L ic.#: Expiration Date.
Job Site Address: city/StateJZrp:
Attach a copy of the workers'compensation policy dectaration 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
tine up to S 1,500.00 and/or one-year impr sonm eru,as well as civil penalties in the farffi 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 maybe forwarded t D the Office of
Inyestigadons of the DIA for insurance coverage verification-
I do DiM-cer.the ris rand penalties of pet�airy that the inj�orrnadiore pxovid®bore_is b ere aaairl correct -
Si Date: 0f ® 2
Phase#: r)09, ° 24 4 39 9) 3
Qfflcial rase only. Do not write in this area,to be completed by city or tonvin o,�'eciraL
City or Town: Permit//icense€i
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/I own Clerk 4.,Electrical Inspector 5.Plumbing Inspector
6.Other `
Contact Person: Phone#:
- - - 6
a
� snnxsreets. �
° Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200-Main Street,Hyannis,MA 02601
www.town.barnstable,ma.us
Office:50&8624038 Eax:.508-790-6230
Property Owner Must
Complete and Sign This Section
P g
If Using A Builder
I, '� `e ,as Owner of the subject property
hereby authorize Pablo Martinez to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
1
Signature of Owner Date
Print Name
U Property Owner is applying_for permit,please complete the Homeowners License Exemption Form on the
1
reverse side.
C:\UsersldecolliklAppData\Local\Micxosofl\Windows%Tempormy Intemet Files\Content.Outlook1DDV87AAZ\EXPRESS.doc
Revised 072110
^^� License or registration valid for individul use only
/�/ __-..__
Office of Cons me A�f rs&Butsines�Regu a
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR
; Registration: _, 142802 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
' Expiration 5/20/2014 " DBA Boston,MA 02116
C V0BUILDING REMODELING
PABLO MARTINEZsr }; f
49 SMITH ST
r ,
N
HYANNIS,MA 02601 = Undersecretary Not valid with ut signature
,,..
a- Nlassachu;setts- Dcpartmcnt of Public.Saf,;ct.
Bo:u-d'of Building Regulations -in Standat ds
I
Construction Supervisor Licsnse
License: CS 103617
Restricted to: 00
it
PABLO MARTINEZ ti
49 SMITH STD, j..
HYANNIS, MA 02601
;Expiration: -11/17/2013:` i
('uuunissinncr Tr#:_'103617
p