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Home My WebLink About0029 LAFAYETTE AVENUE dye 7 r6�- .19 v Y Town of Barnstable to c5�(405 Er Regulatory Services e"s6"'°' is� acre �� MASS • aAatvsrnsrs, • Thomas F.Geiler,Director Building Division, Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038ax:.508-790-6230 EXPRESS PERAW APPLICATION - RESIDENTIAL ONLY C, Not Valid without Red X-Press Imprint Map/parcel Number Property Address ; ! {-61 Ave— Residential Value of Work T Z"6 ( / Minimum fee of$25.00 for work under$6060.06 Owner's Name&Address elk Contractor's Name U.4-(_-�_:C.0 (l C,n Cr`�'1� U - U� � Telephone Number Home Improvement Contractor License#(if applicable),_ Le�( 10 Construction Supervisor's License#(if applicable) qci �2 ❑Workman'sCompensations'Insurance X-PRESS PERMIT Check one: ❑ I am a sole proprietor OCT2010 B-1'_hm omeownerave Worker's Compensation Insurance. - TOWN OF BA R IV STA B L E Insurance Company Name Workman's Comp.Policy# ' Copy of Insurance Compliance Certificate must accompany each permit. ` Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof)` El Re-side { #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows 'Where re4u►ned: Issuance - t does not exempt compliance with other town department regulations,Le_Historic,Conservation,etc. ***No `f Property Own must sign Property Owner Letter of Permission. A copy of Home Improvement Contractors License&Construction Supervisors License is . d SI ATURE: CA ersldecolli ppD calWicrosoftiWindowffempordry Internet Files\ComentOutlookl4STGU5Qp1EXPRESS.doc Revised 0 Town of Barnstable Q" Regulkory.Services g bUsa $ Thomas F.Geiler,Director. ''rFonnn�a - Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I , as Owner of the subject property hereby authorize TJ 1T( l C - to act on my behalf, in all matters relative to work authorized by this building pertnit application for: 1 Vic' e- (Addres of Job) .jd • I � dIC7 Signa a of Own Date Print 14ame If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. The Commonwealth of M assuchusetts N Department of Industrial Accidents Office of Investigations a � k, 600 Washington Street Bostoat,MA 02111 . x www mass.gov1&a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Tease Print Legibly Name(Business/Organization/Individual): V`C.o N-A sJ yu&el--: Address: �� 11 5 • to�� City/State/Zip: hone Are you,an'employer?Check the appropriate box: Type of project(required): lam a employer with 4. ❑ I am a general contractor and I ❑ employees(full and/or part time). have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees, These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' insurance� 9. ❑Building addition camp[No workers'comp.insurance required-] 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers'camp. right of exemption per MGL 12 of re insurance required]t c. 152,§1(4),and we have no 1 . employees. [No workers' 13.0 Other comp.insurance required.] "Any applicantthat checks box#I 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 number. I ams an ettaployer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. z �Insurance Company Name: YG`lIz I C Y`� Policy#or Self-ins.Lic.#: UZ ' 0i OIL Q tv �;to 1 - 001 Expiration Date: 1 I 14. 10 Job Site Address: c. 41rr SLCity/State/Zip: Attach a copy of the workers'compensation policy de tion 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 o - r imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a da t the olator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of e DIA for i coverage verification. I do hereby ertify and a ins annd��aal a perjury that the information provided above is true and correct Signa Date: 1 Q Phone '. Official s ndy. Do not:z in this area,to be completed by city or town offuzuL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone##: i - f-04/2010 11:13 5084204474 PALLHM INS COTUIT PAGE 01 2/002 Fax Server ACQRD. CERTIFICATE OF-INSURANCE �ATEt Y� o�-oz-10 mmucot T"CERt MAU Q WWO AS A RAT IER OF WFORMATMIJ WIL(dAM PAT TN8( IM AGCY OILY AND CONFERS TO RW=UPON THE CBRT)FTCATE AINNOLOER.T� GATE OOE; WTAti M.VTERD OR 5V F LMOUT"A ALTER THE COVERAGE AFFORDED BY TIE POLIM DEL(M. Ca FAi.MA 026 T(OAT) COMPAMER AFFOROM COVERAGE COT(TTT'-MA OZ{,35 CDTPANY 77:vNW A TRAVU8R9 Vmu=ASStCWdE T DriSUti® COMPANY T L H►rcHMM MhTMucr)0*. LB SMVEIES INC Comm" 55 LISA LAWS O WW BARNS TABIR.NIA M WS COMPANY D COVERAGE TMGTOCERM"MTTMVWMGFrAMMtACEUUMSMaWMMffWW.+eDj07MgeuRkvNwEv+eOVEFarn&vcMPBn00eATfa�Teallorwirli3tAemsW[a AlArn�e1UI11Bl�R.i�YaR001 OF/w►oOMiRAezoR6�ltErtDOC1A1FxriRfNRgPECTTowIDQISNOQ Etur88d8uEp�tMumwXV, ti1nWApMW PalDcePASCLIDB►THENOIJmrs, �OWEDI�i�S91ATJFCTTr3ALLT1l6TT#z�i,pty AtoMatimWoucliPOltceLLM[99NDWNYaYNAPE6E91A�BY POLWYOF POLICY EKP LT R TYPBOFINBURARCE FOLCYRUINWA DATE(IIumm OATEOUiRmm) L)IN1TS OWMAL Lu1BR" C0WiRCiAIOENEMLLWBWFY 09 RALA00RWATE $ CLAWSWADE OCCUR PRODUCTscomp18PAtae. $ CiNfADT5 A&CONTRACTOR'S PROT. PEFS �URY 3 EADWFM OAMAOE(Any om ft) R AUFOMg8LLEUABILITY F ANYAUTO ALLOWNWAUTOS COMM BNOLE ED 8O Ra parr 8 SCHULEAUT05 MIREDAUTOS BMYMUURV(PWAaWop0 S NON.OWNED AUTOS PROPERW DAMAOE QL%iW UAWLrIY ANY AUTpS AUTD ONLY•EA ACCIDENT 5 OTHERTWW AUTDONLr. EACH ACCIDENT 9 £XCESB Luumi1T AGREOATE S LWM LLA POW DTHm THAN UmWmA Fm ' EACH OCCURRENCE S AGATE S WORICIUM OompmAuM AND A ENPDLYER'SL1A8U" U B4@561� 1144-M 11-14-10 9TATlfTDRYLIMTTg THE YRCPRtETORI X PARTNERUXECUTWS tl1Cl EACHAGOME T' S tOD.�O OFFMERSARE X E3WL SooA0 DISEASE-EACH EEPLOVE£ .. S 100.000 OTHER 01Oi0PERATpp,OCA TH151lEPL10ES ANY'%'MC=TBCA.MM3UW_!OUCCF gCATP.T40LMAMOCTMpiORl SipMP r CERTIFICATE HOLDER CA1�tCELLATta*i "— — - - - - - - — -- . XMaiRDANrCFT!(EABOYEDEfitpl6�pBEC1NiCELLEG6E7-0RETNE EXP✓RIITIONDATE Tf�tEQF.THE 16911BI6COL�ANIIWW.ENDEAI�OA Tt1 WW.I4 --. --_. _- DAYBWRRTENNOTICETOT1tEtr3isq�A7&NOL06RNpt�D Ton�t�T.�tr — _ _ _ FAWlBE1p7A�SLctIADTICE9i1iLLAopB[!f�►T�10RLU8UTYOF�NT _ MO UPM TK COWAW.M.M351MCR REPEfrAMVft A THCROWREPREMUATM Ctaartes J cim t Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 517G Boston,Massac4isetts 02116 Home Improvement Doctor Registration Reakdration: 165907 =_ Type: Private Corporation Expiration: 4/6/2012 Tr# 295484 TL HITCHCOCK CONSTRUCTIOWS .fit THEODORE HITCHCOCK 55 LISA LANE- WEST BARSTABLE, MA 02668 Update Address and return card..Mark reason for chaa u 0 Address Renewal Employment Lost Card DPS-CAI 0 SOM-04/04-G101216 7k 15;�� aaoarlcuaeft Office of Consumer Affairs&B ess Regulation License or registration valid for individal use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:._-165907 Type: Office of Consumer Affairs and Business Regulation Expiration: �6&12 Private Corporation -10 Park Plaza-Suite 5170 — — - Boston,MA 02116 1VTCHC0CKqPM- RWGRM-, ERVICE INC. 4� 4 , THEODORE HITCt1 , 55 USA LANE WEST tiARSTABLE, � Underseavbry Not afore I:r.,�.wclrasetts Department drf Public-Safetw Board of Buildin;Regulations and Standards Cezrss¢€szza�Se:pe.��isn>3gsew�ait'�La:,erls= - License: CS SL 99828 Restricted to: RF,WS T'ED HrrCHCOCK 55 LISA LANE WEST'BARNSTABL.E, MA 026M Expiration: 6fl=2 Cummi..ir.nrr . Tr;#: 99828