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HomeMy WebLinkAbout0019 PLYMOUTH AVENUE J 9 � / �,a�,u, ,q�r�. 9 oFt l Town-of Barnstable *Permitlog 4�' 0 Expires 6 months from issue date w Regulatory..Services. Fee * B"NSTABLE, Richard V.Scali Director UNIT AUG 1 20�6 Building Division Tom Perry,CBO,Building Commissioner' TOWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 tf Property Address 1 0 u U(' ©D Residential Value of Work,$ Minimum fee of$35.00 for work under$'6000.00 Owner's Name&Address f Uth lip. filAthJi5 M Contractor's Name Rf e k -Ai Sin l Telephone Number S`a 2 ' C�R0— T 937 Home Improvement Contractor License# if applicable) o � 0 Email: Construction Supervisor's License#(if applicable) C�6 L ❑Workman's Compensation Insurance , Check 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. Pen-nit 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 e Sou 'l [�(]�Replacement Windows/doors/sliders:U-Value (maximum.32)#'of windows T �$ #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and 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 t' required. SIGNATURE: C:\Users\Decollik\AppData\Local\M ,soft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 f r i' a .. f Public Safety Massachusetts Department 0 and Standards Board of Building Reg J License: CSSL-099486 w Construction Supervisor Specialty PETER J SMITH k p.0.BOX 36 CUMMAQUID MA 02637 +,c Expiration: Commissioner 11/0112017 µ -- - - V he (poorurnoazcaeaCl�a�C �ac�acaeCt Office of Consumer Affairs&Business Regulation If License or registration valid for individual use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Tz egistration: ;<'150950 Type: i Office of Consumer Affairs and Business Regulation xpirationg_;_>_51872018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 PETER J.SMITH HOME-IMPROVEMENT PETER SMITH __ W 3925 MAIN ST. --- CUMMAQUID,MA 02637' Undersecretary Not aid without signature oF� • sMWffneM • ;� , Town .of Barnstable FD Mf►�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 {� t Office: 508-862-4038 _ Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 9 I , as Owner of the subject property hereby auth ize - - to act on my behalf, in all matters relative to work a .rued by this building permit application for: dress of Job) - , gnature f Owner Date' 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.0utlook\2PIOIDHR\EXPRESS.doc Revised 040215 77se Common walth of Alassachusetts t Departimettt of lndusoial Accidents Owe of Investigations 600 Washington Street Boston,AfA 02111 , ' nvon mass gavIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information T Please Print Legibly Name(BasinewOyvaakatiourin«tirridnat}: � J- �N► i�l� Address: 3W M p, A City/stawz : C vmg A2 0.9 1 MIS D-4 3 7 Plan* 5b ' 9 37 Are you an employer?Check the,appropriate box: Type of project(required): 1.❑ I am a employe with 4. I am a general contractor and I employees(fall aadforpact-time). s have hired the sub-contractors 6_ ❑New construction 2.UL I am a sole proprietor orp inner listed on the attached sheet 7. ®Remodeling strip and have no employees These sub-contractor have g. ❑Demolition working for me in any capacity. employees and have worms' [No wodms'comp.ihsurance. comp.insurance.I 4. ❑Budding addition . required-] 5. ❑ We are a corporation and its 10.❑Electrcal repairs or additions 3.❑ I am a homeowner doing all wodc officers have exercised their 1I.Q Plumbingrepairs or additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance regaired.j T c.152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.) •Any applicant thatchedcs bowl ttmst also fill ow the section below showing thek watere comPensaa i Policy infermsdm- t Homeaarn m wbo submit this afffib r iaduating they ne doing all waft amd dm hue oats&coutzactuts must submit a new atTidswit sndwating such kmunuctm that check this box test studied an addiaianal sheet showing the name of the sobtoauactots and state_whether or not those entities l employees. U the mb<oatmcmm bade eWhiMs th 7 must provide;their workers'comp.policy ntmtber. Lam an,employer that is prom ding workers'com pmsadon.insurance for nay.employees, Below is the policy and job site information, , Insurance Company Name: Policy#or Self-ins.Inc:# Expiration Date: Job Site Address: City/StatelZip_ 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:25AofMGL 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_fomarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby fy arnderthe its and penatlies of per,jury that the information provided bone is bne and corre S Date: $ 3a a� ,Y Offl al we only. Do not write in this area,to be completed by city or town ofrciaC City or Town: PermitUcense Issuing Authority(circle one): P 1.Board of Hearth 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6