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Home My WebLink About0043 QUAKER ROAD �� :- 5 Town of Barnstable *Permit# Expires 6 months from issue date � "1 Regulatory Services Fee e2Z6 — Thomas F.Geiler,Director X-PRESS PtRMIT Building Division Tom Perry,CBO, Building Commissioner S E P 2 7 2005 0 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us TOWN OF BARNSTABLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY s� Not Valid without Red X-Press Imprint Map/parcel Number /D Property erty Addre ss 4111 0 ct- 25.00 for work under$6000.00 'al Value of Work $ 3d Residential � Minimum fee of$ Owner's Name&Address d Contractor's Name Telephone Number -<W— L?O 9 l S-V Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor lam the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maximum.44) '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. Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 t - The Commonwealth of Massachuseds Department of 1`ridustrial Accidents Office of Investigations • . `-! 600 Washington Street Boston,MA 02111' www mass.gov/dia Wo>7kers' Compensation Insurance Affidavit: Builders/Contractors/]Electriciai is/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ?v 9,1., Qua Le12�oacQ 1 — City/State/Zip` va Phoned -45 . a 4 , 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.. Now construction employees (full'and/or part time).* have hired the sub-contractors 7. Remodeling 2.0I am a sole proprietor or partner- listed'on the attached sheet t ❑ and no employees workers Building These sub-contractors have 8. ❑ Demolition ship ' comp.insurance. 9. addition working for mein any•capacity. ❑ g [No workers' comp.insurance 5. ❑ We are a corpora d its corporation an 10.❑ Electrical repairs or.additions required] officers have exercised their t of exemption per MGL lY•❑ Plurtibing fepairs or additions. 3`[�/] I am a homeowner doing all work . p myself.'[No workers' comp c. 152,§1(4), and we have no.. 12.❑ Roof repairs i insurance required.]fi employees.(No workers 13tu Other F�oD .c� t 1 A olg comp.insurance required.] •Any applicant that checks box#1 must also fill cut the section below showing their workers'compensation poficy information `e •_ _ fi Homeowners who submitthis-af,&vit indicating they axe'doing all-work sad they hire outside cofactors must submit anew affi&iit indicating such tContracbars that check this box must attached an additional sheet showing the name of the sub-contractors end their workers'cornp.*policy information. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site. information. Insurance-Company Name: Policy#or Self-ins.Lic.#: Expiration Date Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fal ure to,secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of ariminalpenalties of a fine up to$.1,500,.00 and/or one-year imprisonment, as well as,civfi penalties in the form of a STOP'WORK ORDER and aline of up to$250.00 a day against the violator. Be advised that a copy of this statement maq'6e forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: Si afore: Dater Fhone#: SO ?a d OffCcial use only. Do not write in this area,to be completed by city,or town official City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#; rmation and Instructions Info 5 Massachusetts General Laws chapter 152 tequires all emPloyees to Provide workers' compensation for their employees. p�yuant to this statute, an employee is defined as,,...every person is the service of another under any contract of hire, express or implied,oral or written." « ' .: d ers , association,corporation or other legal entity,or any two or more r ,r An employer is defined aS::an iudivi,tra1,.:Pa P'. ' 'la er,or the of the foregoing engaged in a joint enterprise, and in6biaing the legal representatives of a deceased emp y receiver or trustee of an individual,partnership,,association or other Iegal entity, employing employees. Howev..er.te- owner of a dwelling house having not more than three d mam�tenan.centse,co who struction or repair woik'on such dwelling house dwelling house of another who employs persons to ant thereto.shall not because of such employment be deemed to be an employer." or on the grounds or building appurten MGL chapter 152,§25C(G)also states that_"every.state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a biWness or to construct buildings in the commonwealth for any applicant who'has not produced acceptable evidence•of compliance with the insurance coverage required." P ter 152, 25C states"Neither the commonwealth nor any of its-political subdivisions shall Additionally,MGL chap .. § (� enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance Tegnirements of-this chapter have been presented to the contracting authority." Applicants . compensation affidavit`completely,by checking the boxes that�apply to your ituat n and,i' Please fill out the workers' of necessary,supply sub-contractors)name(s),address es other than the es) and phone numbers)along with insurance. Limited Liability Companies(I.LQ or Limited Liability Partnerships(L•LP)with no employe members or p artners; are not required to carry workers compensation insurance. If an LLC or LLP does have employees,a.policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to saga and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or,if you are required to obtain.a workers' coin Industrial Accidents. please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate lime. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Depart neat has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the aPP licant please be sure'to fill in the perwit/license number which will be used as a reference number. In addition,an app that mast submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"lob Site Address e applicant or marked by should the 'ty or toto` all wn locations be provided to the or . . A copy of the affidavit that has been officially stmap e filled out each applicant as proof thax.a valid affidavit is onfile fozh ease or�erinit not rel s..A.to any innew essmor coot bmmerc al v tare year,Where a home owner or citizen is obt in'ng a P (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete 13u5 affidavit The Office of Investigations would hike to thank You in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. artment's address,telephone and.faxnumber; The Dep . The Commonwealth of Massachusetts Department of Ind4strial.Accidents ., . . .. . Office of Investigations a r .6QQ•Washingfon•Street 4 Boston,MA 02.111.. ' `Tel.#617-727-4900 ext 40.6 or•1,877-MASSA•FE Fax#617-727r7749 Revised 5-2645 www.mass.gov/din Town of Barnstable *Permit# �6 ►s Expires 6 months from iss a date Regulatory Services Fee 4,? Thomas F.Geiler,Director Building Division X-PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 AUG 9 2 2005 www.town.barnstable.ma.us Office: 508-862-4038 TOWN QUffit $UBbE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Sic) 209 4�- Property Address L43 QU_4zVj?i2 1�4�UG ny\1 S IV\a- , Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address a �YC4An15 Contractor's Name `^ Telephone Number S6 �' '� ct Z) ;L Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a'sole proprietor .` VI am the Homeowner R. I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to l f1 MIX o6 r i—N C ❑Re-roof(not stripping. Going over existing layers of roof) 0 Re-side ❑ Replacement Windows. U-Value (maximum.44) "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. Home Improvement Contractors License is required. SIGNATURE: i`Je rt Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts Department of Industrial Accidents n. Office.of Investigations 600 Washington Street y� Boston,MA 02111 ' M www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiowIndividual): 1 - 0( J Address: S u C-L e..P CL City/State/Zip: .. �� n n�S VVR Phone#: .6 �)`t 6: 2- 15�I 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 t ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or.additions 3� I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.-[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *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 their workers'comp:policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. - Insurance-Company Name: Policy#or Self-ins.Lic.#: Expiration.Date: 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 maybe forwarded to,the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: 4,4414 � Date: Phone#: 2 l,S`• Ofcial 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 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#•