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Home My WebLink About0013 SPRING STREET /3 S� ;�y sr. -- � � l r Town of Barnstable *Permit 4 ?0C;2F( Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director X-PRESS PERMIT Building Division Tom Perry,CBO, Building Commissioner MAY — 9 2007 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8 -W-ROF BARNSTABLE Fax: 508-790-6230 ' EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ,+ Not Valid without Red X-Press Imprint ap/parcel Number ��/ operty Address I I Residential Value of Work r, 630 6 Minimum fee of$25.00 for work under $6000.00 Pmer's Name&Address 211 �'� )ntracta's Name cd�il/i �Q Telephone Number 7, �69 Me Improvement Contractor License#(if applicable) //JQ � ]Workman's Compensation Insurance. Check one: ❑ I am a sole proprietor ❑ lam the Homeowner WII have Worker's Compensation Insurance surance Company Name 72! orkman's Comp.Policy# 1111Aq )—e npy of Insurance Compliance Certificate must be on file. smut Request(check box) Re-roof(stripping old shingles) All construction debris will be taken toi ? 1�a��' ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. [GNATURE: Forms:expmtrg !vise061306 Department oflndustriaZAccidenO J Office of Investigations ` + 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Iaisurgace Affidavit: ]Builders/Contractors/lElectdclans/Plumbelrs Applicant Information Please Print Leeijbly Name(Business/orgmization/indivi(inal): ?4g 47�/2'W ,�i1� a Address: Z� City/State/Zip: hone:#' Are you an employer? Check the'appropriate box: -Type of project(required):, . 1. I ama employer with 4: ❑ I am a general contractor and I employees (fan and/or.* have hired the stab- contractors 6. New construction . 2.[] I am&'sole proprietor or partner- listed on the'attached sheet. 7, ❑Remodeling ship mclhave no employees These sub-contractors have g, Demolition'` workin for me in an capacity. employees and have workers' •$. . 9; • Building addition [No workers' comp,insurance comp,insurance. required.] S. Rre are a corporation and its 10.❑Electrical repairs or additions officers have exercised their ` 3.❑ I am a homeowner doing ill work 11.[]Plumbing repaus or additions myself[No workers' comp. ' right of exemption per MGL•• 12.('Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13,:0 Other comp,insurance required,] *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 anew affidavitindicating such. �Centrzctors that che*this box must attached an additional sheet showing the name of the'sub-contractors sad state whether or not those entities have employees: If the sub-contractors have employees,they must providtr their workers'comp,polidynumber. I am an employer that is providing tporkers'compensation insurance for my employees.-Below is.th--e policy and job.site information, Insurance Company Name:_ ��1/jSd�l Policy#or Self-ins.Lic,#; A Expiration Date: fob Site Address: , ?"• City7State/Zip: Attach a•copy of the workers' compensation policy declaration pzge'(shovrang the polii:y number and expiration date). Failure,to secure coverage as tequired 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, B e.advised that a copy of this statement may be forwarded to the Off ce of -- - Investigations of the IJ1A-for insurance coverage verification. I do hereby certcfy under the pens-and penalties of perjury that the information provided above,is true and•correct; Si afore:. Dater Phone#: ®ff cLd use only..-Do not write.in this area, tb be completed by city or town official City or Town: Yermit/License# Issuing ALthority(circle one): :1,Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b;Other ConfactPerson: Phone#: Inform'ati®n And Instr'udi®ns Massachusetts General Laws chapter 152 requires all employdrs to provide workers'compensation for their employees. pursuant to this statute,an employee is defined as"...every person m the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the e�P,SPi �tr�eteg of an individual,partner-shin,association or other legal entity einploying employees. I3oweyer the owner.of a dwelling house having not more than three apartments and who resides therein;or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on suchtlwelliug-house or on the grounds or building appurtenantthereto shallnotbecause of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or.local licensing agency shall withhold the issuance or yeueyval•of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant-who.has not produced.azedptable evidence of compliance with the insurance coverage required.' Additionally,MGL chapter 152,•§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work unti acceptable evidence•of compliance with the insurance requirements of this chapter have been presented'to the contracting authority." Applicants please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),addresses)and phone numbers)along with their certificate(s) of insurance. Limited Liability Companies(LLC)of Limited Liability Partnershipa(LLP)with no employees other than the ' members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. B.e advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or.license i.s being requested,not the Department of Industrial Accidents,; Should you have any questions regarding the law-or-if you are require$to obtain a workers.'.. compensation policy,please call the Department at the number listed below, Self-insured companies should-6nter their self-insurance license number on the appropriate line. City or ToWA Officials. please be sure that the affidavit is complete'and printed legibly. The Department 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 applicant. Please be sure to fill in the pezmit/license number which will be used as a reference number. -In addition,an applicant. that must submit multiple permhJlicense applications in any given year,need only submit one affidavit indicating current policy-information(if necessary)and under"Job Site Address"the applicant should write"all•locationsIn (city,or town)."A•cbp. bf the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial ventute (i.e,a dog license or permit to bum leaves-etc.)said person is NOT required to.complete this affidavit, The Office of Investigations would like to thank you in advance for,your cooperation and should you have any questio• ns,�- please do not hesitate to give-us a call. The Department's address,telephone:-and fax number:; ' ' �a��azr�ztanaJ. of 1�Iassa�bus�tts ' ' Dgpzu�mmt of laduWal A.ocidFn a' Gees of In-Ve tigatiow • ��Q��shi�r�€z�8tre� • Bo&toa,MA U2111 Te,1.9 617-727-490.0 ext 4.06 or 1-4 77 MASSAFE Fax WE' 617-727-7 M� Revised 11-22-06 • w .i�as1.ge��d1� • • °F'SHE� Town of Barnstable. Regulatory Services r • '"R' �' MASS. t Thomas F.Geiler,Director y MASS. � q',,rFnsy,p�A'e Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder I, 61,YZ /' 7--Zh ? ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: . (Address bfjol5y = J Signature Owner at Print Name Q:FORMS:O WNERPERMISS ION LMIC: 7VJfrGUVv i I.s til., o , . CERTIFICATE OF LIABILITY INSURANCE OAT@fMN�'GC1Y1 . 0 D�VIe-2 10 0�r06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MAT'm 4F imF9itmAmm ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE $0Z'tWestd Eit augbsire Its. Agency HOLDER.THM CERTIMCATE DOES ALTER THE COVERAGE,AFFO@RDEDNOT AMEND,EXTEND OR BY THE POLICES BELOW, 805 Nast I+Zai1a ST.xa®t Hyamnis 1& 02602 Plloae:508-711-1632 raXtS08-862-•9270 ,INSURERS AFFORUNGCOVERAGE NAIC# !�suec INSURER A, NORrOLK & DEDH.AM 23965 I INSURER B ST PAUL TRAVELERS gavid Cox, Inc. i INSURER i 88 Y& outh4� 0266 INSURER D iNSU'RER COVERAGES TrE POLICIES pF IVSI IPANCE L1ETgP 3ELOw Have BEEN ISSUED TO THE INSUREC NAMED ABOvE NCTAlMHST,pt I-PIG AM RE',?'JIR59IE4T,TERM OF CVNUITION CF AvY ONTRACT OT DTIIEP.C'o(--j 1EIIT W!7H,RESPECT'C,"CH-HIS CERTtr'ICA?E MA BE I:SLED 0`1, M.A'Y PERTPdN,T F-IN3URANCE 8'1 THE FOLIC ES DESCF'15EC-;ERE¢v'IS&S-JECT-0 ALL-FIE`ERNS, CF SUCI- POLICC9 AGGREGATE LIMITS SHOWVN MAY HAVE K714 REDLIM7)EY PA!D CLAIMS.W14-6 " LTR kSR -TYPE OF iNSLFANCS POLICY NJWtldE3R DATE(W doDJY'fft Y) DATE INC.SlDO,'YSC. LiMR9 OENERALLIABddYY i I EA0 000JFRENCE 6/000000 I CoI !ERCWL OENE=IA.L_ISS7I,I7Y {i - Y, ' vREMiSES'Ea eceurence 5$O C D D i C:,,AIMS MADE FX7 O'CIUIF i MED SXP(Any rra person) S Buxiness owners R00300545 03(J14/OS 03/14/07 PEFSCN-L&A0\'qIJLIRY $ 1000000 l--- GE VA kCGREGATE s 2000000 lI-,- iAGGREGA'E LIMIT HpP_IESFMF f !PPO uc-,,-.-Goof A33, $2000000 1 1 POLICY j a( l0: CS3. 2000000 1 j AUTOMOKS LIABILITY i I COMB!•IED S NGIE LIMIT I�ANY ALI 0 (Es ewden:) $ I ALL ON^:fDAJTOS - 90DIL"JNJURY S SCHEDJIEJ ALMOS (Pai DerWn) I HIREOa.UTOS _ - j SODIL"INJJ-V 'e 140Fi0WNED AL."fOS. J I PROPERTY CAMAGE S 7 1 �(Por ecctianll _ GARAOE WASILRY I i AJ.J70 r4t'r•EA.ACCIDEVT 3 ANY A,rO I ;,'TFEk T-AV EA ACC 5 1 I AUTO ONLY, AG6 S EXCESS UMBRELLA LIABILtT( El,CH OCCuruENCE <_ OGGLJft __.1 CLkM5 MADE { i AGGP.EGAT_ DEDUCTIBLE RELENT ON II 6 'WORKERS COWEIAATtON AND X TCFY llMii'$ ER EWPLOYLRS'L"&ITY - — B IANYFROPR!ETS7R'Fa47AlERlE!CECV'(vE 6KUB91OX742205 I 07;15/06 07/15/07 1EI..E.ACFACCIDENT S200004 OMCERIWEMSE?EXCLLCEDY( I ` E.L.DISEASE•EAEVP_0'(EE S 100000 �vN rea,d►ae^IDe urlCx I .CALFRCV(SIONSbBpa i E.L JiSEASE•FOiiCYi!AIT Seja0O00 'J'TF4ER i f $C OF OP RA ICI 1 S I VEHICLUS t EXCLUSiONt AD ED BY ENG EPA NT 7 SPECAL PRO`A81OIJS 144 Piaauickset Rd. , Cetuit, MR GERTIFICATt HOLDER CANCELLATfON °1°OtdN$+�R SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANCM.LED BEFORE TK EXPIRATION DATE THEREOF,THE 16SUNG INSURER WILL ENDEAVOR TO MAIL 20 JAYS'IYRr mN NOTICE TO TH@ CERTIFICATE HOLDER t TO THE LEFT,BUT FAILURE TO DO So SHALL TOWN DIr RAANS TA= - IMPOSE NO OBLIGATION OR LUSBILTTY OF ANY HIND UPON THE INSURER,ITS AGENTS OR 367 1WI4 alfRBRS' - HYAMS mh 02601 REPRESENTATIVES. ACORD 25(2tt0'6f08) QACORD CORPORATION 1988 u✓/tea/z Oflluildin ° ✓G - __ _1, u- g$c;ulationsand,Stand HOME 161pFtOV ards —_ --- EMENT CONTRACTpR License or registration —_-- Regictra,�on. v Ex �r 100497 beforealid for iodividul u.c t the expiration date. If fattnd rettu n to: only 6/18/2008 Roaril of Building TY�e` Pr va`te Cor One,ts;ihurton p al R�bulations and Standards DAVIp COX, INC "° poration ; Toston Rri.130.1 David >VTa.02108 id cox:. - 19 LAVENDER LN u •�,-< W. YARP4OUTH, MA 02673 �._. 1)eputY Administrator ` Not valid ovif !�14C ` - bout signature