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Home My WebLink About0120 STETSON STREET �a O ST�73oiv sue' aF r Town of Barnstable *Permit#e9 ° Regulatory Services Fe mo hs sue d[ue. nsLE, 6 Thomas F. Geiler,Director p Building Division IV A8 Tom Perry,CBO, Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-62 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Numberl;�062 " ``2 Property Address ❑Residential Value of Wo 7 , 66 minimum fee of$25.00 for work under W00.00 Owner's Name&Address MAR' )< To M A 1 LO 7 o a vR w COAT ST w6P5)Lc-;? A, a I60( Contractor's Name T—o" A..J J} w 'T'`YL Fk Telephone Number 5 08� 3(-,�✓`7�iSr.�7' Home Improvement Contractor License#(if applicable) /0 6 CZ7 Construction Supervisor's License#(if applicable) e S 7 Oa �` ,�, , ❑Workman's Compensation Insurance Check one: SEP m 2 Z009 I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLI', ❑ I have Worker's Compensation Insurance /Insurance Company Name /7��L � 5' L/1 L L 6 C 8 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 Tom- TR411,5FE"? 57 7/0*0 Re-roof(not stripping. Going over,.. existing layers of roof) _Re-side Replacement Windows/doors/sliders.U-Value 7V (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic,Conservation.etc. ***Note: Property 0 r t sign Property Owner Letter of Permission. A copy o' Improvement Contractors License is required. SIGNATURE: C:\Users\decol&-\.4p a Local\Microsoff,.VJindows\Temporart Internet Files\Content.Outlook`.MY7NB4IL\EXPRESS.doc Revised100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street T Boston, MA.02111 °'� >�•'• �vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): A.l4; AS 560A TS S Address: o`Z l.- Y/%J/ 41 C L C7, oa6o t City/State/Zip: �7 �A w1`' 'S !�✓I 79 • Phone.#: 5 Q�- 7 7 S 7 'Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 4. 0 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. Q Remodeling ship and have no employees These sub-contractors have 8. 'Q Demolition working for me in any capacity. employees and have workers' . 9. Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions off' have exercised their 3.❑ I am a homeowner doing all work f s 11.0.Plumbing repairs.or additions myself. [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required.] t c. 152, §1(4), and we have no 3.�1 Other L..; �,v I�Q employees. [No workers': 1� 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 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 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.#: 7/0 S�� -o y 7 3AJ98 ` � Q 1 Expiration Date: Job Site Address: _ City/State/Zip:/State/Zip: 'ALA.) M,4 0;;L b�! T-5Q �l 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 S 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 tlip violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for ce coverage verification. I do here c under t enalties of perjury that the information provided above is true and correct signaiure: Date: /off I d Phone#: —7 7 s -7 7 Ste( Official 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#: * =narrseABM pQ M" i6 9' Town of Barnstable �e 10 , rEp IYYF�a , 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: 508-862-4038 Fax: 508=790-6230 Property Owner Must Complete and Sign'This Section If Using A Builder I, MARX Te)/"q/d L 6 ,as Owner of the subject property hereby authorize FZ N f A S.SdC1,AX C S to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of"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\L.ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\MP7NB4IL\EXPRESS.doe Revised 100608 13, /d`bri'vtfdII(vIwo'd Wnffil'N,(*Tr,(r"(Mm Licerise or registrnlion valid fur individui use only -10MF_IMPROVEMENT CONTRACTOR before (lie expirnlJvti ilnte. It Willid rehu-n to! 139nrd of I3uildhig Reguintions find Striudnrds Re IsU2,tt�il: 106627 g .� ,, One Asipburlvn f Ince ill 1301 Expi 4d6I1 1.7_/ 412.010 Tr# 0 Ilvstun, A'.in. 02108 knoo �` r'-�;� I'n ly dual I; JONATI IAN IVI T :r li Jonathan T ler 14 - 67 Cranberry La Pk x r No( valid w�ilhvut sigunture VV I-lydhnisparl, MA f��f;7. P+ .* Admhiish ntvr - S j UUIi I'U tits.q If �111 � Util 09-35 000 of enclosed space t CPrI1ur�'�I �l'I� �f� i 1 JA-Aloont-y only i�, fi i �i�@lied C3 7.25y0 - l 1.hro onpes f'fi r;,i r V I t, l', It I t1f�11 z111710 T F1l 14'11 DIIIuI'.to possess n current evil ou of the • �t:.,ar "I�� '�' � � Massachusetts a�tnte 13i�rlUiligC�•�itle is cause ftli revountiiiu of this i'ideipse. JONA:0101 M 2 LYNXI'It�LM HYANNIS, MA 0280fitr'i i'`5 CtttttiYlhafriil l t � l f fEE ' E FR t i i �'Tlze -�omnzo�.zraecz�� o��/�czaaactivae�ta Office of Consumer Affairs&Business Regulation " License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 164032 Office of Consumer Affairs and Business Regulation Expiration:, �8/14/2011 Tr# 287856 10 Park Plaza-Suite 5170 TYpeTN s 'Pnvaie C r0 ro ation Boston,MA 021 REMODELING ASSOCIATES I'N{C. ( `G JONATHAN TYLER= ji zXlr. 2 LYNXHOLM COURT �� o', HYANNIS, MA 02601 °'- Undersecretary — Not valid without signature (i