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Home My WebLink About0012 WASHINGTON AVE EXT. * pFI�T� Town of Barnstable Pert# ';7 70 ',-"6 Expires 6 months from issue ate • Regulatory Services Fee 7 DAItNSTAHLE, • MASS. Thomas F.Geller Director 9 i6�9. Building Division Tom Perry, Building Commissioner X'P1tESa7 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 J U N 2 2004 Fax: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDE BARNSTABLE Not Valid without Red%Press Imprint Map/parcel Number (�� Property Address Ia l'� �,,n��idential Value of Work Owner's Name 8c Address 3 P.QnhC.- SkVtA C • I a t.�Jasl��n4 4vr� �c•e �v :��,� '• . Contractor's Names r t1�� Lw►l�rtnr2 rV�2 Telephone Number _SO$' ?-75 t7-1 Home Improvement Contractor License#(if applicable) +. Construction Supervisor's License#(if applicable) r^G C06(Dq orkman's Compensation Insurance Check one: [] I am a sole proprietor I am the Homeowner [--have Worker's Compensation Insurance Insurance Company Name f'c 1,VY\ Mu1 a.� �vtSt�✓G�v\CSL_ Workman's Comp.Policy# 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) ,side' 0 Replacement Windows. U-Value Act� (maximum.44) "Where requireck Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,ate. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. VSignature I r Q:Forms:expmtrg RPv1cPn59n03 The Commonwealth of Massachusetts ( ' Department of Industrial Accidents -� 600 Washington Street BostonY Mass. 02111 Workers' Com ensation Insurance Affidavit-General Businesses name 4 address: city state: zip: phone# work site location(full address): ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑Ofce❑ Sales (including Real Estate,Autos etc.) ❑I am an employer with emplo ees(full&part time). ❑Other I am an employer providing workers' compensation for my employees working on this job., C.. ompany name: addresst insurance co. olio. # / I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: 1` comliaiV name f 1 P nf(1)P_KYIEA address 1 l 1l n city H a I At 5 tihone# . 15 T5 i j Ilk.' insurance co. Vlt� Stwa✓�t:� ohc # CrgUy �o1O�� comtiany name•. address:. city` phone insurance co: oliev, # ��. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fore of$100.00 a day against me. I understand that a copy of this statement ma be forwarde Mee of Investigations of the DIA for coverage verification. I do hereby certi er endtie r* ry that the information provided above is true and correct ature Date Print name f t ��! (\ Phone# � S- 7 7 official use only~ do not write in this area to be completed by city or town official city or town: permit/license# []Building Department []Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised Sept 2003) rmrtcmnm�T X.. t _ Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees: As quoted from the"law", an employee is defined as every person in 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 receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However 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 such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be 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 pernfit 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' compensation policy,please call the Department at the number listed below. City or Towns 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 contract you regarding the applicant. Please be sure to fill in the perrrrit/license number which will be used as a reference number. The affidavits.may be returned to, the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address;telephone and fax number: ' , The Commonwealth Of Massachusetts Department of Industrial Accidents M"of Imsdgmens 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 IIOAE 6PROtlB� 1 SPRINKLE 199 Barnstable Road Hyannis,MA 02601 (508)775-1778 Fax(508)775-1350 E-Mail sprinkna,capecod.net Website address: www.svrinklehome.com RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect, and bind those who sign it. Notice: All improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by provisions of Chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director of Home Improvement Contract Registration, One Ashburton Place,Room 1301,Boston, MA 02108. Designated Registrant's Name: Brad K. Sprinkle Registration number: 103757 Salespersons Name: Brad Sprinkle This Agreement made on May 22, 2004 Date Between Sprinkle Home Improvements Inc. Of— 199 Barnstable Road —Hyannis, MA 02601 AND Jeanne Stevens Customer Name 12 Washington Ave. Ext., Hyannis, AIA 02601 Installation Address Same Mailing Address 508 771-0830 Telephone number Hereinafter called "Owner" i ow T authorize Sprinkle Home Improvement to acf'on my behalf in all matters relati ve to the work to be performed on this job (i.e. permits, applications etc.) if necessary. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner signature Contractor Signatu Date Date