The URL can be used to link to this page

Home My WebLink About0047 WOLLEY ROAD ' � - - - --� i pFtF1E rp Town of Barnstable *Permit# P m ate * » .... .. .. .... Expire -•-- . �.... ._. .�_�....�.,:_._-..".:Re ul�ator Semees Fee 6 Cm�onths o issue __,Thomas:F.Geiler,Director - _ .. ....._ BuildiiigDivision- .. Pe , Building Commissioner JAN 1 C 2005- jT3' 200 Main•Street; Hyannis,MA 02601.....•• Office: 508-862-4038 TOWN OF BARNSTABLE Fax:'508-790-6230' EXPRE•S. :PERIMT.APPILICATION RESIDENTIAE ONLY. Not Valid without Red X-Press Imprint vlap/parcel Number din,( dq)I k yk(�, Property Address Residential Value of Work 7;/(i Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name e tt Telephone Number 7., 2�_ Home Improvement Contractor License# Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I amthe Homeowner iry R—I have Worker's Compensationlusurance AcInsurance Company Name 8 ` e.3 fi4 Workman's Comp-Policy I Copy of Insurance Compliance Certificate'must eon file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to , C n ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ` ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this es not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 4**Note Owner t sign Property Owner Letter of Permission. e rove nt Contractors License is required. Signature QTorms:e Revise063004 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations 600 Washington Street, 70 Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbin /Electrical Contractors A; ca : f: orm� do1O ; ; Idle Ib r name: mnrlin address: vi ; city state: - zi :0 1 hone# work site location full address): _ (r ❑ I am a homeowner performing alf work mysel . Project Type: U New Construction❑Remodel ❑ I am a sole pro rietor and have no one working in ny capacity. ❑BuildingAddition I am an employer providing workers' compensation for my employees working on this job �-N`� �-t.�t�s'eee��i 6Fi��"•,'; w)��. cpviy�s�3 f c' ^` k'��' ' 'IDSfIf9nCe;C!)�. * �..'h ;,r" 4.. �j��sc.,,..;s Om11C.�i�..: • r �� _ ' I ❑ I am a sole proprietor,general contractor,or homeowne (circle one)and have hired the contractors listed below who have the following workers compensation polices X company=name. S Ctt : phone#. company Warne � _ . . address cltyi phone#. Insurance To: olle # Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine 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 fine of$100.00 a day against me. I understand that a copy of this statement may be forw the Office of Investigations of the DIA for coverage verification. I do hereb y certify r e ains a p alties of perjury that the information provided above is true and correct Signature Date 11-0 Pri ame Phone# 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) 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 compliancemith 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 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' compensation policy,please call the Department at the number listed below. Rb City or Towns f 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 permit/license number which will be used as a refefence 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 Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: 617 727-7749 phone#: (617) 727-4900 ext. 406 k 01/10/2005 11:22 5087789312 BARNSTABLE HOUSING --PAGE 02/03 MIKE MONCEAU (505) 778-9797 PROPOSAL 7 7 Traders Lane ceii ,5a8) 367•-2646 W. Yarmouth, MA 02673 tic. No. 006670 date. Proposal Submitted To: Mailing Address Work to be performed at: Name: stree-: Street, / C ity: r City; da• .state: Z'Ip Code: State: /iP Co � -� Horne Phone: �`� Lr Work, NOTES/Suggestions: � . W c_ e . b -3 14r_llq� We Hereby propose to furnish the materials and perform the labor necessary for the completion of. � ' sta1 ne��. roof with a Q shingIe6er' Kr' o Re�ioving old roar, in "G estimate ( sq, This price will include a year warranty on workmanship: new alumi- num drip ed�* felt underlayment, roof vent collars, install ice and water barrier around . P Chimney, valleys, nail loose boa clean gu"*ers, a total cleanup and removal Of ali aebris. Color of roof Is to be 2, Venting- can be cri*ical cn certain homes a' Install ft. of Cobra continuous ridge��ent $ (b) Install*wnt ft, of Hicks vented drip edge on soffit, $ (c) Do noo upgrade venting. f (d) Other Q 1,91 All p-laterial in guaranteed to be as specified, and the above work to be performed in accordance with the specifications submi�ed for ' above work and completed in a professional workmanlike moaner for#1@ su-n of 5--'ay (^ with payments is d as toll0ws, Deposit of $ _/LOC , Baiance due upon Corr, ...lion. Respectfully submit-ed Vve resewme rig replace any rotted or broken roof or t irn� ACGEPrANGE OF PROPOSAL The abova price., specificoti�ns end conditions are boards. This will be on extm cost above the quote roof price. The satisfactory and ore hereay accented. You are charge t"rls wri,l be,if needed, SSCIr ,r,plus materia rn materials.A1►agrseent. outhorizzd.to do the evork as specified. Payment will contingent upon caciderts or delays beyond out control. G�itstond be made as outlined 000ve ing balance over 30 days will incur 1,5%finance chorge per month. owr'er to remove all volJables from walls.Lidbility Insurance or)Oil above to be tCkan Out by: Mlke Mongeou