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64
"Pink, 0�%
SFIE Town of Barnstable *Permit#
.o Fxpires 6 months from issue date
,�,,,�,,,,,.8�, • _ ..• y.... . egu1-atory Services Fee
mas:F.-Geiler Director
03
X -..... . .. -.-Building Division � .. _. � _..
. ---• .. . -. .._. --. � -•..-om Per Buildin Commissioner � � �
T Perry, g
.200 Main-Street,- Hyannis,MA 02601- J A N I. G.L U 0 5
Office: 508-862-4038
Fax:'508-79.0-6230'
::: ::.:..::--.:. OWN OF BARNSTAaLE ..:... .....: ...
" EXPR S:S:pERI�t[T AP�I;YCAT ON - -RESIDENTIAL ONLY.
Not Valid without RedX-Press Imprint
ViaP/P arcel Number 12.2,10,2— f '
Property Address
Residential Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
1 -
Contractor's Name n —Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) rP(D
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
0I have Worker's Compensation Insurance
Insurance Company Name il ------------
Worl=an's Comp.Policy# ry,_,
Copy of Insurance Compliance Certificate'must be on e.
Permit Request(check box)
�� �i Ul I�
L�]e-roof(stripping old shingles) All construction debris will be taken to_ ,LB fA f A 1 C%
❑Re-roof(not stripping. Going over existing layers of roof)
[] Re-side
❑ Replacement Windows. U-Value (r axbn,_,rr,.44)
*Where required: Issuance of this ermit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: op 0 er must sign Property Owner Letter of Permission.
Home Imr vement Contractors License is required.
Signa
Q:Forms:expm g
Revise063004
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnuestlgations
600 Washington Street, 7th Floor
_�Ja Boston;Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin /Plumbm /Electrical Contractors
name: `
address:: n
city U) c t 9 t state: zip:n,.21r; phone# 7 2 5 �7 9• f
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole ro rietor and have no one workin in any ca aci ❑Buildin Addition
m an employer providing workers'compensation for my employees working on this job
V.
Mn"� ...name..� -777
..�.. .,.�,-.. .......y _ .,....
{ 5+f ^ K „ e
➢r i
ar� 77
dreSS. w
i �wW�usu w
'
11
lic .< `' .' •--
❑ I am a sole proprietor,general contractor,or homeow er(circle one)and have hired the contractors listed below who have
the following workers' compensation polices
� r
company name.
,
c►M., n7tone#
'iniur%ance ed` oli
addiess. a
c5tyc phone.#.
msirance::ca.
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 enalties 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 be fo d the Office of Investigations of the DIA for coverage verification.
I do hereby cer' der the ains n penalties of perjury that the information provided above is true aZoo
rrect,
Signa Date
f
Print name 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 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 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.
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 contact you regarding the applicant. Please
be sure to fill in the permit/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
Office of Investigations
600 Washington Street,7`"Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
''401/1t/2005 11:22 5097789312 BARNSTABLE HOUSING PAGE 03/03
MIKE MONGEAU '(508) 778-9797 PROPOSAL
77 Traders Lane Cell (508) 367-2646
W. Yarmouth, MA 02673 Lic. No. 006670 Date:
Proposal Submitted To: Mailing Address Work to be performed at:
' f
acme;
Street; Street:
City City:
Sato; zip
Code: State; Zio Code:
Home Phone: ` c} Work;
TL
NOTES/Suggestions:
x"tslQu 3 kH10'.54:11
We Hereby propose to furnish the materials and perform the labor of.
t ,
Removing old r of, install new roof with a �;G I _ shingle
estimate -sq. This rice will include a year warranty on workmanship, new alumi-
num drip e g , 15# felt underlayment, .roof vent collars, install Ice and water barrier around
chimney, valleys, nail loose boards, clean gutters, and total clean up and removal of all
debris. Color of roof is to be
t"(L v4&t.j2 4W4'
2. Ventiglo- can be critical on certain homes
(a) Install too ff of Cobra cortinuous ridge vent $ r
(bl Install r ft. of. Hicks vented drip edge on soffit
(c) Do not an to upgrade vent! g.
(d) Other
'e
eoult
All 456rial in guaranteed to be as specNad, .and the above work to be performed in accordance
with the specifications submitted for above work and completed in a professional workmanlike
manner for the sum of $ ftOO ` with payments to b as follows:
Deposit of $ ` . Balance due upon comp[
Respectfully submitted
ACCEPTANCE OF PROPOSAL ZWrosoive the right to r lace any rotted or broken roof or trim
The obovE pr°cos, specifications and conditions are boards. ThIs will be an eftra cost above the quote root price. The
i. All agreements
.;, i if needed, 5C'hr,plus rnatel.a.s,A � w
� accepted,ted, You are charge e for th s will be, eed , $ ! p 9
satlsfaCtory and ore hereby cocoa 9
authorized to do the work as specified. Payment will contingent upon accidents or Celays beyond oar control. Oatstand-
be made as outlined gbove Ing balance over 3D days will incur 1.5%finance chorge par month.
.-� Owner to remove all valuaoles from walls.Liability Insurance on ail
Gate: o °S obove to be taken out by:
Signature: Mike Mongenu