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Home My WebLink About0360 BAY LANE of4y . o y w P o R Town of Barnstable *Permit# O0(4� 56 Expir mo&from issue date iRegulatory Services Fe ��% X-PRESS PE MIThomas F.Geiler,Director �K gll�z�o6 Building Division SEP U 7 209-6 Tom Perry,CBO, Building Commissioner Main Street Hyannis,MA 02 • ;TOWN OF BAR6�S7AB�� H a y . 601 J11 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 2 Not Valid without Red X-Press Imprint Map/parcel Number V f / Property Address AQ Rqill Clfe.001& Residential Value of Work .26 add! l Minimum fee of$25.00 for'work under$6000.00 Owner's Name&Address C®WTAey ,4 f e4"W _360 Rd,, log' &-ee-l-e✓IlJfv . Contractor's Name S RL(A c we C K640 --e h Telephone Number tl.. 08 7 71 11C HomejImprovement Contractor License#(if applicable) 1/416 qej Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Che one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) �/RRe-roof(stripping old shingles) All construction debris will be taken to GAIAN A 6 y U44 12 ❑Re-roof(not stripping. Going over existing'layers of roof) [2/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. ;***No4te: Pro %Pheme st sign P rty Owner Letter of Permission. Im 8 tractors License is required. SIGNA Q:Fonns:expmtrg Revise061306 t on valid for ia6 idul use to my i rcgistratt It{Duna Tetud Liccascrr iratlon date Stand ds the exp Regulations and Standards before wilding 1301 he�an�ian" ulations and Board of place Building Rog ?eONTRpCTOR Board of B one A.hb,Arton pVEMEN Boston,DSa.OZ1p8 HOMEIM?R istrat►on: 114644 Re9._ �. 1018120p7 `'� - ExP�rat�o p8A _ - t, EMOpEL G t si 7 SIOS B�pG&R , r at G IA LtSlO fi is APIR .P ,.,,' inistrator y �� GVIE OR Adm 1.63. :. A 02632 CENVILLE, M Department of Industrial Accidents L `r - Office.of Investigations: . 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly Name(Business/organization/Individual): Address: 8 / . ,ity/State/Zip: Phone#: ►re you an employer? Check the-'appropriate box:. Type of project(required):- 1 am a empto 4. ❑ I am a general contractor and I Yer with 6. ❑New construction XXmployees (fall'and/or Part-time).* have hired the sub-contractors am a sole proprietor or partner- listed on the attached sheet $ 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any'capacity. workers' comp.insurance: g, ❑ Building addition [No workers' comp.insurance 5. ❑ We.area corporation and its . required] officers have exercised their 10.❑ Electrical repairs or.additions. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions mys elf.-[No workers' comp.' c. 152,§1(4),and we have no. 12.❑ Roof repairs insurance required.]t- employees. [No workers` 11M Other comp.insurance required.] ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: homeowners who submit ibis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. MtMetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infbrrnetion. . im an employer that is providing workers'compensation insurance for my employees.'Below is thepolicy andjob site Formation. Durance-Comp any Name: licy-#or Self-ins.Lie.#: Expiration Date: 6 Site Address: City/State/Zip: tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to.secure coverage as required under Section 25A of MGL c. 152 cam:lead to the imposition of criminal penalties of a ,e up to$.1,500..00 and/or one-year imprisonment, as well as.civil penalties in the form of a STOPNORK ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of iestigations of the DIA for insurance coverage verification. 'o hereby certifyd nd ies of perjury that the information provided above is true and correct Ma / Date: one#: Official use only. Do not write in this area,to be completed by city.or town offxiaL 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#: Information an. Instructions lass achus etts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. arsuant to this statute,an employee is defined as"...every person in the service-of another under any contract of hire, . r,press or implied,oral or written" �n employer is defined as*:`:an?ndividnal,..P P�:associatign,cooporation or other legal entity,.or any two or more f the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the' eceiver or trustee of an individual,Partnership,association or other legal entity,employing employees. However:tie .caner of a dwelling house having not more than three apartments and who resides therein, or.the occupant of the welling house of another who'employs persons to do maintenance, construction or repair woik-on such dwelling house it on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." AGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or •enewal 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its-political subdivisions shall public work until acc table evidence.of compliance with the insurance ,rater into any contract for the performance of p ep equirements ofthis chapter have been presented to the contracting authority." 4pplicants Please fill out the workers' condensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es) and phone number(s) along with their certifieate(s) of insurance. Limited Liability Companies (I.LC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners; are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 flee 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' he number listed below.. Self-insured companies should enter their. compensation policy,please call the Department at t self-insurance license number on the appropriate lime. City or Town 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 'l out in the event the Office ofInvestigations has to contactyou regarding the applicant. Please be sure'to fill in the pennit/license number which will be used as a reference number. In addition,an applicant y given year,need only submit one affidavit indicating current that must submit multiple permit/license applications in an policy information(if necessary)and under"Job Site Address"'the applicant should write"all locations in (city or town)."A copy-of 1he.affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that•a valid affidavit is-on-file for;future permits•or-lic'enses..A new affidavit must be filled out each year.where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office.'of Investigations would Bice to thank you in advance for your 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 Ind4sttial.Accidents . ..Office of Investigations ' f' .600•Washington Street 4 Boston,MA 02111• 'Tel. #617-727-4900 ext 406 or-l-,877-MASSAFE Fax#617-727,7749 evised 5-26-05 www. ss.gov/din I aj °F'THE� Town of Barnstable Regulatory Services B"NSTABM t Thomas F.Geiler,Director' MASS 1659. A Building Division �plfD MPy Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, b •z��./'� ��'��,` , as Owner of the subject property e hereby authorize �c�—� f�� i f li;�% kGl�to act on my behalf, in all matters relative to work authorized by this building permit application for: Address of Job) Signature of Owner -ate,"4�55""-�6') Print Name Q:FORMS:OWNFMERMISSION