Loading...
HomeMy WebLinkAbout0011 BENT TREE DRIVE (I Burr T,r� �� J � � Jr � - a r otTHE r of Barnstable *Permit Expires 6 ma from i Regulatory Services Fes Thomas F. Geiler,Director Building Division. ► Tom Perry, CBO, Building Commissioner' 200 Main Street,Hyannis, MA 02601 ` www.town.barnstable.ma hs Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Yalid without Red X-Press Imprint ei Map/parcel Number ' W,:2, Property Address �W dResidential Value of Work `DZ);), Minimum fee of$35.00 for work under$6000.00 - Owner's Name&Address Contractor's.Name --) x M v Y '� Telephone.Number Home Improvement Contractor License#(if applicable) ?a Construction Supervisor's License#(if applicable) (A ❑Workman's Compensation Insurance X° RES Ch k one: ER IT [ ,am a sole proprietor JA. ❑ lam the Homeowner N 3 2012 ❑ I have Worker's Compensation Insurance Insurance Company Name - "OWN OF RARNSTq Workman's Comp. Policy# - 8�� Copy of Insurance Compliance Certificate must accompany each permit 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) - ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e,Historic,Conservation,etc. ***Note: ,-�ropery Owner must sign Property Owner Letter of Permission. co of the Home Improvement Contractors License& Construction Supervisors License is r qui'ed. ` IGNATURE: 1WPFII.ESIF0RMSIbm7ding permit formslEXPRESS.dac :vised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street t Boston,MA 02111 �' •�••� www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . Address: c, City/State/Zip: e-n►i Phone.#: '?7L/ Are you an employer? dheck the appropriate box: Type of project(required):: 1.❑ I am a employer with ' - ,4. ❑ I am a general contractor and I 6. ❑New construction . ployees(full and/or part=time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have. g, ❑Demolition. workingfor me in an capacity. employees and have workers' y P ty - -[No workers comp.insurance 9. El Building addition comp.insurance.t � required.] 5..❑ We are a corporation and its 10.❑Electrical repairs.or additions 3.❑ 1 am a homeowner doing all work - officers have exercised their 11.❑P umbing repairs or additions myself. [No workers right of exemption per MGL comp. 12.E2 Roof repairs insurance required.]t c. 152; §1(4),and we have no employees. [No workers' . . 13.❑ Other 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. tContractors 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. Iam 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.#: ''' Expiration Date: Job Site,Address: City/State/Zip: 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$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 the violator. Be advised that a copy of this sta'tenimit may be forwarded to the Office of Investi ations of the DIA for insurance coverage verification. I do hereb ,c t u er the pains and penalties of perjury that the information provided above is true and correct • Signature / r. /. Date: . Phone#• �C 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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, §25C(6)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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall i 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 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,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 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. Self-insured companies should enter their self-insurance license number on the appropriate line. 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 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. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"I:he applicant should write"all-locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like 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 lnduste al AQoidems` Office of Investigaf c ns 600 Washington Street Boston,MA 42111 Tel.#617-72.7-4900 ext.406 or 1-977-MAS.SAFE Revised 11-22-06 Fax##617-727-7749 wv ..mass..gov/dia - - 1 A _ p 7- flay'..-.� •_..-�--1._� __ , r �. ,.. _ s i. � ., tl • F .. � #. _ .. ��. � • a ' '- � •. � � .. � n i � a. ,a + � .. y 1 i .. ,. „, r � —_ r. � t �: ., ' 1 � �ie -rPio�r �altl o�'�lcraaa�Zueplta Gffice o Consu ter�i fairs&:a smess.'Re ulahod L�cgpse or registration valid for individul.use only t € i,OME fMp OVEMENT CONTRACTOR before the eirpiration date If found return t, f o f� isttatlon 15ggg2 hype: Office of Consumer Affairs and Business Regulation Exptratwn 6L13/ 012 pt q t lO P a M za2- u to 5170 16n,Bos TI HY-P J614NS©IV`CONSTRUCTION r. ^r ,.. TIMOTHY JOHNSON ; 180 MEGAN Rp HYANNIS,MA 07601 = U,<• t �ersecretar Noi ' id without signature t�htisettti anent ct4'6'tthlirS rfct� 49ations'and Stand Standar ds t Con$tt`u"G-t, Supervi: ,r License License: CS 161696 Restricted to: 00i ` TIMOTHY dOHNSON 816 OLD STRAWBERRY HILL R CENTERVILLE, MA 02632 � - - Expiration: 8/23/2012 Tr#: 101696 r ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel i°Application #OZIA Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Addresses ( ( Beni i—rfle-�br i 1/� Village �Vl Owner �'Code k-�� c cLwtO�-�1�5 Address b 21\J �. Telephone c Permit Request t , S . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation J2�Un0.0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. t Dwelling Type: Single Family M Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑1518 On Old King's Highway: ❑Yes 51516, Basement Type: ull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) © Basement Unfinished Area (sq.ft) Number of Baths: Full: existing 'Z new Half: existing new 4 Number of Bedrooms: -� existing _new Total Room Count (not including baths): existing , new First Floor Room Count r e Heat Type and Fuel: YGas ❑ Oil ❑ Electric ❑ Other , o Arm ks Central Air: ❑Yes 3<0 Fireplaces: Existing New Existing wood/dalt stove: Yesp6 No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing Q n6�R sit_ Attached garage:Akexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name�IL•cp�� Telephone Number '1 '1 4-Z3 B—O 5 Z- Address �� � "�' ����`�e License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 01 .,�,ys-k crn � Le_(,k we S l ) SIGNATURE DATE 2 )—S� \O FOR OFFICIAL USE ONLY APPLICATION# <DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION (rK)3)1>ID FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Tile Commonwealth of Massachusetts .Department of Industrial Accidents ('] 1•- ' Office of Investigations i 600.Washington Street Boston, MA 02111 y% www.mass.gov/dia t Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Lef4ibl� PWName (Business/organization/Individual): o � �� V . Address: City/State/Zip: th k�.e M Irk 0�1 i 3 2- Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1,❑ I am a employer with 4. ❑ I am a general contractor and 1 6 ❑ New construction have hired the sub-contractors employees (full and/or part-time,).* listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner These sub-contractors have ship and have no employees 8. Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp.insurance.$_ r uired j 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additi 3. am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs:or additi myself. [No workers' comp. right of.exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required] Any applicant thatch ecks boz#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 ind,thcn hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional short showing the name of thesub-contractors.and state whether or not those entities have employees. if the sub-con tractors,have employees,they must provide their workers'comp,policy number, 1 ain an employer that is providing workers'compensation insitrance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self ins, Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration datt Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a of up to$250.00 a day against the violator. Be,advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. %gLiature ` ALA ������M Date• Zl�sll� Phone.#: `I- J t.5s2 . 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): I. Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other " Phone#: Contact Person:' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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, constriction 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, §25C(6) also states that"every state or local licensing agency shalt 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, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub.contractor(s)name(s),address(es)and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, 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 maybe submitted to the.Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit.. The affidavi t should be returned to the city or town that the application for the pen-nit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. 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 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. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the 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 licenses. A new affidavit must be filled.out each year. Where a home owner 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 like to thank you in advance for your cooperation and should you have any questions, please do not besitate 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 Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia ENERGY CONSERVATION APPLICATION-FORM FOR ENERGY EFVICICIENC�Y FOR ON-R- AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: 1V tC6C�f' —e - p�S Site Address: print Town: ��� `t•�-�l�t��o�--.-- Applicant Phone: -T7 — ),3 9-- 0 01 Z Applicant Signature: Date of Application: ) ZS /V NEW CONSTRUCTION: choose ONE oftha"followin two'o bons 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE- AND TWO FAMILY.BUILDINGS MAXIMUM MIl1SvlUM Ce%Ling or Slab Option I: $asement Q Fenestration exposed Wall Floor. Perimeter Wall AFCJE HSPF U-factor floors R--Value R-Value R Value R Value R-Value and Depth - National Appliance-En R-•-10� ConsuYaddhAct.(NA .35 R-3 8 P,19 R✓19 R-10 4 ft. 1997 as amcndcd,mini cater as applicabIr Note: This form is not required ifyou choose either of the two versions of REScheck as listed below: ❑ Option 2: R-EScheck Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 REScheck—Web which can.be accessed at http-//www.cncrgYeDd(-,s,gov/rrscht, A�l]ZT oI S oR AT1� tA` IO1 S,To F01STING BIn.�SI�Io 2 5 � s OLD* *puildings under 5 years old must use option 91 or#2 in New Construction section above. Complete the following formula to determine the % of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b = a) ' SF 100 x — - % of glazing 6 _Q - (b) Glazing area equals . SF If glazing the chart below, If glazing is y 40./. rgceed to "S-UNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COW ONENT.CRZTERIAADDITIONS TO EXISTING. LOW.-RISE RESIDENTIAL BUILDIPIGS MAXIMUM Ceiling and Slab Peri ❑ Fenestration Exposed floors alh Floor $ase- Wall R-Val U-factor R-Value R-Value -va uo RValue and De .39 R-37 a R-13 R-19 R•-10 R-10,. 4 EL R-30 ceiling insulation may be used in place of R-37 if th n acbie ' e fu11 R-value over.the entire ceiling area i•e• not com ressed over exterior walls,and-including any access openings). SYINROOM—An addition or alteration to an existing building/dwelling unif where the to" ❑ glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of t addition. Note: Owner to fill out Consr�rrzer ii orrilai n Form found in A endix 120,P `Fowr. of Barnstable o Regulatory Services SrAB Thomas F. Geiler,Director BAMLF— . Building Division PrEO � Tom Perry;Building Commissioner. 200 Maid•Strcett Tl annis,1vfA 026.01 Yi-ww.to crn.barnstable.ma,us. r Office: 508-862-4038 Fax: 509-790-6230 HO1t2EOWNER LICENSE EXEMPTION! Plcast Print DAT OJAXC I\ ( Jos I D -]ON: I\ -62.��-l- -F"e 1(numbcr street • ` ` vilflagc — ;'HOMEOWNER": N10 �� 1/lQf��S T1`\- �i�� name homq phone# worlCpbonc# CURRENT MAMING ADDRESS: T" bl(1\}�. aZI�3Z_ eity/towm stag rip code The current exemption for"homeowners" was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage di an invidual for hire who does not possess a'license,provided that the owner acts as supervisor. DEFINMGN OF BOMEONWER 1'crson(s) who owns a parcel of land on which be/she resides or intends to reside, on which thcrc is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a hdmeovsm er. Such "homeowner"shall submit t the$ui7diag Official on.a form acceptable to the Building Official, that be/she shall be o responsible for all such work performcd under the building permit._(Section 109.11.1) The,undcrsign(,d"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,Hiles and regulations. The undersigned"homeowner"certifies that..he/sbc understands the Town of Barnstable Building DcparttPcnt minimum inspection procedures and requirements and that he./sbc will comply with said procedures and rcquircmcu ts. Signaturo of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the . State Building Code Section 127.0 Construction Control_ )lWaOWNER'S EXEMPTION( .Thc Code states that "Anyhomeowncr performing work for which a building pemrit is required shall be cxempl from the provisions of this seeGon.(Seetion 109.1.1 -Liwrsmg of construction Supervisors);provideda that if the horncown engages a person(s)for hire to do such work that such Homcowna shall act as supervisor. Many hofncowners who use this:cxempti on arc unaware that they an assvrrring the responnbilities of a supervisor(sec Appendix Q, Rules&Regulations for Licrnsing Construction Supayisors,SccEon 2.15) This lack of awareness bflrn results in serious problems,particularly when the homeowner huts unlicrnscd persons. In this case,our Board eannol procccd against thc unlicensed person as it would with a licensed Supcl sar. Tho homeowner acting as Superyisor is ultimately responsible. sure that the homwwncf is fully aware of hisAq responnbilitics,many communities require,as part of thc permit application, To en that the homooVJner ecrhfY that hrlshe understands the respo=bilities of a Supervisor. On the last page of this issue is a,farm currently used by nkcrtifiealion for use in your corrununily. several]owns. 'You may care t amend and adopt such a forr m Y r Tawn of B arnstab-le Regulatory Services ` aixr+srtst Thomas F Geiler, Director so h Building bivision Tom Perry, Building Commissioner 200 Main Strcct, Hyannis, MA 02601 www.to-wn.b2-rngtable.rn2.us Office: 508-862-4038 Fax: 508--7 Property Owxter Must Complete and Sign This Section If Using A Builder as Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to work-authorized by this building permit application fox: (Address of job) Signature of Owner Date Print Name if PT Owner is,applying for perms t please complete the Homeowners License Exemption Form on the reverse -s'ide. l �� �� �� i /� ��� i �� ilk m o�to-tz oFtHE, Town of Barnstable *Permit# _ 12-34 Expires 6 months from is ue date BABNSTABM Regulatory Services Fee v� MASS., Thomas F.Geiler,Director ABED MAC p Building Division Peter F.DiMatteo, Building Commissioner 200 Main Street,. Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / Not Valid without Red X-Press Imprint Map/parcel Number ` Property Address li/ Ze I er- f vl 14e r✓t Z Residential Value of Work 4001 U Owner's Name&Address G t/ l Q1'e 17'Lc / 1 f Contractor's Name �'�� S'G✓-\ Telephone Number D 3 G Home Improvement Contractor License#(if applicable) �I Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one:. ��Q I am a sole proprietor I am the Homeowner �I have Worker's Compensation Insurance Q� AS Insurance Company Name 741C of Workman's Comp.Policy# LA C 1 +' 3 ff\ ­ 71 F,56 67 Permit Request(check box) S.: ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) EJ Re-side Replacement Windows. U-Value • (maximum.44) ❑ Other(specify) *where required:'Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature 1001, �.Forms:expmtrg Revised121901