HomeMy WebLinkAbout0022 FULLER ROAD 'abJ$ Owl
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Town of Barnstable
Permtt#
Expires 6monti from issue date
Regulatory Services Fee
Thoma
s F.Geiler,Director
Building.Division .
.� Tom Perry,CBO, Building Commissioner
'r
200 Main Street,Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERAIRT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number I Q 3
Property Address �101 �
ff Residential Value of Work 1 M Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address Cho 1 KA
Contractor's Name T aS lX, Telephone Number_
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#.(if applicable) ( '� R
❑Workman's ompensation Insurance ' XI 0 V _`011
ChA one:
I am a sole proprietor ."OWN OF SARNSTAK
❑ 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)
ZRe-roof(stripping old shingles) All construction debris will be to ( .
❑Re-roof(not stripping. Going over existing layers of roof)
❑ 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.
***Note: Prope wn r musts` r erty Owner Letter of Permission.
A co of ome pro ent Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
Maryann Taormina
guaranteed Vice President of Mortgage Lending i
® Cell508.237.1424
Fax 508.749.7692
Lowest Rate.Guaranteed. marytee@guaranteedrate.com
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, ; Town of Barnstable.' '
R egulatory Services
i xLk"SfABLE,
y MAC Thomas F. Geller,Director
-Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,NIA 02601
"'w.town.barnstablb.ma.us
Office: 508-862-403 8
Fax: 50B-790-6230
'Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
herebyauthorize JLM�g &dt to act on my behalf,
in all matters relative to work authorized by. building permit application for:
as -�I I�r �o c� � � •
(Address of Job)
t
g nature
of Owner
�
Date
Print Name
Q:FOIZMS:OWNERPERMIS S ION
f
' The Cornmonwealth ofMassachusetts
Department oflndustrial.Aecidents
CffCe o,l` rnvestigczttans
600 FFr,,htnb�ton Street
Boston,AM 02-11-1
` wwrh.m ass..gov/dia
Workers' Compensation In
snrgnce_Affidavit: Bujlders/Contractors/Electricians/Plumbers
Applicant Information
Name (Business/Organization/Individual): �ajy\,Q Please Print Le 'bI_ S' (�-
Address: 0. loxa3
City/State/Zip: Ct 1 Phone.#:
Are you an employer? Check the appropriate box:
1.El I am a employer with 4. 0 I am a general contractor and I 'Type of project(required):
IImployees (full and/or part.time),� have hired the stub-contractors 6. 0 NevV oonstruction
2. I am a'sole proprietor or partner- listed on the'attached sheet• 7. ❑Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. employees and have workers g' ❑Demolition
[No workers' comp.insurance comp. insurance.$• 9• []Building addition
required] 5. (] We are a corporation and its 10.[]Electrical repairs or additions
3.❑ I am a homeowner_doing all work officers have exercised their
-MY self 11.El P;umbing repairs or additions
[No workers' comp. right of exemption per MGL• try,/
insurance required,] t c. 152, §1(11), and we have no 12• ' Roof repairs
employees. [No workers' . •13.❑ Other
camp.insurance required_] ;
*Any applicant that cbceks box#1 must also fill out the section below showing their Workers'cumpcnsation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a>Yidavit indicating such.
fiContractrn-s that cbecic this box muss attached an additionalshect sbowing the niunc of the sub contractors and state whether or not those
employees. If the sub contractors have ooiployccs,they must pro-Vidt;their o entities have
W rAcrs�co mp.policy number.
Ism an employer That is providing 7torkers'compensati
information. on insurance for my employees Beloyp is.the policy and job life
Insurance Company Name:
Policy * .
#�or Self-ins.Lic.#: .
Bxpiration Date: ;
Job Site Address:
• - City/State/zip—
Attach a copy of the workers' compensation policy declaration page(show
ing the policy number and e
Failure to secure covers e as re xpiration date),,
g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.60 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 Investigations of the, of this statement maybe forwarded to the Office of
DIA for insurance coverage verification. _
-fdo her by ce and the ains enalties ofperjrny that the iriforrnation provided a ove i true and correct
Sienature:
- - • Date:
Phone #: —
Officiai use only.-'Do not write in this area•tb be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I-Board of Health 2.BuildingDepartruent 3. City/To�n Clerk' 4. Electrical Inspector S.PlumbinQ Inspector
6. Other b
Contact Person:
Phone#�
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NIatisachusetts - Department of Public Saf'etv
Board of Building,, Regulations and Standards .I
Construction Supervisor Specialty License
' - ! License: CS SL 99138
Restricted.to: ,RF,VVS
JAMES CURL
EY I ;
267 FULLER-ROAD..
CENTERVILLE, MA 02632
Expiration: 1/28/2012
1 Commissioner Tr#: 99138 -
• � l�lze:-Vanv�nai�E,e�� o�./�?aaaacfivaeC7a j ,
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Boa d_of BuildingF gulations_and..St�ndards• - _. .: ......
` — r I jtease orgj- stration valiq.£for nj df idui use only
HO E IMPROVEN NT CONTRACTOR before the expiration date. If found>eturn to:
= Re stration -----Be.ard-of Bui difi
124 1 0 Y••• Y ,32egulatjd sand S a'n.dards
E iration 8/b/209" Tr# 1. 0873
One Ashbur Place Rm 130'
_Type._andivid al
Boston IVIa.0 108
James urley = _
James Curley
28
7
Full r
Rd. , t,
--C e A 02632 Not alj without are
E� jAdministrator W a Y�