HomeMy WebLinkAbout0113 HIGHLAND DRIVE � {.♦,]r f { �'f .�.: R.4 t � ."{ f "�� .. ,. .'k - � !. • if f,, � i)♦ 1` a ♦f ,. 1�
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Town of Barnstable *Permit
Expires 6 months from issue
y7 Regulatory,Services Fee
B"NSTABLE.
� "Thomas F.Geiler,Director'
DIG 7/7�1e
Building Division
Tom Perry,CBO, Building Commissioner
t 200•Main 5treet,,Hyannis,MA 02601
-www.town.barnstable.ma.us
Office: 508-862-4038 Fax:-508-790-6230
EXPRESS PERMIT APPLICATION, RESIDENTIAL.ONLY
Not Valid without Red X-Press Imprint,
Map/parcel Number ` G1 r) )S
Property Address I"1`((l-tLANIJ is (�t'(�G -�ill;l: ,-M
Residential Value of Work 3 -Minimum fee of$25.00 for work under$600000
Owner's Name&Address 1" � � ���cV i✓St t'� -
MA
Contractor's NameJ''E-fW— tAkK,-� aA -Telephone Number
Home Improvement Contractor License#(if applicable), I ® `Lj)
Construction Supervisors License#(if applicable) w RESS fl
Idworkman's Compensation Insurance �� J L
Check one: 0 10
[Sir I am a sole proprietor
❑ I am the Homeowner TOVV -OF BARNSTABLE
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit:
Permit Request(check box) y
[ Re-roof(stripping old shingles) All construction debris will be taken to' V�5p�L'
❑Re-roof(not stripping..Going over "existing layers of roof)
,. .
Re-side E. ,• � � ..
#of doors, ..
0 Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows
a , _.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc:
***Note: .`. Property Owner'must sign Property Owner Letterof Permission.
A copy oft home Impr vement Coniractors,License'&Construction Supervisors License is
t required.
SIGNATURE:
C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5Q0\EXPRESS:doc'
Revised 090809 - ry
The Cooamoni esllia of Massachusetts
_- -- Department oflndusoial Acciderw
- Offkee of lrauest'igadons,
600 Washington S&eet
Boston,ll9A 02111
wnm mass goufdiaa
Workers' Compensation Insurance Affidavit. Builders/Contractors/EI'' rician llambers
Applicant Information Please Print Lexib1�
Name aminewo pmzationtk&zidna y Pt��e�- "U eJ go — bAp_1q STA-5Le LA_I�
Address:q l RA424�ar, -
CityrfStatePZ n: MA dUec,( PhOne f !;7-0 i3 1 S7•2 3q
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with en-p 10 4. ❑ I am a feral contractor and I
6. New construction.
men loyees(fin andlor part-time)_* have bared.the sub-contractors2. I am.a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
sump and,have no employees Them sub-contractors have $. ❑Denmlifiorn.
working for me in c c employees and have was'
� t3'=
(No.i►Grkers'Comp.is immm�e Comp.insuraum, }. El Budding addition.
required.] 5. ❑ We are a corporation.and its. 10.❑E1ectucal vep aim to additions
3.❑ I am a homeowner doing all work officers have exercised their I LE]Phmabing repairs or additions
myself[No workers"comp- right of exemption per MOL 12.❑Roof repairs
iusu ra=e d-]I c..152,§1(4!X and we.have.no.
employees.(No warloers' 13.0 Other
comp_insurance required.11
"Amy applial ultra d ma fill decks bm#1 mast also ova the section below showing workers''compensation policy information-
i Homeowners who submit dw affidavit imdiicating they are doing all wol.and&m hire omtiid'e contractors mist sulmaia a now aff dirdt indicating such.
ZCcnttactors dut chach.ibis baK.must atrached an additional sheet shotrng the mama of die sub-contracmas and stage whe her or not those eoeut@es have
employees. If the subcomftwors Name empTtrgeas,*W must.provide their workers'cmanp.polky number.
lam arm emp1agwr Matispr@vhffiig workers'caarlrsnsrr&n irn zinmce fbr atV eiqp1qvm Bdolr is thepaNcy arm job site
iaaformadirm.
Insurance Compare Name-
Policy#or Self-ins.Lie.#: Expiaat on Date:
Job Site Address: City/State/zip:
Attach a copy of the workers'compensation policy declaration.page(showing the policy number and expiration slate).
Failure to secure coverage as required under Section.2.5A,off MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00,andlor,one-fir impffison t,as well as civil penalties in the fam of a STOP WORK.ORDER and'a fine
of up to$250.00 a slay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesdigatioms of f11e DIA for insurance coverage verifixcation-
I do hemby reran jr rhean
rlpenaleks qf*dniry that the informadonppa oWdedahmw ai triter and correct
Si tare: Date: ' I 0
Phone#:
Offleial mw only. Do-not write in ffi s area,ro beL Callip&ted by catg7 or tvnvnn o fnc°tat
CRY or Town: Permitll aicense#
Issuing Authority(curele one):
1..l3oand of Health. I Building Department 3.Cityffonu Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:` Phone#:
* STABLE. •
639. �1�
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
- Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 F, Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I 1— as Owner Of the subject
1 property
hereby authorize��� �r' vttJD 0.j to act on my behalf,
4 r
in all matters relative.to work authorized by this building permit application for:
(Address of Job)
UAM,P Ito v
Signatuy of Ow r Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the -
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QO\EXPRESS.doc
Revised 090809
- ` ✓ �O�IJ7/I97bI7.C!/FIYt'r. *"" aJ�r ICLC/2GQf.G[6 , + -
s I Board,of l3udding Regulatiofis and Standards
v'..:
Construction,Supervisor License
License CS ..'96399 '
3 s Birthdate` t 1�0/29/1965 A €?'
Ez i tar ion Tr# 96399
� a p 1�0/29/2010
1Restriction 00°
PETER MUNRO�
97 HARBOR BLUF17S ROAD
HYANNIS"-MA 02fi01 Commissioner'
' 4 EF
u° �*
77-
LL � �-�.�.�...._-.-..' ✓tie -U�aminea?�use�z�i o�✓�,Ci��zc�uca'etta i I , F `
Office of Consumer,Affairs&Business Regulation '
r HOME.IMPROVEMENT CONTRACTOR
w Registration a15101,6 Type
Expiration 5/11/2012 Individual
BARNSTABLE,BU�RLDER _ it
� I \ ,
PEETER MUNRO
� g
97 HARBOR BLUFFS RWfE r 4��
HYANNIS MA026W,i Undersecretary z-
f
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Y
.. � ..."+-.._._.,. .r+-e •-,,,..:-tom.-.• .� .r-..-..- ..�.. -- � _
3
"di iduluse
o for in
c w License or.reg�r tion date`If found return to only
i' before the^exp Regulation
Office of Consumer Affa►rs and Business, r
10'Park Plaza_Suite,5170;-`
Boston,MA.02116; M1 {
Not valid withogt signature
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