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45
lad,
Town, of Barnstable *Permit#
o Expires 6 motto m issuaae .
i }
Regulatory Services Fee r
• �xrvsr�sr.E.
MAM 'Thomas F.Geiler,Director; .
prfD MA't� ,
Buildi n* g Division 0 d I l2IlZ
Tom Perry,CBO, Building Commissioner
200 Main Street,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 l ?moo j y
Property.Address 5 . L O t�
❑ Residential Value of Work 2 o o C) Minimum fee of$35.00 for work under$6000.00,
Owner's Name&Address t J I L L�� y►� /h o F�7 s 5" NC z�c1 F�3 .�. '.fin I✓i
Contractor's Name_-� 'Telephone Number. SO i�" 33, B -9/
Home Improvement Contractor License#(if applicable) . 16 72
-
SS
Construction Supervisor's License#(if applicable)" /0 Z/0 '7 G PERMIT
❑Workman's Compensation Insurance N01 Y.e �012
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner J®w
N ®F PARNSTABLE
have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# C '2 (J — ��F 3
Copy of In Compliance-Certificate must accompany each permit.
Permit Request(check box)
®Re-roof(hurricane-nailed)(strapping old shingles) All construction debris will be taken to^ 13.erne'
❑Re-roof(hurricane nailed)(not stripping. Going`over existing layers of roof)
❑ Re=side
#of doors
ri Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
0 Smoke/Carbon Monoxide detectors 4-floor plans marked with red S and.inspections'required.
Separate Electrical&Fire Permits required
*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 Letter.of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
Department of Industrial Accidents
Office of Investigations
u 600 Washington Street.
_ Boston,MA 02111
..:� N".mass.gov/diu '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly'
Name(Business/orgaaization ladividual):.
Address:
City/State/Zip: - Phone.#:
Are you an employer? Check the appropriate bog:
Type of pr•oject'(required:• •
1.[ am a employer with ' 4. ❑ I am a general contractor and I
* have hired the gab-contractors 6. R New contraction .
employees(full and/or part time). . .
2.❑ I am a'sole proprietor or partner- listed on the•attached.sheet' 7., ❑Remodeling
s and have no employees These sub-contractors have 'g
hip ❑Demolition
working for me in any capacity: employees and have workers'
co roar„once.#' 9. ❑Building addition `
[No workers comp.insurance �' 10. Electrical re airs or.additions
required.] 5• ❑ We are a corporation and its ❑ p
- offi.cers have exercised their r
'3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions '
Myself [No workers' comp. - right of exemption per MGL . 12.0 Roof repairs
c. 152 1(4),and we have no
insurance required]t ' § 13.❑ Other '
employees. [No workers'. ".
cow.insurance required-]
*Any applicant that checks box#1 must also fill out the section below-showing(heir workers'compcnsatian policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. :
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
.employees. If the sub-contractors have employees,they must providb their workers'comp,policy number. ,
'I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: 2 y K� .
Policy#or Self-ins.Lic. Expiration Date:
Job Site Address: 5 L 0N6 LGdT.r ) I� City/State/Zip: CG A/TE/Z 1/1 GG,65 Jn �.
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 statement maybe forwarded to the Office of
Investigations of the MA for insurance coverage yej:ification
I do-hereby cerkfy under the pains•andp.enalties ofperjury that the information provided above is true and correct
Sienature: 7rJ2 Date
Phone A 5,03 p
Official use only. Do not write in this.area,to be completed by city or town officiaL
'City or Town: PermitUcense
Issuing Authority(circle one):
a. .'t Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector w/
j 6. Other 1
'Contact Person: Phone#: .
VDAC 1
WOR
K COMPENSATION
AND
ZUJUCH
- EMPLOYERS.LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01:( A) ,
POLICY NUMBER: (6ZZU6-4083P83-4-11 )
RENEWAL OF (6ZZU6-4083P83-4-10)
INSURER: AMERICAN ZURICH INSURANCE COMPANY F NCCI CO CODE: 80012
1. PRODUCER:
INSURED: MARGARET J GRASSI INS
MULLIN, MARK M DBA 1188 MAIN ST
MULLIN ROOFING & .SIDING p - WEST-WAREHAM MA 02576,
7 CONNEMARA WAY
W. YARMOUTH MA 02673
insured is AN INDIVIDUAL
ers are shown in the schedules)attache
Other workplaces and identification num d
b 'lin address.
2. The policy period is from 12-08-11 tO 12-08-12 12:01 A.M. at the insured s ma g
3. A. woRKERs COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of.the state(S) listed here:
MA
® B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease:. $ 100000o Policy Limit
Bodily Injury.by Disease: .$ 1000000 Each Employee
C. :OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE ,REPLACED BY ENDORSEMENT WC 20 03. 66A
D. This policy includes these endorsements and schedules:
SEE LISTLNG OF ENDORSEMENTS EXTENSION OF' INFO PAGE
4_.. The premium for this policy Will.be determined by our'Manuals of Rules,.Classifications, Rates and Rating
Plans. All required information is subject to verification and change by,audit to be made ANNUALI Y
DATE OF ISSUE:: 12-06-11 DB ST ASSIGN: MA
OFFICE: ZURICH-ORLAN _ 809
PRODUCER': MARGARET J GRASSI INS 7282M,
asa -
� BARMF.
s
6 ,,� Town of Barnstable
Regulatory Services
Thommas F.Geller,Director
Building Division
Thomas Perry,CBO .
Building Commissioner
200 Main Street. Hyannis.MA 02601
www.town.barnstable.ma.us
Office_ 508-962-4038 Fax. 548-790(i230.
Property Owner Must
Complete and Sign This Section
If Using A Builder
I U'V c'..' G yrvO('r.� ,as Owner of the subject property,
hereby authorize to act on my behalL,
in all natters-relative to work authorized by this biulding permit application for: .
--'(Address of Job)
.ignanire of Owner Date
Print Name
If-operty Owner is applying for permit,please complete the.Iiomeowners License Exemption-Form on the
reverse side. .,
C:%Uscrs\dcxo Ihk1{1ppDsnlLncsll�crosofdWipQow•SlTompurary lntcrttct I•tics\C.ontcntUutlaoklQRF(,711RTd1F.XPRF$S•Qnc:
Revised 053012
Ulz�.. ar�z��uvruo � aa, uraeG�
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only.
1`.. before the expiration date: if found return to:
ME IMPROVEMENT CONTRACTOR
i egistration', 167281 Type: Office of Consumer Affairs and Business Regulation
xpi ration:.� 8/-W/201;4 DBA 10 Park Plaza-Suite 5170 .
t _w Boston,MA 02116
MULLIN ROOFING AND SIDING 4
MARK MULLIN
7 C,ONNEMARA WAY o ��
f. W.YARMOUTH, MA 02673 - Undersecretary Not valid without signature
r•=" IVl t+ti.ichutiCtts. Uclia►'t�tn.cnt of Publ t 5 iYctN -
Bo rid.tif"Bui.ldni-Rchulatio s ut<I'St<utd.0
Construction supervisor License
License:'.CS 104076.
Restricted to ._00
MARK MULLIN
10 PERRY AVE.
E V1(AR�HAM, MA 02538 73
Expiration: 9/7/20T3
( nm nisi�ncr' Tr#`. 104076'
r -
The Town of Barnstable
Department of Health, Safety and Environmental Services
BAt;tWABLL 'r Building Division
ca5 367 Main Street,Hyannis MA 02601
•
TED t+AA{►
Office: 508-790-6227 Ralph M.Crossen
Fax: 508-790-6230 Building Commissioner
Home Occupation Registration
Dater l 'V 7
Name: LC c I W U Lb'nFA-ZO Phone t#: Z 7.s-
Address: S fd EEL.LQ I � l Vllage: l=f1JIC/�I�1L( fi'
(//90 dad
Type of Business• k C, �� CL ap/Lot• 6 3 q
INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the
activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor,no visual
alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,located
within that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• Tliere are no external alterations to the dwellingwhich are not customary in residential buildings,and
there is no outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular
matter,odors,electrical disturbance,beat,glare,humidity or other objectioruable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess
of normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There is no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the.
dwelling unit.
I,the undersigned,have read and agree-with the above restrictions for my home occupation I am registering:
- Q Applicant: t���� —Date: �