HomeMy WebLinkAbout0022 LONGFELLOW DRIVE r
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' ® Town of Barnstable. *Permit#
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X-PRESS !—ERMIT Expires 6monthsfrom issue date
Regulatory Servvices Fee.
MAY O 2013 Thomas F,Geiler,Director
Building Division /
Tom Perry,CBO, Building Commissioner (6k) S/,`�3
TOWN OF BARNSTABLE 200 Main Street Hyannis,y ,MA 02601
www.to wn.bn rnstah le.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDE FIAL ONLY
r ` Not Valid without Red X-Press,rmprint
Map/parcel Number
Property Address a LU ' 1 �ICnV �
[Residential Value of Work ✓=/W • �� Minimum fee of$25,00 for work under$6000.00 M
Owner's Name&Address
SV•'1 0 l�
Contractor's Name M10 A `V , `�S Telephone Number_ �V
Home Improvement Contractor License#(if applicable) u43
Construction Supervisor's License#(if applicable) C
❑Workman's Compensation Insurance
Chc one:
am a sole proprietor
❑ I am the Homeowner.
❑ I have Worker's Compensation Insurance
Insurance Company Name
Worl man's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box),
�e-ro.of(stripping old shingles) All construction s deb 'n will be taken 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: Pr erty Own st Prop Owner Letter of Permission.
copy of the e I prove e on-tractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
t
� of1HE, o -'own of Barnstable.
Regulatory Services
7AFtNSrAELE, +
MAC $ Thomas� F. Geller,Director
lEo �a Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601.
"`W.town.barnstabk.ma.us
Office: 508-862-403 8
Fax: 508-790-6230
Propexfiy Owner Must
Complete and. Sign This Section
If Using A Builder
as Diner of the subject property
hereby authorize . S 0�A t.14.
to act on my behalf,
in all matters relative to work authorized by this;15Rding pest application for:
( dress of Job)
Signature of Owner Da e .
Print Name
QTox.Ms:owr»ERPERrIssrorr
' .• The Ca"m'irtattivealth ofMassachusetts
` Department oflrsdustria1 Accidents
Office of I>tvestzgattons
s600 FYnshinirton Street
iBnst®i11IVA 021rI
'' VVHI.rnass.. ov/dia
Workers'' Couipensat7ioxt xnSurnce' dayt..BuiIders/Contractors/Eiectricians/Pl
A licant Information j� umb ers
Pease Print I;e 'bI
Nam e (Business/Organization/Individual):..
•Address:
City/State,/Zip:
Are you an employ P y heck the appropriate box:
1.❑ I am a employer witli 4� [] I am a general contractor and I -Type of project(required):.
/haployees (full and/orpart:time)• ": have hired the siib-contractors
2. 1:am a•sole proprietor or partner- listed on the'attached sheet 6. New construction .
ship and have no employees 7• ❑Remodeling
i These sub--contractors have
working for me in any capacity, employees and have workers' 8' ❑Demolition
[No workers'comp:insurance co insurance.$ 9•
re uired_ L°P ❑Building addition
3.❑ q 1, $• [l We are ti corporation and its 10.
I am a homeowner doing all work ❑Electrical repairs or additions
. officers have exercised their t,
rnyselt [No workers' comp. right of exemption per MGL. l l'�P bmg repairs or additions
insurance required.] t i c.152, §1(4),and we have no 12• Roof repairs
y M1 i employees. [No workers' :.13.[] Other
camp.insurance required.]
*Any applicant that checks box#1 must also fill out the section bcloivshowing their workers'c
t Homeowners who submit this em
a$idavit indicating they arc doing all wank and tbcn hire outsides o tractors muscubf nr a new affidavit in
d'
tContractors that chests this box must attached an additional sheet showing t}ic puree of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors Izi e rovloyces,they must rovidt their Workers co leafing such.`
p 'comp.
.Ifn an errrplayer that is providing>�arkers'compensation insurance for my ernplvyees Belayp is the ollc nn
information, p y d•lob site
hisurance Company Name:
Policy#1 or Self-ins.Lic.# .
Expiration Date:
Job Site Address:
' . .
Attach a copy of 'City/State/Zip:
Me compensation policy dedarafioa page(showing the policy number
Failure to secure coverage as require
fna tip to$1,500 d under Section 23A of c. 152 can lead to the imposition
expiration date),
.00 and/or one-year imprisonment, as well as civil penaltir in the form imp osition of criminal STOP WORK O penalties of a
Of up to$250.00 a day ag e violator. Be advised that a copy,of this statement may be forwarded to the O ER and a fine
Investi ons o CID foe' overa e Verification, flice of
16 h eby certify nder t pains• penalties ofpJ er'ut7,that the information provided ah ve 's true a nd correc4
SiLmature: i cc n
t ate D J o`
Phone --0 cial use only. Da not write in this area,•tb he completed by city or town ojcj7cjaj
t
City or Town: ,
' - �* Permit/License#
Issuing Authority(circle on
/
x.Board of Health 2.BuiItiingDepartmetit 3. City7'o��Clerk 4•Electricallns Inspector 5.
6. Other P Inspector
p .
Contact Person:
_ - - Phone#1
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