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Town of Barnstable *Permit# '
ft Expires 6 mondis from issue dale
Regulatory Services Fee
Thomas F. Geiler,Director
Building Division C lc gljs-)64
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.barnstable,ma.us
Office: 508-862-4638 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address q U o iTU yj I�j
residential Value of Work �/t • 0 UMinimum fee of$25.00 for work under$6000.00
Owner's Name&Address r-1CI (I 0- 1(1�
1 .°m I � Dr •
Contractor's Name C -> UC Telephone Number -1 9 U l��
Home Improvement Contractor License#(if applicable) i- '
Construction Supervisor's License#(if applicable) qq 13 V
❑Workman's Compensation Insurance PERMIT
VCh k one:
am a sole proprietor
❑ I am the Homeowner A P R 14 2009
❑ I have Worker's Compensation Insurance
TOWN OF BARNSTABLE
Insurance Company Name
Workmen's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Requ?8tl,,efck box)
o (stripping old shingles) All construction debris will be taken to D CL I I11 1
T
❑ Re-roof(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
"whcrc required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Prope w/ner mns sign Pro rty Owner Letter of Permission.
A o of e Home pr v went Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Reyise061306
The Comrnomvealth of Massachusetts,
Department oflndustrialAecidents
Office Of rnvestrgations
600 YPashfngton Street
Boston,MA 02111 ,
www,rn ass.gov/dia
Workers' Compensation InsurAnce.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Orgaaization/fndividual):, �vI. wry
Address: .X(
City/State/Zip:
Are you an employer? eck the appropriate box: -Type.of project(required)
1.❑ I am a erployer with 4. ❑ I am a general contractor and I
* have hired the eu'b-contractors 6 0 New construction .
loyees (full and/or part.time). �
2. a'sole proprietor or partner- listed on the'attached sheet: 7. ❑Remodeling
s and have no a to ees These sub-contractors have
�P mP y '8. ❑Demolition
working for me in any capacity. employees and have workers'
i co insurance.$ 9. []Building addition
[No workers'comp.insurance comp.
required.] 5• ❑ We are a eorporation'and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑P umbing repairs or additions
myselL [No workers'.comp. right 6f exemption per MGL 12. 00frepairs
insurance required.] t C. 152, §1(4),and we have no
employers. [No workers' .13.❑ Other
comp.insurance required.] .-
*Any applicant that checks box#1 most also fill out the section below showing fhcirworkers'compensation policy information.
t Homeowners who submit this a$idavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
P tintractors that check this box must attached an additionalsheet showing the name of the sub-contractors and state whether ornot those entities have
r nployces. If the sub-contractors lave employees,they must providh their workers'comp.policy numbcr.
Iam an employer that is providing workers'compensation insurance for my employees Below isYhepolicy 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 6. 152 can lead to the imposition of criminal penalties of a
fine tip 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 may be forwarded to the Office of
Investigations of the INA for'I-pslimice coy verification.
I do hereb under a ains-an pe.: ties ofperjurh that the information provided
(a ove 's true and correct.
Signature: Date:
Phone #: 1 O
Official use only. Do not write in this aregYo he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board ofHealth 2.Building Department 3.City/Town CIerk 4;Electrical Inspector 5.Plumbinglnspector
6. Other
Contact Person Phone#:
tiof-THE r Town of BarmSta ble
s,Y o
h Regulatory Services
i 1AANSTASLE, +
y MASS. $ Thomas F. Geller,Director
�ArFD MA�a,� Building Division
Tom Perry, Building Commissioner
200 Main Street Hyannis,Mk 02601
"vJown.barnstable.ma.us
Office: 508-862-4038
Fax: 508=790-6230
Prop eTty Owner Must
Complete and Sign This Section
If Using A Builder
-P
as Owner of the subject property
herebyauthorize to act on my behalf,
in all matters relative to.work authorized by building permit application for:
ddress of Job)
Signature of er
g Date
Print Name
QTORMS:OWNERPERM]S SJON
• Nlassachusetts- Department of Public Safety i
Board of Building Relrulations and StandardskW--,
Construction Supervisor Specialty License
License: CS SL 99138 -
Restricted.to: .RF,WS
JAMES CURLEY
287 FULLER ROAD..
CENTERVILLE, MA 02632
- j
Expiration: 1/28/2012
i
Commissioner Tr#: 99138
Board of Building Regulations and Standards' License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registrafion �_24310 One Ashburton Place Rm 1301
Ezpiration _g%}l2009 Trt# 130873 Boston,Ma.02108
Type-lntlividual
James Curley
James Curley
287 Fuller Rd.
Centerville,MA 02632 Administrator Not valid without re
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