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Home My WebLink About0062 MARIE-ANN TERR } tIR +I s .J�.. i .e.w �.fib-. .P., 'i .r.. T;) .�1. !1'i, ➢ 1,. x �45.:' Y$�, - •.ts •iA - ''-d; �;. a ,f a�'"- ,� k te. t "S, Ai„C,•'+S,.rn t .:y,/. l xk i 17 If A t i i ➢ .�,... , a ` � e 0. 5 1 1 f Y, I Y 9 , nl` .' '11 �... e � - �.• , Op THE Tp� Town of Barnstable Expires 6 months front issue date Regulatory Services Fee ' BARNSTABLE, MASS, v�A �639 15. 1 Thomas F. Geiler, Director �s127169 rED MAt (�C7j�j Building Division 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- Property Address - C� Z S//G{/', P f//�/�� t S �'( �/,��•(, �' [9-Residential Value of Work. X:5-0'1c0. 10 Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address A-it-,�L,l.� l--. rr� Contractor's Name `�Cte1L kArlb, '- r-s Telephone Number 5-OV (/ZO I Ionic Improvement Contractor License#(if applicable) Construction Supervisor's License# (if applicable) zZ4 9 d 33 C S ❑Workman's Compensation Insurance Check one: an ❑ I am a sole proprietor �S„�� `., ❑ 1 am the Homeowner TO\NN OF &A R [;� Thave Worker's Compensation Insurance �- Insurance Company Name Ave l i 6Ayl e* �1 5,11,YJIYI U, 60 Workman's Comp. Policy # 7 Z O 6 66 L 55- 7 — 0 Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) / " `75` � e- / roof(stripping old shingles) All construction debris will be taken to �a�nSta /ra e7S4/ ❑ 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: Proper Owner must sign Property Owner Letter of Permission. A co of the Home Improvement Contractors License is required. SIGMA"rL'RE: Q.`W PI-Il,LS\RAMS\buildi g permit ibrms\EXPRESS.doc Revised 100608 a The Commonwealth of Massachusetts 02. Department of Industrial Accidents Of lce of Investigations' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Address: City/State/Zip: /A% ��.6 Phone.#: 502s Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 2: ' I am a soleproprietor or partner listed on the attached sheet. 7. .0 Remodeling ship and have no employees These sub-contractors have g.'0 Demolition workingfor me in an capacity. employees and have workers' Y P h'• $ 9. ❑Building addition [No workers'-comp..insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 1 LE]Plumbing repairs or additions myself.[No workers' comb. right 6f exemption per MGL 12.0 Roof repairs insurance required•]t c. 152, §1(4),and we have no 13.0 Other employees. [No workers' comp.insurance required_] *Any applicant that checks box#1 must also fill out the section below showing their workers'comprnsadon policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have mriployees. If the subcontractors have�employ=,they must provide 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: Zit1-G11 ' Amzrilcon_ ISia sail U_ Policy#or Self-ins.Lic.M 6-z-7L 13 Cities 1 Expiration Date: 6 — 49 0 ` Job Site Address: IO �4�•ti �h>i�.. (Gr. `i � City/State/Zip: 622:&,01, �l Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure io secure coverage as required under Section 25A of MGL c. 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 DIA for insurance coverage verification. I do hereby certify under pains•and penalties of perjury that the information provided above is true and correct. Si e: Date: S _ Phone Official use only. Do not write in this area,to be completed by city or town offMaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health '2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions .y Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more �_ of the forego kg-engagedm atom en rpnse inclu�n` he leg represenifaliw f derxased-empin�er, orrthe=._--.-.- receiver or"tee of an individual,partnership,association or other legal entity,a loying employees.'However the owner of a dwelling house having not more than three apartments and who resid therein,or the occupant of the dwelling house ol"another who employs persons to do maintenance,constructi or repair work on such dwelling house or on the grounds or`b�uilding appurtenant thereto shall not because of such a loyment be deemed to be an employer." MGL chapter 152, §25C('6)also states that"every state or local licensing gency shall withhold the issuance or renewal of a license or permit to operate a business or to construct bu' dings in the commonwealth for any applicant who has not prod ed•acceptable evidence of compliance vs3ith the insurance coverage required." Additionally,MGL chapter 152\§25C(7)states"Neither the commonwe In nor any of its political subdivisions shall . enter into any contract for.the performance of public work until accep le evidence of compliance with the insurance requirements of this chapter have been presented to the contracting au ority." Applicants 1 Please fill out the workers'compensation affidavit completely,by heeling the boxes that apply to your situation and, it necessary,supply s keontiactor(s)name(s address(es)andpho number(s) along with their certificate(s)of insanance. Limited Liability Companies(L or Limited Liabi' Partnerships(LI.P)with no employees other than the members or partners,are not required to carry orkers'compe tion insurance. If an LLC or LLP does have employees,a policy is required Be advised that affidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. o be s e to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for a pe t or license is being requested,not the Department of Industrial Accidents. Should you have any questions re the law or if you are required to obtain a workers' compensation policy,please call the Department at then er listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed gibly\Thepartment has provided a space at the bottom of the affidavit for you to fill out in the event the Office f Invhas to contact you regarding the applicantPlease be sure to fill inthe permit/license number whic willbeference number. In addition,an applicant that must submit multiple permittlicense applications ' any given year,ne only submit onp affidavit indicating current policy information(if necessary)and under"Job Site ddress" the applicant s nuld write"all-locations in (city or town).".A copy of the affidavit that has been officiall stamped or marked by th city or town may be provided to the applicant as proof that a valid affidavit is on file for permits or licenses. A w affidavit must be filled out each year.Where a home owner or pitizen is obtaining a li rise or permit not related fo an business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said erson is NOT required to comple this affidavit The Office of Investigations would like to.thank you in advance for your cooperation and s uld you have any questions, please do not hesitate to give us a call The Department's address, telephone-and fax numb The Co lanwealth of Massachuse s Deput=m t of Industrial Acci&-nts OWi ce of Investigations 606 Washington Street Boston,MA 02111 TO. # 617-727-4900 ext-406 or 1-977-MASSAFE Fax# 617-727-7749 Revised l 1-22-06 www.mas�s.gov/dia 4 SHE! Town of Barnstable , Regulatory Services awtwsTnst.E, : , MA& �,, Thomas F. Geiler,Director- 039. �m " Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038 Fax- 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I `i ,as Owner of the'subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application;for. (Address of Job) s-/ Signature of er F. Date ri A;4)Ile Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. a f , is f) a, ��O'y'ry'LO' ions and Standards License or registratio date;If found return` tod for individul use�nly I Board of Building Regulat before the expiration Board of Building Regulations and Standards. HOME IMPROVEMENT CONTRACTOR One Ashburton Place Rm 1301 Registration. 159608 Boston,Ma.02108 Exp�r�Uon=5/1512010 Tr## 268268 ! lug }!T q x T 1 e; Lt�d;Uability Corporation �a y YP tt' SANDY NECK BUILDERS ' ANTHONY NESE,"" of v id without signature 179 ROBBINS ST r Administrator OSTERVILLE,MA 02655-"" Y Massachusetts-Department of Public Safety IM Board of Buildint, Regulations and Standards MWConstruction Supervisor License License: CS 90335 , Restricted to: 00 ANTHONY M NESE F 179 ROBBINS STn OSTERVILLE, MA 02655 010 Expiration: 11/9/2