HomeMy WebLinkAbout0047 MAUREEN ROAD
r Town of Barnstable *permit#�L1)0&
Expires 6 months from issue date
• Regulatory Services Fee t 00
MAO&r *
Thomas F.Geiler,Director
' Building Division
V Tom Perry,CBO, Building Commissioner o.
200 Main Street,Hyannis,MA 02601 a r00/, CT S 7?O ®1'
www.town.bamstable.ma.us Ql �6
Office: 508-862-4038 Fax-508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
p/parcel Number ��"► �(Q�
perry Address
Residential Value of Work Minimum fee of$25.00 for work under$6000.00
ner's Name&Address n ji!kK44->6'\
OCLree- tZ 6� lite
ttractor's Name Telephone Number
ne Improvement Contractor License#(if applicable)
tstruction Supervisor's License#(if applicable)
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor -
I am the Homeowner
❑ I have Worker's Compensation Insurance
trance Company Name
rkman's Comp.Policy#
)y of Insurance Compliance Certificate must be on file.
nit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. 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: Property Oynfff t sign Property Owner Letter of Permission.
me Im ovem t on ctors Lic _ ' equired.
NATURE:
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;e071405
The Commonwealth of Massachusetts
t Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111,
r � www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
licant Information Please Print Legibly
"lame(Business/Organization/Individual): 6AI K— ) to ,9,601
ddress: Wow re 2Ul
-Tr-
i /State/Zi : 04 4 1t Z Phone#: =S 6 Q
re you an employer? Check the appropriate box: Type of project(required):
❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the'sub-contractors
❑ I am a sole proprietor or partner-
listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp.insurance required.] i,.
y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, w
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
m an employer that is providing workers'compensation insurance for my employees. Below.&the policy and job site
ormation.
urance Company Name:
licy#or Self-ins.Lic.#: Expiration Date:
Site Address: City/State/Zip:
tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
e 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
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification..
Latur
hereby c r ify u er the ains andpenalties of perjury that the info ation provided above is true and correct.
one#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: