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Town of Barnstable *Permit#
Building Department �enthsfr�usuedate
o� Brian Florence,CBO
163 ? Building Commissioner -
EO MAr 1C y 7/1 A0 Main Street,Hyannis,MA 02601.
www.town.barnstable.ma.us
Office: 508-862-4038 "14 Fax: 508-190-6230
91
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
/� Q_0 Not Valid without Red X-Press Imprint
Map/parcel Number �. 4 1
Property Address 44 Q ( 'J-F-U Sk e 11h-1 fc(\( D
❑Residential Value of Work$ "j�� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address e 1 1 L ll L-et .V 4
Contractor's Name " L _C_ Telephone Number '50�_-S&2-Z-7 O
Home Improvement Contractor License#(if applicable) l (, Email:
Construction Supervisor's License#(if applicable) CSO� 2j ( (c_ 1 fi`i5 y 1
2,Crkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name I Ci
{
Workman's Comp.Policy# j�(1' (7�`�`� 0 1 2n 1!2
Copy of Insurance Compliance Certificate must accompany each permi .
Permit Request(check box)
['Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �,i.t�5 .
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
*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 th a Improvement Contractors License&Construction Supervisors License is
require ,
SIGNATURE:
QAWPFILESTORNISTMESS2017
•vim- . �` _ .... -
The Commomreaith ofMaysrrdhmettr
Department&f1 shialAccidents
O fre o,f�"esligadom
600 Washington Street
_ -- Bastvn,MA 02M
tvrvxu muss, fdia
Workers' Campensat onInsurance Affidavit:Builders(Contractors/Mec dci ns(Phunbers
Applicant InfitrmatEon Please Print E.e�'bly
. 1`1sffie c'srr�cclY7 aSII�3h•4Illjaj� ��K��� c/� %���� 1 L°_ . `
tSi7tJat�SS: � \ A(� T!U G� 1/�L[,1� (l�cJ •
Cityf5latef r 4z7, rue 7
Are you an employer?Check the appropria ox: ' Type of project(required):
I.❑ I am a employer.vith 4. I am a general contractor and I 6- ❑New eons action
employees(Rd amYor part-time).* have hired the sub-cgntmcto s
2.❑ I am a sale pzoimietor•orpartner- listed on the attached sheet~ 7- ❑Remodeling
ship and have no-employees These sub-contractam have 8.,❑Demolition
wmuldng forme in any capaci4y- employees and have wod ers' 9. ❑Building addition
[No W.Ddcers'camp.insurance Comp-
required-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3_El aura homeowner doing all iAork 1L❑Plnmbingregaiss of additions
o wro mm' 12_❑Roof repairs.
of exemption per MGL repair
i nce required-]F c.152, §1(4k andwehaveno
employees.[No wod=e 13.❑Other
cam-iusuraam ]
'dicey appticavtthat rhedmbox ff1 mast also fMootthe sectionbelowshuvdag tueirwa mime compeamtigmporv-yinE mafion_
llomwwao s Who sabot tl aS dtid='i i&rating they are chino all Wa&and&m hEm outside con=ctoisamst submit a new affidn t indica, such_
ZComxacrws that eheck this boot ch mast attaed sa addrtianal sheet sbouiag thename of due m&-conttscm¢s sad state whetin or nit those en itier bxae
employees.Ifthemb-contactoeshweemployee%dieymmstpiuuidetair worken'camp.policy nunbez
lam au eittpZapr that isprotzdfng ivorke.rs'congxwdiati f mirance jbr wy employees .Se1viv is flue policy artd jah s&e
informadam
Insurance Company N": r�
Policy#of Self-iM I.ic-# tA 0-' !`60f)`)' 2/2Z 1 Expiratioa Date: 2-1 �-
t
Job Mte Address o f Q CitylStafelzg: 0 'Z—
Attach a copy of the workers'compensation policy declaration page-(showing the policy number and e=pirateon date).
Failure to secure coverage as requiredunder Section 25A of MGL Q 15-7 can lead to the imposition of criminal penalties of a
fine up to$1,500 OD andror one-year imprisonmenl,as well as civil penalties in the form of a STOP WORK ORDER and s fine
of up to$250-Da a day against the violator_ Be advised that a copy of this statement maybe forwarded to the Office of
Imvestigations of the DIA for insurance coverage verification.
I tfa hereby. f'uZ 6 pains andperiaTfies of
pe{juty that f ie hzfarimrtnmtprot- abmv is b11ars and correct
Sitsratnre: � Date: �itJ
Phone irr
O„�cial use 4suFy. I3a rrat evrets in fFeia areQ,frr be ctrmpleted by urifp artnir�n aij'aeEat
,City or Town: Perugitl icense#
Issuing Authority(circle one):
L Board of Health ?.Building Department 3.Qtp Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
a 'on and Instructions
QI`I71 tI ti
MassarT setts GeheaalLaws chapter M regimes all employers to provide workers'compensation for their eaipIoyees-
ParSUantto this state,an iurplayee is defined as.`�:evmypeas6n.in.the service of another nader any contract ofhfir,
e1131ess or impliecL oral or " ,
An ezrplayer is deed as"an indiYidna.I,partnership,association corpm--don or other legal entity, or any two or more
of the foregoing mgaged m a joint etapase,aad including the Iegal representatives of a dwzased employer,or the
rw,aivw or trustee of an individual,partne rs4,association or other legal entity,employing employees. However the
owner of a dwelling howa-haying not more than three spar and who re sic e therein,or the occogant of the -
dweIIn$g house of anoiherwho employs persons to do make,canstiuLtion,or repair waik on such dwelling house
or on the grounds or the�to shO not because of such �aymeat be deemed to be an employer."
MGL chapter 15Z,§25CT%7
t everystate or local Ircensnrg agency
shallwithhold$ie issuance or
renewal of a license or e a business or to consiract b dings im the commonwealth for rap
applicantwho has notpacceptable evidence of comppran with the insurance coverage regtaired"
Additionally,MCrL chapter 152X
C(7)states-Neither the nor a'uyofits political subdivisions shall
enter into any contract for the pance ofpublio wor3c uutl table evidence of compliance with the 1nsm-a n ce.
re,� Mts of this chaptez.have li prrseuteedta the arrihoiXty."
Applicarrds
Please fill otit the w03ers'compensation davit mplet ly;by checlong&o boxes that apply to your situation and,if
necessary,supply sob-contractor(s)name(s). es)and phoneiixmba(s)along with their=tificate(s)of
;n�rrr mce. Limited Liability Companies(LL United Liability Paitimmbips(LIT)withno eniployees other.93.an.the
members or partners,are not requir d to rkeas3 compensation insraance. If an LLC or LLP does have
employees,apolicy is required. Be ad chat ' affidayitmaybe m9 mitfed to the Department of Industrial
Accidents for conffimation of i veragb. o he sure to sign and date the affidavit The affidavit should
be retr:nned to the city or town that licatica a pccmit or license is being requested,not the Department of .
Ladnsft al A cc Pants- %GU.1dyou any questions - the law or ifyou are regodred to obtain a workers'
compensation policy,please call Departm eat at the er listed below. Self-insured companies should enter their
self-i snance license nmmber the appropriate line.
City ar Town Offircials
lease be sure that affidavit is complete and printed legibly. e Department has provided a space at the bottom
of the affidavit f you to fM out in.the event the Office of Inv - has to contact you regarding the apPIicant
e be fill in fhe peamrtllicrose number which will be used a reference number. In.addition,an applicant
$at must submit maniple pemaWlicense applications inany given year', only submit:one affidavit md)caimg dent
policy information(if necessary)and under"Job Situ Addrese the appli should wrifi-"all locations in (�Y or
town)."A copy of the affidavit that has been officially stamped or madced a city or flows may be provided to the
applicant as proof that a valid affidavit is on file for fnfm permits or Iicenses_ new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related, any business or commercial venture
(ie. a dog license or permit to burn leaves e .)said person is NOT required to lete this affidavit
The Office of Investigations would like to thank you m advance for your cooperation d should you.have any questions,
please do not hesitate to give us a c2l
The Department's address,telephone and fax ntnnbear
tb�aMassachntts
Depadaent Gf 1ad z Accidenta
f�t�e of Xn�e�tig�tio�
Bwbx MA 0�11I
`pc,-L O 617-727-4900 CXt 4€6 or 1-977 MA S.4F
Fax 617 727-7M
Revised 4-24-07
STEPHEN DUFF Customer:
CONSTRUCTION LLG. K Address: 44o Old S-k-ram 1 l
z_—
BARN5TABLE MA.02030 EV.
508--B62-27C 7 Telephoner
S��UFFGO@Y�HOO.GOM Dote:
a For The Amount Of..
tyi E21�t? 4 "��'_l a y Cm
t 41�' gd/ 4 GAL 144-4-- ./ T
f r rX,4 J L,( -/f
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a
it k� .5 Xd 94462
Payment Scheduler .,
l�
6:�2,25 ZLIZ 4 la
Stephen Duff Date Customer Date
iU�aaaas�apuD
alnjeu6�s;noylinn pike I I el
-
`�JJ r wQSINN H 9851
t � fld N3Hd31S
Oil'NOI1gREilSN03 3f14 N3Hd31S
91LZ0 tlW`uolsog 6lOZ/ll/60
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OLIs al!ns-ez8ld)laed OL I —
uola n6a ssaulsn ue sa!e jau nsuo ;o aol uo!3 3 ualle�sl ay
1 1 a 8 P litJ O ll0
:ol ujnlaa puno;;l •alep uollejldxe ayl ajolaq uo!jujodi�;3a�1
Aluo asn lenpinlpul Jo;Allen u01leJis!688 kiOlOtldlNOO 1N3W3A0lidWl 3WOH
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Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-086728 - err
Construction Supervisor `
JOSEPH A RENNIE
4 WAYSIDE LANE .
SANDWICH MA 02563 ,. ..
Expiration:
Commissioner 12/16/2017
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FeW8, 2006
Town of Barnstable
Town Hall
367 Main Street .�.
Hyannis, MA- 02601 _. ,pil
Zoning Board, y®
Health Department, C�n4,
Fire Chief,
Police Chief
I am writing to register a complaint regarding the sanitary/safety conditions on the
property located at the northeast corner of Old Stage Road and Great Marsh Road
intersection. This property has an accumulation of debris, trash, auto. parts and The
Lord only knows what else.
Primarily this is an eyesore for this neighborhood, but is a.location which may provide a
nice environment for vermin breeding. I would expect that the existing conditions
violate several town residential ordinances, particularly Health, being a personal
Dumpsite, and possibly fire safety laws.
I ask that the town investigate the situation and issue clean-up requirements to the
owners of the property.
Sincerely, 0K��
tom• �;� L'�- V
Robert S. Webb
355 White oak Trail
Centerville, MA 02632
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