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HomeMy WebLinkAbout0314 PHINNEY'S LANE _�- �#. ..,.z t..aig ,�� �,,Y--" a •d w'� 'L°y 4 3�, y�®gsisf� pry �1y ° �. .. ` ,r w • , a I e r.o Q IKE Town of Barnstable *Permit k s 2 Fxpires 6 months from Issue date Regulatory ServicesNAM Fee oo v� s 1st Thomas F.Geilert Director �E0 .,• Building Division Tom Perry, Building Commissioner IT 200 Main Street,.Hyannis,MA 02601 Office: 508-862-4038 JUL 13 2005 Fax= 508-790-6234 EXPRESS PERM IDOF IT APPLICATION - RESENTIAIWONLY�ARSTA Not Valid without Red X-Press Imprint apiparcel Number �9 30 /,3 ope Address �J�. rJ .�4,/1� ��f 1� l /�/ 0.26,E l aside al Value:,f Work �'r MEnimum ee of$25.00 for vPor_ k under$6000.00 ?vner's Name&Address nz5fe � ��J,Yj 3i' i e me /o/2 �/e . . AV QZ3 2 mtractor's_Name • Telephone Number C�0 4 _ ��.�__���� y )me Improvement Contractor License#(if applicable) mst uction Supervisor's License#(if applicable) ]Workman's Compensation Insurance Check one: . 2 DI am a sole proprietor • '� ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance nuance Company Name orkman's Comp.Policy# )py of Insurance Compliance Certificate must be on file. nd-Request-(check-box) -- -- dpte-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) i *Where required: Issuance of this perrmt does not exempt compliance with other town department regulations,ix,Historic,Conservation,etc..' ***Note: Property Owner t s• Property Owner Letter of Permission. me Imp ov tr s License is required, y gnature . 'orms:expmtrg vise063Q04 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ' Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nance (Business/orpnization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bog:. Type of project(required): 1.❑ I am a employer with ' . 4. ❑ I am a general contractor and I 6. ❑ New construction ernrioyees(full and/or part-time).* have hired the sub-contractors ng 2.❑ I am a sole proprietor or,partner- listed on the attached sheet t ❑! Demolition ship and have no employees These sub-contractors have 8. ❑ emolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition o workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions ITeqUired.] officers have exercised their 3. m 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.] *Any applicant that checks box#i must also fill out the section below showing their workers'compensation 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 $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'_comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy 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--secur-e-coverage-as-required-under Section.25A-0f I LL-e.-152.can-lead-to-tk►e�impos}lion-of edminal-penalt3es-of a fine up to$1,50Q.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 ce u er the ai an e 1 es of perjury that the information provided above is true and correct: Si afore: Date: Phone#: 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#: cFTHE Toy, Town of Barnstable *Permit# `ls io P� �•p Expires 6 months from issue date Regulatory Services Fee �- o � MASS. $ "Thomas F.Geiler,Director �p s63g..aim lEo�A� Building Division Tom Perry, Building Commissioner X-PRESS PER 200 Main Street, Hyannis,MA 02601 - OCT 1 s 2�� Office: 508-862-4038 Fax: 508-790-6230 BARNSTABLE EXPRESS PEWM APPLICATION - RESIDENTI � Not Valid without Red X-Press Imprint Map/parcel Number J { Property Address 6 / � idential Value of Work 2 Owner's Name&Address ` " _ Contractor's Name��`t�l� °�f� 1AC Telephone Number�6s "�'G Home Improvement Contractor License#(if applicable) d Construction Supervisor's License#(if applicable) Q© � U S'0 ❑Workman's Compensation Insurance =am : sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roofl ❑ Re-side � �S �/�p � Replacem nl Windows. U-Value (maximum.44) �_ CS, C Other( Ps ecify) / 1 t'� " �( �o ��c� n �� *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. C Signature Q:Forms:expmtrg Revised121901