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HomeMy WebLinkAbout0503 SANTUIT ROAD .� � �. �. i .Y .. � � � � �� �� � � � . , . ,. . „ . ,. , - � ,,, ,,, F ,, Cotes- �u 7 i n i I (0f�los- e Olt ISE,p� Town of Barnstable *Permit# �-�- �P�' �p Expires 6 months from issue date y BAMSTABM Regulatory Services Fee s K"A Sm mp Thomas F.Geiler, �A t639• p ,Director Building Division Tom Perry, Building Commissioner X-PRESS PEP 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 JUN � 0 2005 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDE9Dft9EI RNSTA6L2 Not Valid without Red X-Press Imprint Map/parcel Number 0 I lZs Property Address �'6 ®Residential Value of Work 6D Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address -2y Zzz� Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction 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 Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. 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 roof) © Re-side [A Replacement Windows. U-Value (maximum.44) "Whererequired: 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. Home Improvement Contractors License is required. Signatures! Q:Forms:expmtrg Revise063004 The commonweaun of lvlassacnuseaa; _ Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: � ..� City/State/Zip: i� Phone#: 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 employees(fall and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. t �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions 3. 1 am a homeowner doing all work p 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#1 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. tcontractors 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 secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 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 the pains and penalties of perjury that the information provided above is true and correct: Signature- Dater 4 ado Phone#: y �8 yo2 272-2- 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#: