HomeMy WebLinkAbout0042 CODDINGTON ROAD E a
Is
oFIxr r Town' of Barnstable. XPermit#
E.ipires 6 Onflis jronr issue date
`r ^ Regulatory Services Fee
Bnxrrsresr s E
Y� MASS. Richard V.Scali,Interim Director
Ar Building.Division ,
Tom Perry,CBO,Building Commissioner ( C°��% C%
MA`( `�6 20�5 200 Main Street,Hyannis,MA 02601
r 'fie ASTABLE Nvww.town.bamstab1e.ma,us f .
O Ire �KO'8 '6� 4�D3 . Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY -
Q 1^ Not Yalid tvitleout Red X-Press Iritpri»t
Map/parcel Number "J f
Property Address
[Residential Value of Work$ —1 U� O • v Minimum fee of$35.00 for work under$6000,00
Owner's Name&Address
Contractor's Name 9 Telephone Number
Home Improvement Contractor License#(if applicable) I I Email:Sit.cu
Construction Supervisor's License#(if applicable) -I
❑Workinan's Compensation Insurance
Che4c one: - 1
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 accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
Voof(hurricane nailed)(not stripping. Going over existing layers of roof)
side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical•&Fire Permits required. =
*IVhere required: Issuance of this permit does not exempt compiiance with other tomm department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner . roperty Owner Letter of Permission:
AA co o the me I o went Contractors License&Construction Supervisors License is
eq ired,
SIGNATURE:
QAINTFILESWORMSIbuiiding permit formslEXPRES .doc r
Revised 061313
t
A*IHE l Town of Barnstable
Regulatory Serwees
{
qWPA Thomas F.Geiler,Director
�p x639• 1� - ,
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hya6is,MA 02601
www.town.barnstable.ma,us
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section If-Using A Binder
I, M 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
Coen .
(Addt f Job)
**Pool fences and alarms are the responsibility of the applicant.' Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner ature of Applic t
l�nLEI
Print Natne Print Name..
Date
Q:F0RMS:0lVNERPERMISSI0NP00L-S 6R012
I ,
271e Clmrrraimealth ofMassachmsetts.
Degarfrsrit of firdrist>*ial Accidents
Off 4Ce of lrcvestigatforis
' 600 Washirrgtoa&reef
Boston,MA 02111
litM11.Y11aS&g0V1dia
Workers' CampensatianIummnceA.ffidavit:B'Izilders/ContractoxsMeetricianslPlumllers
Applicant Information Please Fruit Legibly
Naive 0E usineasldrganizahonllndividml)
Address: Vo �0 X (0�
City/StaWZip: �I s \ �! ! �7iV1 Q I Phone#_ �C` �► ZJ
Are you an employtdCheekthe appropriate box: TJTe of project(roquirea):
1.❑ I a employer with 4 0 I ara a general contractor and I
la
(fall andlorpart-time).
* have hired the sub-contractors 6. []New construction
2. am a sole proprietor orpartner- listed on the attached sheet: 7: []Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp,insurance comp.insurance.$ 9_ 0 Builcrmg addition
required-] . 5. ❑'We are a corporationand its, 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work^ officers have exercised their 1Ln Plumbing repairs or additions
myself[No workers'camp. right of es-etnptiouper MGL 12-C]Roof rq ails .
instuance required.]l c.152, §1(4),and we have no
employees_[No workers', 1311 other
comp.insurance required.]
*Airy applicant that checks bm#Imnst also fill out the sectionbelow showing ihet<woAeis'compeasntionpolicpin ar�naei
HGzawwnets who submit this ai' Uvh indicating they ate doing all wok sac!then hire outside conttwrors 7imsI subunit a new affidivit indicating such_
tcoatmctors that cbea this boat must attached an additional sheet showing thenameof&a subF-co&achm and state whetherocnot Chow amities hmme
"layees. If the sub cont meson hate employees,theymust provide their svorkess'tamp.policy number.
lain an employer tltatisproii&ng ttrorke.rs'coniperrsafian inmrance for my empitryees Below is rite policy and job site
inforwafon.
Insurance CompauyName:
Policy#or Self-ins.Jac #: ExpiratiouDate.
Job Site Address: City/Statelzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratiou 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 iurpris t,as well as civil penalties in ihe 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 statea=t may be forwarded to the Office of
Im,e stiga ti ous of the DIA for' c ge v cation_
I do Fereby certify ritr - s prti lid to * s erjury tttat the information pratdded bove`•hus nd correct
Si Date: 90
Phone#: I .i
o jiciai Ilse only. Do trot write iu this area,We completed by city or town ofjiciat
City or Town: PeradtUcense#
Issuing Authority(circle one):
L.Board of Health 2.Building Department 3,Citylrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Gther
Contact Person: Phone U.
6'
z •
- _ Am Massachusetts -Department of Public Safety l
Board of Building Regulations and Standards "
Construction Supervisor Specialty
License: CSSL-099138
JAMES'P CURLEW
287 FULLER RoAD s
Centerville MA 6632
✓ ��, >> �.� Expiration
Commissioner 01/28/2016 i