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HomeMy WebLinkAbout0019 HARRISON ROAD � ;.-:•;�.. ,:- >... r, ,^ s ,,; •. .. :... ... ... :,;.'a' .: .�. 5, ..,�,e. - 'u'�t� {; - _ -,r 'sue..F:. ,�,.. ., '.tip r.t� •� '��� s ,i ` �`� . + i •...>. .,,:... ,. ,,, �, . �..- .._,:�''T.!.o s .,.y.;� , �I r.r 4 "..tj°w � i..4 ;�F �i.- :1' 4F;�e� ,.F::' a., r:a•',•. ..Yt.'u tti - Of s.37f' FA"i 11 4s xs : �2 i:� 1 r Si `p°itc as4� i� F o � o r • u� r. i , e 41 owl • r - „ , c o , u o �•i Town of Barnstable *Permit# S Expires 6 ftmffis om is Re ulator Services ' - P � g YFee _ 9� i639p 0 2010 Thomas F.Geiler,Director i OF SAfity Building Division." y1 rf�/or ABL 'om Perry,CBO, Building Commissioner 200 Main Street,Hyannis,'MA 02601 _ www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION. - RESIDENTIAL ONLY 4 Not Valid without Red X-Press Imprint Map/parcel Number 2_ `—o Property Address o. r�,�►'�so,n Residential Value of Work �tp ©� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address - �.(� . Contractor's Name,/� /`tr�� ` ' I t� j6he r Home Improvement Contractor License#`(if applicable) 1 162 Construction Supervisor's License#(if applicable) U� � ❑Workman's Compensation Insurance [1 I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance w Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. .. Permit Request heck box) a f Re-roof(stripping old shingles) All construction debris will be taken to S r &Z705" ❑Re-roof(not stripping. Going over existing layers of roof) Re-side m #of doors.' . ❑ Replacement Windows/doors/sliders.U Value : (maximum ,:44)#of windows *Where required: Issuance of this perinit 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 the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:1Users\decollik\AppData\Loca]Nicrosoft\Windo Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 4 : Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration _ 41776 s f4r Expiration 2/5/2012 Tr# 293553 1r Type:.,,'' IntlN�tlual *�•. MILES J. DELOID ;1, 3 MILES DELOI �,' 3 t' 7 SANTUIT POND RD # ` MASHPEE,MA 02649 - = Undersecretary t, ivv Lee ocrobo rS 0 *.. 3 a�xt; ted to�, �� �-, Rest��e a ,O\O • •' "'tr _ i p 2d,'�%�, o " '•5• _ ' p 0Z00 �cati\On:. 5638 . 3 Z+ ,j L n - n ii .,..�:Y���'r't__ Y •`!,_e�.. k�y�.}j 'rfP 4`�t%.�'?'e&� 1�.t ya+ t+ ec a 04; r a v u ft 14 r���"a} t .�''a�� � � s •s' �'�lz��� �7 �� � "a �f 1 s * � f} ' f cgs a Mo QUM y 'i� � +1 1 f: d •1 _ r , , , t�� c.� � ,� t ;- y � :Y xc a�'t,-,�} f.+t _'F �,��ahx �r,(�'.-� i.�, .,� • r .�� S/ ' �: a\ � A�n # r I�'�'• r t� / ddCp x 1 s yl.�i rl M �:. t aY i&, kfi ys� "'r r•%a," S Y�E:a {F�' R':..;� 1 R t j•f4 r 1 rat JV ,z54 , t F 53 MG #al AN101s qurulo,j l LOZ/8/9 :u011ea1dx3" 6b9Z0 VW '33dHSt1W } r ON aNOd iini s L f I110130 r S3]IW � �Y F` .�y�,„ s+ � ''Y x s '�• �` ��� as r � a: 00 0l'pai31j;s08" w k g' ' 7 >" OS9L8 So :asuaai�. a `x : . rt r 1 asuaoi`l J * x osinaadnS uol;o .� wlsuo� $ sp.irpur.1S hur, suoijuln,ag twipplig,lo p ;;�IrS ailynd,10luawlncd�4 -s�lasny�rssr.1V 7 a' 4` r 4 License or registration valid for individul use only ' before the expiration date: If found return to: a Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 51.70 f 3,!,:- Boston,MA 02116 `1 - Not vali rthout signature ` ` T/te Conrmompealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wmt,.mass gov/dia '? Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1_ M Please Print Legibly Name(Business/organization/Individual): be"IA 1411 Address: I City/Stat&Zip: 09) eC, o ' t 07 q Phone# 277Y^ R�3D'A / Are you an employer?Check the appropriate box: Type of project r 1.❑ I lover with 4. ❑ I am a general contractor and I 6.3� New construction d) loyees(full and/or part-time)-* have hired the sub-contractors ❑ 2. I am a sole proprietor or partner- listed on the attached sheet. ?• ❑Remodeling Pe no p These sub-contractors have ship and have no employees 8_ ❑Demolition wonting for me in any capacity. employees and have workers' 9_ ❑Building addition _ (No workers'comp_insurance comp.insurance-1 required.) 5. ❑ We are a corporation and its 10_❑El al repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑P g repairs or additions myself[No workers'comp. right.of exemption per MGL 12. Roof repairs insurance required.]p c. 152,§1(4),and we have no 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- 7 Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. 'Contractor that check this box must attached an additional sheet shouting the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their worker'comp.policy number. 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 it or or Self-ins-Lic.#: V,5 /1 /o 14-76 Expiration Date: Job Site Address: o City/State/Zip: 'J 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 51,500.00 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«rider t)repain ►td p s o perjury that the information provided above is a and correct Si tore: Date: o l I o Phone M V77 T �a✓ ®o Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit Ucense# 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#: saxxsTns�. MASS. ,� Town of Barnstable MP'i A Regulatory Services Thomas F.Geiler,Director Building Division , f Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ' s 44 Office: 508-862-4038 Fax: 508-790-6230 s Property Owner Must Complete and Sign This Section If Using A Builder -j ;r r 7 i Sho,� as Owner of the subject property hereby authorize / es �� Its 0&'rP17MJto act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature Date [T*0 Print Name JJ If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the �F reverse side. s C:\Users\decollikWppData\Loca]\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QO\EXPRESS.doc ,1 Revised 090809 4