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Town of Barnstable *Permit
EwTres 6 mo from issue date
Regulatory Services Fee
• BARNSTABLE
MASS. Richard V.Scali,Director
'°rFcw►�► Building Division
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imptznt
Map/parcel Number 7a7,
Property Address (,Dz
esidential Value of Work$ Z-��� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 6P t � o Z. C�I,� ` �V C-- ��• '`L �J��.
Contractor's Name�(� V v 1 p_.� fl Telephone Number -7 7 7524P 'G-S Pt
Home Improvement Contractor License#(if applicable) 69(0 7 Email: � 15`� l 1 by V IK4 42 `+ '
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance !RAW,
Chec e sFP I am a sole proprietor �j����412
❑ o
I am the Homeowner �
❑ I have Worker's Compensation Insurance
Insurance Company Name
Y
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
❑Re f f(hurricane nailed)(not stripping. Going over existing layers of roof)
e-stde
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.,
Separate Electrical&Fire Permits required.
*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 the ome Improvement#Contractors License&Construction Supervisors.License is
re uired.
t ,
SIGNATURE: epK
Q:\WPFILES\FORMS\buil ng permit forms\EXPRESS.doc
06/20/16 `
4 •
Town of Barnstable
R
Regulatory Services
URNSTAME,
MAss. Richard V.Scali,Director
s699.
�M � Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
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 application for:
,
(Address of 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
1 s ctons are performed and accepted.
Ile,
ignature of Owner SigKature of.Applicant
Y
1
Kctte--, A—
Print Name Print Name
1
Date
r
27ie Cownrompealfii ofMaysadixsetts
B'eparbucut a f ndustrid Accidm&
Ojrwe of LTw-%6gtrtiwu.
.00 Waslsurgiort Street
Boston,MA 021111
immYnaxLgorldia
War•lm& Cmipensaf an Lmumnce Affidavit B.triTdeim/Cantractar&Mectr ciansfPlambers
APPUca nt Please Print
Naim
Ada,:
tol
Cityf��tels � �
Are you an employer?.Qteckthe appropriate b= Type of project(required):
I.❑ I am a employer with. 4. ❑I am a general contractor and I 6- ❑New co ustcuC6 ax
eee3(full aud!or part-timed* have luretfie sub-contractors
2. am a sQ1e proprietor or partner- listed on the attached sheet I- ❑Remodeling
sbx p and have no emplcyees. Mese sub-contractors have 9- El Demalifioa
working forme in any testy_ employees andbave worms- 9-.Q S,uilclmig addition
[No wad mrs'Comp-rice comp- # -
r -] S- We are a-corporati n.and its 10-Q Electrical repairs or ad&fions
I❑ I am a homeowner doing all work officers have exercised their 11-❑Plumbing repairs or adclitions
myself[No workers' right of egempfiau per MGI. 7 eF�
, = requ �]t c.5.�, §1(4�andvReha�rezpn L.OR�ofr
13_❑otheremployees_[NOworlrers' 1
coop-insurance require]
'$-ay gVHcmtdwt cbedmbaa fl mast also fRoufthe sectfonbeIdwAxoning ides woffcea'am3p=mfi=parwyinffia3s6mL
�F�ameaviaers trho sab�it this s$idaeiF in�r�g they axe doing slE�oxlc said then 1�autsid¢craatm�*+*��st sobmit a nem affida�t indieaaina sstcIi ,
TCa s ban Est attad, =additional sheet doa:iag the names of the sob-cco=b3m zad state whethet or nut those conies hwe
employees.Ifthe have mnpIaye?-%dwynmsrpmvide&es wadEeW c=P•Fly nmmbez
I am are employer float is prmzdirrg�vr�rkers'comlrerisrdian ursuratFce�nr�r�empFuJ�ex B�toty is ri�t�paFic�curd jQla rite
irrzornrrelian
Insurance Company Name: '
-Policy iF or Self-ism I.ia;g E�piratiaaI�ate:
Job Site Address: Citylstawzl p.
Attach a-mpy of the svnrl;we compensationpolicy declaration page(showing the policy number and expiration.date).
Failme to secure coverage as required under Se-cti(m 23A of MGL c_157 can lead to the imposition of criminal penaltises of a
fine up to$150tk Oa andlar arie-year impdsonxnenk as weiU as rivil penalties in the faun of a STOP WORK ORDER aid a fine
of up to _DO a day abaamst the violator. Be adsdsed&at a copy of this statement maybe fxvmded to the Office cd
Investegatians ofthe DIA for insraznct-coverage vetifficatioa_
I do leerzby &epZ7dPV ahkr al` that the iraf ar�raIfmj-pr-m.WW a bpe is hpm and correct
osaafnrrs- Date- `
--(
Phone
Of 7citd use only: Do not write in flds area,to be completed by city artatrn a,oicial
My or'I'aasa: PerntlLieense;ff
Issuing Authority(ca de One):
L Sward of Health *.Buffilng Department 3.CAyfrown.Clerk 4-Electrical Inspector 5.Plumbing fimpector
b.Other
Contact Person: Phone#-
-- 6
ormation and lastraeflons
e General Laws chapter M requares all employs to pravide W= '�easaiion for theiF eruployees.
Pursaat-to this state,an MnP&Y='is defined as�_.evety p=6n in 8ie service of anofm ender any contract Ofbire, ,
esprass or implieCL oral or writs=f
An enployer is defined as ran indiviina.I,partnershjp,association;carpM--6 n or other Iegal espy,or ray two or mole
of the foregoing engaged in a joint ,and i achzdmg the legal of a deceased emplayer,or ffic
of an' -A .association or otherlegal entity,employ mg ea¢ployees- However'the
receiver or trustee: individual,garFneashrp .
owner of a.dwelling hanse having not mom than three apartments and who resides therein,or the;occupant ofthe -
dwdling house of mo�.er who effiploys peirson te�ce
s to do mafi ,cao`sf rr c on or repair wow.on-such dwelling house
or on the groTmds or bin-Idmg appMj=ant ffieret4 shall not because of surer=3playmeuf be deemed to be an enxpto Y=
MCH.chapter 152,§25C(6)also states that"every state or local Hc=Zmff agency shall withhold ffie issuance or
renewal of a licen a or permit to operate a buskers or to constrict buHdio-gs in the commonwealth for ray
applicant who has not produced acceptable evidence of cumpfancewith the 4n mraannce.covexagerequire
Additionally.MCrL chapter M,§25CM stains fileifher the ca®=v7mn nor any ofits political subdivisions shall
eater fiAD any contract for the prance ofpublic work until acceptable evidence of compliance;with The insarance.•
regu;,-era ems of this chapter have been p=C13 ed in the CQZd CtiD a ar faozity-"
A.}�plicaats
Please fffi ovt the wori�as'compensation affidavit completely,by g-&a boxes�apply to your situation anl,if
necessary,supply sub-contractors)name(s), addi-ess(es)mdphonenumber(s) alongwiththeir cextcEicate(s) of
insurance- L=t—,dLiabR4 Compames(LLC)orLia itedLiabi y'Parineshrps(LIP)wi$.no eInyt offier tininthe
members or partners,are not ruined to casy vmrke&compensation iasarmce- If an LLC or LLP does have
mpIo ms a cJi�Y
is rmnned. Be advised tl:A this afidaYitmaybe mbinifted to fae Department of Industrial
-
Accidents for confsmation ofmsunrp coverage. Also be sure to sign and date the affldzvit The affidavit should
be retied to ffie city or town that the application for the permit or license is being requester not the Department of ;
lndstrlaI Accidm. gmuldyou have any questions regarding the,law or ifyou ate rcqak-edto obtam a workars'
compensationpoficy,please calif m Department at&amnnberlisted.belovr Self-firm edeompanies should eoterthair
self-fi sur`aace license amber on the agpmpriate line.
City or Town OfEldals
Please be sore that the affidavit is complete and priatedlegibly- 'Ihe Deputmexitbas provided a space at the botfnm
of the affidavit for you to fill.out in the event the Office oflnve<stigafi�has to cost you ding the applicant_
Pleas e b e s=in fIl i a the pennit/Iicrose mnnber which vM be used as a refere nca number. Iu addition,an applicant
Brat must sabmit multiple p=,Vliccmm apply-co ions is any given year,need only submit one affidavit indicating eosent
policy information Cif necessazy)and udder`Job Shn.4 dffir-"the applicant should w,�e"all locations in (city or:
town)-"A copy of the-affidavitfh.at has been officially stamped or marked byAe city or town maybe provided to the
applicant as#oo-fthe a valid affidavit is on file for f&e permits or licenses A new affidavitim st be filed oit each
year.Where a home owner or citizen is obTaming a license or pexiiit not related io any business or commercial T=Xt=
(i e- a dog license or pen t to bum leaves etc.)said person is MOT reed to complete this affidavit,
The Office oflnvestigHtiow wouldIiketo thankyoum advance for your cDopera ion and shouldyouhave any questions,
please do not hest ate to give us a call
The Department`s address,Telephone and fax zmmber:
-ft of M&sSa� ,
t of In a]Accidents
Qffi=Of 7nVe&V k
MA Oil11
Tel.4 617-' -49W QExt406 or
Fax#617` 277749
R.avised.424-07 W V-Mega-dd
t Massachusett's Department of Public Safet'
Board of Building Regulations and Standard's
License: CS-094654 rz
Construction
tion S ,.u e
KYLE A MARTIN ,
466 BOXBERRY HILL RD
EAST
6>,
FALM �" ,OUTH MA :02536J,-
i
'3 a. ..
b Expiration:
r atio
Commissioner P n' -
11/11/2017
ff4 CWv ' .
Office of Consumer Affairs&Business RegulatiGon _
a
HOME IMPROVEMENT CONTRACTOR
Registration IZ4667 Type:
Expiratiou�_- ) 3120118 Individual
—�
KYLE A.MARTIN i
KYLE MARTIN
466 BOXBERRY HILL RD4
MA 02
E.FALMOUTH, 53$ t Undersecretary
construction Supervisor
- Restricted to:
Unrestricted-Buildings of any use group which contain
less than 35,000 cubic feet(991 cubic meters)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
DPS Licensing information visit: WWW.MASS.GOV/DPS
`I License or registration valid for individul use only I
before.the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,MA 02116
• j
: r
Not valia without signature
l
Town of Barnstable *Permit#
of t"F ram, ,
Expires 6 months from issue date
°•� Regulatory Services Fee
BAMSTABM : Thomas F.Geiler,Director ftL
�i, i639 ,•� Building Division
'OrEn �A e5
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ova L.)uS'
Not Valid without Red X-Press Imprint
Map/parcel Number I I C)
I IsProperty Address
Residential Value Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address l�l r__\ 0 i
G12 L� 15 t�t�. �� �✓i I �f 1 ' 1
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance IT
Check one:
I am a sole proprietor APR 02008
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name r—k—D l 5 CL
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to `I
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc:
***Note: Property Owner must sign Property Owner Letter oj Permission, .:
A copy of the Home Improvement Contractors License is r quire :.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC
Revise020108
The Commonwealth,ofMassachusetts
Department of Industrial Accidents
kiOffice of Investigations
600 Washington Street
Boston, MA 0211:1
www.mass.gov/dia
Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Legibly
Name(Business/Organizarion/Individud): J 60
Address: toz U,k l) )I `-
City/State/Zip: l �y1�l V►' p '''i`0 �J�Phone.#: 6�"O � �
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and 1 6. ❑New constriction
employees(full and/or part-time):* have hired the sub-contractors
2.❑ I am a'sole proprietor or partner- listed on the attached sheet- 7. ❑Remodeling
ship and have no employees 'These sub-contractors have g• Demolition
working for me in any capacity.• employees and have workers' 9 Building addition
[No workers' comp.-insurance comp.insurance$
required.] •5. We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their 11.❑Plumbing repairs or additions
KVII am a homeowner doing all work
myself[No workers' comp.. right of exemption per MGL 12,&Roof repairs
insurance required.]t c..152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp,h mn-ance 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.
ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the subcontractors have employees,they must providt their workers'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#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 tip to,$1,500.00 and/or one-year inprisonment,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 u der pains•and penalties of perjury that the information provided ove true and correct;
Simature• C Date: —
Phone# ,C✓ �'a- "t L�1- `
Official use only. Do not write in this area,to be completed by city or town officlaL,
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
t
6.Other
Contact Person: '.•Phone:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees:
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representative's of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work until acceptable evidence of compliance-with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. also be sure to sign and date the affidavit. The affidavit should
be returned to the cityor town that the application for the permit or license is being requested,not the Department of
PP P g eq'r
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Towp Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit.must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone-and fax number.
The Commonwealth of Massachusetts
Department of Iadust dal Accidents .
Office of Investigations
600 Wwhington Street
Boston, MA 02111 4)1
Tel. #617-727-490_4 ext 4-06 or 1-977-MASS E /
Fax# 617-727-774
Revised 11-22706
www.mass.gov(dia
/A
Town of Barnstable
�Oc1HE Tp��
Regulatory Services
+ «
Thomas F.Geiler,Director
BARNSTABLE.
9 MASS.
1639. Building Division
�JED ,ra Tom Perry,Building Commissioner .
200 Main Street, Hyannis,MA 02601
urmv.town.barnsiable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
-------
HOMEOWNER LICENSE EXEMPTION
G Please Print
DATE:
JOB LOCATION:
number �n; street Ol-agg`ee (�
"HOMEOWNER":
name l home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners".was extended to include owner-occupied dwellings of six units o'r less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor. r
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to
be, a one or two-family dwelling,`attached or detached structures accessory to such use and/or farm structures. A
a two
period shall not be considered a homeowner. Such
person who constructs more than one home in
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building pemut. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations: f'
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
req ire e f
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be.required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that:,"Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would Huth a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible. .
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
oFtHEra,, Town of Barnstable
Regulatory Services
HAS& Thomas F.Geiler, Director
i639•
'OrFnt�u►t" Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-8627403 8 ax: 508-790-623 0
Property Owner Must
Complete and Sign This Sec 'on
If Using A Builder
10j�� , as Owner of the subject property
c
hereby authorize to act on my behalf,
in altmatters relative to work authorized b this building permit application for:
(Address of Job)
Signature of Owner Date
A
Print Na
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on the reverse side.
t
1 Town of Barnstable *Permit#a M7P7 �{ Co
Expires 6 months from issue date
+�.E, • PERIw Regulatory Services FeeMASI
� 26 2007 Thomas F.Geiiler,Director
T - Building Division
N OF BARNSTA j3Lji Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230
EXPRESS PERMH APPLICATION - RESIDENTIAL ONLY
Not VaW without Red X-Press Imprint
Map/parcel Number ( �1 -5 0
Property Address a. N o l l Si -2 -Dy. Le.,,,ke-a v a`Ck e— U2G 3
Residential Value of Works Sa 7 I Minimum fee of-$25.00 for work under$6000.00
t
Owner's Name&Address
Contractor's Name kcc 1Cj� Telephone Number SD b 398 f S H
Home Improvement Contractor License#(if applicable) / 2 cle-7 53
Construction Supervisor's License#(if
❑Workman's Compensation Insurance
Chec one:
I am a sole proprietor
la m the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name I�)ALAZ 9, t"UA &4tLu
04+�6�/.`�y_
V4tar]ana G olicy# 20 22,a Y,2�Q
Copy of Insurance Compliance Certifcate must be on file.
Permit Request(check box)
❑ Re-roof(stripping"old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows. U Value 6, 31 ( .44)
*Where required:required: Issuance of this permit does not exempt compliance with other town deparhneat regulations,i.e.Historic,Conservation,eta
***Note: Property Owner must sign Property Owner Letter of Permission.
/( pHome h=rovement Contractors License is required.
Signature
QForms:expmtrg
163004
Department of hidasAd Acctd'ents
Office.of Investigationg ' .
► ; 600 Washington is eat
Boston,M ,02111
www.mass:gov�dla .' . .
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electiidans/Plu3nbers
Applicant Information r ' ' '" ` Please Print Leta'bly
Name (Business/Orgamzation/ladividnal): SC('7 1S kLZ C"P 6ht' 1f
-------------
Address: '*C1 '(Y1Mf]�TR 12
City/$tate/Zip: Phone#: , f
-
Are you an-employer?Check the appropriate boa:. . , T� of project(required)--
1.❑ 1:am a•employcr V# 4. ❑ I am a general contractor and I 6. ❑Now cowtuccdoon
]nyees(faIl'and/dr pazt tmne)*' have hired the sub-contractors r x r.
' .
Remo
2. I am a sole piopnetor or partner ', ? listed on the attached sheet t • _ 7 .❑ Aj delmg: r
-ship and have no`eiuployees i J"These-sub-contractors have 8..❑D. molitiaa Y -a��
it
L Jt x#
worlQngjk mem any Cap�Y ' ' , t.vvoikets' comp:msuranca:. 9.U Buildiagaddidon,
[No workers' comp:insurance ' 5 ❑ We are a corporation and its { ❑
ram] - "#u • �"L officers have exercised weir 10 Electncal iepafrs or.additions
3.❑ I am a homeowner"dog aIlrior>t'�'" 'right of exemption per MGL 11.❑Plambmg epafrs or,additions
;myself(Nov*keirs' comp. i CM-Of' �'c. 152,§1(4),and:we.havena - , ..12.❑ Roofrepaas �
insurance required,]t T'employees.[No worlce, 13. Ofliet a
�. � comp.insurance required,) . y`4' .
*Any apphcaat9iat chabboa#1=nt also fli cage archon below showing they wor]cets'c ou peasatioa pohay,won: b
t Hom�wnas•wbo submitbis affidavit bAckim they are doing of vmk endlbmbi n outside cout:adminms m tdt a-new affidavit 4ndicaRmg mi t-h,
tcmi ti at cheektbis box,must attached en additional,sheet sbdwing the name of*e sab•conhact tad weir worker;'comp•policy informagoa.
in ornt4tWIL ,
�CompauyName: 115
y is
1;a 0�C�- 2 Q ZPolicy#o Sf E#i=ation D /.Z—'ZOOa
Job sineAddress /o f�>I��/��° f• '' °' 4 City/State/4:
Attach a copy of the workers compensatfon policy declaration page(showing the poRcjiiumber and e*h*tton date).
-Faz7ure to.secure coverage as required lender Section 25A of MGL e. 152 cari lead to$ie imposition o#'ariwmalpenalties of a
fine up,bo.$.1,500,0 and/oi ane�year mrpnsomment, as well as:civil penalties in hie form of a$TOP'WORK ORDER•andl a fine
ofp^ $ d ev
. o hio % -13e'advised that a copy of his statement maybe forwarded to the Office of
I do;hereby certify' r the paliss imdp ofRidul that the information provided above is true and correct
:., -,q. . �;. .,� �� ,r { ! F t 'Date: . : uo 0 .
Phone#• '� � /S // .. r _
0ftidl`use only.,,Do not write-in this area,to be completed by cuy or town of,�cial �•
• - .5.. `f t- • w .p _.. • r+ ,_-.ax -. . .L �� a,j.. 3 -•. ....t ` <c'.{:ins,.f6t.tl�"P''r'
- .. N+ • itt .F t i f f n J 'It! rt
.c <•'7 "t }..'+!' r.,.! - !, {
City or Town.
N 4 n.M•
Issuing Authoritq{(circle one): _ M-
1.Board,.of Health 2.Building Department 3.Cityl Town Clerk 4.Electrical Inspector S.Plumbing Inspector
C4IItaCtPerSOII: .` t . . . •5',.
Phone#. -
Information cilia. Instructions
Massachus General Laws chapter 152 tequires all-employers to provide workers',compensatwn'for'theirMezriployees
ee is defined as"...every person in the servke•of another under any contract of hire,
pursuant to this si~atute, an emP_I°3' •_ _
express or m�phek oral or Wrim.m" ,r rn � , ,
=�LAn pliryer is define aS:": ► .p � sociati�n,�' p°ration°r other legal ems+,or any two or more
of tlie�foregoing•engaged aJomt enterprise;and inchtding the legal representatives of a deceased employer,or_the
receiver or irostee of as individual,partnership,association or 66ei legal eaiaty,employing employ. 1kWv�:er:*e•
owner"of-a dwelling house having not more than three apartments and.who,resides.thereto,or the occapam of the
ersons to do mamtetce,�nstrachon or repair house
` worYtin such dyll�.g e
dwelling house of another who emP P _ y -�. e e _
ai`on the grounds or btn'Id appurtenant thereto shall not because of sack employment b� deemed b as employer"
L __.
�M =o�pter Z,§ �� ,,.. ., .... ..
15 25C also states 9iat every state or local licensing agency_ahall withholdthe issuanm or -•• - .
exmft•to operate a business or to construct buildings In the commonwealth for any
renewal of a,license or p • � , • P. •
applicant:who.has ant p rodneed acceptable evidence of compliance wltL the insurance coverage required" • ^
rA • • , ter 152 25 states"Neither&e cosmm�We"mbr any of its-political subdivisions shall -
ddttio MGL chnpr § .. 7)
s � j, fo he mo 'dense of comVlice with the insurance
.��,cAn r the petfonmance:o - work u�acceptabl
� enter m .�. .� .
ements of is_choter have�em presen to the.contracting as "S •- `4 ';` w
• _. •I• 1 pia.. •i • .l1 -
.•.�,1�
Ann]scants re
,i -Tr7 . .:1•. J] t,.. Jj =`� l a •t, •�;• P�W�yVYa.lien and,if.. •
Please fM,O t.the workers compensation affdavrt completiekY,b3'checking the boxes app N
'" .' l sub-covtraetm(s)nai*s),address(es)and phone mnmber(s)aloagw�idi ftir cdtific-aRe(s)'Of"
necessary,suPP Y - ' s with no employees other than the
r: insurance. L=*dLiabi'1styGorupauies_(LLC)..orLimiWLialt�ityPazt=sh� (L•LP) �._ . ...
members or partners;are not ngd#ed to carry workers'_compensation in=mce."If an LLC or LLP does halve''
Depart
flits affidavit may
employees,a policy is required»_Be advised that y be submitted the Department of Industrial
Accidents for confnamation of insurdace coverage. :'Also besure to sign and date the affidavit. The affidavit should
x t'be setnrned tin the city,O r town bat flee application for flee permit or license is being requested,not the Departmeht of
" 3l ouid'"you have my questions regarding flee kw'or•if you•are regnired to,obtain a workez5'A '
Industnal Acctdeints
'` lease cad the Department at flte number listed below, Self-insured companies should enter their
compensattonp_ohcY,p , —
celicense natnaber on flte �lme.
. ...self-msuran►
4
. OMC�S a
GYtp or Town .
Please be sore that tl a affidavit is complete and printed legibly..;The Department has provided a space at the botbam
of flte affidavit fo Yon to fi1t'bux in the event the Office of Investigations has.to contact y;ou regardrmg flee applicant
. ., ...
•"please be sure to fill iri fire permrtlhcense mtmber which will be used,.as a reference immbm. In addit M as appheamt
thatmast submmtn m1tiplepemuidlie e,applications in,any,&=year;need only submit.one ak"idavrtindicating current
it ) C•h P• k
Policy"- O nation"(ifnecessary)and under"Job Site'AddresC-the.:applicant:should write"all locations
A11 , ed or:matked by the or tnwn may be provided to the
IDS), of thea$vdavit thathas been officially stamp
-applicant as proof that a valid affidavit ism file,for;future pemnita or-licenses..A new affidavit=st be filled out.each
4 ' e owner or citizen is obtaining a license or permit not related to•any business oz ccippeercial v®tie
year Where a ho=n
i(ic a dog license or Pemnt.to bin°leaves etc.)said person is NOT required to complete flris affidavit
e Ofice of Juv ons would like to thank you in advance for your cooperation and should you have any.questions,
�. ,.please do�thesitate to give us a calL .
The*Departiueufs address,telephone and•fax mtmber:
_ - ._ . _ The Commonwealth of Massachnsetts . - _... .. _. ._._
. ppparhnent of Industrial Accidents . . .. • '. .
Qf 1]IYeftat pus
4'+y f r r � t.. r`t. « , .•A:.- +..h...„•. :.? ..600.'Washingo -§Jr ee t- ., �
fi Botan *A 0211�s .. ..._, _
-. '! - ,t.•i-" to to a..;!,.3.ter. ;.i 3 .. :'t " j y ' .e�� _...�.,Y -. .! t �' .-.j..# .. •!1 a^
Tel.#617-727-4900 ext'406 ot'•1477-MASSAM
Fax`#617-727-7749
Revised 5+26 OS � wwov.mass.gOv7aa
4 � ?t" 'f*.,lr.} -bpi - ;a�1.1 ��•#6 1`�.. .�'l ,. ..
PROP
VAk0::kUNEZ CARPENTRY
7.9 Mayfair.Rd..: Page 3 oT
SOUTH.DENNIS, MA 02660
MA Ltc 4069680 ,
N:1 C #124793
(866) 398.1511 . Tolt Free.
(508) 398 1511_* Dennis, MA
PHONE DATE
TO: Ms.. KIm Spiro 508=7289844 6>. /2007-
.
JOB NAME/LOCATION
62 hillside Drive :
Centerville MA 0263.2- Andersen`w2ndows
E terror Ent
xryway
JOB.NUMBER .:;
r JOB PHONE
9 8:4 4 SAME.
We hereby submit specifications and.estimates for.
bolt:
New fiberglass exterior door. . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . $ 437.75
Labor to install door less new door. . . . $ 340.00
** Grand total . .$ 777 7.5
** This proposal° does not include any. painting, staining.ror repairs not. described` above
** All Andersen products described above'.will:'be`prepGid`:'r�y _Yome.`owner: '
** Supply interior/exterior trim and, framing :mate.rials::where needed.. Interior:trim: will. be
clamshell casing, and :exterior will be :white cedar sidewall•.shingles.'brought to sides_,:
and bottom of windows
** All Andersen windows described. above are t:he 400. series with Low::-E4 ..argon gas :f ill ed'
insulated glass and energy star :rated.
Supply town building -permit
** Take all debris from this job to town landfill.
** Make arrangement for delivery of. .new .windows'.and doors
*** If this proposal is satisfactory, please s;ign. the YELLOW copy .and. return..with payment
schedule.
vase Rake a check payable to Vasco Nunez,,Carpentry in the. amount of $ r for
yo - v, Andersen products listed abGv2 and please include this chec-_ wiSigned
pr"posai. Gr.' 3-4 weeks fo_'' delivery.
s.
We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of
4 lave : Thousand Three Hundred FortV Five and 69/100 Dollars dollars($ �, 44 �r �• �1,`.,
Payment to be made as follows: au ®s
Labor: 50% Down payment to start at time of start. . . . . . . . . . . . . . . . . .
Labor: 50 o Upon completion at time of completion. . . . . . . . . . . . . . . . . .... . {�,�
m k�l lahnr 11 �6�
All material is guaranteed to be as spect ied.Al work to be completed in a professional
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature — Zf
charge over and above the estimate.All agreements contingent upon strikes,accidents or
delays beyond our control.Owner to carry fire,tomado,and other necessary insurance.Our Note:This proposal may be
workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within 30 days.
Acceptance of Proposal'—The above prices,specifications and con-
ditions are satisfactory and are hereby accepted.You are authorized to do the work as
,. Signature
specified.Payment will be made as outlined above. g
z
Signature
� Z
Date of Acceptance:
PRODUCT 13129E USE WITH 771C ENVELOPE NESS To Reorder 1 800-225-6380 or www.nebs.com ' PRINTED IN USA., A
A Y
✓) •,�Y�// P. /�/ ;../ .�,asac�zctoe�i`s
ff A�tW 6r6 DI It(REGULATIONS
License: CONSTRUCTION SUPERVISOR
$y' Number CS 069680 F
ttt .;
Expires tQ10312008 Tr.no: 2714.0;
VASCO E NUNEZ i l*
79 MAYFAIR RD
S DENNIS, MA 026ti1?
CommissionerI
.. .
tie �an;,naonur o�✓�ir�xsac�iva�lt . r ..
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:. 124793
Expiration;:: 8/25/2009 Tr# 132409
Type: Individual t;
Vasco E.Nunez III e
I _
Vasco.Nunez, III
79 Mayfair Rd. GLao..-�
S.Dennis,MA 02660 Administrator
1 ..
•
r
f -
FTHE I', Town of Barnstable
ti
y Regulatory Services
�axrrsraBr�' ' Thomas F.Geiler,Director
MAW a �
9�°ArEo .� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
.Office: 508-862-4038 Fax: 508-790-6230
NOTICE TO THE BUILDING DIVISION OF WITHDRAWAL OF
LICENSED CONSTRUCTION SUPERVISOR FROM PROJECT
'I, )���S O U n , C e
# LV�I lreb certify that I am no longer the Construction Supervisor listed
Y Y g A
on the application for the project under construction as authorized by building permit
Dd D� sued to roe address''
# � (property X S
on , 200_.
I
I also certify that on CZ �5 D a , 200_.0_, I notified the property owner,that theme
project under construction must cease until a successor licensed Construction Supervisor,
is submitted on the records of the Building Division.
ZZ
LICEJSlf HOLDER ATE
q/forms/newcontr
reference R-5 780 CMR
r Town of Barnstable *Permit#02 b V �o
Expires 6 months from issue date
MA • �� 11' Regulatory Services Fee 3(0
MASS
1 639. Thomas F.Geiler,Director
2 8 2007 "
�. Building Division
N OF SARNSTAg�E :Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230 r ..
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 19 -1 O 3
Property Address fa al 0 1 9i 2 T t OQw V 4��f— 026 3 Z-11
Residential Value of Work Minimum fee of-$25.00 for.work under$6000.00
Owner's Name&Address_mil S_ K,M
va iCds(-�e `or. `.Yr",�v kh 4 14 az6.3 2-,
Contractor's Name LC-, � Z , Telephone'Number___-5-0-2) 3 I F I T/
Home Improvement Contractor License#(if applicable)_ / 2 7 S 3
Construction Supervisor's License#(if appficable) _ �q 68 .
❑Workman's Compensation Insurance
Chec one:
-ATI am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name �(:�-( (Z !}elan &4tLcc V
licy# 26) 26) ` ,—>0 2--
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 ',Val etmf�Tl7
❑Re-roof(not stripping. Going over existing layers of root) N:
❑ Re-side
L2}-Replacement Windows. U Value 6, 3 / (maximum.44)
•Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner mast sign Property Owner Letter of Permission.
Home ovement Contractors License is required.
Signature
QForms:expmtrg
Revise063004 ,