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HomeMy WebLinkAbout0200 HORSESHOE LANE s, : Town of Barnstable *Permit# 5 9 rz- Expires-0 months om issue date Regulatory Services Fie" Thomas F. Geiler,Director mPRESS IT Building Division Tom Perry,CBO, Building Commissioner AUG ® 9 2005 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF B.ARNSTABL Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint vlap/parcel Number c�)•O 1 115_� ?roperty Address .100J Residential Value of Work A 6 00. Minimum fee of$25.00 for work under$6000.00 < � r Nwner's Name&Address contractor's Name Telephone Number &00 Home Improvement Contractor License#(if applicable) construction Supervisor's License#(if applicable) ]Workman's Compensation Insurance Check one: []/am a sole proprietor U 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. ?ermit 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 ' 7_;0 (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 must sign Property Owner Letter of Permission. ome I vement Contractors License is required. SIGNATURE: ZTorms:expmtrg Zevise071405 Town of Barnstable °* Regulatory Services DSA39. Thomas F:Geiler,Director �A ' 'AtE6 ;.�A`` Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I 4✓ ,as Owner of the subject property hereby uthorize5 `�-'�L [ ►-l�S to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) tore of Owner Date ���c w.✓-� `�c �.lc�c tLA li Print Name QTORMS:OWMTERMISSION The Commonwealth o Massachusett "1 f s ' Department of Industrial Accidents Office of Investigations A ' ' d 600 Washington Street y Boston,AM 02111 wwiv.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly [dame,(Business/org nization/Individual): Address: Opoo City/State/Zip: 10• N A- t t-©q-V dal M: Phone#: ►re you an employer? Check the-appropriate box:. Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6, .❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its equired.1 officers have exercised their 10-❑ Electrical repairs or.additions I am 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' comp.insurance required.] 13.❑ Other 6)i ti,000 A1.Ekka, ny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: � :omeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information, !man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rormation. Durance-Company Name: licy#or Self-ins.Lie. #: . Expiration Date: Site Address: City/State/Zip: tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Uure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of . restigations of the DIA for insurance coverage verification. o hereby certify under a pains and penalties ofperjury that the information provided above is true and correct aiure:. Date S .�. .a�o 0 one#: IV' 15®Y> -7�I 1&86_7 . 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 6.Other 5.Plumbing Inspector Contact Person: Phone#: