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Home My WebLink About0353 HUCKINS NECK ROAD C, 3��a ��s �' �� { . :! �., n �. _ � ,iv V 1 tc Town of Barnstable *Permit# aoO66 7 Expires 6 months from issue date Regulatory Services Fee `7 X-PRESS PERMIT Thomas F. Geller,Director Building Division oR ,SlZ�od� MAY 2 3 2006 Tom Perry,CBO, Building Commissioner TOWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address ❑Residential Value of WorAS ay. Minimum fee of$25.00 for work under$6000.00 Owner's Naive&Address G,cr M Contractor's Name .(z, 4—"va mQ�( -( Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) () 1}B b SL ❑�doIkman'S Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name Q 1 VK fM is r trVk L- Workman's Comp.Policy# P I L� 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 ❑ Replacement Windows. U-Value (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. Home Improvement Contractors License is required. SIGNATURIE: Q:For=:expmtrg Revise071405 Department oflndustrialAccidents UT Office of Investigations 600 Washington Street Boston, Mf4 02111 www.mass.gov/dia Workers' Affidavit-1 Compensation Insurance Adavit: Builders/Contractors/Electricians/Plu.>aoilbers Applicant Information Please Print Legibly Name(Business/Organization/lu&vidual):_ 9 g �A Address: L � b f-k)G, s i-5 LAVE City/State/Zip: • MAP CTh 0y Yh i LLS (11 V�at-A Phone t SOD Are you an employer? Check the•appropriate box: Type of pro ject'(requia-ed): 1.❑ I am a employer with 1 4. ❑ I am a general contractor and I 6. New construction employees(fall 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 & ❑ Demolition worlang for mein any capacity. workers' comp.insurance. . 9. ❑ Building addition [No workers' c mp.insurance• 5. ❑ We are a corporation and its required,] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I1-❑ 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' 13,❑ Other c,3mp,insurance required.] 4P.ny applicant that checks box#1 must also fill out the section below showing their workers'compeasatioa policymforrnatiow t.Romebwners wbo subrait this affidavit indieatiag they are doing all work aadt'hen hire outside contractors must submit anew affidavit indicating such =Contractors that check this box must attached an additional sheet showing the aurae ofthe subcontractors and their workers'comp,policy infDrn2ation. ram an a»iployer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: A l fy'\ M u I U O L IL) . C(-)- Policy#or Self-".Lic.#: Expiration Date: Job Site Address: 3 5 3 iA c t f-k i yQ< (1 Eck'. P-c City/State/Zip: t -1 j� (t 1 F 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 a. 152 can lead to the imposition of criminal penalties of a fine up.to$1,50000 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to SZ50.00 a day against the violator'. Be advised that a copy of this statement may be forwarded to the Office; of Investigations of the DLk for insurance coverage verification, 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct:. Simature: 9a cL- Q g nQ Date: 5- Phone Off dial use only. Do not Vrite in this area,to be completed by city or town of ccial City or Town: Permit/f.ricense# Issuing Authority (circle one): 1.Board of health 2.Building Depaatment 3.City/Towm Clerk a.Electrical!asp eetor 5,Plumbing Inspector 6. Other Contact Person: Phone . �t Li iVilt7 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. V Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,.6ial 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 representatives 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 bean 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 permfrt to operate a business or to construct buildings in the cornmonwealtb for any applicant wbo 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-contractor(s)name(s),address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LIP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or UP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents far confirmation of insurance coverage. Also be sure to sign and date the affidavit. The-affidavit should be returned to the city or town that the application for the permit or license is being requested;not the Department of' . Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' comp ens ationpolicy,please call the Department at the number listed below. Self-insured companies;dmouM der their self-insurance license number on-the appropriate line. City or Town 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 pern*/Iicense number which will be used as a reference number. In addition;an applicant that mast submit ran.141c 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a lieens a 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 hlse to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a can The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigations 600 Washington Street Boston, MA 02111 Tel. T 617-727-4900 ext 406 or 1-877-MASSl- FE Revised 5-25-05 Fax#6 17-727-7749 w-ww.mass.gov/eia °FINE Town of Barnstable ti Regulatory Services nnxxsrwBt.E, v MASS, $,� Thomas F.Geiler,Director 16 0 "pTE39. , Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, q r* V 13 (k ,as.Owner of the subject property hereby authorize 6 k 1R a PA,&& k to act on my behalf, in all matters relative to work authorized by this building pem:ut application for. J. 3S3 iAu kiu S �J Eac �(� C�NrrcU�UGLi (Address of Job) afore ofJOwner Date Print Name Q:FORMS:OwNERPERMIMSION �r -- . .•-..� ,.yam. - - _ r zITI 0 CD m r ; F m � co vD ' v ; .' o .lCL �. r