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r Town of Barnstable ` -*Permit#-->?e91,)0;5,39 7
Expires 6 months fr issue date
± Regulatory Services Fee 75,a S
+ s�xxsresi.E. • ,,ll
9�A 163s. Thomas F. Geiler,Director /S/I L d
�6 d
tED MA'S�'
Building Division X-PRESS PERMIT
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 S E P - 2012
www.town.barastable.ma us
Office: 508-862-403 8 - Fax: 508-790-623 0
EXPRESS PERMIT APPLICATION - RESIDENT BARNSTABLE
Not Valid without Red X-Press Imprint.
Map/parcel Number ` PP�
Property.Address C� �'Vt �`"'1" v
CAJ
El'Residential Value of Work Minimum fee of$35.00 for work under$6000.00
. _ j
Owner'sName&Address (� /C.1-bA4 P 0
Contractor's Name Fa o ,'u� 'Telephone Number "4
Home Impiovement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance.
Check one:
❑ I am a sole proprietor
❑ I am the omeowner
ave Worker's Compensation Insurance
Insurance Company Name C—O C--1C5t(
Workman's Comp.Policy# 6t
.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-roof(hurricane nailed)(not stripping. Going over: existing layers of roof)
e-side
#Of doors
Replacement Windows/doors/sliders.U-Value` +� 6 (maximum.35)#of windows @ "�
❑ 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 ofTermission:
A copy of the Home Improvement Contractors License&'Construction Supervisors License is
required..
.SIGNATURE:
QAWPFILES\FORMSIbuilding permit forms=RESS.doC
Revised 053012
The aCrrmmunweafth of Massachasetts
Deparhnmt offadusftialAcciden&
Office a,f In tigations:
600 Waskrington Street
Boston,M-4 02111
n mrrss.�ovfdia.
Workers' Compensation Insurance Affidavit. Bmlders(C-ontractur,s lectrician-JPlu nbers
Applicant Information Please Print Lej bly
Name MusiuesO U:. 9-0 6A-t c�
�t rs a a _ Cie ; (�, WMN Phow fP `2 -7
Are you an employer?C,Mck the appropriate box: T of project r
4. I am a contractor and � p .i (required):
1_❑ I ama em Toyer With ❑ 6- ❑New construction
C�'� �W and/or part-ime).* :have hired the sub-contractors
2_ - am a sole proprietor or partner- 1irEed on the attached sheet. 7. ❑Remodeling
ship and have no employees These;sub ccanteactors have g_ ❑Demolition
o. and have- worinng forme in any capacity_ employees 9_ ❑Building addition
[IvtJ NOFlOe[3'Comp-insurance comp.incuvarscr X
reposed-] 5- ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am.homeowrnerdoing.all:work .. officers haveexeicisedtheir 11.❑Plumbing repairs or.additions
myself[No workm'camp- right of ekemption per MGL 12-❑Roof repairs
insurance required.]t c.152, §1{4X and we have no
employees-[No wmkgrs' 13.0 Other
compt.insurance required
' ] appiicaat @rat checks box 01 ams#also fill our the,section below showing rhea wo leW compensation.policy iafarmarim
1 Homoeoar�ers.wha submit tLis affidavit i&czdng t1tey ae doing all vm&amd dum lie outside comzactan mast submit a new aff dwk indicating sucl
ZCaatxactors that check this boar must aitsi lied.n additibnal sheet dawkg the manse of the sk-cautracLors and:state whethff oraot fhose entities ham .
®Ployees..If the nub-contactoes have employees,ffiey mtut pmVide tleeir workers'Comp.pokey umber.
I am an empinysr that isprmiding worker$'congwnsad".imuran ce for my ampler es. Bdot'v is the poNcy and job silo
informadon.
Insurance Company Name: Ar-s C X di
Policy#or Self-ins.Lic.#_ ��✓L��' �°ka' g Expiration Date:
Job Site Address. .C7 _ city/Statelzip: C✓d �-eo`ld ��.. �
Attach a copy of the workers'compensa onpolicy declaration page(showing the policy nnmber.and expiration date).
Failure to secure coverage as required under Section 25A.of MGL c 152 can lead to the imposition of crunmal penalties of a
fine up to$1,500-00 and/or ona year iMpliSOJOHIent,as well as civil penalties in the foam of:a STOP WORK ORDER and a fine
ofup to$250.0 0 a day against die yzalator- Be advised that. a copy of this statement may be forwarded to the office of
Investigations of the DIA for insurance coverage venfication .
I do'heraby cRrhfj,under tha pain s andpirnaltees ofpej:ftxty that fha info rmathm p,rati&d abiova is true and correct
Date: "41
Sianature-
Phone# '�:_
1
f�►f cciaL tree and:, Dt:nfrt.trite iri this arm bs comp&ed by city a),town official
City or Town• PermitfLicense#
Issuing Authority[circle one):
1.Boar.d of Health 2.lading Department 3.CVyiTown Clerk 4._Eiectrical Inspector S.Plumbing Ins�tor
6.Other
Contact Person: Phone#: !
ej 6 tJ
_ Cag;aaaasaapun �' Z£9Z0 dW'3111M31N30
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a2illlFl`kb2i38Md2j1S dl0£99
NMo2la 1Z13808
J 1 P r v
SNIl340W3b 9Nfall(18 iIVOlS(10 NM0218 lb 02!
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uol;gln2ag ssauisna pug safeMV aawnsuoD;o aag;O 8010`d211N001N3W3A02idW1 3WOH
:o;uan;aa puno;;T •a;gp uoi;g udxa aq;aao;aq uogein;lag ssauis g Ig sa!e33V aawnsuo03o a333o
Aluo asn lnp!A►puI ao3 p!IgA uol;ga;s�;taa ao asuaatZ a„ ,�o I
AFM Massachusetts- Department-nf Public.Safety
Board of Building Regulations and Standard.
Construction Supervisor Specialty License'
License: CS SL 100878
Restricted.to: RF,WS
ROBERT•..BROWN Afi
563 OLD STRAWBERRY HILL R w 'Y` R .
CENTERVILLE,.MA`02632
Expiration: 10/10/2013
{` Commissioner . Tr#: 5228
Town of Barnstable
0316 Regulatory Services
Thomas F.Ge er,Direetor
Building Division
Tom Perry,CRO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.towiLbarnstab➢e.maxs
Office: 509-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder-
IA-4-N./a ,as Owner of the subject property
hereby authorize C, to act on my behalf,
in all matters relative to work authorized by this building permit application for.:
(gym of job)
Signature o Owner 'D to
VK
Print Name
Q: OnMOMMIT9
Rev= 71405