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Home My WebLink About0040 JOAN ROAD 0 At oFTHE, Town of Barnstable *Permit# (0 Expires 6 months from issue date snatvsraBt.E. Regulatory Services Fee Q MASS.9. era Thomas F.Geiler,Director Building Division f Tom Perry, Building Commissioner X-PRESS PERMIT Uz- 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 JUL 2 7 2006 Fax: 508-790-6230 TOWN O EXPRESS PERMIT APPLICATION - RESIDENTIAL 9NLYRAR SLE pp� Not Valid without Red X-Press Imprint Map/parcel Number -sas U v .Property Address A 0 -1ro ai�s Cs�OV s�i2 U J aG %Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owners Name&Address MID -_%,0 Q� :�E Ala e- A4tl Contractor's Name 2 t (/�� J^�� Telephone Number S= /4 2-1? Y Home Improvement Contractor License#(if applicable) 3 14-4 Ll-1 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance. Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 2 /i'e'd G K ameo—le-1 CAIL/ Workman's Comp.Policy# x -43.1 /1 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) •Whererequired: 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. o e Improvement Contractors License is required. Signature N Q:FoiTns:expmtrg Revise063004 I . I ` i I ;I License or registration valid for individul use only Gf�Q Y�n� °" tan.ae. s iration date. If found return to ds a/ o ni ing egu" s an before the exp Regulations and Standards HOME IMPROVEMENT CONTRACTOR Board of Building g One Ashburton place Rm 1301 Reyistrt 134747 Boston,Ma.021�08 Expiration aJ14/2008 EZ C RPEtJTRY `... RICARDQ FERNANI RICARDO FE � No valid wIt out signature 8 REDBERRY LANES ,/ e u 4dm +lstratA u - MARSTON NI1-.L MA 02648 P-l' ' The Gommonweattn of massacnuserrs Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,AM 02111 s 5�•` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): L e� OF-19-4 12,1L1,41"S Address: Q6-7>BAR-10 L r City/State/Zip:,/ - r/�� Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 0 Z _ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet $ �• Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised their ❑ 3.❑ 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 insurancerequired.].t employees. [No workers' 13.R Other EL%12Q®�/�/i"1/� comp.insurance 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 tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Zo a` eK- MA-1Z f geiffiAl Policy#or Self-ins. Lic. #: 01 514 X 4 Expiration Date: Job Site Address: "r 0 �Il"�' City/State/Zip: CrN"rF�ey t LL.gf-Loll 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$1,500;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 cj#4A and the pains and penalties of perjury that the information provided above is true and correct: Signafore: Date: ' Phone#• ®®� 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: r °FED Town of Barnstable Regulatory Services vsnxMUM Thomas F.Geiler,Director 6 aye`s 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' 4D7 T-14 QS Nt90 '/ Cr- J�5A,5A ,as Owner5of the subject property hereby authorize ,�/G A R-n O to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Address of Job) 0 71,2S/® Signature of Owner Date SN Print Name QTORM&OWNERPERMISSION