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0228 LAKE ELIZABETH DRIVE
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I- � , , �� ,, ,,��_ , , �� � ,t,',�:.� , ,�_ - 1 , , o', �,; � , I , ", ": '�� 11 1 10011 -1. 0� �V�,", i , 1,11� , , , " �-,� � �L.., ,� , ` A , , , , � ," � " - � _Vv , :- - , ,� - , I ,�:� _' -�K � - � , , , ,, � ,�ii : ,, 1�1 Ir� 11�, � .. ..... , ,_�� �"_i , �� '' - � L I� 4 , z �;` __':��,�''i`�:'_:i ",", , _;'�-:�.'_'��',`:",�,.�%,�,-%�:,-,��,� �� �,i-'Z,,,� ; I - � �_ - S, , , �: ,'' , � _�I'��-,_��," I� ,,� �, ,_ �_", ""', - - , i:,i, , � , - " ,__�,,_ 1111-1 "Ul.-�-.-�.��-� '.".� ","--� ", -1 -LV _�_�_ :2� �""",_.'� , I I ,� � 1 ON 0: , I; , ,;, ,__�,� ,, .,_�,%L-I I _ -", Town of Barnstable * ermttJ Fxpires 6 months from iss a date Regulatory Services Fee 4" X-CRESS PERMITPERMITThomas F.Geiler,Director APR 2 3 2009 Building.Division ® y12g10 I I 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 PERMIT APPLICATION - RESIDENTL&L ONLY f Not Valid without Red X-Press Imprint Map/parcel Number 0 `l Property Address rt �_�GyC JL. !Z lJ` ��' �( `'-f—I ZResidential Value of Work 00 Minimum fee of$25.00 for work under$6000.00 M Owner's Name&Address Win CJ1( i 6 �E I'Z-9+ (z1 II K rK Contractor's Name �t+�' J C"U l� Telephone Number 9 G LZome Improvement Contractor License#(if applicable) -bonstruction Supervisor's License#(if applicable) e ❑Workman's Compensation Insurance Ch one: am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) E/Re-roof(stripping old shingles) All construction debris will betaken to -on bps cqu-.l Nmocr ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) "Where required: issuance of this permit does not exempt compliance with other town department regulations,ix,Historic,Conservation,etc. ***Note: Prope O /er Property Owner Letter of Permission. co y of the Ho e I rovement Contractors License is required. SIGNATURE: Q:Fomu:expmtrg Revise061306 . The Cornmomvealth of Massachusetts Department oflndustrial Adddents Offree efl"nvestzgations 600 Mashington Street Boston,AM 021I1 ' y www.mass..gov/dia Workers'Compensation Insurance,Affidavit: Builders/Contractors/Eleefricians/PIumbers Applicant Information Please Print Lp 'bl Name (Business/Organization/Individual):. I1� (� Address: c}� City/State/Zip: Phone.#: ]q0 -45M_ Are you an employer? Check the appropriate box: Type of project(required): I.❑ II am a employer with 4. ❑ I am a general contractor and T 4__3am. ployees (full and/or part time).* have hired the stb-contractors 6 ❑New construction . 2. a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees 'These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp,insurance comp.insurance•$ 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10•❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their . 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption perMG1, 12 L'— Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' .•13.❑ Other r comp,insurance required_] . 'Any applicant that checks box#1 must also till out the section below showing theirworkcrs'.compmsation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ._f tContractnrs 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 sub-contractors Lave employees,they must providt;their workers'comp.policy number. lam an employer that isprovlding workers'compensation insurance for my employees -below islhepolicy 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 ofMGL 6. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.60 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WO RR 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 Investi ations of the IDIA for insurance coverage verification. I do he by\cep -nMa ,nalties ofperjury that the information provided ab vg is ue and colrect �Sienature, Date:Phone #: I --------------- FOther only. Do not write in this area,Yo he completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4:Electrical Inspector 5.PlumbingInspector son: Phone#: Of JHE 7, : Town of Barnstable. Regulatory Services atxxsre��, ► . y Asa $ Thomas Fc Geller,Director AIFo �� 13uil ding Dlyision Tom Perry, Building Commissioner 200 Main street Hyannis,MA 02601 "'w.town.barnstable.ma.us Office: 508-862-403 8. . Fax: 508=790-6230 ropexty Owner Must Complete and Sign This Section if Using ABuild.er as Owner of the subject property - herebyauthorizel� S J to act on my behalf, in all matters relative to work authorized bythis building permit application for: (Address of Job) `t q. 1 nature S o f Owner g ate r Pint Name Q:FORMS:oWNERPERMIS S 10N L Nlassachusetts Department of Public SafetN`' !. Board of Buildin Regulations and Standards Construction Supervisor Specialty License License: CS SL 99138 I Restricted.to: RF,WS . JAMES CURLEY 287 FULLER ROAD.. CENTERVILLE, MA 02632 i Expiration: 1/28/2012 Commissioner• Tt#: 99138 Board of Building Regulations and Standards• License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratiiori :_1..24310 Board of Building Regulations and Standards •Expirations 611/2009 Tr# 130873 One Ashburton Place Rm 1301 Jn:dividual Boston,Ma.02108 -YP • James Curley =_ James Curley � 287 Fuller Rd. Centerville, MA 02632 Administrator Not valid without ure i