HomeMy WebLinkAbout0340 MAIN STREET (CENT.) (6) a�g Vy.c�
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_�- Application number...... ..................... ..
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P% �o „ AGING DEPT. CCoO ��
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Fee ..............................................................................
1ItAK\ti-TAE3LE ; FEB
2 7 Z020
%11 „ASS. /�,/ Building Inspectors Initials..
1-0.....................
1639. �0
�fD NIA • TOWN OF ggRNSTA6LEhV
Date Issued......ZJZ:?...........................................
Map/Parcel....... Jl(�..�?.",
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION: SCANNED
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
FEB 2 8 AM
PROPERTY INFORMATION ULU
Address of Project: 3 y%D I /I gliy sT CeAlte�,��le l(� V IV
NUMBER STREET VILLAGE
Owner's Name: -aMJ f 161XJ6) Phone Number
Email Address: Cell Phone Number Soo r -771 7 .3 S 7
Project cost$ , UZTp `� Check one Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make applic f,atmQor a building permit in accordance with 780 CMR
Owner i s Ci`- lz77 6 Z D
S gn ture: _ Date: Z
TYPE OF WORK
Siding 'V Windows (no header change) #--4— Insulation/Weatherization
Doors (no'header change) # Commercial Doors require an inspector's review
_ Roof(not applying more than I layer of shingles)
Construction Debris will.be going to
CONTRACTOR'S INFORMATION
Contractor's name _7';�0t;V 4S De k<-,�
Home Improvement Contractors Registration (if applicable) # J b y Z 1 (o (attach copy)
Construction Supervisor's License# 14 1 (attach copy)
Email of Contractor'1-Y1)0(8( 16SOe Phone number,5 og 73) 7 Jj'
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
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APPLICATION NUMBER ............................................................
*For Tents Only*
Date Tent(s)will be erected Removed on ./number of tents total
Does the tent have sides?Yes } No (If yes please ach floor plan with exits marked)
Dimensions of each Tent�X X
Additional tent dimensions can be attache n a separ a piece of paper.
Purpose of Event
I Check one: this event is a: for profit on-pro vent
Check one: Food served>t�ent
No
Flame Spread Sheet of st be attached. Provide a site with the location(s) of each tent
If food is being served at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval
*WOOD/COAL/PELLET ST VES
Manufacturer# del/I.D.
Fuel Type Testi
Offsets from combustibles: front back le e right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures, specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date
APPLICANT'S SIGNATURE
roSignature 40 Q Date �7 zo�_D
All permit applications are subject to a building official's approval prior to issuance.
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructi'&Al boervisor
CS-009474 Epires:08/22/202"
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THOMAS R.MORSE �}�
393 LAKESHORE DR t µ
SANDWICH M4 02663 f
rl !�N
Commissioner R
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE,Individual
Registration s Expiration
104296 w s> 01/27/2022
THOMAS R.MORSE
$r j
THOMAS R.MORSE
393 LAKESHORE
SANDWICH,MA 02563 Undersecretary
Item Qty Item Size(Operation) Location Unit Price Ext. Price
0001 2 WDH24310E(AA) A $ 636.68 $ 1273.36
RO Size=2' 6 1/8"W x 4'0 7/8" H Unit Size=2'5 5/8"W x 4'0 7/8" H
400 Series
Unit, Equal Sash,White/Pre-finished White, (Top Sash) High Performance Low-E4, Divided Light with Spacer, Colonial,3W2H, 3/4", Chamfer, Ext Grille-
LLJ White, Int Grille- Prefinished White, (Bottom Sash) High Performance Low-E4,Traditional,White, 1 Sash Locks
Equal Sash, Insect Screen,White
Viewed from Exterior
U-Factor:0.30, SHGC:0.28
0002 1 WDH24310E(AA) B $ 543.28 $ 543.28
11171 RO Size=2'6 1/8"W x 4'0 7/8" H Unit Size=2'5 5/8"W x 4'0 7/8" H
400 Series
Unit, Equal Sash,White/Pre-finished White, (Top Sash) High Performance Low-E4, Divided Light with Spacer, Specified Equal Lite,2w1 h, 3/4", Chamfer,
Ext Grille-White, Int Grille-Prefinished White, (Bottom Sash) High Performance Low-E4,Traditional,White, 1 Sash Locks
Equal Sash, Insect Screen,White
Viewed from Exterior
U-Factor:0.30, SHGC:0.28
0003 1 CN14(R) C $ 380.86 $ 380.86
RO Size=1'9"Wx4'0 1/2" H Unit Size= 1'81/2"Wx4' 0" H
400 Series
Unit, White/White- Factory Painted, R Handing, High Performance Low-E4 Glass
Insect Screen, White
Hardware Pack, PSC,Traditional Folding-White
Viewed from Exterior
U-Factor:0.28, SHGC:0.32
Quote#: 8276 Print Date: 01/03/2020 Page 2Of 3 iQ Version: 19.2
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The Commonwealth of Massachusetts
Department of IndustHdAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information �^ Please Print Legibly
Name(Business/Organizatiorybdividual):
Address:
City/State/Zip: 54KOW10 62 ylo Phone#: 5co r 3 2 11 7 �S
Are you an employer?Check the appropriate bozo Type of project(required):
1.❑ I am a employer with- 4. I am a general contractor and I
6. [-]New construction
employees(full and/or part-time).* have hired the sub-contractors
2 I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling
p and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers'comp.insurance romp.insurance.
t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or.additions
3.❑ I am a homeowner doing all work - officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13 Other iU�Oc.y S
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:.
$Contractors 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 have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: L (,./C2
Policy#or Self-ins Lie.#: O Expiration Date: g'22! 20 Z I
Job Site Address: -M 0 A(/y S7, City/State/Zip: A 3&
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 certify d the pairs and enalties of perjury that the information provided above isre and correct
St store:
a �- Date: l Z? / �- Z v
Phone#: O
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.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." I -
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,mid mchiding 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 be an 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 permit to Operate a business or to construct buildings in the commonwealth for any
applicant who 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 number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for 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'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license 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 like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents Y
Office of Investigations
600 Washington Street
Bastan,MA 02111 -
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax##617-727-7749
www.maw.gov/dia-