The URL can be used to link to this page

Home My WebLink About0650 OLD STAGE ROAD �� ,: .. . _ .� �. � . . _ . M , o . .. .,. �. .. . . � . . . 4 ,r . . , v ... .: ,. .. s '� -� ,- �. . . ,, ... �, ,- �. a.: � ... ..�� ... .. .. .. .. ,..: _ ' ,� - _ � .. : �� .. .. � .. z� .. .. :..:' ,. n < �. ., _ ' _ .. :. .� :a � - _ � � c .r.. .. _ ..'., :. _ ,. y � ,, .. '.. � :. .. - _ :. �. - - , �. �. � ,. - � .. �: ,, - � .. .:. �, .: .. ..� �., .� _ � ;E. �*' - .t .... .. a; c i - ', :. � .- a. .-.. ., a 4 n , .... r, .W G_ U .. .: �,. ,� .. n. .,, ., ... �. ,.. .. ,. �, _ .. , .. ,. , ° �„ ,. yap _ y ::.. '� ... ,. tea. .� _ c. � a. - o' ar�• rs� ,.. �. :�, ,. :. i ..- { .. .Y '�� t ., :, v,., a ,, ..: ., • ,: �,;' a-: � �Q �: ,• _. v .. „ t,. -, x 3 � �. � �� ,; ,. F , . . _ - .. :. .. _ c � �., _' -. -1' - ,.. .. - ss. .. .. - . '.. .. .. � �..� r .; i` i S _ ,; .. :. ,_ .: � �. _ . �... -� '_ .. .,. m ..- � �.. >' ,. .� .. ,.. a .. .. � �� ... �, .. - .. _ ., .. .. ,.. .. � ;. � 4. _ ,;. _ .' - .. .: � n C .. _ s "�' :' ,.. ��.. .�. .o_ � - � �., � .' � .. t .r ... :. - 4 Town of Barnstable *Permit# K,3 � o D�ZFIE 1py� pj es 6 months from Issue dace el'VlCe5 .... _.. i Fee— AM : ,Thomas F.•Geller,Director Division' .. _. Perry, Building Commissioner - •200Mainftreet,•Hyannis,MA02601--•-• Office: 508-862-4038 - "'� Fax:`508-790-6230' . .. •. . , :;s••, •�:-....._ - . ��;:: �•..•..::. .• .. _. .. . , . .. . . .... .. Yf. _. -• -V_XPUS�SE 'T. �LYCA"Y'TbN RESIDENTIAL Not Valid without Red A--Press Imprint �TOWN 0- Map/parcel Number (� / f Address U50 . Ql d V(� OaR— 9 1 11� Pr . operty [Residential Value of Work 5 1�bnimum fee of$25.00 for work under$6000.00 Owner's Name&Address h' v-'— Le f R �Ukkf V W Contractor's Name �(% OUd Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) []Workmen's Compensation Insurance Che Era a I am a sole proprietor t i ❑ I am the Homeowner ❑ I have Worker's Compensation1nsurance Insurance Company Name Workmen's Comp.Policy# - Copy of Insurance Compliance Certificate'must be on file. _ Permit Request(check box) es All construction debris will be taken to [�Re-roof(stripping'old shmgl ) • ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side.. . ¢ ❑ Replacement Windows. U-Value .. (maximum.44) Board of Building Regulations and Standards *Where required: Issuance of this permit does not exempt compliance with other town `•. HOME IMPROVEMENT CONTRACTOR ***Note: Property Owner must sign Property Owner Letter Registratibn :. 124310 me Impr a nt Contractors License is required. Expiration:...61112005 Type _ Indi"i �96AT mes Curley Signature games Curley Q:Forms:expmtrg 287 Fuller Rd. Centerville,MA 02632 Cab Revise063004 Administrator * i tKE T Town of Barnstable �.� Regulatory Services Tjjomas F.Ge ere Director ��, �,•� Builftg MA Sion �'fD Mpi TomPerrh Building Commissioner 200 Main Street, $yannis,MA 02601 ww wAown.b arustable.ma.us Fax: 508-790-6230 Office: 508-862-4038 Property owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property uthorize s � � to-act on mybel a , • 'hereby a in au natters relative to work authorized by this building permit application for: ( �L 6 g��((Acdl �of Job} Date Signature of Owner Print 1*�ame K ---" ---�_ The Commonwealth of Massachusetts Department of Industrial Accidents office ollnuesdgatlons 600 Washington Street, a Floor cs� Boston;Mass. 02111 Workers' Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors name: address: �' O• bo ci 5 state: zip: phone# 4 9JIL. work site location full address): ��`�) � �� I 1 Mf ❑� Lft a homeowner performing all work myself. Project Type: ❑New Construction em egc� 1J I� 1 am a soleproprietorand have no one workingin an ca aci . ❑BuildingAddition ❑ I am an employer providm"orkers'compensation for my employees working on this job. �" r "�"T1�4 e ♦V4 7 r',,,�. y ;•ate T i x94 ssk� a w-g lan�f�T'"F MOM' K .. 1�'{,�s...+i .'t .a....' 9 e'�i�,• 1 f ,��.'...�,.Sy ''� ..j � � `Y1. .� *! ! �.e Vl �tt. c'��+ x 71 I i t f i Y I I ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices company name = . r City , nTione# T { k I x 1 a t 1 C xOmnanv tiS►me ' city � r x � F n1ione#. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify unde a ains and allies of perjury that the information provided above is true-and e rrec,A- Signature Date I3 (00 Print name v Phone# Cl 0- `l 0 lJ � official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised Sept.2003) Information and Instructions Massachustts General Laws chapter 152 section 25 requires all employers to provide w kers' compensation for their employees. s quoted from the"law", an employee is defined as every person in the s ice of another under any contract of h' express or implied,oral or written. An employer is defined as an individual,partnership,association,corporation or o er legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representative of a deceased employer,or the receiver or trustee of an indivi•ual,partnership,association or other legal entity, employ' g employees. However the owner of a dwelling house having of more than three apartments and who resides there' or the occupant of the dwelling house of another who employs pe ons to do maintenance,construction or repair wor n such dwelling house or on the grounds or building appurtenant the to shall not because of such employment be de ed to be an employer. MGL chapter 152 section 25 states that every state or local licensin agency shall withhold the issuance or renewal of a license or permit t operate a business or to construct ildings in the commonwealth for any applicant who has not produced ceptable evidence of complianc with the insurance coverage required. Additionally,neither the commonwe th nor any of its political subdi isions shall enter into any contract for the performance of public work until acce ble evidence of complianc ith the insurance requirements of this chapter have been presented to the contracting author Applicants Please fill in the workers' compensation affidav completel ,by checking the box that applies to your situation. Please supply company name, address and phone numbe along w' h a certificate of insurance as all affidavits may be submitted to the Department of Industrial Acciden for co firmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned o city or town that the application for the permit or license is being requested, not the Department of Industrial Acci e ts. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation poli ,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and print d legibly. a Department has provided a space at the bottom of the affidavit for you to fill out in the event the Offic of Investigatio s has to contact you regarding the applicant. Please be sure to fill in the permit/license number which w 11 be used as a re ence number. The affidavits may be returned to the Department by mail or FAX unless other arran ements have been m e. The Office of Investigations would like to thank y u in advance for you co eration and should you have any questions, please do not hesitate to give us a call. NEW The Department's address,telephone and fax n ber: The C mmonwealth Of Massachusetts Dep rtment of Industrial Accidents Office of Investigations 6 0 Washington Street,71h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 I