HomeMy WebLinkAbout0700 OLD STAGE ROAD f
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Y Town of Barnstable 'emit
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Expires 6 rnonfhs fr m is n�i
Regulatory Services _ Fee
Thomas F.Geiler,Director
Building.DiViSio>1 ,
Tom Perry, CBO Building Commissioner J�2y�/D
200 Main Street,Hyannis,MA 02601
www.town.barnstable.nia.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERNIIT APPLICATION RESIDENTLAL,ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address o l d I�(J V (I I ei
Residential Value of Work `T =' Mtn_mu-ni fee of$25.00 for work under$6000.00
Owner's Name&Address
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- � Ir
Contractor's Name Telephone Number �1O
Home Improvement Contractor License#(if applicable) I
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance,
Chec one: MAY 1 '0 2010
Iaam a sole proprietor
❑ I am the Homeowner `OWN OF BARNSTARL e
❑ I have Worker's Compensation*Insurance '
Insurance Company Name .
Worlman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
['"Re-ro.of(stripping old shingles) All,construction debris will be taken AAA 1 h1_,� 1 IJ U
❑Re-roof(not stripping, G6ing over existing layers of roof)
[�(Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where rc wired: Issuance of this ermit does not exem t co liance with other town department regulations,i.e."Historic,Conservation,etc
9 P P TnP
***Note: Prope wner °f tsigVrrope Owner Letter of Permission.
A op of the omn Imp ovement ontractors License,is required.
SIGNATURE, .
Q:Fmuz:expmtrg r =e
Revise061306
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4'l JHE71 T6TM of Barnstable:
u Regulatory Services
+ SARNSTAHLE, +
y nsass Thomas F. Geiler,Director
AIFD �b Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,Mk 02601
"ww-town.barnstable.ma.us
Office: 508-862-4038
Fax:. 508-790-6230
Property Owner Must -
Complete and Sign This Section
'If Using A Builder
• 7, •S�l�-�� i W 1 as
-�' O
' wner of the subject property
herebyauthorize V s lam '
to act on my behalf,
in all matters relative to work authorized bythis building permit application for:
-700 a d S 2
(Ad& ss of Job)
ignature of Owner Date
Print Name
QTORMS:OWNERPERMIS SIGN
- The Commonwealth ofMassachusetts ;
Department oflndustrialAdcidents
Offtce efInvestigations
600 Washington Street
Boston,M4 02I1I
www•rn ass..gov/diu
Workers."Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bI
Naijae (Business/Organization/Individual):•To�-me5 1
Address: P b. X
City/State/Zip: Mf �lJ1W 101 Phone.#: Iq Q _
Are you an employer? Check the appropriate box:
4 I am a -Type of project(required):.
1.❑ I am a employer with ❑ general contractor and T
rinp
loyees (full and/or part-time).* have hired the stlb-contractors 6 ❑New construction :
2. I am a'sole proprietor or partner- listed on the•attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working forme 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 per MGL 1Z. oOf repairs
insurance required.] t c. 152, §1(4),and we have no
employers. [No workers' ..13.0 Other
comp.insurance required.] .
*Any applicant that cbecks box#I must also fill out the sccdon belowsbowing 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 additionalsheet showing the name of the sub-contractors and state whether ornotthosc entities have
employees. If the sub-contractors Iave employees,they must providt their woAccrs'comp.policy number..
lam an employer that is providing workers'compensation insurance for Information. my employees Below is the policy and job site
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 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 h urance coverage verification,
I do hereh certify er the sins• d enrilties of perjury that the information provide abov ,is true and correct:
Sienature: 1 10
nn Date.
Phone
Official use only. Do not write in this area,Yo he completed by city or town offciaL
City or Town: Permit/License#
Issuing Authority(circle one);
1.Board of.
f Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6, Other
Contact Person: Phone#:
BAa f '�g>sfeg""io ,a ff..d. License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
•-Registration: 124310
Board of Building Regulations and Standards
Expiration: 6/1/2011 Tr# 284683 One Ashburton Place Rm 1301
Boston,Ma.02108
Type: Individual
James Curley
James Curley.
287 Fuller Rd.
Centerville,MA 0.2632 Administrator `Not valid without signature
L• MassachusettS - Department of Public Safety
Board of Building-Reirulations and Standards
Construction Supervisor Specialty License
License: CS SL 99138r
Restricted.to: .RFAS .
JAM ES
S CURLE Y
287 FULLER ROAD
CENTERVILLE, MA 02632
i
Expiration: 1/28/2012
Commissioner Tr#: 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:
Registratfon':_1.:24310 Board.of Building Regulations and Standards
Expiration _6i172009 Tr# 130873 One Ashburton Place Rm 1301
;Type individual - Boston,Ma.02108 tr
James Curley =_ _
James Curley
287 Fuller Rd. ���
Centerville,MA 02632 Administrator Not valid without ure
I