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Home My WebLink About0423 SHOOTFLYING HILL RD S AX 1 f � s Town of Barnstable *Permit# H 4 3 r_-3 Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee � 2 O C T 10 2006 Thomas F.Geiler,Director Building Division pk j o h3/6 TOWN OF BARNSTABIgm Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 . ale www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address d-_/ ®(Residential Value of Work I rbtlinimum fee of$25.00 for work under$6000.00 Owner's Name&Address %�� ' Y i�o d I t- 190 Contractor's Name v a`JVI�J IK. Telephone Number `10 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Ch k one: 7I 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) (� h iRe-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) *Where required: 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. me pro me Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 i , i �aftMs r � Town of Barnstable Regulatory Services sn MASS. Thomas F.Geiler,Director y Mass, � �A .i6gq �0 PE 639 BuRding 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 bust Complete and Sign This Section If Using ABuilder AV as Owner of the subject property hereb authorize1,�' Y to act on my behalf, in all matters relative to work authorized Othis building permit application for. (Ad 4 t)b) 1 0 CAD Signatur of Owner ate nr V Print Name Q:FORM&O WNERPERMIS SION r 1 he Gommonwealth oj-Massachusetts Department oflndustrial Accidents W Office of Investigations 600'Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1n n n Please Print LegiblAtu Name (Business/Organization/Individual): Address: p, n City/State/Zip: �-� 1�'► �Thone#: V Are you an employer? C the-appropriate box: 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 ship and have no employees These sub-contractors have Sin. ❑ Demolition working for me in any capacity. workers' comp.insurance. g. ❑ Building addition [No workers' Comp,insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL . o 11.❑ Phpnbing repairs i additions myself.[No workers' comp. c. 152,§1(4), and we have no 12.[9-<oof repairs insurance required.] t employees. [No workers' 13.❑ Other 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: 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$1,50Q.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 her by certify under t pains n penalties of perjury that the information provided above�'s true and correct Si a Date: Phone#; -L 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 a.?lumbina Inspector 6. Other Contact Person: Phone#: Y g � wizcv Board of Building Regulations and Standards HOME IM. License or registration valid for i �R;ROVEMENT CONTRgCTOR Re istratiohn before the expiration date. °divtdul use only k teat z 24310 If found return to: _ 007 Board of Building Regulations and Standards vidual One Ashburton Place Rtn 1301 3mes Curley � _ 1 I Boston,Ma.02108 Curley V Ames �, -;�1 I " 417 17 Fuller Rd. i mterville, MA 02632 Administrator Not valid without sign, ure I ' I J i I s PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, .MA,02601 DATE: 10/10/06 TIME: 13:31 ------------------T0TAL>S-----=----------- PERMIT $ PAID 25.00 AMT TEN•D`ERED: .r 25.00 —A.MT APPLIED: 25.00 CHANGE: .00 APPLICATION NUMBER: 20063783 PAYMENT METH: CHECK PAYMENT REF: 1095