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Town of Barnstable *Permit#
Expires 6 monttrs from issue date
Regulatory Services Fee �� k o
t anetvszes[E,
MASS. Thomas F.Geiler,Director
X-PRESS PERMIT
Building Division
Tom Perry,CBO, Building Commissioner JAN 21 2014
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 TOWN OPERIMMLE
EXPRESS PERmrr APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number c?-Y& / ? 9
��
'Property Address
59 Residential Value of Work AG?00 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name /�� C ,,?� Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) 7 7s'
❑Workman's Compensation Insurance
Check one:
0.I 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 accompany each permit.
Permit Request(check box)
] Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to A-,e
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
01 Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*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.
A copy of the Home Improvement Contractors License&;Construction Supervisors License is
required.
SIGNATURE: ---�
C:\Users\decollik\AppData\Local\Microsoft\Win od�emporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc
Revised 053012
1
I �
., s�exsres�, •
,�� ,� Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: .508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
1 IZN �'��i`-V l i u — ,as Owner of.the subject property
hereby authorize AA.a 1'1 c�)6 WC / to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Da
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\E)PRESS.doc
Revised 053012
f
The Connuornrealth oflassaclrtcset[s
_ Departurent ofIndristrial Accidents
." Office of Investigations
600 Washington Street
Boston,-114 02111
•. +r�rht:nrass.gotldia
NVorkers' Compensation Insurance Affidmit: BuilderslCoutractors/Electiicians./Plumbers
Applicant Information Please Print Leaibh
Name(Business-Orgauizadon'Inch ideal): /`'f�Jcs ���•
Address: 4i1
City..StatetZip: Svl: ol.�t /�i G` one :
Are you an employer?Check the appropriate box. Type of project(required):
1.❑ I am a employer with 1. ❑ I am a general contractor and I 6. New construction
I -employees(full and -time).
x have hired the sub-contractors
2. I am a sole proprietor or partner listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for rue in any capacity. employees and have workers'
- 9. ❑Building addition
[No workers"comp.insurance comp.insurance.-
required-] 5. ❑ We area corporation and its iQ.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself `co right of exemption per ti-iGL
�o workers �- 1_.Q Roof repairs
insurance required.]- c. 152_y 1(4).and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
*Any sapiicant th3•a ched5 ttox=I must aiso All out the sectou below howing their workers•compensation policy information.
FQMeowner s who submit this affidavit indi n=they°are doins all woric and then hire outride contrac;ors must su,ink a new affidavit indicatins such.
Contractors that cbea this box must attached an addinonai sheet showin=-the;rage of the sub-corn3nors and state whether or not those entities have
employees. If the sub-contractor have employees.they must arodde them workers'comp.policy number.
I arty an einplot'er that is providing n•orkers'compensation hisurance for tar enrplo.yees. Beloit,is the polity and job site
information.
Insurance Company Name:
Policy-or Self-ins.Lic.r: Expiration Date:
Job Site Address: City.StateiZip:
Attach a copy of the workers'compensation policy declaration page(shoeing the polio-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 S1.500.00 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 DLI for insurance coverage verification.
I do lterebt certify'rr t[ r tit pajns an Imialties of perjnn'that the informationpro+zded above is tine and correct
Si tut ' /" Date:
r
Phone
QQScial irse on r. Do nor+trite in this area,to be completed br city or town official
City or Towit: Permit/License 9
Issuing Authority(circle one):
1.Board of Health '_.Building Department 3.CitytTow•ti Clerk 1.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: 'Phone#:
6
.i c�a naUl�'1�3 s �C2�i4Jf3"cr ., �t � iCi
a7
c IMPROV rVIENT CO_ NTF1At: OR, r fine the exp r* on aat% I2 fo a r rri o
egistraaon 1549" ,a: Gficce of Consimer.Affairs tnd Business Regri,atson
xpira+icn A� 3/2015 DBA J 10 Fark Plaza-Suite 51'10 t
,! Boston'MA 02116
MATT GAGNON ROOFJN f°'
'h
i;
MATT GAGNON �
11 OLD COUNTY WAY",""'
E.SANDWICH,MA 02537. --- Undersecretary j Not valid without sj ature
l � Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor � '
License: CS-069765 T
MATTHEW P GA 0V
n oiLDCOLONYWA,'
East Sandwich MA 02'S�37
Expiration
02/28/2015
Commissioner
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Message Pagel. of 1
Anderson, Robin
Subject: 71"Strawber ,Hill _✓
1 � ry �G�"P
Tom,
A communication specialist came in for a home occ but has clients to the house. She insisted to Sally
that she would have clients at her house anyway even when told that she is unable to. When 1 went up
to the counter I explained that we can approve administrative office uses only and that employees and
clients are not allowed at the house. She explained that clients only stop by to look at her work and it's
not very often. She told me (with attitude)that she would just meet them at the library or Starbucks. So I
said OK and asked her to write that in the margin of the home occ form. As I prepared to sign the
document I explained that if we got a complaint and found that she had deviated from the reg
requirements she could be fined $100.00 a day per violation. She grabbed the DBA form back and said
she had to re-think this and would likely get an office somewhere.
Later she called and demanded to know where it exactly says.you can't have the public at your home. At
the end of the day she wanted me to use her interpretation and she continued to escalated and yell at
me. I told her to stop yelling at me and she said if she were yelling at me I would clearly know it. I replied
that I recognize when someone is yelling at me and she was certainly yelling at me. I also told her that
her interpretation isn't what matters, it is the town interpretation and policy as dictated by the BC.
suggested that she write you a letter of appeal. She stared yelling again and and complaining about how
we are making things up. She is calling the TM's office, her congressman, and you. She demanded my
name-which I provided. The women at the front end can attest to her unpleasant and nasty attitude from
the moment she walked through the door, she obviously wanted what she wants and wants us to suspend
the rules for her.
Rodin C. -Anderson Y
Zoning Enforcement Officer
Io1vn of Barnsta6Ce
200 :Maim Street
3-fyannis, MA 026oi
5o8-862-4027
5/25/2012
C`,� r
YOU WISH TO ®PEN ABUS81\!ES s? . \UJV
�x
'V M�
For Your Information: Business certificates.(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you.
must do by M.G.L. it does not give you permission to operate.) You must first obtain the necessary signatures on this format 200.Main.St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get.the Business Certificate that is
required by law.
DATE- � Fill in please:
APPLICANT'S YOUR NAME/S: S+IVG�
BNESS YOUR HOME ADDRESS: SS
U I i.0 c
6 3'
TELEPHONE # Hbme Telephone Number
NAME OF, J0 N 63 ( 6 7-
NAME OF NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATIO ? YES _NO
ADDRESS OF BUSINESS u ! EL NUMBER (Assessing).
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of 65 �
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200'Main St..= (corner of Yam uth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this tovun. Q� ��V -
1. BUILDING COMMISSIONER'S OFFICE L�
This individual has been informed o
nf any permit requirements that per to this type of business.
Authorized Signature**
COMMENTS:
IN
2. BOARD OF HEALTH
This individual has been informed of the permitrequirements that pertain.to-this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
i#
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