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Home My WebLink About0081 STRAWBERRY HILL ROAD � „ �� .r y: . � . . w y . ,. 1 � is ,.. �: .�, .L� . :�- +; ,. � f .... _ ... [ ♦ i .. r .. ^' _ -�. ,. �. i � , ,. � r �. v� �� j - - ,OK peR o�� 1 '1 2006 Town of Barnstable Permit W>q 10(19 Expires 6 months from issue date T® N Regulatory Services Fee tea ` Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 206 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Lnpnnt Map/parcel Number 6D Property Address O 1 e�r� �j C®!' fj /�j Gi rt�G�7i'l ( � d •1 �0 �• ❑Residential Value of Work D t/ _ NCwimum fee of$25.00 for work under$6000.00 Owner's Name&Address y► 4n A 7011"1 Contractor's Name v12(- P WG 5 P d 1 n C a c n d ira rl"1 j Telephone Number_ Home Improvement Contractor License#(if applicable)Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Ch9zk one: [ 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 be on file. Permit Request(check box) rr �Re-roof(stripping old shingles) All construction debris will.be taken toed 1 S F 4' /� '✓ /�`n f Yc []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,ie.Historic,.Couservation,etc. *Vote: Property Owner must sign Property Owner Letter of Permission. ome provem t Contractors License is required. SIGNATURE: ' Q:l:orms:expmtrg Revise071405 Board of Building Regulations and Standards License or registration valid for individul use only HOME f:< .I IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registtai rt f39619 Board of B r_ � lding Regulations and Standards Exprrafron 'i20/2007 One Ashburton Place Rm 1301 `' "1 Boston,Ma.02108 r-F Type DBA Y JOE POWERS HOME.REN0VAMONS JOSEPH POWERS= 130 FULLER RD CENTERVILLE,MA 02632 Administrator Not tialid without signature I f =' The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street f`z Boston,MA 02111 } ; www mass gov/dia Workers',Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Legibly Name(Business/Organization/Individual): ve. )W eCin6Va-r/ji-/) g Address: J 3 0 I'"4 //,, t yi City/State/Zip: L Cn7t sL)- 11e 114. O Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New constriction ,em ployees(full and/or part-time).* have hired the sub-contractors 2.Ud i am a sole proprietor or partner- listed on the attached sheet.t ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a.homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof 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$1,500.00 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 certi der pains aInpenahies of perjury that the information provided above' tr/ue and correct Date: D Si nature: D • b' b Phone#: 5 v 7 CWkial 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: • Town of Barnstable s MRAWAI ��a ' Regulatory Services Thomas F.Geiler,Director Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.maus Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I re 61 Y 9 eA— as Owner of the subject property 61 hereby authorize _��.lZ �d h✓� to act on my behalf, in all matters relative to work authorized by this building permit application for: '4 12r� (Address of Job) 0 32 06 Sig ature of Owner D e Print Name Q:F ►ms:expmtrg Revise071405