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HomeMy WebLinkAbout0135 STRAWBERRY HILL ROAD w ,- _ - e- ;� . s . . �: ,. � �, , � .. .:: ,.. �. _ .,z . ._ ._ o t ;p � � '� ` . � ,>�, i f o ,, wn of Barnstable Permit# OCT Fapires 6 nths from issue date 3 °* 1012 Regulatory Services Fee. , MASS. Thomas F.Geiler;Director 1639 484, Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY —7 �+ Not Valid without Red X-Press Imprint Map/parcel Number Q. P 7 Property_Address ` R� �/� lL i Residential Value of Work J C� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Nam Telephone NumberC�t� � Home Improvement Contractor License#(if appli ale) Construction Supervisor's License:#(if applicable) 0I;�q ❑Workman's Compensation Insurance Check one: a sole proprietor ❑ I am the Homeowner El have Worker's Compensation Insurance. i 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. ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) e-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 cop of the Home Improvement Contractors License&Construction Supervisors License is b requi d. SIGNATURE: naavncrr Fc�R(lt?HAR�I.,rilA;no nvrm;r fnrmclF.XPRFSS.dnc . Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor . : License: CS-073395 PETER J RENNEI}Y' 444 MISTIC DRa" Marstons Mills NrA 0 a y Expiration Commissioner 11/02/2014 A i y A 7.no eta U) .;F\ O -i.3SF.,o N '*IM Tmi r ,1Z lit ' il O 'iris( �' mf9i }l..l�.Va(1 1� N'z .m ►q ry._. A'+ O ^I p O d fI Qc o o O `1 " ' s •' 0 77je Commonwealth-of Massadiiisetts �Departine;rittof ndx�striirr Accidents Office of, :Investiga ions ' 600 Washmgt n Street Boston,.MA 02111 n:*ww.mass gcrvldirr. Workers' Compensation Insurances Affidavit: BuildersfContractorslE ectric a,ns/Ph mbers. Applicant Information Please Print L egibI�-. Name(BusinessCrganiz�r< Ad&ess--,�H I, A P C1 fStat&Z 'J 4vN' Ph-one Are you an employer?Check the appropriate boz: Type of project(required). 1-❑ I am a employer with 4. ❑.I am.a general contractor and I have hired the sub-contractors(full andtor part4ime). * G ❑New consfruction I am a sole proprietor or P'a rtner- listed on aloe attached sheet y ❑Remodeling ship.and ha.fe no employees These sub-contractors have .g_ ❑Demolition have workers employees and ha %vorking for me in any capacity. 7 $ 9. ❑Building addition [No workers' comp.insurancecomp.msurautx required.] 5. ❑ We are a corporation and.its 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself: [Np workers',camp. . right of exemption per IYIGL 12.❑Roof insurance required.]T c. 152, §1(4),and we have no / d f employees.[No workers' 13'�ther f �f:YX/! comp.insurance required.] '?any applicant that checks box#1 mast also fill ow the section bellow showing their workers',caanpensation policy information - I Homeownen who mbmit this afiidwit indicating they are doing allwork and then hire oartside canttadturs mast ndwrit anew.affidavit indicating such- A—Comrwictors that cheep this boat mast attached an additionsl sheet showing the name of the sub-contractors and stare Whether or not those entities have employees. Iftbe sub-contmaors have employees,theymust:pmuide their W wkers'comp.policymunber. jam all empl jer M&is prm iNng workers'c+otttparrsad on insuranc4 for.nzy amplolre m Belofv is thepriiicy and jaab sifW infdrmattan. Insurance Company Name: Policy ft or.9&ins.Lie.#: Baepilation Date: Job Site Address: City/State/4- 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 andfor one-year impnsonmeat,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 fcrruwded to the Office of Inve f'the.DIA for in®ratuce covwage verification I do h Its andponabies a irry t the inforini tion prcrnided above is hW rend correct Dater It Phone ©trial use array:. D�not write in this area,to be completed by C*ar telvil,a�'..ciarl. City or T'o m: PermitfLicense it Ism ng Authority(tdrde one): . 1..Board.of Heatlth 2.,Bui'ladiug Department 3.City/Tunru Clerk 4.Electrical Inspector 5.Plumbing Inspector . 6.Other Phone#.:,.,.. ;.r..Mw+Fe:ono•. .- .. 10/26/2012 FRI 15: 05 FAX 5086264551 BUSINESS OFFICE 12003/004 _..._._._..._._... —..-.._._......--.................� ._..... y� L7 Sn �sannrvrna� � W ydgq. Town of Barnstable RegulatolryServices I Thomas F.Oeiler,Director r•{. Building Division Thomas perry,CDO l vilding Commissioner 200 Main Street,'Hyannis,MA 02601 Www.town.barostable.ma.uss ' Office: 508-862-4038 Fax: 508.790.6230 Property Omer Must Complete and Sign This Sectioxi If Using A.Bader, i lr as Owner of the subject property heceby autl otize e.!N N1'Eby _to act on my behalf, I f in all matters eclative to work authorized by this building permit application for; 5TQ-AtA)fD6(Z Q-Y "ILL P>j Ce 0UU'L-(-e - (Address of job) V OR 15Z Signature of Owner Date f 9A , Ptiut Name If Property Owner is applying for permit,.please complete the Homeowners License Exemption Form on,the reverse side. :. ' 10/10 39tid £0Z5ILL805 . 7:00 900Z/9z/10