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Town of Barnstable *Permit#
_ .Expires 6 nro the from issue date
Regulatory Services Fee
* *
* ABLE
Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner.
200 Main Street,Hyannis,MA 0260.1
www.town.bamstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X--Press Imprint
Map/parcel NumberEA
Property Address
❑Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
I � Telephone Number 77 CJ I? - 0�3(0
Contractor's Name '1 /� LJIJ t Lt✓t —
Home Improvement Contractor License#(if applicable).
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Che one:
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
❑Re-roof(hurricane nailed)(not stripping. Going.over existing layers of roof)
,I 5QL)A- ZC--- I�l i C_ Cc—DArLS
Re-side #of doors.
❑ Replacement Windows/doors/sliders.U-Value
maximum.35)#of windows
ent regulations,i.e.Historic,Conservation,etc.
*Where required: issuance of this permit does not exempt compliance with other town departm
*"Note: Property.Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
quiredr
SIGNATURE:
C:\Users\decollik\AppDataULo6a1\Microsoft\Windows\Temporary Internet Files\Content.0utl66k\DDV87AAZ\ExPRESS.doc
Revised 0721.10
rA °mvinomeueczl o��laaaar�u4eCQ ,
-\ Office of Consumer Affairs&Bu@mess Regulation k (: License or registration wand for individul use.pnly
HOME IMPROVEMENTCONTAACTO ,. r
before the expiration date. If found return to: '
Registration '112161 ' Typby Office of Consumer Affairs and Business Regulation
Expiration 3/1212013 DBA r r. 10 PArk Plaza-Suite 5170 1
Bost6n,MA 02116 ,
WILLL�MSON CONSTRUCTION
ALL, WILLIAM6M
25 CORRINE DR
E FALMOUTH MA 02536�
- Undersecretary of va hout signature '
11�.111.►�•l1 P
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_nstrUcti . Rc ol,pUJ)li
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License: CS Ory SUP ervis,onr anal SI( S!tct
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H MA 02536
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The Cafai ndn.wealth of Maassdebusetts
ar�nertofInd Accidents
office Irtvestrgatrons
600 Washington Sheet.
Boston,-M 62111
- _ vv►vrumass.govoldin
Workez-5' Compensation Insumnce Affidavit Btuil&.rs/Contractors/EIectt cians/Plumbers
licant Information + Please Print loT'
Name Olsimsst()rgauizanon t-dividmal) I A� � , —t rtM�ys�,l
Address? L z�i.xIE �1{
City/State/Zip:
Are.you an employer?Check the appropriate boa: Type o€project(require4
1.❑ I am a employer with 4. ❑ I am a general contractor and I ❑New construction .
loyees[full andlor part trine * " bane hired the sub cantractois
12117 a sole proprietor or partner-
listed+on the attaclxed sheet- 7_ ❑Retnadeling
,�e no 1 These sub-contractors have g
ship and ha ❑Demolition
employees
employee <and have workers'
working far me in anyeapacity_ 9_ ❑Building addition `
[No orkers'comp.+n ^re cep-insinance$
required.]
5. ❑ Rye are a cosporagon and its 10_❑Electrical repairs or additions
3_❑ Iama homeowwner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'damp:' right.of exemption per 1�Gi. 12_❑Roof repairs
t c.`152, �1(4} an We have too
insurance required-] BE Other
employees,Pi� workers'
comp.insartce iegtrire _] -
'Any applu�t dat c,ILkks box#1 nest also fill out the secd6n,bel showing theme, Geis'C.OWensati€tn gsrl�cy in€o�a�tia� .
I RoMeowaers who submit this afhdas�t iudocatint they ale daiag au woaR and then hire outside coutractnrs rims[submit a new affidavit indicant,such . .
I Ontiactors#hat chew this�mug attached additio®sl sheet sho'cs'mg the name of the sub-cautrwtors and state whether ar not these eir$tses pace
emp9or If he sub-santcactors hake e33ploFees,obeli must pxn>side their irYkms oomp pohe'number:
lam an�utplr�xer that is pravrdutg 1vorkers'catrgrensativrt presz1rarace for arty ertrptuj Bemis th di arzd job site
utfbarnatiatt.
Imiirance Company Nape:::
policy R or Self-ins.Uc.#: Fa pirahon Date
Job Site Address: ;.:: CityfS#ate�+Ztp:
Attach a copy of the workers'compensation policy declaration page(showing the policy rumbet and expiration date).
Failure to secure coverage as rerluuen under Section 2,5A of MGL c,152 can lead to the itnpow4on of ctrrrrt,ral:penalties of a
one up to S 1,544_{8tk and/or one-year itnpriso�rtient,as�xrelt as c!" penalties iai the form of a STGP RF()RR ORDER and a fine
o€up to$25t9.�a day against the violater. 13e advised that a copy o€this statement easy be forurarded foe Office of
Issestigations of the DIA for insurance,coverage verification:;
a tttst the ira trtw�att an prrxi did ra tnw and carrect
I do drMIT oe est the s d p ors ofPei ty .. f
Date:
Phone# �Q -71
Ofjiciad itse onlp. Do eat asnte in this rtrea,fa'be cotatpleted by cat} ar tati�n Q ti[it
City or Tow€► :: Perlia #
Tssnutg Anthoi�t; [cu�cle one},
1.Board of.Dealtit 2.I3urZdirrg Depat•tment 1+Citar,+'I`O W11 Clem 4 1 Iectrrcal.Wpec or 5 Pltambing InsT.
pector
6.Other
Contact;Person: Phone#
_ _ _. 6
.. 1
snsxsrnaLE, "
�,3. r Town of Barnstable
QED MA'S 4
Regulatory Services
Thomas F.Geiler,Director
Building Division.
Thomas Perry,CBO
Building Commissioner
260 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038
' Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property ;
' ( I � i LL 1/� S to act on my behalf,
hereby authorize M
in all matters relative to work authorized by this building permit application for:
dac:)i_t_C— A c--"�JE ,�— \JIL'L-C—; �
r
(Address of Job)
S ture of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption'Form on the
reverse side.
+ soft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
C:\Users\decollik\AppData\Local\Micro
r Revised 072110
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