HomeMy WebLinkAbout0036 SUNSET LANE (4) '.2.-- • i''"''''''''''' '''''''hi6 :--
,:fib
L.
it ,
•
•
o
G ..
it .. r. �. .. _ '
. , , ‘,...... d.._,...
/--if
. . ,
,. .
•
•
.l
,. ��.. .. w,. .,
s
•
y
Town of Barnstable *Permit# a 70-VelO
Expires 6 onths from issue date
Regulatory Services • Fee j aQ
Thomas F.Geiler,Director
X-PRESS PERMIT Building Division pk � ' 3 O)
Tom Perry,CBO, Building Commissioner 7
JUN 2 9 2007 200 Main Street,Hyannis,MA 02601
OTOw eF6 �ARNISTABLE www.town.barnstable.ma.us
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
lap/parcel Number 3'9 OZ y-) 44-fri
roperty Address L..3 &sent ppwS4.4 (€_. "AA
c9 0
]Residential Value of Work l.qOpp Minimum fee of$25.00 for work under$6000.00
'wner's Name&Address &41W M 0 L.L. t ni 2,ictn
:ontractor's Name .J e Coy' VD Telephone Number.6-be ax, ?g
lone Improvement Contractor License#(if applicable) 7 ' / a A/o )4/
:onstftraibl ivisor Liuei,se#(i -appiicable) 00 6;5'
]Workman's Compensation Insurance
Check one: -
,�I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
asurance Company Name
Vorkman's Comp.Policy#
:opy of Insurance Compliance Certificate must be on file.
'ermit Request(check box)
IX Re-roof(stripping old shingles) All construction debris will be taken to pNekvil,v44, -re AW S
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc,
***Note: Property Owner must sign Property Owner Letter of Permission,
A copy of the Home Im rov-ment Contractors License is required.
;IGNATURE:
!:Forms:expmtrg
.evise061306
• , • , • The Comrrionwealth of Massachusetts • .
. =w� Department oflndustrial Accidents •
Office f 'v
:I
1_ U ce o In estigafions
ft=4.7•��_a' • 600 Washington Street . .
-_ • Boston,MA 02Z.t1'
•
wrv>v.mass.gov/dia '
• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information • ,Please Print Le lv • •
• Name(Business/Organiiation/Individual): , P : . Cim ttnmAYJ •
•
• • •Address: h:vi;14.g� •�v .
City/State/Zip:CP pv t mA. p?a6> ,•Phone.#: S'0 & tt ?$> ' • •
- Are you an employer?•Check the appropriate box:
:Type of pioject(required); •
1;L] I am a employer with 4. ❑ I am a general contractor and I •
'employees(full and/or part time),*, , .have hired the stab-contractors 6, ❑New construction .
2.KI am.a'bole.proprietor or partner- listed on the'attached sheet: 7. 0 Remodeling
ship and have no employees • These sub-contractors have g, ❑Demolition. '
• 'Wyorking for me in any capacity. employees and have workers' • 9 B ' addition'
[No workers' comp,insurance comp.insurance.$' ❑ • g . •
required] 5; 0 We are,a:corporation and its 10.❑Electrical rep airs or additions
— ---- '3.❑I am-a homeownerdoing-sxl.work - -__ ' °facers-have exercised their . 11.❑Plumbing repairs or additions ' -
• • myself.[No workers'comp, right of exemption per MGL. ' 12, Roof r
insurance,required]t ,c. 152,§1(4),and we have no'. ❑ epairs
• employees, [Na workers' ..13.0 Other '
• comp,insurance requited.] • •
*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 woik and then hire outside contractors must submit anew affidavit indicating such,
Contractors that check this box must attached an additionalcheet showing filename of the pub-contractors and state whether ornot those entities have
•employees, If the sub-contractors have employees,they provide theirworkers' •comp.policy number. '
•
• I am an employer,that is providing workers'compensation insurance for my employees. Below is.the policy and job site'. •
information. ,
Insurance Company Nam •
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 numb er and expiration date);
• Failure,to secure coverage as required under Section 25A•ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine tip 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 acopy of this statement maybe forwarded to the•Office of•
Investigations of the bIA for insurance coverage verification, ' . • •
I do hereby certify under the pains•and enalties f perjury that the information provided above is true and correct •. .
Signature: /7—c1 f .
Date:• (+� ''7� Q`!. ,
Phone#: �� ,�,g 0— SS • • •
Official use only. Do not Write in this area,tb be completed by,city ar town official. '
•
City or Town: •• . . • Eermit/License# . • 0 ' .
• 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#;
i�..AormaLlwi allU•.�U LE LIi3LIUU • •
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thou employees. ,
Pursuant to this statute, an employee is defined as",,.every person in the service of another under any contract of bie, .
. express or implied, oral or written." • • •
An employer is defined as"an.individual,partnership,association,corporation or other legal eniity,or any two or more
•
of the foregoing engaged in a joint enterprise,and including the legal representatives of a'deceased employer, or the
receiver or trustee•of an individual,partnership,association or other legal entity,employing employees, However the
• owner of a dwelling house having not more th an three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do'ma,ntenance,construction or repair work on such dwelling house
• or on the grounds or building appurtenant thereto sha11 not because of such employment be deemed to be an employer."
IvIGL chaptert152,.§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any
• applicant who has not prod uced•acceptable evidence of compliance with the insurance coverage required." .
Additionally,MGL ohapter.152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
• 'enter into any contract for,the performance of publ c•.workuntil acceptable cvidens6•of•compl{nee yfithtlie ixance• ,
requirements of this chapter have been presented'to the contracting authority.'t , • • ' '
Applicants , • , • '
i
Please fill out the workers' compensation affidavit completely,by checldng the boxes that apply to your situation and,if
necessary,supply sub-conti:actor(s)name(s),address(es)and phone number(s)along with their certificate(s) of ,
insurance. Limited.Liability Companies'(LLC) or Limited Liability Partnerships(LLP)with no'employees other than the
members'or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have •
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial '•
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should •
be returned to the city or town that the application for the permit.or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law•or if you are required to obtain a workers'
. compensation policy,please call the Department at the number listed below. Self-insured companies should enter their . .
self-insurance license number on the appropriate'line. •
City or Town Officials • .
• Please be sure that the affidavit is complete•and printed legibly. The Department has provided a space at the bottom •
' of the•affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. •
• • Please be sure to fill in the permit/license number which will be used as a reference number: In addition,an applicant
that rn»st submit multiple pemiit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and►miler"Sob Site Address"the applicant should write"all•locations in_ (oity'or
• town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the
' applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each •,
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves•etc.)said person is•NOT required to complete this affidavit. •
The Office of Investigations would like to thank you in advance for your cooperation and should you have-any questions,
• please do not hesitate to givens a call. S •
The D epaz1ment's address,telephone and fax number:. •
• : p rat of A.Aozde its. : ' r '
• • . ; ,. Qmee of Investi onz • •
•
• ' POW .S . S ' '
• • •• . - Batons MA 02l 11•• •, ••.
• • Ted. 617 7214� ext 406 r r I$$ 7-MAS AFB
• • l7 727 49' .
Revised II-22:06. �.m g iVihet .
ft
ri 7
Zlite C.009ivinoweveala o/,/ifaaaaciuweat
Board of Building Regulations and Standards
License or registration valid for individul use only
r HOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
Registration: 124074 Board of Building Regulations and Standards
, •,,,,,,.-T,.,
,•Expiration:- 5/9/2009 Tr# 129558 One Ashburton Place Rm 1301
. ,
JYpe:.DBA
Conrad Remodelingr:-.2-7,-..L.';
• Z.I. 1
1
•(... ...,4,,,ACI.A.,........._ I
.._____________- •
CENTERVILLE,MA 02632 Administrator t valid without signature,
, .
1
7. ip, Town.of Barnstable
/44.-. ss,,; ` Regulatory Services t B Erin r, *
Thomas F. Geller,Director
as,►ss, g .
9
�,..?E 9;:, Building Division
Torn Perry, Building Commissioner
• • 200 Main Street, Hyannis,MA 02601 •
ffice: 508-862-4038 Fax: 508-790-6230
Property Owner Must
II
Complete and Sign This Section
If Using A Builder
I, �o�1,S w • t�o LtivEAV�[ as Owner of the subject property
.J €FREY t4 . C�„� (%A
Cp R
herebyauthorize ct,RO lorJt�►0 E RODE)to act on my behalf,
in all matters relative to work authorized by this building permit application for:
33 S'U ET LA) - gARN3iiiiM ►AA 01C30
(Address of Job) .
ature of Owner Date
s0{A.S UJ . 001,1.I0EAU X
Print Name
Q:FORMS:O WNERPERMIS SIGN
I
I\I