HomeMy WebLinkAbout0410-0412 BEARSE'S WAY 14114
Town of Barnstable *Permit# �S
Expires 6 months from issue date
IT
Regulatory Services Fee c-,?Z 7�
-ca E1 Thomas F.Geiler,Director
Building Division /
OCT 2 2 2007 Tom Perry,CBO, Building Commissioner {"
®F GARNSTA�LF 200 Main Street,Hyannis,MA 02601
TOWNwww.town.barnstable•ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY
Not[Valid without Red X-Press Imprint
Map/parcel Number 9 * - 0 3
Property Address �r 71.) 44,!lce-f V�y
[Residential Value of Work �V �00 Minimum fee of$25.00 for work_under$6000.00
Owner's Name&Address
Contractor's Name 6 lip Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
Uaam a sole proprietor
m the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box) 1
[F(Re-roof(stripping old shingles) All construction debris will be taken to R/J4 �6171 ZW14,�#
❑i Re-roof(not stripping, Going over existing layers of roof)
E Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
**here required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
.***Note: Property Owner must sign Property Owner Letter of Permission.
A cop of the Hom p ovement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
' The Commonwealth of Massachusetts
Department of IndustrialAdcidents
Office afInvestigations
600 Washington Street
Boston,AM 02111 ,
www.rn ass.gov/dia
Workers"Compensation Insurance Affidavit:: Builders/Contractors/Electricians/PIumbers
Applicant Information 42Please Print Le 'bI
Name(Business/Organization/Individual):/
Address: C/
City/State/Zip:� V
Are you an employer? Check the appropriate box: -Type of project(required)
1.❑ I am a employer with 4. [] I am a general contractor and I
6. ❑New construction
employees (full and/or part time)." have hired the sub-contractors
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• n Demolition
working for me in any capacity. employees and have workers'
insurance.$' 9• ❑Building addition
[No workers'comp.insur coance mP•
quired..] 5• [] We,are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
rnysel£ [No workers' comp. right of exemption per MGL . 12.[s�Roof repairs
insurance required.] t c. 152, §1(4),and we have no WS
employees, [No workers' 13.[I�Other 1�/h sl /'2
camp. 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 additionalshret sbowing the name of the sub-contractors and state whether ornot those entities have
employees. If the sub-contractors lave employees,they must providt their workers'camp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below tslhe policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
lob 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 penaltirs 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 WA for insurance coverage verification.
16 hereby certify:rude the pain en Ides of perjury+that the information provided above is true and correct:
SiEnature: Date:
Phone#: l G
Official use only. Do not write in this area,Yb 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 CIerk 4.Electrical Inspector S.Plumbing Inspector
6, Other
Contact Person: Phone#:
' WHErp�yO . : Town of Barnstable,
Regulatory Services
1AHNSMIX, •
y MASS. $ Thomas F. Geller,Director
� 7
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
"-w.town,barnstab l e.ma.us
Office: 508-862-4038
Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
here byautho to act on my behalf,
in all matters relative to work authorized bythis building permit application for: .
(Address of Job)
/G ,? G 7
Signature of Owner D e
Print ame
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