HomeMy WebLinkAbout0128 LOCUST STREET /old' �oea s7- .Sfi
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��++►► Town of Barnstable *Permit#
-PRESS 7 Expires 6 wiltsfirom issue date
SEP 112007 Regulatory Services Fee
Thomas F.Geiler,Director
TOWN OF BARNSTABLE 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 PERNIIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number Po 31
Property Address
E Residential Value of Work //) 6) - G //Minimum fee of$25.000 for work under$6000.00
Owner's Name&Address e�
J( UC/Yd6Y� r l �/7 l�
Contractor's Name 17y C'a� l°r� Telephone Number 77 G cUllk
Home Improvement Contractor License#(if applicable) 7 P d,7-
Construction Supervisor's License#(if applicable)
Korkman's Compensation Insurance
Check one:
❑�a sole proprietor
L=1 1 am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name V f�
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box).
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Qivner must sign Property Owner Letter of Permission.
A co the Hom&imnrovement Contractors License is required.
SIGNATURE:
Q:Fonns:expmtrg
Revise061306
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston,MA 02111 ,
www.mass.gov/dia
Workers"Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):. � G i9i✓T `A/L 12
Address: 3
City/State/Zip: &nj6� i Ao C-c Phone.#:
Are you an employer? Check the appropriate box: -Type of project(required):.
1.❑ I am a employer with 4. I am a general contractor and I
. employees(full and/or part-time).
have hired the sub-contractors 6. ❑New construction .
2.❑ I am a•sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling
' ship and have no employees These sub-contractors have 8. ❑Demolition •
worldng for me in any capacity. employees and have workers' 9 Building addition
[N workers' comp.insurance comp.insurance.$
quired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3. I am ahomeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t C. 152, §1(4),and we have no
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 iuch.
lContracton chat check this box must attached an additional sheet sbowing the name of the sub-contractors and state whether or not those entities have
employees. H the sub-contractors frave employees,they must providt their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below islhe policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date: 1,/
Job Site Address:
Attach a copy of the workers' compensation policy declaration p ge(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 certify un a pains•an enalties of perjury that the information provideddabove is true andcorrect
Sip-mature: Date: / `(/ 0 _
Phone#: JO, Ir
Official use only. Da not write in this area,'fb 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 CIark 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
�pP ZHE I°�y
'down of Barnstable.
Regulatory Services
y MASS. Thomas F.Geller,Director
f16 9. ]Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
w-vv w.town.b arnstable.ma.us
Office: 508-862-403 8
Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subject property
he re byauthorize to act on my behalf,
in all matters relative to.work authorized by this building permit application for: .
(Address of Job)
61'_61r7
Sign e of Owner Date
Print ame C
Q:FORMS:OWNEUERMIS SIGN