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Home My WebLink About0055 LOUIS STREET ��_-��G�-lifro �— - -----�------ - - - -- — J THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR . ' QUALITY ORIGINALS) i M A.t K C DATA Town of Barnstable *Permit# °�tHB TOE,_ Expires ,months from issue date Ivgulatory Services . .. Pee F.'Geiler,Director R Building Division- _ '.. . _.. - — -"Torn Perry, Building Commissioner •200 Main•Street,•Hyannis,MA 02601--••• APR .l Office: 508-862-4038 __ TOVVo'�'- ��:.....: Fax:'508-79.0-62305 , ONLY. -• "EXPS :' REVERIGIIT' MYA"TYON - Not vaNd ivuhoutRed X Press Imprint Map/parcel Number 3 q a o 40% Address Jr'� v�.� S)�c c, Property! � . ❑ ��o Minimum fee of$25.00 for work under$6000.0 Residential Value of Work Owner's Name&Address L ,5-� CA Telephone Number Y� 0 Contractor's Name Home Improvement Contractor License#(if applicable) e s d3 � 7di Construction Supervisor's License#(if applicable) t ❑Workman's Co ensation Insurance Chec ne: I am a sole proprietor ❑ I arnthe Homeowner ❑ I have Worker's Compensation Insurance C- Te Insurance Company Name Wotkman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. permit Request(check box) e-ro0f(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roofl r 92L �? ?� Board of.Bnitd Rein ❑ Re-side g galahons and Stagy ` HOME IMOOVEMENT CONTRA ❑ Replacement Windows. U-Value ( 44) Registration; 120689 EzpirafioI 1i•30/2006 *Where required: Issuance of this permit does not exempt compliance with other town { Hype DBE *** Owner must sign Property Owner Letter J.L.CA�E'A-ULT; _#` t ' Note: Property ` _ f Home Improve ent Contractors License is require JAMES CAZEAUCT 183 CLAMSHELL COTUIT,MA 02635\ Signature Administrator` Q:Forms:exp S Revise063004 Town of Barnstable o� Regulatory Services = Thomas F.Geiler,Director . Building Divis ion � • . . ib99 �m 'OrFDMP�A Tomperry, Building Commissioner 200 Main Street, $Yam,MA 02601 wwvtwAown.barnstable;ma.us Fax: 508-790-6230 ' p 'ice: 508-862�038 Property Owner Must Complete au.d Sign TMs Section If Using ABuilder as Owner of the subject property • .. authorize: .. ��n ems.•' 2 .to•act on mybehalf; hereby . is all matters relative to work authorized bytl is building permit application for. {Address of fob) —44 S1gria of Owner ate print 1�Tame • ' --- -- Department _ The Commonwealth of Massachusetts -� _ s T Department of Industrial Accidents IX ' Office of Investigations 600 Washington Street, 74 h Floor Boston,Mass. 02111 ��-r� Workers'C sation Insurance Affidavit:Building/Plumbing/Electrical Contractors APDII 71 171�"PMR> 0 f a° :a s PIe� �! lz a rlr% �^ Se Pit ee1b x .a name: 2K 4u 1 address: 7-:K Z citv CJ T 'j state: zip: phone 2.1-2 v work site location(full address): ❑ 1 am eowner performing all work myself. Project Type: ❑New Construction❑Remodel am a sole pro . rietor and have no one working in any capacity. ❑Building Addition :�r^f" ter.: .x ❑ I am an employer providing workers' compensation for my employees working on this job. company name: L Z{ A v' 57— address• city l i, I phone# v2 i1 d insurance co. policy# m a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers'compensation polices: company name: address: city: phone#: insurance co. olic # company name: address: city: phone M insurance co. nolicv# a.;. ? � } �: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement ma• e forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify un r the pains d pe Ities of perjury that the information provided above is true and correct. Signature Date �O a-s S' Print name �M C-s' Z-�9 1 fi Phone# �s a �01 D t ;t' ° [check nly do not write in this area to be completed by city or town official : permit/license# ❑Building Department oard immediate response is required ❑Selectmen'Bs Office ❑Health Department on: phone#; ❑Other03) - e ' F Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual,partnership, association,corporation or other legal entity, 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 than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 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 produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. �. Mll Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7te Floor Boston,Ma. 02111 fax#: (617)727-7749 phone #: (617) 727-4900 ext.406