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HomeMy WebLinkAbout0601 OLD STRAWBERRY HILL ROAD 6ai /2�f/lt��G�^. /��c - -- — - —__ _ _ _� � aPc\ J ` _ _ _ - --- - - . �� 1 Town of Barnstable *Permit#C Fapires 6 months from issue date ti BARNSTABLE. ` Regulatory Services Fee�vr' Mnss: Thomas F.Geiler,Director jD t6,3q. fb Building Division Tom Perry,CBO, Building CommissiAPP R E S S PERMIT 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ,JUL 2 8 2006 Office: 508-862-4038 Fax: 508-790-623� TOWN OF BARNSTABLE EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY 7 / Not Valid without Red X-Press Imprint Map/parcel Numbers /3 f Property Address15SAV t4 1"h/S esidential Value of Wo s --� Minimum fee of$25.00 for work under$6000.01 Owner's Name&Address & j I Contractor's Name 41C c PA_ C��. Telephone Number S©�' �1- 1 �("73- Home Improvement Contractor License#(if applicable) l mot' a Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Chec I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) e-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: e s:expmtrg - Rviseevise071405 - The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street ' Boston, MA 0.2111 www.mas.&gov/dia- Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plu abers _Applicant Information L Please Print Legibly Name (Business/organization/R dividup., HOED �s +cif CSC,f jam] Address:! Z Q l <TRAtAi P, City/State/Zip; Phone#; 5V? - 7 3 Are you an employer? Check the-appropriate bog: Type of project•(required): 1,❑ I am a envloyer with 4. ❑ I am a general contractor and I to (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 7• ❑ Remodeling 2. am a sole proprietor or partner- listed on the attached sheet$ ship and have no employees These sub-contractors have 8. ❑ Demolition worlang for mein any capacity. workers' comp.insurance, 9. ❑ Bw7ding addition [No workers Comp.insurance 5. ❑ We are a corporation and fts officers have exercised their 0.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I LM Mmbing repairs or additions myself.[No workers' comp, c. 152,$1(4),and we have no 12,❑ Roof repairs . . insurance required.] t , employees.(No workers' 13.❑ Other camp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'oompensation policyinfcnnatioa: t Homeowners who submit this affidavit indicating they are doing aIl work andtheu hire outside cont actors must submit anew aMd%Yit indicatin$such 1conb actass that check this boat must attached an additional sheat showing the name of the sub-contractors and their workers'vomp.policy information. ram an employer that is providing workers'compensation insurance for.my employees. Below is thepolicy andi'ob.siti - Informadon, Insurance Company Name Policy, r or S;Ci".Lac. : r-= Doi: Job Site Address: City/state/* Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Mime to secure-coverage as required under Section 25A of MGL c. 152 rmd lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisamnent,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statemen#may be forwarded to the Office of Investigations of the DIA far insurance coverage verification. 1 do hereby certify tinder the pains and penalties of perjury that the information provided above 6 true and correct, SrQnature:�� Date: —7 0 f,1Z.% Phase# �S-01;�j S—I —7 ^',fib '`' Dsr,�M E#rfMana tobtc ' dbyc :or L-id `v cZia�K5� ofi� , City Town-orn: Perm /License Imuing Authority(circle one): 11.Board of Health 2.Building Department 3.City/Towa Clerk 4.Electrical inspector 5.Plumbing Inspes for 6.ether Correct Person: Phone : Information and Instructions Massaqhusetts General Laws chapter 152 requires all employers to provide Wbrkers' compensationforAw employees. pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express orimplied,.oial 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 finch dw-elling house or m the grounds or building appurtenant thereto shall not because of sucb employment be deemed tobe an employer." MGL chapter 152, §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 produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,125C(7)states"Neither 1he commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance wits the insurance requaemen s of this chapter have been presented to the contracting authority." Applicanta Please fill out the workcrs'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 partaers,are not required to carry workers' compensation insuramce. 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 licit the application for the p ermit or license is being requested;not the Deparraient of Industrial Accidents. Should you have any questions regarding the law or if you axe required to obtain a workers' t the number listed below. Self-insured eo anus 1-hem- their. artmen at mrmb tiara oh lease call the D mP , compensa policy,p ep . self-assurance license number on-the appropriate line. City or Town Officials . _ ... -. •is v d+;i?. Please be sure that the affidavit is complete and printed legibly: The Department has provided a space at the bottom. off Zffi&ayft for yin to fill actin the event the Office of Investigations has to contact you regarding the applicant - Please be sure to fill in the permit/license number wbicb will be used as a reference umnber. in addition,an applicarit that roust submit multiple permitllicense applications in,any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Joh Site Address"the applicant should write"all locations in_„' _(city or town)."A copy,of the affidavit that has been officially stamped or marked by the city or town may be provided to•the applicant as proof that.a valid affidavit ism file for future permits or licenses. Anew affidavit must be filled out each ' year.Where a biome 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 bran 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 nothesitate to give us a call. The Depm1mmm'a address,telephone and fax m fiber: The Commonwealth of_Musadmset Deparbment of Indust ial Accidents office of in ' 600 Washington Street Boston,MA 02111 Tel, 617-727-4900 e-nt 406 or 1 077 Iv1ASSAFE ' Fax L 617-727-7749 Revised 5-26-05 -vrwv.IIass. ov/d:ia ,ro •y ., Town of Barnstable nn�xseas MAN. Regulatory Services fo °' Thomas F.Geiler,Director 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 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize&J 2 4 P to act on my behalf, in all matters relative to work authorized by this building permit application for: 7`7 1 (Ad ress of Job) ' 12 0 Signature of Owner Date 41- Z'o zoLC� --- Print Name Q:Forms:expmtrg Revise071405 ✓fie -Pj ,- . Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR ? RACTOR Reg�strat�on 1,48 n Ez 999 �rra � 9/16/2007 ROBERT BROWN an.- ROBERT BRpy�N TQIIBUILDING REMODELING I 563 OLD STRAWBERRYHIlLRD. CENTERVILLE,MA 02632 -6 Administrator i J 6 a i SKI .Z, �.0 O Ap � 41 4N �` , 23 6�Pyo�THE. � TOWN OF BAR.NSTABLE i • j BABBSTAIILS, i "N O MPY BUILDING 0 SP C O CE p' APPLICATION FOR PERMIT TO 'i�'`-e �� TYPE OF CONSTRUCTION ..............!�v..r!—E ....... .. .�'e�!.�...,T... .�. ?... ........... U �.3./...19:9.. t TO THE INSPECTOR OF BUILDINGS:` - - - --- The undersigned hereby applies for a permit according to the following information: a� Location .......�..... ..........4±1............ ....Q.... q i 11 J "Proposed Use ...�.H.<U.S: .. ... .. nl-. .. .. .. <... ............................................................................................ Zoning District .... .. . .�� .4:`.'Q '4...0�.�:�. .. ...... .Fire District ..........................`.......................... ....................... Name of OwnerE3A..Y.1.A.�..........��.5.�.............. Name of Builder ..C. .Y1.lC.�... .tlti.�..IC! ?� ..........Address J..�... .'Yy�G..l.( .L .......1 .1�..5...�'...................... . _ y Name of Architect ......... 1C '`.' ....................................Address ................5.. r.................... Number of Rooms ...........+ ...................................................Foundation .7.d.......... ..u�`.` ..Y........C.U..v?.G.lk.'Qi4.`4'�:.. 9 Exterior ..d�4s.. ..1.k�. ►.. 5.............................Roofing `e..`h.`Q.�..I.S. a h,•J••......... Floors ...... ..d..0...rL...........................................................Interior .�..1� (.!lC- I..................................................... Heating .... ..�. .�-��f l �. .................... Plumbing ��.` '�..6`.�...rr. ......... q.1�'f" .... ti ,.. ....... ........ ......... Fire la p ce .......�i.....cJ...Y.1-A......................................................Approximate Cost � i.. .Q. .i. ............................... Difinitive Plan Approved by Planning Board --------------------------____ Diagram of Lot and Building with Dimensions �n�', ,3-I�d LS V 0 i�k d 3 r _ 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ����� °naueoup ' ~ 13538 ' ~ � I 1/2 etor�^������—. Parmh �n ----�!—.--...... ..No single family dwelling —'-'........—'-'-......----'.......----'----' \ , . Old Strawberry BiII Pd ! Location ------------------..�-- o .........................Byaooi_________.____.. Owner ____8iohaI#oa..Choxenbx»_.____ | ^ � Type of [nnsfraConstruction -------------- / ' \ `_____^___~______...._________ | \ Plot �» � ' ---------. -------.�..�-- '� Dmoeo��r 8 Permit Granted -------------]g '�� � . Date of Inspection �� uo/o Completed PERMIT REFUSED . l . � lV � �L ^----'----^----------- , ~ ` ) ~—..---------------------.— . . .................................................... .-------. � ^ � —.~---------...---.......—.----- � ---------~--.-----..,—..----^. � ' | , ' | Approved ................................................. lA | � ` ~ | � ! � / ^ ---------------.-----..----.. ) . ' -----------.---------'.—.---- �