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Home My WebLink About1095 PHINNEY'S LANE / �j r J I � - - - J I i t ,� i �.�� _ l Application numbe ....................................'.... Fee ...................... ...................................................... MAMs,�srwsu�, Building Inspectors Initials.... ... ............................. . 1611 t NOV 20�� Date Issued..... ��..................�......................... ........ n� TOWN O� 8AH S N SABLE Map/Parcel........C�...I.......................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 1 0 56 -A )-cans. C�^n NUMBER ST ET VILLAGE Owner's Name: 7:�®w^ Cc d e A�o Phone Number 6 o G 3 60 3'-+ 15 Email Address: yy1cgJer0-FI4 e4cL 0•C-oy4 Cell Phone Number. 3LayS6 9 g Project cost $ 10 D00.01 Check one Residential�_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 0T Siding Windows (no header change)'#- Q Insulation/Weatherization ffDoors (no header change) # 9— Commercial Doors require an inspector's review ' . MRoof(not applying more than 1 layer of shingles) Construction Debris will be going to -tyoa$1 CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable) # (attach.copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ' *For Tents Only* Date Tent (s),will be erected Removed on i number of tents total Does the tent have sides? Yes. No (If yes please attach floor plan with exits marked) Dimensions of each Tent X '{X , X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: `cx� ca-m P O V C4� yNk ofo Telephone Number 'D 4-'1 5 Cell or Work number 3 y �l5 663 99 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of arnstable. '—SlWature Date I �, APPLICANT'S SIGNATURE C-Signature Date D I P All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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/In-dividual): s W1V©vee��P %�l yV�-QrQ Address: t'tk 5 City/State/ZipGey\�&_u A, e MA 02.6 3 2-Phone#: -3 L1 4 Are you an employer?Check the appropriate box: Type of project(required): LEI❑ 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 g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P t5'• $ 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 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 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 hive outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ 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 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 caeder li�pa'ns and penalti�ofrjury that the information provided acb�ove is true and�correct., Si afore: Date: f —2 J' Phone#: Official use only. Do not write in this area,to 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ,w> .., A Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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,§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, §25C( )states"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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(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 bereturned 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 must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 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 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 Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MA.SSAFE Fax##617-727-7749 Revised 4-24-07 www.mass.govCdia I <� OFTNE r Town of Barnstable *Permit# �� Expires 6 months fron issue date 9,ARxSTABLE, Regulatory Services Fee < 039. Thomas F.Geiler,Director $pTFD1"p`A Building Division PR Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 V 1 7 CUU3 Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARN6 ti EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not�Validd without Red X-Press Imprint Map/parcel Number c21 cY.0 / ja Zd,, a Property Address /6 e esidential _ Value of Work Owner's Name&Address &?4V- Contractor's Name L d 1/7�la jr2 Telephone Numbers 15"j �r Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orlanan's Compensation Insurance Check one; ❑ I am a sole proprietor ❑ I ,ua4he Homeowner have Worker's Compensation Insurance Insurance Company Name �iC � Workman's Comp.Policy# O o �/ 2 f o Permit Request(check box) -roof(stripping old shingles) ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature/.,a Q:Forns_expmtrg Revised 121901 f 4 f' eFSHEToy, Town of Barnstable Regulatory Services " BABNSrABLE, ' Thomas F.Geiler,Director y nsass. g `bA 1639. A Building Division Tf0 MAy Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder J2 L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for (address of job) � k/-2 Signature of Owner Date Print Name QTORMS:O WNERPERMISS ION 1 s �6e TDommwouuea�,�i o�✓�raaaclzuaelta Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrafit►on Vg560 Ezptrati`9n 4/ 2005 yl tJic{IV idual RICHARD VILLAIN}N 3 :' 19UpLICATF RICHARD VILLAR, 109 WAGON LANE\ h Y HYANNIS,MA 02601 Administrator