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Home My WebLink About3576 MAIN ST./RTE 6A(BARN.) � � � ��` _, .F, _. ;f.�.2 t r. � __ _. ., . . �o`' k.. x ., k .. �; a ,... � .. . _ _- __-_.. _ ,� v tttrrr^ a .. .„ ,. .. .. �,. .. P ., ' �, n ,. .v o e ,:. i ,. � ;,, - ,- . ro Y 0-f Town of Barnstable *Permit# P� Expires 6 mont/rs from issue date T Regulatory Services Fee Lvttvsras[.e, 9� '"ate 039• � Thomas F. Geiler,Director pTfD MAC A Building Division s,, _'' Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 s i'f www.town.barnstab le.ma.us Officer 508-862-4038 VJk_�' Faz 508-7V 6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid witlrout Red X-Press Imprint Map/parcel Number l S ZPrope Address _35�(/,7 1414 t � �� ; � �T Residential Value of Work c Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address GL(.1/ ' Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ Vm a sole proprietor iP I am the Homeowner V, y� ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# '.l {"' 5 �ar�r '_7 , Copy of Insurance Compliance Certificate.must accompany each permit. 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 #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows "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. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: ' L Q:\WPFILES\FORMS\building permit forms\EXPRESS.dOC RP,.;4 n7nt to NThe Commonwealth of Massachusetts E I Department of Industrial Accidents J.. Office of Investigations n w- I► �� 600 Washington Street Boston, MA 02111 . � I www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: 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 6. El 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 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [N workers' comp. insurance 5. ❑ We are a corporation and its quired.] officers have exercised their ]0.❑ Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I 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 additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I 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. Lie.#: 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/of 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 under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: 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#: it I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide wor e'rs' compensation for their employees. Pursuant to this sl'atute,an employee is defined as"...every person in the servi of another under any contract of hire, express or implied,oral or written." An employer is defined'as"an individual,partnership,association,corpor ion or other legal entity,or any two or more of the foregoing engaged\arine int enterprise,and including the legal rep esentatives of a deceased employer, or the receiver or trustee of an inal,partnership, association or other leg entity,employing employees. However the owner of a dwelling houseg not more than three apartments and ho resides therein,or the occupant of the dwelling house of anotherploys persons to do maintenance, c struction or repair work on such dwelling house or on the grounds or buildp enant thereto shall not because o such employment be deemed to be an employer." MGL chapter 152, §25C(6states at"every state or local lie nsing agency shall withhold the issuance or renewal of a license or peo opera a business or to constr ct buildings in the commonwealth for any applicant who has not prd acceptab evidence of compli nce with the insurance coverage required." Additionally,MGL chapte §25C(7)state "Neither the co onwealth nor any of its political subdivisions shall enter into any contract for formance of pu is work until a ceptable evidence of compliance with the insurance requirements of this chapte been presented to a contract' g authority." Applicants Please fill out the workers' compensation affidavit complete by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and p ne number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Lia ill\inran Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' comp sance. If an LLC or LLP does have employees,a policy isTequired. Be advised that this affidavit atted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be s re d date the affidavit. The affidavit should be returned to the city or town that the application for the pe it obeing requested, not the Department of Industrial Accidents. Should you have any questions regard' g th y are required to obtain a workers' compensation policy,please call the Department at the num er listSe 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 le bly. The Department has prove ed a space at the bottom of the affidavit for you to fill out in the event the Office of nvestigations has to contact you garding the applicant. Please be sure to fill in the permit/license number which ill be used as a reference number. addition, an applicant that must submit multiple permit/license applications in y given year, need only submit one a idavit indicating current policy information(if necessary)and under"Job Site A ess"the applicant should write"all loc tions in (city or town)."A copy of the affidavit that has been officially s amped or marked by the city or town may a provided to the applicant as proof that a valid affidavit is on file for fu a permits or licenses. A new affidavit mus be filled out each year. Where a home owner or citizen is obtaining a lic se or permit not related to any business or co ercial venture (i.e. a dog license or permit to burn leaves etc.)said pe on 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia • 1 zrti Town of Barnstable ' Regulatory Services • f Thomas F. Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable a.us Office: 508-862-4038 Fax: 508-790-6230 Property -er Mus t mplete an Sign This Section If Us' LY A Builder I, Owner of the subject.property hereby authorize to act on my behalf,. m all matters relative t6 work thorized b this building permit application for. (.Address of Job) Signature of Owner Date Print Naive If Property Owner is applying forpemmit please complete. the Homeowners License Exemption Form on .the reverse side. 't �ofV�E ray Town of Barnstable Regulatory Services Thomas F. Geiler, Director � 1639. ,�� Building Division PrEo ` Tom Perry, Building Commissioner 200 Main.Street,_Hyannis,MA 02601 vswfv.town.b arnstable.ma.us Offi6e: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 7 01 A-�inf �— number' �J street �) viillaic "HOMEOWNER":� / v 31 name harm phone# work phone# CURRENT MAILING ADDRESS: eityhown state rip code Tile current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who,does not possess a license,provided that the owner acts as supervisor. DEFINMON OF EOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which-there is, or is intended to- be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the buildinp,permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building.Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION -The Code states that: "Any homeownv performing work for which a building permit is required shall be exempt from the provisions of this scction.(Scction 11)9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a peson(s)for hire to do such work,that sum h Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Superyism,Scction 2.15) This lack ofawarmcss often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware ofhis/hcrespoanbilitics,many communities require,as part of the permit application, that the homeowner certify that Wshe undcrstands the resp=bilitics of a Superrisor. On the last page of this issue is a.form currently used by several towns. You may care t amend and adopt such a form/cm-tifieation for use in your community. Town of Barnstable *Permit# °-)6-70 I Expires if months from issue date Regulatory Services Fee �0 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bsm table.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ,� Property Address 3 >-7b, 1",nn�-L Vs. St 1 'LA5 �'�Residential Value of Work 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �yx -F AA Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: X-PRESS PERMIT ❑ I am a sole proprietor [-fam the Homeowner NOV ® 9 2007 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE 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) 0 Re-side [`Replacement Windows/doors/sliders.-U-Value (maximum.44) 1-►'1tt&r5�oyx I `Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic;Cons;rvation,etc. ***Note: Property Owner must sign Property Owner Letter,of Pernnissiop. A co of th Home Improvement Contractors License is required'. , SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts Department oflndustrial Accidents Office afInvestigations 600 Washington Street _ Boston,MA 02111 , www.m ass.gov/dia Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual):. M � _ •Address: q<-Ve rKA, yL -- City/State/Zip: � Vl /) Ph ne.#:� O Are you an employer? Check the appropriate box: -Type of project(required):. 1.❑ I am a employer with I4. ❑ I am a general contractor and I . employees (full and/or part.time). * have hired the su.b-contractors 6 New construction . 2.❑ I am a'sole pioprietor or partner- listed on the•attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have_ g, ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition o workers' comp.insurance comp.insurance, ' equired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ' I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions amysel£ [No workers' camp. 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.] . M 44W' 5 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subinit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractm 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(rave employees,they must provide;their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below isfhe 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 tip 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 DIA for insurance coverage verification I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct. Sienah�re; ZZ / Date: _ Phone#: ' Official use only. Do not write in this area,Yb be completed by city or town o.17ciaL 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 ti.Other Contact Person: Phone#: THE Town of Barnstable �Op r�ti Regulatory Services + BARNSrABLE. Thomas F.Geiler,Director y MASS. g v0. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE LICENSE EXEMPTION / Please Print DATE: JOB LOCATION: number ll street village "HOMEOWNER": C JGYJ �t �G name ,t home phone# work phone# CURRENT MAILING ADDRESS: �ll(/A n�^ A city/town state rz p code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Hom owner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with.a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt pUIMETOk, Town of Barnstable Regulatory Services • BARNSTABLE, + v MASS, Thomas F.Geiler,Director �A .t63q `0 . TF1639 Building Division tiill,� Tom Perry, Building,Commissioner 200 Main Street, Hyannis,MA 02601 www.town.ba rnstable.ma.us f' Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Comp ete and Sign This ection Using A Build I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this uil permit application for: (Address of J b) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION 1_ Town of Barnstable *Permit# ::? a Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director - PERMIT f Building Division '. ri :3. Tom Perry,CBO, Building Commissioner MAY 0 1 2006 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us .�ax:�S8-_iT9D=j.�TABLE Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ,cc Not Valid without Red X-Press Imprint Map/parcel Number t% 1 Property Address t ' N '72111" Residential Value of Work �� Minimum fee of$25.00 for work under$6000.00 Owner s Name&Address 36 Contractor's Name Telephone Number 2- 3(?-6 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: 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) Qj)*Re-side 4,-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. Ho a roveme tractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations ~` 600 Washington Street Boston, MA O2111 kvi wrww.masagov/dia- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers _Applicant Information Please Print Legibly Name ousmess/Or, ni7ation/IndividuaD.- Address: `347 'P City/State/Zip: � Phone#: -3 6 2 3 2- Are you an employer? Check the'appropriate bog: Type of project'(required): 1,❑ I an a employer with 4. ❑ I am a general contract and I . 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2.❑ I an a sole proprietor or partner- listed on 1he attached sheet t, 7. Remodeling ship and have no employees These sub-contractors have SS ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' Camp.insurance 5. ❑ We are a corpflration and its required.] officers have exercised their 10.❑ Electrical repairs or additions _i L=a homeowner doing an work right of caemption per MGL ME] Plumbing repairs or additions mys` elf.[No workers' comp. c. 152,§1(4),and we have no 12[]Roof repairs instance required.]t . employees.(No workers' l3.❑ C1@ier comp.insurance required.] *Any applicant that obecka box#1 mast also 0 out the section below showing t'hefr workers'compensation policyinfonaation: t Horneownem who submit this affidavit indicating they an doing all wank endt'hen hire outside caatraotora must submit anew affidavit indicating each tCoatracto:s ibat check ffiis boa meat attached as additional sheet showing the name offfie anb•contrnctors and than workers'camp policy iaforrnatioa. ram an employer that is providing workers'compensation Insurance for.my employees. Below is thepolicy.andji'ob site information. Insurance Company Name: Policy#or Behr.Lic.t#• Job Site Address: Citylstste/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to se=.e-coverage as required undei Section 25A of MGL c. 152 cm lead to the imposition of criminal penalties of a fine up to$1,50Q.40 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 ce er the pa ns and penalties of perjury that the information provided above is true and correct; Sir tore: Date: �// o-6 Phone#: ��?S G -L ( � CV c►a►'us¢ ,tee or Cityor Town: Permit/License# ; I Issuing Authority (circle one): 1 11.Board of health 3.Building IDepw tmeat. 3.City/11 own Clerk 4.Electrical inspector 5.Plumbing Inspector 6. Other 1 ! Contact Person: Phone#: Information and Instructions) F Massachusetts General Laws chapter 152 requires all employers to provide workers' compensationfortheir employees. pursuant to this statute, an employee is defined as"...every person in The service of other under any contract of hire, express or implied,.Dial or written." An employer is defined as•"am individual,partnership,association, corporation other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal repres fives of a deceased employer,or the . receiver or trustee of an irm ' ' al,partnership, association or offer legal ,employing employees. However the owner of a dwelling house h ving not more than three apartments and W. resides therein, or the occupant of the dwelling house of another w o employs persons to do maintenance, co' ction or repair� wk un such dwelling house er on the grounds or building t thereto shall not because of ch employment be deemed to-be an employer." ` t hold the issuance or MGL chapter 152, §25C(�also`sdates that every state or local li using agency shall withhold renewal of a license or permit t�operate a business or to con et buildings In the commonwealth for any applicant who has not produce `acceptable evidence of com ante with the Insurance coverage required" MGL chapter 152,§ C( Additionally, 7 states'Neither the c can nor any of its political subdivisions shall dditi enter into any contract for the perfo . ce ofpublic work acceptable evidence of compliance with Ike hzwaance requaemecds of this chapter have be esented to The con cfmg authority." Applicants Please fill out the workers'compensation ' comp by checking the boxes that apply to your situation and, if necessary,supply Sub-QOntractor(S)name(s), ess(es) d phone mmtber(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC) Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry w k mpensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that davit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. o e sure to sign aad date the affidavit. The-affidavit should be returned to the city or town that the application f e 't or license is being requested;not the Depariment of Industrial Accidents. Should you have any questi a ar the law or if you are required to obtain a workers' compensation policy,please call the Department th listed below. Self-insured companies fhavad der their self-insnz•ance license number on-the 'a ' e City or Town OfBciah . Please be sure that the affidavit is complete d printed legibly: The D ent has provided a space at the bottom. of� .for you to fill Diann the ev the Office of Inv cantact you regarding the applicant - Please be sure to fill in the pern*lieense er a wM be uto, 3 a r number. In addition,an appliccaat that waist submit multiple permiftense licatiany given need only 't one affidavit indicating current policy information(if necessary)and and "Iola ddress"the app 'cant should ,all locations in__ (city or " affidavit that has be off ' stamped or mar by the city or may be provided to the A of the �' town) copy applicant,as proofihat•a valid affidavit is file for future permits or li es. Anew affidavit the filled out each year.Where a j one owner of citizen is 4 . g a Ji, 0 or permit notrelated to any business or mmercial venture (Lt.a dog License or permit to burn leaves etc.)said person is NOT regnirad to complete this affidavit The Office of Investigations would like to,tlumk you m\advance for your cooperation and should you h any questions, please do not hesitate to give us a call The Depmtraent's address,telephone and 1h number: Cortbm:onweallh of Mas r ms- went of Industrial Accidents Office of blvedlg.-Am 600 Washington Street Boston,ILIA 02111 Tel. #617-727-4900 ext 406 or 1 077 MASSAFE, ' Fax#617-727-7749 Revised 5-26-05 www.mas5.govldia Town of Barnstable ermit: -7y3o7 �OFTNE?o�� Regulatory Services D ate: r Thomas F.Geller,Director ee: KrAB,E : Building Division 9 i6 q � Tom Perry, Building Commissioner �''°TEn r�►a'i°' 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT ' AC, Vtk" '!fir'/ a? 3 6 �, I Z 6 . Owner: `-�Q�UZie Phone: Install at: ��? a` Village: 8f N S Map/Parcel: r`7 ! Date: Stove A. New/Used B. Type: Radiant/Circulating C. Manufacturer: UR ro-t&� 0-6ml'o Lab.No. D. Model No.: 2, )lu-C. Chimney A. New/Existing (If existing,please note date of last cleaning) B. Flue Size - T" '� C. Are other appliances attached to Flue? k��D. Pre-fab Type and Manufacturer E. Masonry: Lined/Unlined Hearth A. Materials: B. Sub Floor Construction: Installer Name: Address: ' Phone: Location of Installation: APPROV ED BY: /O �i�� A� Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove - - • e ,fit ,. m £ 3 � � t , At j,, 4 3576 Main St. Barnsta 10/08 , 0 . 1 r` t•$ �dr. .e� g�] I o C _ a,ry " r a ..�. I A 0- Ma 1 11 in St=.:-,-Barnsta.- Ali,-e f. � � gg �. @ .ram.. :„� �. .•++r .._R "' — t ,�,{. k'iv>. fi rr _ = F . G �-< y 4 1 Imo . r r a ' a .. � _• ,Wye L �a m y 7 - u. rr r b� s •f d X 2- A s �w t` gnu Az yG