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HomeMy WebLinkAbout0191 SEA VIEW AVENUE i� Q ___ ,. _ � 3S6S— �o�r►�r roy� 'I'®�v� ®f�a>r�S�ab�e Permit# o Regulatory Services Erpire + B,ARYSrABLB, + � ttgSS. p 1614- �0 Thomas� F. Geiler, Director o 19) t Building Division � Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: 508-790-6230 No! valid Wthoal Red X-Press Imprint Map/parcel Number 00 (1 D Property Address 1q , Ll`" Cf w &* 0sk ru l "e, Residential Value of Work NV l Minimgm fee of$35.00 for work under$6000.00 Owner's Nam e & Address DiLHal I .5 r Li Lie, Contractor's Name— 111Y 'Telephone Number__Qgjf / Home Improvement Contractor License#(if applicable) l0 (00 Construction Supervisor's License#(if applicable) QQ a 5 I ( Workman's Compensation Insurance �UN 1 201 // \\ Check one: 2 ❑ I am a sole proprietor ❑ I am the homeowner TOWN OF BARNSTABLE Ihave Worker's Compensation Insurance Insurance Company Name fq-2pjQJ Pic IN Workman's Comp. Po icy#' OQ go Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ' ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop ty Owner must sign Property Owner Letter of Permission. p of the Home provement Contractors License & Construction'Supervisors License is r u' ed. SIGNATURE: •QAWPFILES\FORMS\buildingpe iii forms\EXPRESS.doc Revised 07211.0 The C'omxrmoniaealth of Massachusetts Department of Industrial Accidents Office of Investigations 4� 600 Washington.street Boston, MA 02111 - � W)IM.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r /,/ Please Print Le0bly Name (Business/organization/Individual): •J• v Y_�l�f�i� Rw `�L��r l,o�� Address: City/State/Zip: ffq(Jk/v 5 /79t5i 02&0 / Phone#: (5-08) ?179 Are E,reyyoou an employer? eck the appropriate box: Type of project(required): 1. 1 am employer with aw p y a em 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P 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' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 656 �TA t7� I AI E CO • __ Policy#or Self-ins.Lic.#: 00 Expiration Date: 0/ UI f Job Site Address: M1 S!Q4A1(uW LGVY 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 c er tlae pains and enalties of perjury that the information provided above is true and correct Sienature: 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#: l ® DATE(MMIDDIYYYY) �► o CERTIFICATE OF LIABILITY INSURANCE 1./25/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: ErICa H.O'Connor HART INSURANCE AGENCY,INC. PHONE (508)759-7326 FAX (508)759-7366 243 MAIN STREET ac No PO BOX 700 ADDREss: BUZZARDS BAY,MA 025320700 INSURE S AFFORDING COVERAGE NAIC 0 INSURERA: ARBELLA PROTECTION INS CO 41360 INSURED EJ Jaxtimer Builder,Inc INSURER1: ARBELLA PROTECTION INS CO 41360 48 Rosary Lane' INSURERC: ARBELLA PROTECTION INS CO 41360 Hyannis,MA 02601 INSURER DARBELLA INDEMNITY INSURANCE COMPANY 10017 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY-CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES..LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUER POLICY EFF POLICY E%P I TRR TYPE OF INSURANCE POLICY NUMBER MMIDDMlYY MMIOD/YYYY LIMITS A GENERAL LIABILITY 8500042039 01/01/2012 01/01/2013 EACH OCCURRENCE S 1000000 DAMAGE TORENTED 300000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S CLAIMS-MADE W OCCUR MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2000000 POLICY PRO- LOC S B AUTOMOBILE LIABILITY 21662400004 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT 1000000 ! Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ' AUTOS AUTOS - NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per accident) S C UMBRELLA LIAB OCCUR 4600042040 01/01/2012 01/01/2013 EACH OCCURRENCE $ 2.000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE S 2,000'000 OED RETENTION$ $ D WORKERS COMPENSATION 0053890111 01/01/2012 01/01/2013 wcsTATU- OPq TH- AND EMPLOYERS'LIABILITY. Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? SOO,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HYANNIS,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �a ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i Office.of Consumer Affairs and Vusness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cori r`'actor Regis raiuil Registration: 1-10609 _Y Type: Private Corporation !111 Expiration: 11/3/2012 Tr# 205399 E J JAXTIMER, BUILDER, INC. i_.- -ERN'EST JAXTIMER F i 48 ROSARY LN. HYANNIS, MA 02601 Update Address and return card.Mark reason for change. °_.✓ Address Q Renewal Employment .'Lost Card DPS-CAI v 50M-04/04-G101216 .................... .. . .... Office ofon meif ai�iine`ss fYeQ;utano License or registration valid for individul use only before the expiration date. If found return to: HOME-IMPROVEMENT CONTRACTOR Registration: 10609 Type: Office of Consumer Affairs and Business Regulation Expiration: �L-I13_7.R012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 E TIMER, Bt7fi1^9E1— -7 ; iA ERNEST JAXTIMER��_/�) 48 FtOSAR'Y:LNJ .u,. �<< HYANNIS; MA'0260t= Uirdersecretary Not valid without signature iM Massachusetts - Department of Public Safety Board of Building Regulations and Standards ('011A UCtiOn Super1 ko l' License: CS-003251 ERNEST J JAXTIlVIER.=__ 48 ROSARY 1;ANEi HYANNIS MA 02601 1 Expiration i Commissioner 01/14/2014 l THE,, Town of Barnstable Regulatory Services y MABS. $ Thomas F. Geiler,Director �jDlEpµ►Ct16 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 Property Owner Must Complete and Sign This Section . If Using A Builder I, He�.�•.t S ��-+�� , as Owner of the subject property hereby authorize JfT, 1� to act on m behalf in all matters relative to work authorized by this building permit application for. 2�11 dress ofjob) Signature of Ownel Date Pent Name. If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FOR MS:O WNERPERM1SS10N