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SMEAD No. 53LOR UPC 12543 smead.com Made In USA 3 � -v r Town of Barnstable *permit# Expiee167�dalej Regulatory Services Fee 4 2015 Richard V.Scab,Interim MectorTARNSTABLE Building Division Tom Perry,CBO,Building Commissioner 0 `L 200 Main Street,Hyannis,MA 02601 www.town bamstable.ma.us Office: 508-8624038 Fax:508-190-6230 4; EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid withotdRed X-Ph=Imprint MLarcel Number 31 O Property Address Residential Valve of Work$ 3 Minimum fee of$35.00 for work under$6000.00 Ownea's Name&Address _4ke, A Ae, QVID Contractor's Name S o dAerN k)_F—. /A F_A7A')1,SoAJTe1cphone Number l d 1—2.2—r` 7900 Home Improvement Contractor License#(if applicable) _`c�173 S- Email: Construction Supervisor's License#(if applicable) D /�'0 7 XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I.have Worker's Compensation ll Insurance Insurance Company Name N /PS Workman's Comp.Policy# 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 Replacement Windows/doors/sliders.U-Value - 3 0 (maximum.35)#of wind #of doors• ..❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections-required. Separate Electrical&Fire Permits required. •where required: Issuance of this permit does not exempt compliance with other town dq [regulations,i.e-Histmic,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. t SIGNATURE: TAKEVIN D\BiW bg Changes\EXPRESS PSRWNWRESS.doc Revised 061313 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/12/2014' 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). CONTACT PRODUCER Willie of New Jersey, Inc. NAME: c/o 26 Century Blvd PHONE FAX P.O. Box 305191 E-MAIL 1-877-945-7378 A/C No:1-888-467-2378 Nashville, TN 372305191 USA ADDRESS:certificates®willis.com INSURE S AFFORDING COVERAGE NAIC B INSURER A:Selective Insurance Company of SR 39926 INSURED Southern New England Windows LLC INSURER B:The Beacon mutual Insurance company 24017 D/B/A Renewal by Andersen INSURER C:Argonaut'Insurance Company 19801 26 Albion Road Lincoln, RI 02965 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER?S29169 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. INSR ADDLSUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY M DDY� MM/DD� LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR PREMISES RENTED A ISES Eaoccurrence) $ 100,000 y MED EXP(Any one person) $ 10,000 S 2029459 08/10/2014 08/10/2015 PERSONAL BADVINJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 POLICY PRO- JECT a LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY iOMaBBIINdED SINGLE OMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) S A ALL O SCHEDULED AUUTOSS AUTOS S 2029459 08/10/2014 08/10/2015 BODILY INJURY(Per accident) S X HIRED AUTOS Ix NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ i $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,„000 EXCESS LIAB CLAIMS-MADE S 2029459 08/10/2014 08/10/2015 AGGREGATE $ 5,000',000 g DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X STATUTE ERH _ B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBEREXCLUDED? NIA 0000068028 08/21/2014 08/21/2015 (Mandatory In NH) E.L DISEASE-EA EMPLOYE $ 11000,000 D es,describe under E.L.DISEASE-POLICY UMIT $ • DESCRIPTION OF OPERATIONS below 1,000,000 C Work Camp/EL Covg: WC927938352394 08/21/2014 08/21/2015 E.L Ea. Accident - $1,000,000 Statutory Limits - WC E.L. Disease Policy Lmt - $1,000,000 .L Disease Ea. Employee - $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AddlUonal Remarks Schedule,may be attached If more space Is requlred) own of Hattapoisett is included as an Additional Insured as respects to General Liability when required by written contract/agreement as per policy orm. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of mattapoiaett AUTHORIZED REPRESENTATIVE 16 main St IwI ttapoisett, HA 02739-0000 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of,ACORD SR ID:6629625 BATCH:Batch q: 79627 i . ,. The Commonwealth of Massachuselts Department of Industrial Accidents t( Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114 2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Aualicant Information Please Print Legibly Name (Business/organization/tndi-tidual): SOUTHERN NEW ENGLAND WINDOWS LLC Address: 26 ALB10N ROAD• City/State/Zi : LINCOLN, R102865 407-228-9800 PPro Are you an employer?Check the appropriate box: Phone#: P ' 1. I am a employer with 20 4. ❑ I am a general contractor and I Type of project(required): 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 working for me in any capacity. employees and have workers' 8. Demolition [No workers' comp. insurance comp. insurance.t 9. ❑Building addition 3.❑ ]'equired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 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 insurance required.] i C. 152, 51(4),and we have no 12.❑Roof repairs employees. [No workers' 13.0 Other DOOR REPLACEMENT Any applicant that comp. insurance required.] checks boa nl must also fill out the section below shooing their workers'compensation policy information. eHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavitindicating such. mployees. If the sub-cContractors flint check this boa must attached an additional sheet shoi�ine the name of the sub-contractors and state whether or not those entities have eontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing, workers'compensation insurance for my infonnation. employees. Below is the policy and job site Insurance Company Name: ARGONAUT INSURANCE COMPANY Policy#or Self-ins. Lic. #: WC927938352394 — Expiration Date: 08/21/2015 Job Site Address: o City/State/Zip: �7iys/ �� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 74 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties-of perjury that the information provided ab ve is tr a and correct. S' a e: s Date: �Z Phone#: 401-228-9800 Of•ficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/]License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: FPR-26-2010 91:35 FFOM:LR 5d "gM113 T0:40163366(32 P.1.7 byArN�pYCd1 Vt jpyy°rf'.4I V-11 � .a s�Y�•�3Gi4 �Nhiin TL jud • Iiacvin.R10'�8Fi5 u:-d eM��aiY.at Phq my 11kili563.2235•F%4UI AM.0002 raG 41 ra.n xtrwaoa t� Soadhora Now Sti`hied Wiadwws.LXC d/b/a Raatwal by Asdan ate or Soudwa New England CUSTOM WINDOW AND DOOR REMODEUNG AGREEMENT J PteatMACuotem Cry$.w..a ztr c.a. �hw� e�,�wef►Lltte�Cdhw1lS�Afo7� tu.AOSa1t,l,oaaitntAa� �vo �O�- �.eaaauwn ��'.1St1 H••pc•{�)t,r.�►.rj�+i�sly rn.l. .ally agar.u, N—w England NVindvvn,LW WWa Rcnc%-A by Andown rA%rioc kern Xcw 2ngland txl onlraCYA"t.In acturda+ice w1th die tenne and ox0iuk4as dexribod oti die Guist and the mwree ur rhis Ug".41411rin mirk fit the.n u Iwcl yls.v:ifr;uitn,Oirrt(c)(k'n1kylivrht O dilerorle f3 eoisdo D efOAy Tont)obAmounr taw4wsue ogPaat: Mcehadof Payment: UCbwk )(Cash Ufirancod UWo1ftRotttw4(3M is-10 MKS Croke Corth arc ttatepted for trepasK Drily-e+trttutno 113 of t41e 8otn0&'u stets at ab C33xk bantueed Compkdos Dort yr4m cat.Oleo ie see Oe&Card Arty m Farm)By t�tl the AQrwnm you tdmawfadv drat IN 11aMw at Sun of lab and dw @a'am an Subsm tW Mince on 5denrrc;ar CompMim of lob gmnot bee um*by crodit Cam ofiob(3m 2-48 card end mist be made by presonsl theft bank died,or ash. Bayer(s)agrees sad emckrStaada that Ibis Agri mom caastitntes this euttre as derstaBdlwg between the patrde ae and that theft are an we at maderstandiugs citaa$ng nay of the terms of this Agrmo=*&'L Buyer(s)ookmewhdgas that Buyer(*) (1)boo read this Agreement,understands the terests of dds Agreement,and has nKutwd a aompieted,shed,need dated copy of this Agmemente imghmtin6 the twn attached Motkes of Cancenatiiom,as the date Gect..eittta sL..—v d 12)was andly lafaeswtl of BuyWo rISM to oaaeet Ibis Apreeeoent.DO NOT SIGNTHiS CONTIUCT IF THERM ARN ANY BLINK SPAMM (Rpoala/skmd Saar Only)notice to Buy jr.(I)Do not wign this Algroommat If nay of d a spaces intended toe the a;md terms to the ea twat of then ovadafiAe infos nation are left Maul.(3)You are eadtled to a copy of this Agreen ant at the time you alp& it.(3)You stay at arty test*pay ca tie NU unpaid balance due under this Agaesmea4 patl to so doing you may be ead ded to reetitvt a partial rebate of the finance aced insurance charges.(4)IMe seller hat no right to unlawfully eater your primiaQa or oamatit asry breach of the peace to repossess goods purchased trader•this Agreement.(5)Yon may cancel this Agepseyaq If It has rust been erred rt ihcmaia office or a brwmclh office of the seller,prwfted you notify this seller at his or her main offices or broach office abnwu in the Agocmiut by registered or certified email,wW&ahtell 1/c pmahcd not later thw re idnight of taw third eakidae day&Der tie cloy out Ad&tim buyer sipaa the Agmea cat,txtladios Sersd■y and any holiday om whick rsaehr mall def venlss are net made.Sew the socompetayiva tootiec of ct WCffatioa Form far as eaplanai' n of buyer's eeghts. &trr(sI rrceivtd thr tm�ivwettr rducaGun matt "Ixeaeidrtl by thr III Itvk IslAnd CuntricLon Regktratim Board. (81WI hi6w React-at Try Aadarttw of Soudma K%w England IIu � tioyet�a) By: _ nacre dais •MI;'•T Sigt�Lu� SiLerituw.. FrinL Name of Product txwt-r Print Manz, Print Nanec YOU, TILT: BUYER(S). MAY OANCM TM TRANSACTION AT AM 1111 PRIOR TO MIDINIGHY OY THB TmKRD BUSINESS DAY AFrBR THE 001 Op TINS TPA.�iUMION.SW TM ATTACHED NOTICE OP CANCEIdATION F1OMMS MA AN EMANATION Or inks RIGHT. - - - - - -00- - - - - - - -•- - - - - - x- - - - - - - - - - - - - - -bc NOTICE.OF CANCELLOTION X NOTICE Oft pate ofTranaactian 3ja3! .You may tuner;) pats ofTratLwcdon J1�__,Tou may caned this tradaactlon,without any penafey or obligttkar%within Neis transawon,without any penalty or obliptilon,witMn three bee%iness days f vet the above date.It you erane01.sny I three business��y*am Me abeua data.If you cancel,acty property traded IN WVY Payments evade by you under the I pnoverty traded fn,any patrryLetlts mach by you under the CCarttrxx or Sale,and any no le InswurntInt wMeuted I Cosltraet or Safe.and any t>e�oeiable itestrtm,aret--- -t:ed by you WIN be returned within ten business days fo&owing I by You will be returned wir�tn trine businm days fellow6lag receipt by the Salter of your cancellation nodoe,and arty I racefpt by the Sener of your cancoUlton notice,:Ind any seturiiky intrenIk arising Part of the transaction will be sscurlty nteresc arfsing aue 04 to c transaction will be canceled.If you Canoal,yyo.pu must make available to the Seller I canccic&if you cancel,you must mate*ava'Table to the Seller at your residents,in substantially as goad condition as when I a;VW ratidanee.In substan,"ly as toad contli ion as when► r*Wived.any goods dilvered to you under tlas Contest or I rayed.any goods deiive and bo you under this Contract or Sale:or you nMA if you With,comply with the incteu mcuis of I Sale;or you treay.If you wish.eomply,with tha Instructions of the Seller ragardirtg the return sMpment of the goods at the r� tie Sebt r rega►dietg ilia returnohlpt+terht of the goods at tlh® Sellers expense and rlsft.Ifyau do make the gg000tic available SeITees exWse and risk.Ifyou do make the goods available to the Seller and the Seller does not pick them up within to the Seiler And the Sandi dots not pick them up within twenty days or the dm of Cancellation.you may retain or I twenty da s of the dates of caecollatiory you may retain or 1 3e of the goods without any further obitatlon.if you i d'ap�a ofrthe goads witlohR duty further obligation.if you bed twomake the goods available to tha Seller,or if you agree I f. to make a,rai to the SoNp.or if you agree to return the to the Seller and hied to do so.then you 1 to return tha goods to the Seller and faS to in so,thorn you remain liable ear parforrnanee of all obligations under the remain tads for perfomtance of IL11 obligadons wWar the ContrraetTo tail this trwmaction,map or deliver a tlgned 1 Cart rut Tb caltOtI this transaction,mail or delnpr a signed and dated ropy of this conceliatien notice or any other 1 and darted copy of tlkls cancttltation notlm or any other writ etneticr,ormendatJcgratnto Renewal byAredersenof I written noetine,or send atelegram to Renewal byAoderssnof Sovdtam New En��lt�Ind at Albion Road,U eo RI 2865, 1 SaWhe n Now En;tand ac 26 Albion Roam R10t8rtf, NOT e}LATER= HIONIOHT OF I NOT LATER THAN P11DNIGkT OF IEIMEBY'CANCUTI'1ISTRANSACTICK k i HE)E8Y CANCEL THIS TRANSACTION, auytrt SWAM" Pdtet wise. o.e. tap n u�cesurs D,fnt Mena out. ftA Copy.whit Uff Cops;Ye►tow bbrrr Copy:Nrdt r Southern New England Windows d.b.a Massachusetts-Department of Public Safety I. Board of Building Regulations and Standards. 1 Construction Supern•Lcor License: CS-095707 �0- �., BRIIAN D DENNLSON 7 LAMBS POND iM Chariton MA 01507 Expiration Commissioner._ 09108/Z016 Office of Consumer Affairs 6d Bus iness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/19/2016 DENNISON BRIAN j 26 ALBION RD LINCOLN, RI 02865 Update Address and return card.Mark reason for change. SCA 1 - 2MA-05n1 Address C Renewal C Employment Lost Card ' C�Xc�o»rruwru+cal(/e o`C../l�r;.;rrt�n.•c((J Mee of Consumer Affairs&Business Regulation-. �• (, License or registration valid for individul use only - OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - ' Office of Consumer Affairs and Business Regulation R 10 Park Plaza-Suite 5170 Expiration: g g/2016 Supplement ard % w Boston,MA 02116 1 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON DENNISON BRIAN 26 ALBION RD LINCOLN,R102865 Undersecretary Not va ithout signature I • V o n+� Town of Barnstable *Permi' # 1r GG�s -P IT Regulatory Services Feaedvte RAPMABM Thomas F.Geiler,Director Building Division TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 d ( ' t /Aj ❑Residential Value of Work 5'D ,00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ( ,a,, Contractor's Name C k(LtS �L 1 h�� Telephone Number 5D ~-7 j 7— a 07�, Home Improvement Contractor License#(if applicable)_ Construction Supervisor's License#(if applicable)- 1 61 fo ❑Workman's Compensation Insurance Cheslc one: , I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name j Workman's Comp.Policy# 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) 5KRe-side ❑Fence over 6' #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: Property Owner must sign Property Owner Letter of Permission. copy of the Home Improvement Contractors License&Construction Supervisors License is' equired SIGNATURE: Q:\WPFILES\FORMS\building permit forms EXPRESS.doc Revised 051811 f The Commonneakh of Massachuseift Department of Industrial Accidents 09we of Investigations 600 Washington Street Boston,MA 02111 nvmv.mass gov1dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electdcians/Plumbers Apiplicant Information Please Print Umbly Name(Basme aolfndividoaU. r (h A- Address. 2 47.`5 ok A 1 u 1 City/State/Zip; (L0 111f to A a Phone ik S'b - '7 3 7- 2.07� Are you an employer?Check the appropriate box: Type of project r 1.111 am a employer with 4. ❑ I am a general contractor and i employees(full and/or part-time).* have hived the sub-conhactors 6 ❑New construction 2.M 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 wtnlCers' [N o workers c msurance.Y 9. ❑Building addition 'comp.instrance �P• mo _ d_] 5. ❑ ❑We are a corporation and its 10. Electrcal repairs or additions 3.❑ I am a homeowner doing all.work officers have exercised their 1 L❑Plumbing repairs or additions myself[No worlmrs'comp. right of exemption per MGL 12.❑Roof repairs insurance require&]T C.152, §1(4),and we have no 13.❑Other employees.[No workers' comp.msvraace required-] •lay applicm�that checks boa#1 mast also fill out the section below showing their workers'compensation Policy information, T Homreoar.who submit this affidavt indicating they are doing all wmk and then hire outside contractms mast submit a new affidavit indicating such. Zconuwm that cbech this boot must macbed as additional sheet shouiog the name of the sub-cautracuin and stare whether oriu t those entities have employees. If the sub-contactors Lave employees,they must provide their workers'comp.policy number. lam an employer that is proW&ng workers'compensation.insurance for my a wplayeex Bdow is the policy and job site information. Insurance Company Name: Policy#or Self ins.11c.#: 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 c under the pains and penaties ofperjury that the informafion pro drd above is true and correctA� `�7 . Si /% Date: / Phone#: 5 6S "7 3 7 Zo 7 Co Official use only.. Do not write in this army to be completed by city or town offic&t City or Town: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: phone 9. 6 • lARNWA13M • 9 1639. `0� Town of Barnstable Regulatory Services Thomas F.Geiler,Director .Buildings Division Thomas 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 (A!y I , as Owner of the subject property hereby authorize c Y I(z'S CC�1 to act on my behalf, in all matters relative to work authorized by this building permit application for: i (Address of Job) Signature f Owner Date Aze Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHL ESTORMMbuilding permit formsEXPRESS.doc Revised 051811 SINE> Town of Barnstable Regulatory Services 9 'm g Thomas F. Geiler,Director 1659. Building Division . Tom Perry,Building Commissioner 200 Main Street, Hyannis,NIA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip 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 wbo 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 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 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 ubWSI`�V��\� �c�•Q l\Sr•�O cn .,x 5e A0 • nc L Ger e`J`5 ` 01 r SJp ok ?' Go G`l N c-ev\se GG \- ele �P� 2 VIP` �� Gp �j251ZG1 Ez G`r�t\S�pOP�\���OP�2655 �xP`�a���t4"r•. 26�6 , _.... ..,.- istration valid for individul use only �� License or registration Regulation ,� tgiCsiness egu ahon before the expiration date. It found return to: ��consumomtenr aA'�a►rs Offce o CTOR Office of Consu Ser Affair uite 5170 and Business Reg Type' 10 ParkPlaza- HOME IMPROVEMENT CONTRA Individual Boston,MA 02116 Registration: �1 ;y56038 Expiration: -5129'12013 . GIB h.•IF',:�: 1 _ ,-1 nature CHRIS COLBATH �s = - x` Not valid without sig 383 OLD MILL ROAD OSTERVILLE,MA 02655` ''` Undersecretary ' FINE 10 Town of Barnstable *Permit �- Expires 6 mon t from, ue d Regulatory Services Fee +� MRNSTABLE, • 9eb MAM Thomas F. Geiler,Director 1639. �0 QED MA'S A Building Division Tom Perry,CBO, Building Commissioner n �' 200 Main Street, Hyannis,MA 02601 www.town.bamstable.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 ���' V J Property Address P A 1 ?Qt jo 0j j [Residential Value of Work (�,.c2®Z�. %�4;2�j Minimum fee of$35.00 for work under$6000.00 Owner's Name& Address A-1 A Contractor's Name CX (-i S y CZ- Cs, 164AV Telephone Number ,502- TO aQ7b Home Improvement Contractor License#(if applicable) r 03 Construction Supervisor's License#(if applicable) 49 6 1 " ❑Workman's Compensation Insurance Chet am a sole proprietor X~P R.ESS PERMIT . ®®fi�nnIT ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance A U G ' 4 �(J j.j Insurance Company Name- Too/N DE S,�ISTABL.E Workman's Comp. Policy# 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) Re-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. opy of the Home Improvement Contractors License & Construction Supervisors License is re uired. SIGNATURE: K 1 Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 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/OrganizatiorAndividual): a.1 Address: �,� (��c� CA., I City/State/Zip: �MF_ ��I�S'Phone #: •_0 7�7--9 076 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2X 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' comp. insurance.# 9. ❑Building addition [No workers' comp:insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LF]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 13.❑ Other employees. [No workers' 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 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: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer nd r the pains!;dpe [ties of perjury that the information provided above is true and correct Signature: Date: 14 p�Q Phone#: i�'n$j -7 3-7 - 0`7 L 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#: oFt"Era,, Town of Barnstable Regulatory Services • B WSfABLE, y MAss. Thomas F.Geiler,Director �A .i63q �0 rED 39 A 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 L (04) '6i� 62 , as Owner of the subject property hereby authorize C1 ai—siziPk£a-- Ato act on my behalf, . in all matters relative to work authorized by this building permit application for. (Address of Job) fly h Signature f er Date aA-P, Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on'the reverse side. Q:FORMS:O WNERPERMISSION i SHE Town of Barnstable 4 - �pF r�ti -• y�P Regulatory Services BARNSTABLE, Thomas F.Geiler,Director p MASS. g 1639. 1', Building Division lfO � Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 H011H OWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip 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 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 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 Supensors);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 usad'by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt _4,\ Office o7 fo"m'A i•s g2s;ness�eggaulaao�`f; License or registration valid for individul use only !I HOME IMPROVEMENT CONTRACTOR before the expiration date. If± found return to: i Registration:;4*156038 Type: Office of Consumer Affairs and Business Regulation I Expiration: =5/29%2013 Individual 10 Park Plaza-Suite 5170 --' Boston,MA 02116 C' IS COLBATHII�'_-.-.--T.-__�,r='+��-�__i fj� I CHRIS.COLBATI-� 383 OLIJ MILL ROAD , OSTERVILLE, MA 02655 Undersecretary Not valid without signature Massachusetts- Department of Public Safety' Board of Building Re!aulatimis and Standards Construction Supervisor License License: CS 49696 _ Restricted to: 00 CHRISTOPHER W COLBATH 383 OLD MILL RD OSTERVILLE, MA 02655 Expiration: 5/25/2012 ('nnnnissiuncr Tr#: 26161 i 0p1HF jOq, 'Town of Barnstable *Permit � -'�{. Exp' 6 maiths from issue date BARNs,,B� ; Regulatory Services F H 1�� Thomas F. Geiler, Director 639, a Building Division MIlTm Perry, ,CBO Building Commissioner ��y 200 Main Street, Hyannis, MA 02601 9� www.town.barnstable.ma.us Office: 508-862-40AUL 2 Fax: 508-790-6230 ERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number -3 ( 0 Cj Property Address ` C� �a 10 wa-. LaR r.S -ck.jb f 0pr. Residential Value of Work 1 1, q00' Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address R aott0 Contractor's Name L hi{=71 S C CA!6 Farr Telephone Number _50' _7 11 'I.vj6G Home Improvement Contractor License #(if applicable) Construction Supervisor's License#(if applicable) CS 11 9 (440 ❑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 0 Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacemebt 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 I ve e adetors License& Construct Supervisors License is required. SIGNATURE:' - Q:\WPFILES\FORMS\Express\EXPRESS PERMIT.DOC Revise06O4O9 The Commonwealth ofMassachusetis Department oflndustrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lefribly Name(Business/Organization/Individual): Cm,t1 Q i '�j Address: 'S l U�a City/State/Zip: o5Ve.11>�l, ve--.Mck 0,1V.a5 Phone.#: so? --'1 j11 —ac 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 i 6. ❑New construction employees (full and/or part-titn.e).* have hired the sub-contractors ..2. 1 am a sole proprietor or'partfter-' listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have g. '0 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers'.comp.-insurance comp. insurance.# required.] req ] 5. We are a corporation and its I Of]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEj 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•thatchecks 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 hire outside contractors must submit a new affidavit indicating such. lContractors 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 isproviding workers'compensation insurance for my employees. Below is the policy andjob 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 DJA'for insurance coverage verification. I do hereby certify u.nnder thef ains and penalties ofperjury that the information provided above is true and correct Signature: (-�N" ( l/ 1 Date: -Z C� — Phone#: � ��• �� �� C P Official use only. ,Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# I Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: 1"- .J 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 Iocal 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(7) 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«pith 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-con&actor(s)nairie(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 be returned to the city or town that the application for the permit or license is being requested,not the Daparhnent 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 .Plea se 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 roof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each p year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to burn 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 C6rnmonwealth of Massacbusetts Department of Iudustri.al Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.mass..gov/dia z ro�ti Town of Barn-stable , ` Regulatory Services 9RA"R9.r Thomas F. G•eiler,Director o 19- a�� Building Division 0 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 1Using A lBuilder AWT, , as Owner of the subject property hereb authorize �j � to act on m behalf, y ch � s.�h �- y in all matters relative to worle authorized by this building permit application for.. -(Address ofJob) to Signaturd of Owner Date 6L��. Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable 1Regutatory Services • Thomas F. Geiler,Director s.atwsrwsLe; 'i6 3¢6, P. Building Divisioi3 . %� �PrE° Tom Perry,Building Commissioner - 200-Mairi:Street—Hyannis,-Mr102601 w".town.b arnstable_ma.us Office: 509-862-4038 Fax: 508-790-6230 HOAIFOWNER LICENSE EXE IMON Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': work hone# name home phone# P CURRENT MAILING ADDRESS: city/town state zip 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 HOMEONVNER 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 Barrastable,Building 1)epartment min;mum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatum 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 EXEMTnON The Code states that "Any bomeoworr perforrning 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 persons)for hire to do such work.,that such Homeowner shall ad as superosor." Many homeowners who use this exemption are unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q, Rules&Rcgulations'for Licensing Construction Supervisors,Section 2.15) This lack of awareness often rcaults 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 rrspun.6bilitics,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supavisor. On the last page of this issue is a form currently used by d adopt such a foonTVicertification.for use in your community. several towns. You may can t amend an Board offun0j Ong fit(o- egu a ionS�n—da"r HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only Registration:, 156038 before the expiration date. — Expirations" Board of BuildingIf found return to: 5/29/2011 Tyt 283569 One Ashburton Place Rm Regulations and TYRe Individual Standards 1 01 I CHRIS COLBATH ''f =gz�:_ ` Boston,Ma.02108 CHRIS COLBATHf.`R�' 383 OLD MILL ROA'Dt MA 02655;4 Administrator � ' Not valid Without signature 4� r ✓die 'toomirnoo"� a�✓�aaaac�utdell6 j�• v ,w,: i D' Board of Building Regulations and Standards Construction Supervisor License i d License.:.CS 49696 Exp ration 5/,2010 Tr# 23478 Rbstrmfio ;a,.. - t 0 �' ` CHRISTOPHER W.COLBATH 383 OLD MILL RD 'v ' OSTERVILLE,MA 02655 Commissioner ; i Town of Barnstable *Permit# DO 0 DO� , Expires 6 months from issue date (� Regulatory Services Fee Thomas F. Geiler,Director 249 PIRMSE" r ERMhTuild.ing.Divimi n 07 APR 17 29 Perry,CBO, Building Commissioner (� 6 200 Main Street,Hyannis,MA 02601 TOWN OF NSA ABL w.to An,barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Arot Valid without Red X-Press Imprint o j p/parcel Number I perry Address ipr W - &r �A Residential Value of Work t4jr2LI Minimum fee of S25.00 for work under $6000.00 1 . ,ner's Name&Address I UCF l 1 s ntractor's Name Telephone Number ime Improvement Contractor License#(if applicable) o S-03 �$ 'sot's-Lictmte�{�-appiie-ab3e-) lWorkman's Compensation Insurance. Check one: ❑ I am a sole proprietor ZIarn the Homeowner have Worker's Compensa 'on Insurance ;urance Company Name orkman's Comp..Policy# WX A 01°7 d I 1'_Z1(0 )py of Insurance Compliance Certificate must be on file. rmit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris mill be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side replacement Windows/doors/sliders. U-Value , 3 (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 mus ign roperty Owner Letter of Permission; A copy of the Ho ovement tractors License is required. :GNATURE: Forms:exp-15g wise061306 \ +Department oflndustrialAccidents Office of Investigations a` a 600 Washington Street' Boston,MA 02111 www.mass.gov✓dia ' Workers' Compensation Iizsunmce Affidavit: Builders/Contractors/Eldctricians/Plumbers Apl3licant Information Please Print Le2lb Name(Business/Orgmization/In.divi(ival): •Address: city/state/zip: i. nin,vPiyt Phone:#: Areffn employer? Check the'appropriate bog: 'typeofproject(required):.1. a employer with 4. (] I am a general contractor and I employees (fall and/or part;time).* have hired the stab-contractors 6.. New construction . 2.[] I am&'sole proprietor or partner- listed on 1he'aitsched 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 workei s' comp.insurance comp,insurance. e are a corporation and its 10.❑Electrical repairs or additions officers have exercised their . 3.❑ I am a homeowner doing all work 11.[]Plumbing repairs or additions myself [No workers' corgi. right of exemption per MGL` 12.E3 Roof repairs insurance required.]t c. 152,§1(4), and we have no employees. [No workers' Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation information. policy infoation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a bew affidavit indicating such. #Contractors that check this box must attached an additional sheet sbowing the name of the'sub-contractors and state whether ornot those entities have employees;,If the sub-contractors have employees,they must provide their workers'camp,polidy number, I ain an employer that is providing workers'compensation insurance far my employees.-Below is.the poFigy and job.site information. �4 Insurance Company Name: Policy#or Self-ins.Lic,#: Expiration Date: �// fob Site Address: City7State/Zip Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure.to secure coverage as required tinder Section 25A of MGL c. 152 cast lead to the imposition of criminal penalties of a- fine tip 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 Mk-for insurance coverage verification. I do hereby certc fy under the p' s d alties a f perjury that the information provided above is true and,correct, Si afore:. Date: l Phone#: Fjssm=' Cr only,.-Do not write.in this area, to be completed by city or town offrciaL n: Permit/License# hority(circle one): Health 2,Building Department 3.City/Towa Clerk 4.Electrical Inspector 5.Pluxnbing Inspector rson: Phone#: 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 anther under any contract of hiie, 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 ...iyar or ttee•of an individual,partnersb association or other legal entity employing-employees. However the owner.of a dwelling-house having not fnore man three apartments and who resides therein;or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair woric onsuchAW611irng-house or onthe grounds orbuilding appurtenantthereto shallnotbecause of such employment be deemedto be an employer." MGL chapter 152, §25C(6)also states that"every state or.local licensing agency shall withhold the issuance or .reneW4 of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant-who•has not produced-a-cceptable evidence of compliance with the insurance coverage required" Additionally,MGL d)apter 152,•§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into my contract for,•the performance of public work until-acceptable evidence.of oompliauee with the insurance requirements of.this chapter have beenpresented•to the contracting airthority." i Applicants please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, i� necessary,supply sub-confractor(s)name(s),addresses)and phone numbers) along with their certificates)of insurance. -Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the ' members orpartners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. B.e advised that this affidavit maybe submitted to the Department of Indus[trial 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.licensels being requested,not the Department of Industrial Accidents; Should you have any questions regarding the law•or-if you are require$to obtain a workers.' compensation policy,please call the Department.at the number listed below, Self-insured companies shw,M,6mher their self-insurance license number on the appropriate'line. City or Tower 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 pennit/hrense number Svhich 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)anti under"Job Site Address"the applicant should write"LU-locations'in (city-or town)."A.cbpy'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, Anew affidavit,must be filled out each year.Where a homeowner or citizen is obtaining a license or permit-not related to any business or commercial ventute (i.e.a dog license or per to bum leaves-etc,)said person is NOT required to.complete this affidavit The Office of Investigations would h7ce to thank you m advance for you¢cooperation and should you have any questio._,y�- please do not hesitate to give us a call. The Depajuent's address,telephoue:-md fax number;- Tb.Commcmwl J41h of Masmar,bust�tts . Office Qf ny�stigafions • . fiflf��ashi��t� Sheet R.ostcm,MA U 111 W,#617-727-490.0 ext 406 aF 1-$77-MASSAFE Fax �17-'t27-74� Revised 11-22-06 www'Mu".go-VIdia __.... --.. : ---. .. . . . ..._ _ ...._. ............._............ . : _- ' ,per 7/a �\ Board of Building Regulations and Stand i'rds License or registration valid for individul ti HOME IMPROVEMENT CONTRACTO I before the expiration date. If found return �* Board•,of Building Regulations and Standai Registration:, 100503 -----� One�Eshburfon Place Rm 1301 Ezpi�at on5611.9L200,8, }}�� :, _ ,, Bost A.Ma:02108 ( YPe=Supplement Card j CAFE FREE HOMES; J DANA PICKUP.JFt,M ' 1' 239 Huttleston ave ,.ate ✓ I j Fairhaven,MA 02719 . Administrator Yot valid Aith4outgin�iture w. l _ i 'OFFICE: (508)997-1111 °° MA. Builder's Lic. #021330 FAX: (508) 997-1297 AWCARE FREE Home Improvement TOLL FREE: 1-800-407-1111 ��� InC. Contractor's License WEBSITE: #100503 MA. www.carefreehomescompany.com 239 HUTTLESTON AVE. (FIT 6)•FAIRHAVEN, MA 02719 #15179 R.I. NAME !��Gi/y� GI-cAe-e DATE ADDRESS ��lr I)(. ZIP CODEtF- ADDRESS OF JOB /7)LS TEL JOB DESCRIPTION J Scheduled Start lJ wb Scheduled Completion l�/�> A. Replacement of missing or rotted lumber is not included unless specified. B.All start&completion dates are approximate and could change due to weather conditions. C. Stripping of roof includes removal of up to two(2) layers of shingles, eac, additional layer to be charged Q ft2. D. Replacement of rotted roof boards/plywood to be charged @ ft2. E. Existing chimney flashings will be reused; replacement, if necessary, s not included. F. Care Free Homes, Inc. is not responsible for mold/mildew condition that are pre-existing or result from leaks not brought to the attention of C.F.H., Inc. promptly. The Company hereby proposes to furnish labor and material to complete the above work for the amount herein. Fulfillment of this order is contidgent, however, upon the want of strikes, fires and any natural disasters, the ability to obtain materials, or any other conditions beyond the control of the Company. r Cost of Project$ G� �� PAYMENT TERMSIF �� _ Date C�A/— 1. You,the Owner,may cancel this transaction at anytime prior to midnight of the third business day after the date of this transaction. 2. You,the Owners,agree to pay any and all expenses incurred by Care Free Homes,Inc.in collecting money due under this contract and.enforcirig the terms of this contract, including but not limited to, reasonable attorney's fees, interest and court costs. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES CARE FRE OM , IN A By; Buyer acknowledges Owner CA FREE OMES,INC. receipt of fully completed copy of this Agreement Owner All contractors and subcontractors shall be registered by the director and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director;Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 Tel. (617)727-8598