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Home My WebLink About0050 LISA LANE a y. UPC 12543 as No.53LOR HASTING$, ON y ao �z3> X_ PERMIT Town of Barnstable *Permit# O Expires 6 � hs fim issue date Regulatory Services Fee f B 2013 Thomas F.Geiler,Director HIED MA't TOWN OF BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 r www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTLU ONLY Map/parcel Number)I Not Valid without Red X-Press Imprint t �� Gl✓ /tee Property.Address ❑Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C 4 k.)4 C,.- et Contractor's Name C hT2 .0 5/�i• 5 ��0�j 51 r yL L 69elephone Number `l �?fo ee Home Improvement Contractor License#(if applicable) L L5 � Construction Supervisor's License#(if applicable) y ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance I Insurance Company Name L ✓ 7�j�A 1 Workman's Comp.Policy# l� C l� 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Of Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �CIryi ❑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 ❑ 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 department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner m ign Pr perry Owner Letter of Permission. A copy of t o e mprov ent Contractors License&Construction Supervisors License is required. SIGNATURE: QAWpFILESWORMS\building permit fbbX\EXPRES .doc Revised 053012 _ Office of Consumer Affairss&uS10es✓s R gu al h�"°P HOME IMPROVEMENT CONT — ' Registration:.-s=.1.65936 ACTOR Expiration; Type: 4/9/2014 Private Corp CAPE&IS C? = p ration LAND CONS � ' ,.I,�TRUCTION (SCO INC. ., JOSHUA KOURI �c� � �• :==T �, I 55 ELM AVE. HYANNIS, MA 02601 Undersecretary �= 901•Z1, :#_Jl �auizsnumn.) £LOZ/ZL2 :uoiiendx3 I Z£9ZO VVY '31lIn831N30 OLZ XOe Od i2jnoN X vnHSOf 099bL SO :9sua31-1 asuaall JosinJadnS uoi;anj;suo0 sp.I.r.purts puu suolluln;aZl ;ulplln8 Jo p-mo8 C»•Ir.s �lltp�d to Juiiva.ir.did -sllisnyirssr.IN •�• ' The Commonwealth of Massachusetts Department of Indushial Accidents TjOffice of Investigations 600 Washington Street Bostonl.AL4 02111 . twtt'w.mas&gov/dia Workers' Compensation Insurance Affidavit: Bu ilders/Contractors/E.lectncians/Piumbers Applicant Information Please Print Legibly Name(BusinessMrpnmt1on&dividua1): C� t C Fi Address: U city/state/Zip: Pho=4- � - L9 c„ AFfI a an employer?Check t a propriate box: Type of project(rewired): Lemployer a em l er with 4- ❑ I am a general contractor and i * l:ave.lxired the sub-contractors 6- ❑New consfrtxctYon I employees(full and/or part-time). 2-❑ I am sale proprietor arpartner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees 'ham sub-contractors have g- ❑Demolition. employees and have woticess' working forme in any capacity. � � 9.- ❑Building addition � IN-.o workers' comp-insurance comp_insvrance.Y required.] 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3_❑ I am a.homeowner doing all work officers have exercised dwir 11-0 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 thst checks box Al nmst also fill out the section below showing their workers'compensation policy infarmstion- 1 Homeowmers who submit this afadsvit indicating they are doing sawont and diem hire outside coa=wFs mast submit anew affidnit indicating such rContractors that check this boa mast attached as additional sheet showing the ustne of the sub-coattrxtm and state whether or not those entities have employees. If the sub-contma-ars have emploFees,they must.provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for iny empioyea& Below is the po&.),,and,job site informatiom Insurance Company Name: c Z—� � �-- ZZzPolicy#or.Self--ins-Lic. 5`l o — /�-Expiation Date: %— ? -t !mil l �- City/State/Zip. Job Sine Address: /� �� 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 o€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. advised that a y of this statement may be forwarded to the Office of Investigations of the DIA for insurance co ge verificati I da hereby cerd >tnd er a 'ns a ah'ies of that the inforal dion provided a h and correct Si tare: Date: !'(, /3 Phone#: 9 " Ofcial arse only: Do not write in this area,to be completed by cilty or latwo ofciat City or Town: PeruritlLlcense# Issuing Authority(circle one): 1.Board.of Health 3.Building Department 3.City/Town Cleric 1.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone Ih 6 Rebecca A. Pierce January 10, 2013 50 Lisa Lane West Barnstable,MA 02668 508-367-1210 To Whom It May Concern: I authorize Cape and Islands Construction Company to replace the roof of my home at 50 Lisa Lane,West Barnstable. Thank you. i Reb cca A. Pierce i i ACC>RV CERTIFICATE OF LIABILITY INSURANCE °ATE`"n"°°rff" �..�- 5115/2012 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 temis 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 FRANK L HORGAN INS AGENCY INC CONTACT NAME: 44 B A R N S TA B L E ROAD PHONE a Et): 508 775-5830 FAX a No): 508 775-6688 HYANNIS, MA 02601. E4I11ML ALDRESS INSURERS)AFFORDING COVERAGE NAIC# INSURER A:. LIBERTY MUTUAL INSURANCE INSURm--- ---' --- ------ INSURER B: CAPE & ISLANDS CONSTRUCTION COMPANY INC PO BOX 210 INSURERC: CENTERVILLE MA 02632 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 13 95795 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. NJTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIRC ATE MAY BE ISSUED CR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, D(CLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR ..._. .___—.TYPE OF INSURANCE ADM POLICY IMMER POLICY Wd MWDOVYY LIMITS GENERALUABIUTY EAGHOOCURRENCE $ O7MM1fi[:IALGENERALUASILfTY PEM oaxrretaeli $ — _—J CI WA.S MADE I-�CXXXIR AHED EXP one person)-$ -- PERSONAL&ADV INJURY $ _ - --' ---- - __ C84EaALAGGREG4TE $ C,_EN1LA(X',REC',ATE UNATAPPUES PER: PRODUCTS-CCriIPM AGG $ - PDucY PRO} LCC AUTOWBILE UABIUTY il $ ANY At ITO BODILY INJURY(Pea person) $ — A LCW14ED � ULED BODILY INJURY(Pe det a� t) $ Al fR-A-- PE FOREDAUTOS H— AUTOS a� $ $ F. $ UNBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS MADS AGGREGATE $ DED Ll RETENTION$ $ - A WOWB3S COWS SATON WC5-31 S-377540-012 5ff/2012 5f7/2013 / T(�Lt�TS IC& AND ENPLOYERSr UABIUTY Y/N ANY PROPRIF rC)rVPARiNEfJEXECLMVE E 1 EACHACCIDENr $ 100000 i)rngcRMCMtr.RCXCI.000rr' F-N] N/A ---.--._.._ (M-datory in W EU_DSS-- E-EA EMPLOYE $_ 10000d IF Yy8s'dEWiW ttr]ar E.L.DISEASE-POLICY L1MFT $ 500000 nt,rRIrinr1N r1F r)PFAAncw.q iv4mv 1 I DESCRW ION OF OPERATICS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Rerterks Sd)edule,If mere space Is required) Workers minpensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLEF)BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL'BE DELIVERED IN 200 MAIN STREET ACCORDANCE VATH THE POLICY PROVISIONS., HYANNIS MA 02601 ALf(FiDRIZED REPR6E11frATFVE Jeff Eldridge 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD "dl;r IN.: 1.tUY:/:"t Nuk .t ca-..11cr 5/1b/2U12 it:54:04 AM Page 1 AL 1 Tl,�s cei'tiii.:yce a�SlL:C1G 3:1 eul ct:sciles ALL r,,:e i usly ssued certifieztes. iartmcnt of Public Safety a •. Massachusetts- nel . ' Board of Biiildin� Re� ulati ons an(l Sruulards Construction Supervisor License License: CS 74660 JOSHUA X KOURI p0 BOX 210 ; CENTERVILLE. MA 02632 Expiration: 2j12/2013 Tr##: .12106 ('ummisiuncr n0 t. lie IS 91, c gzgld?f OLT ali Wnsuoo n� ZY ssanlsng-V s 2199 oll�as da al l 10'asuaa1'1 uollgl a n a�,pnno;}I t1—A nor�Bt; _.: J • ...` Al