Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0830 OAK STREET (CENT./W.BARN)
0 OxfordNO. 152 1/3 ORA S -LT 10% O O p p 6 r Application number y ................................................ • _ Date Issued......................... � ®_�" +� Building Inspectors Initials...641 ... � .........•';. MAS& CFO MA'S a �. Map/Parcel............................................................... FtJWN Ot tWN I ABU TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGIWINDOWS/DOORS/TENTS/STOVES/WEATIERIZATION PROPERTY IWOR ATION Address of Project: 9.So 0,q-k- w. NUMBER STREET VILLAGE Owner's Name: Ja III c� L h c' Phone Number 7-7-1-q-q 7�rI 5 Email Address: 'I�.,n c e�,�•, ,�,' �,„.:I.r o Cell Phone Number Project cost$ 12 L-1 c, 7 — Check one Residential V1 Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Sep ,�-{�Q�� C'�-��-� Date: TEE OF WORK Siding Windows (no header change)#' 8 D Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to Gcl s-><e-���� P��� - ,���c o/•'► / L CONTRACTOR'S INFORMATION Contractor's name fit an �Rnn;sc✓� - � e�� 4/P� Fri(rv,� i'11JOwS Home Improvement Contractors Registration(if applicable)# 17 3 2-q S (attach copy) Construction Supervisor's License# 01 S 7 07 (attach copy) Email of Contractor a SLiea 9 q s@ 6e2q C t,M Phone number q0/- z 2 g -9 go() ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. i APPLICATIONNUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X 9 X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEONVNERIS LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures;specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT9 S SIGNATURE Signature Date 30- 15 All permit applications are subject to a building official's approval prior to issuance. i Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England Janice Manni WRIT Legal Name:Southern New England Windows,LLC 830 Oak St SI RI#36079, MA#173245,CT#0634555, Lead Firm#1237 West Barnstable,MA 02668 WINDOW RE IACEMEMT 10 Reservoir Rd I Smithfield,RI 02917 H:(774)994-7695 Phone:866-563-2235 1 Fax:401-633-6602 1 sales®renewalsne.com Buyer(s)Name: Janice Manni Contract Date: 01/18/19 Buyer(s) Street Address: 830 Oak St, West Barnstable, MA 02668 Primary Telephone Number: (774)994-7695 Secondary Telephone Number: Primary Email: jannicesmanni@gmail.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively, this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $12,467 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $6,233 Balance Due: $6,234 Estimated Start: Estimated Completion: Amount Financed: 7-9 weeks 7-9 weeks $12,467 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: 50% deposit by bank,balance on completion by bank Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed, and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 01/23/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Ren Andersen of Southern New England Buyer(s) Signature of Sales Person Signature Signature Paul Sandrey Janice Manni Print Name of Sales Person Print Name Print Name UPDATED: 01/18/19 Page 2 / 10 I .�/Z� !�C}/��/�ZC�/?GG��CGG��C��i"�.i�:�-J-CC��2�CG1-C��l�✓ � I Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS,LLC-` Expiration: 09/18/2020 10 RESERVOIR ROAD SMITHFIELD, RI 02917 Update Address and Return Card. SCA 1 Ca 20M-05117 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. If found return to: RepiWation Expiration Office of Consumer Affairs and Business Regulation 113246 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW EN GLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON ��IL CGlr��a 10 RESERVOIR ROAD U SMITHFIELD.RI 02917 Undersecretary vv. aq without signature r Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construct bn 'Supervisor CS-095707 Epp i res : 09/08/2020 A BRIAN D DENNISON f: 8 BLACKWELL-DRIVE CHARLTON MA y 01507 — ...C JV b ; i Commissioner i The Commonwealth of Massachusetts �'- Department of Industrial Accidents I Conn.ress Street,Suite 100 Boston,M9 02114-2017 www mass.e ov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriciaas/Plumbers. TO BE FILED WITH THE PER=LYG AUTHORITY. Applicant Information Please Print Lezibly Name(Business/Orsanization/Individuaq: �jG��h e/ ►V ��Ili �s1� 1 I n dr l js Address: _o _S UDl r ?;?,aj City/State/Zip:SM t't�-6 etjt??( 0Z7 17 Phone#: Are yo an employer"Check the appropriate box: Type of project(required): L l am a employer with ;;Z— 4—employees(full and/or part-time).* 7. []New construction 2. I am a sole proprietor or partnership and have no employees working for me in $: Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.]r 9. ❑Demolition 4.[][am a homeowner and will be hiring contractors to conduct all work on mY PPeRY•ro I will [0 D Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employers. 12. Plumbing repairs or additions i.a I am a general contractor and I have hired the sub-conuactors listed on the attached sheet [3.❑R repairs These sub-contractors have employees and have workers'comp.insurance.* � 6.M We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other W„- �fr�fn/ M,§1(4),and we have no employees.[No workers'comp.insurance required.) ne-do lQ«irr tom •Any applicant that checks box 9i 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 npt those entities have employees. If the sub•cotmactors have employees,they must provide their workers'comp.policy number. 1 am an employer that is proiddin;workers'compensation insurance for my employees Below is the policy and job site Information. /J Q Insurance Company Name:_'�re AA F/7's 1.1 o Ay— Q. • OF Policy#or Self-ins. Lic.#:_ l,1/C f} 1 S& 7 2 fl'1 (4 Expiration Date: Job Site Address: 3' t9a k City/State/Zip: (� / p-(A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration ate). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisorunent,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.A.copy of this statement may be forwarded to the Office of Investig coverage verification. ations of the DIA for insurance I do hereby ce aderthepaimi penalties of perjury that the information provided above is true and correct Signature: Date: U Phone#: !!gal Official use only. Do not write in this area,to be completed by city or town offieiaL City or Town: Permit!License# Issuing Authority(circle one): 1. Board of Health 2.Building Department J.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: acoRL> CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/28/2018 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 CONTACT CoBiz Insurance, Inc.-CO NAME: PHOE 1401 Lawrence St., Ste. 1200 ACNNo, o E • 303-988-0446 Alc No:303-988-0804 Denver CO 80202 nooliEss: COMail@cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER B:Flremen5 Insurance Company of WA,D.C. 21784 Southem New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER 0: Smithfield RI 02917 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:787175890 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 TYPE OF INSURANCE ADDL SUBR . POLICY EFF POLICY EXP LTR POLICY NUMBER MM/ODIYYYY MWDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 11112019 11112020 EACH OCCURRENCE $1,000.000 DAMAGE TO RENTEU-- CLAIMS-MADE a OCCUR PREMISES Ea occurrence $300.000 I MED EXP(Any one person) $10.000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECOT LOC PRODUCTS-COMP/OP AGG $2.000,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/112020 EO arB'l,)INGLE LIMIT $1 0 0 0 X ANY AUTO BODILY IWURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY I WURY(Per accident) $ X HIRED AUTOS N NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ A X UMBRELLA LIAS X OCCUR CPA3158728 11112019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000.000 DE X RETENTION 8 a $ B WORKERS COMPENSATION WCA315872924 11112019 111/2020 X AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N NIA E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$1.000.000 C Pollution Liability 7930073340000 1/112019 1/1/2020 Each Occurrence $2,OOD,000 Claims-Made Policy Retroactive Date 06/20/2013 Aggregate $200,000 Deductible b25, 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION . DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE N� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Town of Barnstable 'Permit rl _V �'s Expires 6 ivnths fi issue dat �s Regulatory Services Fee_ , �^ • IAtZTISTA13M Richard V.Scali,Interim Director Building Division �- '�/ RAY 1� Tom Perry,CBO,Building Commissioner o'A V/u OF 2018 200 Main Street,Hyannis,MA 02601 �i R VS r/n� 1' www.town.bamstable.ma.us N�/ry��E Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number .216 —DO I Property'Address 2 3 a Oc, 1< Sfi Residential Value of Work$ -7 7, 1 _ Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address M(lice M A nn; 0300 n K t 0. ���ens�w le 0 Z6 S Contractor's Name r tC6 /Sol✓ Telephone Number 401-zzr—fWW Home Improvement Contractor License#(if applicable) 1 732- Email: Construction Supervisor's License#(if applicable) d FS7,0 7 Norktaan's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner .I have Worker's Compensation Insurance Insurance Company Name &010A)AL1q_ IIUS . (•f�/12Q�IJlJ Workman's Comp.Policy# W c_-9a g' W i ?_-3 9 y 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 1 r ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [rReplacement Windows/doors/sliders.U-Value . 30 (maximum.35)it of windows ) #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. sVVheie 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: QAWHILESTORMSIbuilding permit formslEXPRESS.doc Revised 061313 'Renewal by/�) lSE'iL RENT wkL BY AINDERSN, vrcvev evaaepo"" ., .. • U-r ,RI02865 (Tl aacl ^te.- 2G Aibiaa Reed Peons 866a63.2333•FL7r 401..sy34•Fi6t12 �:�]Taa 9�e3>ei=i;�o Sondws4 Noc"Enabul l:Wtoamv,1=d1b/s Rcxewal lay Aadtsicta OC Soatbe«;3eav Hs#ad GLWFiOM V INDOW AND DOOR REMODEUNG AGRIMf&W l� III L -15 3�Ulirc�w.tt�cktsm-a:ezpcmtz<rro.ts,� • °''-' O�—v'� o i. � 5 2 7C .m l � � 1�����n9oea��rr2a��t,.tnglxiul`� �:r.�ic d/bJaiitz,Eual by Andereer of Soujrrn NNew F.'algl A,"C.Antre ,in erce.sitb thr tcrxm ril crnde?aa-q d d as the f wi and the rvu t of 3\, thin Egrge ep--t aid say the=clrod:pedio ii)D SbeW,,i(coUcctiv*this^Aggeem�� V*HtseQric O Canto 0 HOW? ToWlobAmov— tu �, � aoteaS=CN� y of raa ,,tea � o , n t DIP=iler�rtvod(334 I C2 -� — eras caedY atr �s ro.ae ony_.,r t rn IlI d du &!tree dt SUM of fob ql%7 . r P^? east e e Gde Coe} dy„ // -t.yw-*W-130v th-*.adwm x sum of fat wed dw Butt Oct sub=mw It s re' edure on Sal Carpls6n o`)ob twee ba erad•b!sake CornpH.ew d fob(114 -d and rnm be mode by par-ml dyed;bards d►ec$or ena#w Burr(s)agrees and understands that Wo Agrwmeat coustktarree the an tog betvreea the parties,and that them ace no vexha1 undassisadags el-gueS any of(`e besms of this Agmmen`$eyer(s)acknowl&dgeS that Baye*) (1)has.red.(bo Apreemea<t,w4et As the terns of tkk Aigaemc a,d,h"reralred a eoei le d of this ''' �, sue,andwas d� copy iioetudiaS the tv►o a�a.r.r\'otacep o�F Qrenceflation,oaths date first vrrMm><bwe and(z)was orates informed of ffnver's reybt to cancel thisAga vernent DQ NO` S[QN,THIS GOWRACT IF THERE AF&ANY RI ANK:S[PUNS. PM04 lirlwrd Srrlea t7rr J tielllet to 8uy¢s+:(l)Do not sloe this Agteerneet if any of the Iatamded Jim the,pted train,, w the attest of then.revttilable Inforasatfan era leiikblaa><.('2)Ycrn are catfded to a ccg7 of this'A ent at ter a time yoa,,ian It.(,3)Yan tray at any tir"pay off the!tall unpald balance dne under this Ag+eeeemeat,sae 14 w do4a9 Yon alas be entitled to reeeive a pardalrehete of the nuance and Insurance charge&(4)The eeBer has no rigbe to ns&%fully enter.year premises of commit stay breach of dbe peace to repossess%,sods pa rehased,nadar this ASft enL(S)Yea may c 4 tbd,,Agaeeraerrt If it has not been signed at five rosin o9ke ors braach fife:of tko sailer,provided you eotifp t4 seller as bus or her mixin aMee or branch ice shown in the Agreeawent by registered-eked mail,%mch,,haft be pasted ant[user than,ntidaiglrt of the did calendar dray aRer the day anwhich the buyer sfegaa the A nmment,_,dadieb Sand:y.and any ieNday on.wlsirh eegn&+rtnail delimrics am act made.See the acconapanying notice of ptaecilados farm for an.eph-alliea of be pips , &er*)settit,cd the mmu per abca&n motdels pm,-.d:d by rye Rhode Island Owfractnaa S &IID73.$card r�jrr4�nrm�) Renewal der of SotuberaNewlangkand Buyers c) Brryir(s) deb A v tc 2ga LLL Jtxnic�s. h��nn� PFMT_ OfProd-.a Print NI l4 ;mz YOU THE'BUMtM, NQY CAN IHL:'IMS TRWV&4C!'ION AT ANY TLM PPJOR TO mmMGM,OF THE THIRD BVSINUS DAY AFTER THE DATE OF THIS TRANSACFIOA.SIX TWE ATTAcmm XcMCH OF CAN'G'FtdAIIDN FORI►LS FOR A v EXPLANw 7(O.N OF THIS RiGWr NOTICEOF ON — —— — E tsE NcAtlota Qste of Transar:ehott ' t,�pu ttttgr tsnoel � Date of Tort - -- - -4 - - -- -�,- - tWo barwwdon,w' astir or obllaadon.within I this trinsaction,"IrdtoutPenalty. You,rat eaneeA three businea days:tom the dote~If you:carreek 0 I �eee business dap f vtrt dire aove at�1l or �t���arty pmpotty traded fi+,my PzYments nvade by Xmr ue�r the t MY Payments made I� � e by you under ilea trenbort or Sates and ><rry eeeEotiabte btstruntieett etae6uroed I or Salny and ury negotiable,i,f,ia,mrr�r,E rawact�sd by,you wlU be returned wi n cen business days 6ullowtnS I by you will be re. reed whirr,~ten bus&t.ess dirt following receipt by flee Seller of your cancelfttiat:notice,am anf I reoca�rt by the Seller'Of your can[ettrutsorn rro6tx.and ,,try security interest arising out of the traaesaedon will bs adorers utbeerst Dreg out. of tthe bwmaetion will be cano¢tod Ifyou cancekyou must snake available m lice Seller a cumAtid.Ifyou!t must...■ica v a0'able too tho Satin at your reii1dence,in substandWy as good candhion as wtwm I at your c%in t race trek,any floods detiraeed to you under dds Contract or I rxefved,any Van&d.rrrered YOU C fttyaee o _Saltto�%_yt� yqu whk comp_*,.rth tfie,a�re��ns of I..War you rna�t,it you wisi4 toe++p�w;tla.dte.e ens of the&eel&re�ine tfie rettetr aFiiPrt►e t a tfie goo at tlie' flit SedlEr resfndi`UK retueves+vpme et:c the s o,ds at th. Se1I���nso and ride.tl:you do make the avallabte S611-19 and risk-thou do n►ake the avaibdAe to the=er and the Seller does not pfdt often up withP� . _to the�and,dm Seder doe nut!pick t�nl up whWrt earrrCttty dare of fire dace of(�elladoey torn may retatin oar I twang dens of dm date of camelhgon,you 4W reunite or d1 V lire goods witlwut any furdeer obfiswon.tf 7ou I fa8 �of tlea goods Without anlr Anihei obtigat€orw If you fat s to rr�atas the roods avaitable to the Saar. If you agree i far7 m malue tlse I-1"--laws to,Um Seiler,or it you arms to lessee lice goads to die Seiler and W to do sot,then you I to,return ttfi elks to tee Seller atvd r>ed to do w tleen you remain liable for pertornrance of all obfiaadons under the netnai►tenet•!or rfomzaetpe of all 466 Contract-To caned Otis Wamctlory mall or dallmr a slgrted a t'rofttracs.To t�rtcd this tratwsaesaon,nil w d�cllr¢rna dptad and dated copy of licit+ canc Wtion notice or Wry other t and dated eapq of this cancetlb i antics or any otfik wAttee rko,6ce,or sand a telezvgm to Renewal byAndcrvan of M t eem nadoe„or sera a Jv Renewa.1 by Andctssn of Soadhern Nirnv�'at 2A Albion -i U n.Rl 5. a Soudieem New Frigiatul at 2 Albion Rea Unwl�PA 02045. NOT))LATER MtDNIGMT OF t NOT LATER THAN MIDNIGHY OF- IIHEitEBYCAMCELTHISTAANSACTIt N. � I ER BBYCANCELTHkSTRANSACR & �Y'u'a fFpaeic+v ~stet eramv ants spryer► • ►err etsn,o _08. €{bA Copr Wh to E'er G%r Yebow Nyfei CoFr I;r k { r Southern New England Windows d.b.a Renewal by Andersen of SN E '. Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen isor ' License: CS4095707 �VJTS BRL►N D D1NNIISfiN 7 IAMBS POND Chariton MA 01567 f Expiration Conurtissioner 09108=6 � C-Tfie � o�C/�ac�u • Office of Consumer Affairs d Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOW E�iration: 8/191tOt6S LL DENNISON BRIAN 26 ALBION RD --_-- LINCOLN,RI 02865 'Updam Address and return ard.Mark reason for change. SrAS 0 20MM, - o Addrew c Renewal 0 6mploYosem ❑Lost Card 16a of Cautemer At6Ln&Bmiaos Reealatioa Liesnae or registration valid for individui use only t1#PROTIEs1ENTCONTRACTOR before the expiration date.Iffoand return to: ofrim of cowatner Affairs and Business Regulation egletatlon: 173245 TYPE• 10 Park Plata-Suite 5170 Es�iratlon 91192016 SuPplernerd.-ard Boston.MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BYANDERSON DENNISON BRIAN 26 ALBION RD - LINCOLN.RI 02865 Uaderw reury Not valid without signature ' Ili a Commonwealth of 11Iassach usetts Department o,f Industrial Accidents l _ Office of Investigations I Congress Street, Suite 100 Boston, MA 0211 4-2017 i www massgov/dfa Workers' Compensation Insura;<nce Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you an employer? Check the appropriate bog: F6. ype of project(required): 4_ I a general contractor and I 1.� I aft a employer with 20+ ❑ am ❑New construction employees (full and/or part-time).*` have hired the sub-contractots _ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition comp. insurance.* [No workers comp. insurance 10.n Electrical repairs or additions required.] 5. We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their I I.E] Plumbing repairs or additions rnyself. [No workers' comp. right of exemption per MGL 12.0 Roof renai- i c. 152, §1(4),and we have no insurance required.] �[r1�O� employees_ [No workers' 13. Other comp. insurance required.] I I xAny applicant that checks box 91 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 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lic.#:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: - 0-3v 00/< .S+. City/State/Zip: � �Zlrn s`��h 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-ef;IGL 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 fbA insurance coverage verification. I do hereby certify under thJ ains and penalties ofperjury that the information provided above is true and correct. Si afore. Date: Phone#: 4012289800 Official use only. Do not write ih this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): i.'Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone#: SOUTNEW-01 SHETTYSHT DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 8/1912015 IS THIS CERTIFICATE IS ISSUED AS A MATTER OF NEGATIVELYINFORMATION ONLEXTEND y AND CONFERS ALTER THE COVERAGE AFFORDED BY THE POLIR.CIES CERTIFICATE DOES NOT AFFIRMATIVELY O BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHOR IZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. must be endorsed. If SUBROGATION 1S WAIVED,subject to IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policAies) 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). Co ACT WilliS Certificate Center PRODUCER PH N (888)467-2378 PHONE 877 945-7378 Willis of New Jersey,Inc. Al No Ext c/o 26 Centu Blvd E-MAIL certificates@willlis.com ADDRESS: NAIC>I P.O.Box 305 91 INSURER(S)AFFORDING COVERAGE Nashville,TN 37230-5191 of Southeast 39926 INSURER A:Selective Insurance Company 21970 I NSURED INSURER B:OneBeacon Insurance Company `1970 ngland Windows LLC INsuRER c:Argonaut Insurance Company by Andersen INSURER D: INSURER E: 65 INSURER F: REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: INSURED ED OVE FOR THE ED TO THIS IS TO CERTIFY THA THE ANY IES REQUIREMENT, REMENT TERM LISTED OR CONDITION OF ANY CO BEL RAVE BEEN ISSUNTRACTT CONTRACTOR DOCUMENT WITH RESPECT TO WHICH THE THICY IS INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSLIED OR O SUCH POLICIES.LIMITS SHO MAY HAVE BEEN REDUCED BY PAID CLAIMS.DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CON NPOOLIIp EFF P p LIMITS ILTR TYPE OF INSURANCE INS W VD POLICY NUMBER 1,000,000 EACH OCCURRENCE 100,000 A X COMMERCIAL GENERAL LIABILITY 0 811 012 01 5 OW1012016 PREMISES Fa ocwrrenoe ETOS x�occuR s 2029459 10,000 CLAIMS-MADE MED EXP(Any one person) b 1,000,000 PERSONAL-8 ADV INJURY S 3,000,000 GENERAL AGGREGATE S 3,000,000 GEN•L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S POLICY®JPRO- ECT 1-5cl LOC S COMBINED SING t.E LIMIT S 1,000,000 OTHER (Ea accident AUTOMOBILE LIABILITY 0811012015 0811012016 BODILY INJURY(Per person) 15 A X ANY AUTO S 2024459 BODILY INJURY(Per accident) S ALL OWNED SCHEDULED PROPERTY DAMAGE S AUTOS AUTOS NON-OWNED per accidentl X HIRED AUTOS X AUTOS S 5,000,00 EACH OCCURRENCE $ 5,000,000 X UMBRELLA LIAR X OCCUR 0811012015 0811012016 AGGREGATE $ A EXCESS LIAB CLAIMS-MADE S 2029459 Is OTH- DED REfENT10N$ X STpTIJTE ER WORKERS COMPENSATION $ 1,000,000 AND EMPLOYERS*LIABILITY Y I N 0000068028 08121/2015 O$121/2016 EL EACH ACCIDENT 1,000,000 B ANY PROPRIETOR/PARTNEREXECUTNE NIA EL DISEASE-EA EMPLO $ OFFICEWMEMBER EXCLUDED? 1,000,00 (Mandatory In NH) F_L DISEASE-POLICY LIMIT S II yes•describe under' DESCRIPTION OF OPERATIONS bet. Attached C928058352394 08l21/2015 08121/2016 See C orkers Compensation DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is required) CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ACCORDANCE WIT TE H THE POLICY ONSCE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE 1 g88-2014 ACO RD CORPORATION. All rights reserved. Evidence of Insurance © ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD oFtM�� Town of Barnstable *Permit#Z_WI OErpires 6 nrontlis froin issue date Regulatory Services Fee ■ARNSTABLE, * v v� 16 9. ��� Richard V.Scali,Director �f0 Mtp�a Building Division 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 Map/parcel Number /40 l Not Valid witltout Red X-Press Imprint p Property Address P WQS( residential Value of Work$ 34 v b,0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 'f5vi e S MA1VYi i A0 13 OX y 2- 10. A41tr'1JJ?aQ je,, 1�l,,4 a 266� Contractor's Name c�_el,41 Jiletlmyk' Telephone Number Home Improvement Contractor License#(if applicable) /00 7 y/0 Email: C 41 e, ('4 e f yp JV L0 ' Construction Supervisor's License#(if applicable) es ydP1 I �y gorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ® t ❑ I am the Homeowner �� [►�I have Worker's Compensation Insurance NOV O �M"141 o Wit/. � 1015 Insurance Company Name �/�/►11 nr- Workman's Comp.Policy# 3'��'a ®� BAR�ISTgBLE 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 / [j Replacement Windows/doors/sliders.U-Value a' P (maximum .32)#of windows 17.4fie le - #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 department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Im nt Contractors License& Construction Supervisors License is required. SIGNATURE: > C:\Users\Decollik\AppDat cal icroso indol empo ry Inte t File Content.Outlook\2PIOIDHRTXPRESS.doc Revised 040215 a, t Capizzi Home Improvement Inc. Page 7 of 7 Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I/WE,JANICE MANNI, OWN THE PROPERTY LOCATED AT 830 OAK STREET IN WEST BARNSTABLE,MASSACHUSETTS. I HAVE AUTHORIZED ZI=HOlVIE IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: -830 Oak St., W.Barnstable,MA 02668 OWNER'S TELEPHONE: -774-994-7695--\, LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., COtuit, MA 02635 APPLICANT'S TELEPHONE: 508428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: I RESPONSIBLE OFFICER TELEPHONE: V/re�iane�iranract�ll�a�C��CIJJCCOI rlJe� • ffice of Consumer Affairs&Business Regulation License or registration valid for individul use oial_y ME IMPROVEMENT CONTRACTOR before the expiration elate. of found return to:' Office of Consumer Affairs and Business Regulafion egisiration: 100740 Type: 10 Park Plaza-Suite 5170 9,Expiration: 6/23/2016 Supplement Gard Boston,Iy[i A 02116 CAPIZZI HOME IMPROVEMENT,INC. JOHN STRUMSKI 1645 Newion Rd, Cotuit, MA 02635 undersecretary Ialot valid Evithout signature *� Massachusetts -Department of Public Safety Board of Building;Regulations and Standards Construction Supervisor - License: CS-0641327 I' � IUM / 18 AILDEN ATE - Buzzards Bay Big 02532 I ✓. �, Expiration Commissioner 06/11012016 The Commonwealth of Massachusetts v Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):CAPIZZI HOME IMPROVEMENT, INC Address: 1645 NEWTOWN ROAD City/State/Zip:COTUIT, MA 02635 Phone#:508-428-9518 Are you an employer?Check the appropriate box: Type of project(required): 1.0 lam a employer with 40 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.®I am a homeowner doingall work myself 9. ❑Demolition y [No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ repairs re airs These sub-contractors have employees and have workers'comp.insurance.= 14.0 Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. y ZVI yIQ 4ulf 152,§1(4),and we have no 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 thepolicy and job site information. Insurance Company Name:AmGUARD INSURANCE COMPANY Policy#or Self-ins.Lie.#:R2WC527200 Expiration Date:12/25/2015 ` Job Site Address: �31) 041,1 S� w City/State/Zip: ` 134,01- ma @ 2 G 4 J Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the viola copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificaf I do hereby ce �derenalties ofperjury that the informationprovided above is true and correct. Signature: Date: Phone#:508-428-9518 Official use only. Do not write Kihis area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i 31.12 2014 16:49:00 Lollard Insurance Guard Insurance Group 1/1 i aco O CERTIFICATE OF LIABILITY INSURANCE 12 0 2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcypes)must be endorsed. IF SUBROGATION IS WANED,Subject to the terms and conditions of the policy,certaln 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 CONTACT NAME ROGERS&GRAY INSURANCE AGENCY,INC. PHONE FJHx i A1C No 434 Route 134 INSURER AFFORDING COVERAGe NAIL 0 South Dennis MA 02660 INSURER A: ATGUARD Insurance Company I?=RED I INsuRIER B: � CAP122I HOME IMPROVEMENT INC INSURER C: 1645 NEWTOWN ROAD INSURERD: INSURER E: COTUTT MA 02635 naSURER 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 i 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. LTR TYPE OF INSURANCE POUCYNUMRER MD C ANC-PRIMP N C RIP LIMITS OEN EARL U48LLtTY EACH OCCURRENCE S COMMERCIAL OENERAL UABILITY PREMISES arcunenca S CLAIMS-MADE O OCCUR NED EXP(Any ane parson) $ PERSONAL&ADV NJURY S GENERAL AGGREGATE 5 GEN'L AGGREGATE ULUT APPLIES PER, PRODUCTS-COMPIOP AGO E I POLICY QPRa LOC S i AUTOMOBILE UABRITY C BIN $I i d1 ANY AUTO 80DILY INJURY!Per parson) E ALL OWNED SCHEDULED BODILY INJURY ft academl S AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS actldenD E UMBRELLALIAB OCCUR EACH OCCURRENCE E EXCESS LIAR CLAIMSTNADE AGGREGATE $ DIED RETENTIONS 3 A WORKERS COMPENSATION x. YJC STATLY. OTFF - ANDEMPLOYERSLIABILITY R2WC527200 12/25r2014 2125/2il15 - ANYPROPRDETOMPARTNERIEXECUTIVE YJN NIA EL EACH OCCIDENT S 1,000,000 1 OFFTCERRIMENBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLO S 1,OOo,000 If yea,Oeaalbe under DES P ON OF OPERATIONS heron EL DISEASE-POLICY LIMIT S 1,000,000 {7 Fti DESCRIPTION OF OPERATION$I HACATIORS!VEHICLES(Mach ACORD Iat.Addldonal Remarks Schedule it morn apace Is ragwred) Thomas Capizzl]r is covered by the workers'compensation policy. ) CERTIFICATE HOLDER CANCELLATION - Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE j . ©1988-2010 ACORD CORPORATION. All rights reserved. I ACORD 15(2010105) The ACORD name and Wgc are registered marks of ACORD I k z a z I ♦ 1Mli � �11 � ��iL fi'� 1 0 �c- ii . >I I INK? Nod AM AU !" 71. 3 � �Y��ft�yfr(i�41i�11 �+�I�YIY V d � .r :"�s ��.,� �"'� ���►. " . -. ' �: I a.." BFr��118ri14 MWtr k� I➢'I^� w OiR ki- , 1 irk i oFSHE r Town of Barnstable *Permit# CX�. Expires 6 nonths fron '.rue date Regulatory Set-vices Fe =` �"� Thomas F. Geiler, Director ►639• �lFD MA't A V 1 0 2008 Building Division 'TOWN OF Tom Perry, CBO, Building Commissioner SARNSTABLE 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__-1�J O 00 1 Sf• �lJ, ��Cr V'v� S ,e— 01Residennal Value of Work 3 . 0 6 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address V�t C e ' \� V-) tl I Contractor's Name Telephone Number I lame Improvement Contractor License#(if applicable)__ Construction Supervisor's License #(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor [ l 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) II 2<1 e-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Q Replacement Windows/doors/sliders. U-Value (maximum .44) i *Where required: Issuance ol•this pen-nit 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 is required. S1CN,ATURE: . Q:'WPFII..f.:S\FORtYI building permit forms\EXPRESS.doc Revised 100608 �oF Town of Barnstable t� y�P o Regulatory Services EAR ST,B Thomas F.Geiler,Director MASS Building Division rfD MA't 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 EXEMPTION Please Print SATE: I 1-11 D-1.o'S? JOBfLOCAnom g 3 C5 OCL Vt w, �G YZ VIS�Q l number street village HOMEOWNER":\� ce— M I ) ►n 1 name home phone# work phone# CURRENT MAILING ADDRESS:. ? O - Za X ��Z (4/• So, e y)S lQ l� �'_ Mn I n V a6 z cl 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 BOMEOWNER 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 be/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. aturc 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/certifi cation.for use in your community. Q:fomis:homeexempt �IHETo Town of Barnstable ti Regulatory Services raeax ��wscE$ Thomas F. Geiler,Director �fo �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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit pleas mp ete e Homeowners License'Exemption Form on e verse side. !1•ClDA.(C•(1\3/1.TCD DCDI.RTCC1l1),I ' The Commonwealth of Massachusetts Department oflndustrialAccidents Ofj7ce of Investigations d 600 Washington Street �< Boston,MA 02111' www.mass.gov/dia Workers''Compensation'Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A_pplicant Information Please Print Legibly Name(Business/Organization/Individual): n I co. n�)n n I Address• B 3 OC e N City/State/Zip: Phone.#: 3 Areyou an employer? Check the appropriate box: .Type of project(required):. 1;❑ employer I am a e 4. I am a general contractor and I yer with 6. ❑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 g. Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. We area corporation and its 10.[]•Blectrical repairs or additions '3.❑ I am a homeowner doing all work . officers have exercised their 11.❑Plumbing repairs or additions ' myself.[No workers'comp. right of exemption per MGL 12.EK000f 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. lCantractors 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 provid8 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: lob 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$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the Office of Investigations of the CIA for insurance coverage verification. 1- do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct b S Si ature: — Phone# 3 b D--)b 3 Official use only.. Do not write in this area, tb be completed by city or town official City or Town: ' Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6. Other Contact Person: Phone#: r ,per The Commonwealth ofMassachusetts \ Department of Industrial Accidents Office of Investigations ' 600 Washington Street �< Boston,MA 02111' y� wlvw.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Eleetricians/Plumbers Applicant Information .Please Print Legibly _ame-(Business/Organization/Individual): - ' Ci /State/Zi iN t04, hone.#: 77, 3 � Are.you an employer? Check the appropriate box: :Type of project(required):. 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction . employees,(full and/or part-time).* • have hired the sub-contractors c listed on the sheet. 7. ❑Remodeling s2. I am a'sole proprietor of partner 1 These sub-contractors have g• 0 Demolition ship aiidhave no employees working for,mein any capacity. employees and have workers' 9. Building addition [No.workers'_comp_insuiance� comp. insurance.$ required.] 5. We are a corporation and its 10.El'Electrical rep airs or additions 3.❑ I am a homeowner doing all work . officers have exercised their 1 L EI Plumbing repairs or additions ' myself.[No workers'comp right of exemption per MGL 12.0 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 anew affidavit indicating such. tContractors 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: lob 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 maybe forwarded to the Office of investigations of the MA for insurance coverage verification. I do hereby certify un r the pains-and es of perjury that the information provided above is,true and correct. store:" Date- �C7• v�3 _ Phone#: Official use only. Do not write m 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#: int®rmati®n ana instructions l Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and-including the legal representatives of a deceased employer, or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall,MithliOld-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 ehapter.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 cornplznee with the insurance requirements of this chapter have been presented*to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,it necessary,supply sub-conti•actor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies*(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members'or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate-line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the-affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in - (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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:. Jbe CO.M Onwealth of M.assarhusetts Department of Industrial A.ccidezts Office of Investigations 600 Washington Street Boston,_MA 02112 TQL #617-727-4500 ext 406 or 1-977-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.matss.gov/dia