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HomeMy WebLinkAbout0317 PLUM STREET �IIII nO `�J��FECVC(fppp2m - UPC 12543 � No.. 5�3LOR HASTINGS,MN o GI o/�o� �"� Town of Barnstable *Perml.�` Expires 6 mont! ror is eedaf Regulatory Services Fee • enaxsrABLE, 9 moss. $i639. Thomas F.Geiler,Director �0 Building Division p 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 Not Valid without Red X-Press Imprint ��L OD/z Property Address oa ❑Residential Value of Work � i7 \� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name /n/1 I A j Telephone Number y�3 ~ 84 Z 2. Ek ,U G' Home Improvement Contractor License#(if applicable) # /O 3 K-2 9 Construction Supervisor's License#(if applicable) C - Y IS-0 ❑Workman's Compensation Insurance Check one: JUL 15 2014 ❑ I am a sole proprietor ❑ I am the Homeowner ['I have Worker's n Com ensatio Insurance Compensation TOWN®FRRRNSTMLE Insurance Company Name PU2.m /�/}OL I/►/ J N 5y�RAIC t% Workman's Comp.Policy#_,oz>,] G--,,6 j f Y Copy of insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Z 2 0 4'!6' #of doors l [Replacement Windows/doors/sliders.U-Value (maximum.35)#of window$ �i/,(��,p.4/i ❑ 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: erty Owner must sign Property Owner Letter of Permission. A c py of tht4hpe Improvement Contractors License&Construction Supervisors License is r uired. SIGNATURE: C:\Users\decollik\AppData\Loc \Microsoft\Windows\T m ry Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 i THE r° Town of Barnstable Regulatory Services 9snxx Le.� Richard V.Scali,Director i639• �0 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 '\�o%Q& to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner igno&e of AD c ;2n Print Name Prin ame `7 s D to Q:FORM&O WNERPERMIS SIONPOOIS Town of Barnstable Regulatory Services ��oF rOiyy Richard V.Scali,Director °^ Building Division = s t BARNSTASM • Tom Perry,Building Commissioner 9� 16 ��� 200 Main Street, Hyannis,MA 02601 ATED►M,t A 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 MAU-ING 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. DEFD41TION OFHOMEOWNER 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 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. I Q:\WPFILFS\FORMS\building permit forms\EXPRESS.doc Revised 061313 { i4 The G'mmmss t of Uassr chmseff-5 'ep=&n mt of huhuftmi `Accidents - Office OfinvesA..rdiaIns 60,0 WaY7r&zgtbn Street Boos&��MA 02M wnw.inosr,gov1dia Workers' Compensa€ionInsurance dam BuildersfContractors/Ele-ctriciauslPlumbers Applicant Information n Please Print Legibly Name{Sus�lOqpiT�on&avidnan_ ��U PAL '/'l,4�2 I /n�C',4 V Acidness c� fed S 11 City/State/Zip:U-)r..s!1 r,r- IJ Phone;l�- Y13 Z 2, Are an aru ern to er"ChecktM appropriate box. _._T a of gxo ect_k_. _._... - L&tam a employer With 4- ❑ I a a�dal sub-c cfor aid�Z 6- ❑New,00mstactioa employees(Eiji and/or part-#ime)* �v� the� �._❑ I am a sole proprietor or partner- listed an the attached sheet 7- ❑Remodeling These sub-contractors strip and have no employees es andehave g- ❑Demolifiaa w edl�orking for me in any capa employs rand have vrt>rkers' a e insurance.: 9- ❑IlnildFng addition [Noarorkers'comp_insurance 5_❑ We are a corporaiionand its 10-0 Electrical repairs m additions officers 1 hnm exercised their Plumbing airs or additions 3.❑ I am a homeowner doing all wow �-❑. g myseM[No workers'camp- right of 1(4m and we have 12_❑Roof repairs instrrauct:regained,]T �152,§1(4},and we have� employees [No worms' 13_0 0ther/ 4/ comp_insurance regrnred_I !Airy savpYx=t that checks box#1 mast also fll out the section belaw shaving their worms'compensi6i •pow i t Homeowners vrho sabmit Ibis afddxvid i�Ycxtn[g thpy are doiag a9 trade sand&m hire Do tsi&coatmcmrs nmst sabmit a IIeae affidavit indicating ssrTi !CantnctDa f i check this bax must siurhed as addidnaA sheet shaving the name of the sAt-(�and state crhether DCnnt$mse Mies b-we emplayees_ If the snlrtonto dUM hire mtpIrryees,they mast provide their warb-Ms'comp.policy aUMI).— I am arz employer fhatis prm idiiW workers'conrimnmrfian irmirtuaca for my etrrployess. Belau is thepaUcy attd job site infirmat&uL Insurance CompanyNkme: Policy f#or Self ins Uc-;Ii: 2 L '7 tei � 1�'If Expiration Date: Z �( ,Joh Site Address: �y) 1� /n S� CityfStafelZtg: R led/ Attach a copy of the workers'compensafi,on policy dedaration page(showing the policy number and exlm anon date). Failure to secure coverage as requiredundes Section 25A o€Mr-TL,c. 152 can lead to the imposition of criminal pe©alties of a fine up to$1,500.0a and/or one pear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup.to$250_DO a day against the violator_ Be advised that a copy of this statement maybe forwarded to the Offim of Imrestigations of the DIA€air msarance coverage vetifrciation_ Siscoa - - lathe f Ida f rrnz-aEa1n}apt�ra zddaJSet aan[IcorracG �f Phone#: E3,,UEdal use only. Der not write in this area,to be camped by city or town of ciaL City or Town: Pcru itucense# Issni Authority(drde one): 1.Board of Health 2.Binding Department 3.CitFJrown Clerk 4.Electrical Inspector S.Phxwbmg Inspector 6.Other Coat act Person: Phone#_ �a Information and hnstructzons Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 tustee 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 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 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,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their ce tificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partaersbips(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 m' s urance coverage. Also be sure to sign and date the affidavit. T1ne 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. Sella insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be are 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/licease 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 submif one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations lira (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 fut ze 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 bum 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 f x numbe'r: The Commaw-e-ealth of Massachust tM Department of Industrial Accidents Q•fflee of kVesfigatFaris 6-4f1 washivou street Boston,IAA 02111 TeL A-617 727-4900 at446 or I-V7-MASSAFE Revised 4-24-07 Fax#617-727-` 149 -texas-s gav>/dia i ,4co O® CERTIFICATE OF LIABILITY INSURANCE F °AT "" 07/0812017/08I2014 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(les)must be endorsed. If SUBROGATION IS WAIVED,sybject 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 TA T DIANE L MASON AGENCY PHONE .413-569-2307 FA, lee:413-569-2308 FARM FAMILY INSURANCE E-MAIL 504 COLLEGE HIGHWAY INSUR S AFFORDING COVERAGE NAICY SOUTHWICK, MA 01077 INSURER A:FARM FAMILY CASUALITY INSURANCE 13803 INSURED INSURER 8 ROGER MARTINEAU INSURERC: 342 WEST ROAD INSURERD: WESTFIELD,MA01085 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Q OCCUR DAMAGE TO RENTED E 50,000 2007XO205rencol � MED EXP(An EFFECTIVE: 6/10/14 6/10/15 one n s 5 000 PERSONAL 6 ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 POLICY❑JET LOC PRODUCTS-COMPIOP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINdED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) E ALL OWNED AUTOS SULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY lcda HIRED AUTOS DAMAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE E EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DIED I I RETENTION E y AND WORKERS YERS' SATION ABILIT 2007W6194 1 1/1/13 11/1/14' M PER o - ANDEMPLOYERS'LIABILITY T AT Eg ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N OFFICER/MEMBEREXCLUDED? NIA E.L.EACH ACCIDENT S 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE E 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,maybe atiachad If more space Is required) CARPENTRY DETACHED DWELLINGS THE WORKERS'COMENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ROGER MARTINEAU. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE JOHN&FAITH NEKITOPOULOS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 317 PLUMTREE ROAD ACCORDANCE WITH THE POLICY PROVISIONS. BARNSTABLE,MA AUTHOR �AVTAnVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and loco are realstered marks of ACORD cJ/ae �panvnaaru�ea 0, 7id . License'or.registration valid for individul use only Office of Consumer Affairs&Businesbefore the expiration date. If found return to: OME IMPROVEMENT CONTRACT Office of Consumer Affairs and BusinessRegulation— — egistration: 03899— 10 Park Plaza=Suite 5170 x iration:` .7L10%2016= I p Boston,MA 02116 ROGER R.-MARTINEAU Roger Martineau ,.E= - ' 342 WEST RD. i.._, _ I WESTFIELD,MA 01085 Undersecretary ti Notyali 't out signature Massachusetts =Department of Public Safcei�4 t jBdard of Building Regulations aid 5ttdi C(instruciion Supervisor :;,3," .o,. License: CS-034750 { ROGER R MART#4EAU'- ra' j.. . 342.WEST RD .WESTFIELD Ma•J85 _Y ",� t`,� t;ti` 1 Z � xM n ! : 1PAW fY. 1 b i Town of Barnstable *Permit# bg0 Expires 6 months fi m issue date W Regulatory Services Fee 0 , v t anaxsT,�, i 039, Thomas F.Geiler,Director 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 PERMTT APPLICATION - RESIDENTIAL ONLY 1 Map/parcel Number �J (/S7/Nnt'Valid without Red X-Press Imprint I Property Address ❑Residential Value of Work /�.Gbp Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 11.\\ Contractor's Name I S oct P 4- h J is ACj Telephone Number �/��� 9 �S�,G y f�(L,�� � eP Y i3 ,rG 2 -�ti 'L2, Home Improvement Contractor License#(if applicable) CAS �3 t1 75"C0 ;0 103 9'V Construction Supervisor's License#(if applicable) C 3y t 50 ❑Workman's Compensation Insurance PERMIT Check one: ❑ I am a sole proprietor MAY 12 2013 ❑ Tam the Homeowner [a'I have Worker's Compensation Insurance . Insurance Company Name fi lk V)l r A tn1 I I TOWN OF BARNSTABLE Workman's Comp.Policy#_ Q00 Copy of insurance Compliance Certificate must accompany each permit. Q Permit Request(check box) D`ke-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to —'PI't' �ttr ❑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 must sign Property Ow Letter of Permission. A copy of the Home Improvement ontra tors jjcans�&Construction S Oervisors License is required. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ ontent.0utlook\QR PRESS.doc Revised 053012 The Commonweakh of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ?` Boston,MA 02111 ww v.masmgmt/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Elerts-icians/Plumbers Applicant Information Please Print Le 'b Name(Busine&Organization(lnddividnai): Address-.— City/State/Zip: AIZ9', Q A D/0006%one# Are you an employer?Check the appro rate box: I am a contractor and I T3�of project(rewired). 1.�I am a employer with�_ 4. ❑ ��employees(full and/or part-time)_' have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees 'These sub-contractors have g_ ❑Demolition working for me in�'capacity.. employees and have workers' I 9_ ❑Building addition insurance[No workers'comp.insurance comp.insurance_ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officer have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]1 c_152,§1(4),and we have no employees.[No workers' 13/W Other_new yoo comp_insurance required.] •inlay applicant that checks box#1 must also fill our the section below showing their workers'compensation policy information- Homeowners who submit this affidavit indicating they are doing all work and.then hire outside contractors: submit a new affidavit indicating such- ;Contractors that check this box mi=attached an addirional sheet shouting the name of the sub•coutrsctors and state whether or not those entities have employees. If the sub-courtractars have employees,they must provide their workers'comp.policy number. lam an employer that is proWding iporkers'compensation insurance for my employees Below is fire polio and job site information Insurance Company Name: /-,9Y-Il ' ,�Vm.,x fL'auC,a) T-e-S Policy 4 or Self-ins.Licc..it: Expiration Date: Job Site Address: T/4M -Pee ��7`- ,&/,4S6 City/State Zip:A", 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER.and a fine. of up to$250M a day against the violator. Be advised that a copy of this statement may be fbrwarded to the Office of Investigations of for insuapee coverage verification. I do here certifj ruder e t n a o fury 1 t the infornuntioat prouvde/d-above is bore and correct Sigo 7 Date: Phone#: r Official use only. D not write in this area,to be completed by city or town official. City or Town: PermitlLicense# 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#: 6 05/10/2013 08:55 4135SK338 DIANE MASON PAGE 01/01 f'ca CERTIFICATE.OF LIABILITY INSURANCE VAT E(MW9j PYTYY) 05/10/2013 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 POLICIN3 BELOW.• THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFMATE HOLDER. IMPORTANT: If the certillicate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed, If SUBROGATION IS WAIVED,Subject to the terms and conditions of the policy,cedvin policies may require an endorsement. A statement on this certificate does not Confer-'tights to the certificate holder in lieu of such endorseme a. PRODUCS=Jt DIANE=L MASON AGENT v P. we _.. .. 413-569 2307 I FAz' _ FARM FAMILY INSURANCE AS No141 a SG8-230fS 4 COLLEGE HIGHWAY �'-~— INSURER(ktgFOROING COYERA6) ) SOUTHWICK,MA 01077 -- ---- -- -- ---- i Nalca_ _J ___...._._._._._______._..........�_.—�_ ................. INSURERA:FARM FAMILY CASUALITY INSURANCE ! 13803 INSUREc _ ROGER MARTINEAU lwsuacRc, 342 WEST ROAD INSURCRO:_ ! WESTFIELD,MA 01085 INOYRERE INSURER F: COVERAGES CERTIFICATE NUMBER, REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD SNDII',ATED. PIOTW!THSTANDING.ANY REQUIREMENT,TERM OR COND:TION OF ANY CONTRACT OR OTHER DOCUMENT VAT"RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TC,,ALL THE TERMS, EXCLUS10Nq AND COrornONS OF SUCH POLICIES,LWITS SH01 1 MAY HAVE BEEN REDUCED BY PAID CLAIMS. _. ' �aacttsuertl..__-----•--,W.•,...�....�._.�.��YE�>�"�LTt�P�,—'----_.....,,.,._..__..__.___....._..----- --.-._..._ . TYPE CF W>UtANM aufiRl unm POLICY NUMBER (fflwD0/YYYY) IMIAM i LIAMT3 n �llCii'Al_LIAli1LJTY I I I EACHOCCURRENOE MN£RCIALGENERALLIABILnYE I CLAIMS .0E r X�occuR 2007XO205 8/10/12 6/10/13 C..J I i EFFECTIVE RENEWAL 6/10/13 6110i14 - --------- F_RSONALtACyINJURy I S 1,000,OOU� I iENERALnGGREGATE T8 j GEN L AGGREGATE LUAIT APPLIES PER: I PRO0UrIT6-CQs11'/r AGGJ 9 ",000.000 POUCYI•, PR4- LC,C I i gf AklY0V1CBILELIABILITY sca MEINI!D MNGLI!LIMIT I I I BODILYae ANY AUTO L,•IwGF'r!Pe_roar�nt 1.5 .._...-•----.._....-.:.,....... ALL AWNED - SCHEDULED I I I BODILY INJURY(Pei Bciwidt:/u1I$- AMT48 ' AUTOS I I I I WIRzvAUros NON-OWNED i I A; CRj'wrvoAhaAc;--_'.5•.,.,",..•.,-'-__._...._.._._- va)IReur,ual; I CIS 1II I I � _AGGEROOCPCYUER REdCE I s PxaEasuAe CLAIMS-MADE £ H is cE—�I 11IFTaNTloNaD • .-i WORKERGCOMPWISAT I I I s AImEMPLOVEJ UABIIIJTY �07Wfi164 {I{ ii/1/12 11/1113 1 �Q,rv$�yjLT._..___is5 --------.---.— I ANY PROMRIeTr7RIPARTtrCR.ZX000TIV): Y I N ! i I .E.L.EACH�4CCIDEN.7 OFF1Ger?INcMElNREXGLUO86? OIN1AI i i '-. _...............L..._-.—____._.i.....___ I (ManAakory In NN) E.L.D19CASSE_Er.EMPLOY 6eI a 100 000 I M 7ynas,dexndn un0at ' •-- DESCRIPn10N OAF OPEPA'n NS Dalow I 1 I _.L.DISEASE.PpL!CY LIMt* 5 l500 000 I I 1 I • 1 DESCRIPTION OF OPeU1NONStLA0An0N8/vEI16L"(At,2onAC0Ro101,A40lonal RemaAcs Schedule,Nm=space fe mquirad) CARPENTRY DETACHED DWELLINGS THE WORKERS'COMENSATION POLICY DOES NOT PROVIDE COVERAGE FCR ROGER MARTINEAU. i I I CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIS PO POLICIES ISE CANCF-L S!D BEFORE THE E?XP11RATION DATE THEREOF, NOTICE WIL4 BE DELIVERED IN FAITH&JOHN NEKITOPLOUS ACCORDANCE WITH THE POLICY PROVISIONS, 317 PLUMTREE ST W.BARNSTABLE,rvIA AUTHO Wow a ENTATIVE /7 C 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(20101051 The ACORD name and loco are realstered marks of ACORD oFism r, • aaxtvsrnBte. 9� ,.� Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building 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 I, on t1.�QK`T oA o v\O S , as Owner of the subject property hereby authorize b o eat' c�:v% e t0 act on my behalf, in all matters relative to work authorized by this building permit application for: 3 V1 0\y van (Address of Job) 0 oy\as 1 02 0 l3 Signature of Owner bat VNV-C\A A. NEK ITOQ DU L OS Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 i i ✓fze: onvinonu c�'✓��aaaacju%aeC�a - Office of Consumer Affairs&-B�siness Regulation '. -..,,HOME IMPROVEMENT CONTRACTOR Registration:.;.103899 Type: Expiration: 7%1O12014 Individual - ._ _....... ROGERR;>MARTINEAU;`:r:i.a._'`:�.r,;. Roger Martineau 342 WEST RD. WESTFIE 1085. ' `�ilndersecre J i • 11�is..achu�ctt.= Dep• r lent of Publi ".11tE.f :.:. BldBuildingRc_•� Regulation" f Mad -.and `.Y ..•ronstructiori Supervisor License License: CS 34750 ROGER WWMARTINEAU � 342•WEST RD -<-. l WESTFIELD, MA 01085 : r. Expiration:;8/31/2013....' o P�OFiHE Ioy� Town of Barnstable *Permit# a o,� tres 6 monthrfrom issue date Re ulato" Services • BARNSTABLE, • J Thomas F.Geiler,Director i63q.. �m ��rFo Mai a Building Division X-PRESS PERMIT Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 OCT 0 9 2002 G' Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTi�BLE EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address residential Value of Work 1 G Owner's Name&Address Z Contractor's Name '� ��T C ` G , s'C Telephone Numbery,�Y 3 3lc� Home Improvement Contractor License#(if applicab �S^ Construction Supervisor's License#(if applicable) Q C v ❑Worlonan's Compensation Insurance � �' b �L � Check one: ri ❑ I am a sole proprietor { I G G ❑ I the Homeowner /-Y '� • !have Worker's Compensation Insurance NIfL- �cl- Insurance Company Name Workman's Comp.Policy# 4/y / Permit Request(check box) Ae 00�j o / d4-/' ✓� C� `��G R r r� eRe-roof(stripping old shingles) All construction debris will be taken to , ❑Re-roof(not stripping. Going over existing layers of roof) �l 1— i ❑ Re-side � ❑ Replacement Windows. U-Value (maximum.44) — C-n ao ❑ Other(specify) N) m *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg Revised121901