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HomeMy WebLinkAbout0063 MOCO ROAD mo(z boa oc- uu UPC 12543 No.5_3LQ HASTINGB.YID! Opk6a n+e own of Barnstable *Permit OCT / 201Q F�rres 6 months from issue date ' Regulatory Services Fee Ot 8AH0VS iA8L#ichard V.Scali,Director ��► `� Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 R www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY �^OD� Not Valid without Red X-Press Imprint Map/parcel Number UL. Property Address P)� 'n, esidential Value of Work$ 3, . Ulf Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address v Contractor's Name Telephone Number .Dg' 6 7 O 7 13� Home Improvement Contractor License#(if applicable) Email: 51t9ki(" S21 MUj-,,WkAd • dy .Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑R oof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #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 Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: • Q:\WPHLESTORMS\building permit forms EXPRESS.doc 06/20/16 r The Com olriveaM!BLESS drus& 4 Department of rad-mlrid Accide OfflGG Of�nT afi=5. 600 WashhVioi<t rSYre f Boston,MA 02111 kVFVkll.ill�,�D9��If1 Wcwkers' Canlpensadan Insurauce Affidavit:Builder-s/Contra-ctursXlecEricianslPhunbers Apifficantlufmmiating Please Pxin Address6-3 r 43sow ci�fs7r �e 2 ~Cy��` 7)36 Are you an employer?:Checkthe appropriate box / Type of project(required : I.❑ I ant a employer vrth 4_ ❑I am a general contractor and I 6- ❑N6w oonstxUCtiorx employees(fall andfor part=lime)-* have hiredtfie snb•-contractors 2.❑ I am a sole proprietor or-partner- listed on the attached sheet; 7- ❑-`etnodew. �rese sus-contractors have sh£p and have:no employees S. ❑Demolition woddn g fnrmain any capacity employees and have wodmm' 9..❑Build acidifioa ems'comp.iasu�ce comp-mmranrl'l 5- ❑ We are a corporatifln and its 10:❑Elechical repairs or additions j officers have exercised t�ir 1L Plumbrn r airs or additions 3� I am a homeov�doing all work ❑ 1? eP - Myself[No worlcErs'oomp_ right of esempfion per MM 13.❑Roofrepaim »ancerequized.]i c.152, §1(4h aadwe have no employees(Noworkess' 13-❑other comp-insurance required-) 'dap apgEics�Bsat chedeshos�1 mast also ffio�the secrica6eJuwsho►vag Bteirwoa�ess`comptmsatiaapaTicyi�osmafatni ) a+n41s`cabo submit ibis af5dairk ID dwy am dui-all waalt sad Brea]site oa=&can=cYtIIs— o9ma t anew affida ft mdi—da sacs, ZCoat<adM*XtchecYtW9b=Estrftr-ls asadditimatshee2shoRmgtltenam4&ofthesuja-�and stafewhelhe[or not tl»eerititinb.X e employees.Iftbemb-c atactasshave employees,McY=nsrpwv2dL-d'w wodums'app•pdlkF- m -Tam an eurpIaFsr f7iat is prQuidutg workers'cottrFerrsrrfion irtsruarrce for ary empFny�ees Sefnw is ilia prrticy tub job site infor nzatiam Inismaace Company Name: Policy-4 or Self-iris.Tic- ExpimtionDate: rob SAFAMress: �� 1�� E C tSs��: AJ, Aim Aftach a-mpy of the workers'compensationpolicg declaration page(showing the policy,number and expiration date). Fwlare to sectme coverage as requireduuder Section 25A o€MGI.m 157—can 1wd to the impostion of criminal penalises of a fine up to$1,500 00 and for one-year impdsDlFment as Well as rival peed ies,ia the form of a STOP WORK ORDER and a fame of up to$25(-OO a dap again sf the violator. He arhdsed that a copy of this statement may be forwarded to the Office of Imvestcgations of the MA for insurance coverage v-erifrcstinn- I do heraby certify under the pains andpwaMn of erju ty fhafthe informa€mi-proviiW aboiv is true and correct Phone ik Ojai uss mily. Do not write in fhis Area,to be cmmpleted by city artown gjoi iaL City or Town: PermitUcense; IssuingA Aority(curietine): L Board of Health :d.BWTcImg Dq=tm rt 3.CA)Yrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Otiher Coact Person Phone#: -- - 6 ormation and Instructions y. h6 mchmeffs Gmt=al Laws chapter 152 reqmires all=q3lC7=ID provide worb-e&campe S5ftM for fl en.employees. Pmr9u;ant7tD this a-tStEft,au eZr9rIoyee'is defined as¢.eVMypersonm$ie scavice of Mlafficr under any con:tract ofhae, e pre:=or implied oral or wrhmar " 14n Moyer is.defined as aaa inchvidnal,parine2sh�,asso :is inn;corporation or otbea Iegal entity,or any two or mom of the foregoing=gaged is a joint entm-prise,and i mhrdmg the legal representatives of a deceased employer,or ffie receiver or trustee of an mdividnal,partnership,assooaa±M or other legal entity,eazploYmg en3Ployees. However the ec owner of a.dwelling house havingnot mare bran three aparhnents and who resides ffim-ma,or the occupant of the - dwelImg house of ano9ier who employs persons tD do make,consttuction or repair work.on such dwelling house or oil the grounds orbuacrmg app=tcn lh refo shallnotbecanse of such employment be deemed to be an employer." MGa,cbapter 152,§25C(6)also states that"every state or local licensing agency shall withhold$e iss-aance or renewal of a license or permit to operate a business or to construct bufldings in the comm Gnwealth for any applicautwho has not produced acceptable evidence of compliance with the insurance covexage required." Additionally.MCrL chapter 152,§25Cg)states fiTeither the nor any ofits political svbT .lions shad enter into any cont and for the perfmmanw ofyubho woticuotil acceptable evidence of compliance with the insu rm�p.. reTnr=ems of dais chapter have been presented ID the Mnh�anfhoiity_" Applicants Please fill out the woi3='wrnpeasation affidavit Completely,by checkixgthe bones that apply to your situation and,if necessary,supply r(s)niUne(s). d es)and phone— er(s) along with their ccrtificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnmships(LLP)wi$nno employees o&=than the members or partners,are not required to cant'worke& compensation insurance- If an LLC or LIP does have =pIoyees,a.policy is respired. Be advised-hat this a$da:yk may be submitted to the Department of Industrial Accidents fur corm ation ofmsmance coverage Also be sure to sign and date the afnda Vie The affidavit should be renamed to Sae city or town that the application fur the permit or license is being regnes'hA not the Depmtneut of ; huh,st ial Ar • =L_, Should you have may gnesdans regmarmg the law or ifyou are requned to obtam a workers' compensation policy,please call the Department at the n=bea listed below. Self-ios�'companiesshouldeutL-rtheir self inSM7ance license m mmber an.the appmpri-aiee line. City or Town Officials f Please,be sure that the affidavit is complete and priated.legibly. The Dcparimenthas provided a space at the botham of the affidavit for you th fll'out in the event the Office of luvest�has to comact you regarding the applicant Please be sate to Ell in the pennit/license nnnnber which will be used as a reface nnmbcrr_ In-addition,an applicant that must submit mvliiple pe='Vjicm se applit:ations in any given year,need only submit one affidavit indicaimg cuseut policy information Cif necessary)and vndea`Job Sif=Address"the applicant should wide"all lacafi ms in (may 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 prool=that a valid affidavit is on file for fbinre pemiity or licenses A new affidavit must be f mcd out each year.Where a home owner ar citizen is obtaining a license or peonif not related to any business or commercial venture (Le_ a dog license or pemit to bun leaves said person is NOT requhed to complete this affidavit -min advance for your cooperation and should you have any,questions, The Of3ace of Investigation would h1m to t�k yo please do not hesitate to give us a call. The Department's address,telephone and fax umnbea_ DegtinMt cif Accidents ice of 1nVe&tkAti0= Bwbm MA Cd111 Fax 617 727 774-9 Revised 424-07 W Wzi g a Town of Barnstable Regulatory Services oIF Richard V.Scali,Director Building Division t RkR?4STA1= Paul Roma,Building Commissioner MASS 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us i Office: 508-862-4038 Fax: 508-790-6230 i HOMEOWNER LICENSE EXEMPTION Please Print ATE:_3 10 _ Z� _ /f // _— l� le ,1oB_L 66AT O ( 3 Mzd number / street village("HOlv1EOWNER": Al t' S /lJ1(�D p��u .�D �1,3;6 , 77 S —f76 7 name home pho a work phone# CURREN.T_MAILING ADDRESS: l )) ��/� --- �--C ci /town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility f6r 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 7/she will comply with said procedures and requirements. �.— ature_of Homeowner�i 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,Rteles&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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe 06/20/16 'THE Town of Barnstable Regulatory Services B"M Richard V.Scali,Director Building Division. Paul Roma,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 ) IS 7Own the subject property hereby authorize to act on nb ] in all matters relative to work authorized by b ' ding pemzit application for: (Addres of Job) **Pool fences and alarms e the responsibility o e applicant Pools are not to be filled or tilized before fence is ins d and all final inspections are perf ed and accepted. Signature-of Owner Signature of Applicant Print Name Print Name Date QYORMS:OWNERPERMISSIONPOOLS ti4E Yp� Town ®f Barnstable Permit# Fxpires 6 onr' tle Regulatory Services Fee 96 4, SS f1 V.Scali,Interim Director Building Division .VA Tom Perry,CBO,Building Commissioner TOWN OF BARNSTABL2C Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERLMT APPLICATION - RESIDENTL&L ONLY Not Valid without Red X-Press Imprint Map/parcel Ntimber. 6-� Property Address3�pY} Q(',Q; / aa, ®Residential Value of Work$ e��� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ?AR N 1CAMY)t gric 'f P=O r03 MC>Lo Kd� 1�_ f( Sind a � oa( wf Contractor's Name(,Uft-Y n N le d S 1 ss , oar Telephone Number,46 i -aa,? ' 6-D ��1u+✓n Home Improvement Contractor License#(if applicable) 11 3,)9.5 Email: Construction Supervisor's License#(if applicable) (' Cj 1 p'j. XWorktnan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner I have Worker's Compensation Insurance Insurance Company Name RrOW 011-11" Workman's Comp.Policy# D q.3 X 3 j2-----)ql4 Copy of Insurance Compliance Certificate must accompany each permit. k 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) ❑l a-side bQ Replacement Windows/doors/sliders.U-Value t� (maximum 35)#of windows � !� ##of doors: t/ ❑ 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 to��n departmeut reo lations,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 requ' SIGNATURE: T xKEVIDI MBuilding Changes)ExPRESS PERMIDMRESS.doc Revised 061313 b7/'1f ewalrsemlM rI !RENDVAL BY A�jDER.SII�N snow>eurwm .area trtaru 26 A16M'toad- unu in,Pl i1n63 . crixsx• N 8� f-%3.2255-Fax,3fll.fa33 5Gt12 rsarn rss aO s✓.sseWv 3011deraNeW 11941110dVandOW1061LCdA/a 7teastvr3 ryAaiersea of gssiheettNtteHru�aad Cu n*omW3NDOWANDDOORRBhfODffi1NGA:GRMMEW r SuetaK rhea __-IG TATR 8uewss�l6sue�rsueea�itrceen��.� b3 Moen _St.D. ------ ---- - _ t?,it"Srhy►fte rM&- p U b 8' a�i.w:�S�E1�hC1�V?SAVL�URSDI)►�iD.ORG wA.sr�,�w.s�S!�'��7136 ��...��-�0 SLYrri`J �Ned!Znd wally{fiRrt top=htcc the pindmrs andhw rmsr=cT Sm9Lc a�'c%Fmila�xi WitAms,].W dfi,/a Itcnru-J trg Ands acn of Southern Nrw England j"Cbattrutnr" in acxead mte%ith for tErnh xrKi a+uditiuus dnaibrtl um ilk-frunl sled the m16YA-0f ibis atm mmi and on the a��'���Z��i6��caiioa ihmjs]{ecllccvn+rht thb:lgrrrutad;� 0 ifdoc�c^^(3 Cosdo G BOAT pl tonl)obArnamt jj _ 'ASO" tleehaddApmteeeA CilCarahy a"frunerd i�� bv-h $ft--50 + CreditC"*ate,aaep"dfor&VWkdnV-0W&M nv3ofdie fishnet at Sat of job 0ft--,=&- tksG proles tost.lReeie ree�ia3t fadRrtemerr FaernD B/s4pwKths l�eanern.you adce tixRtltt BaLnae tt 5eart djab tine Q�e .54, WWA6 0,&ftmmv 1-6 NVU on&*=WWC*WWdan*(j*- be ffdk by credit aayerjs)agaves and undemitandu fhu this Agreement eonstbntm fits eotue naderetaadiag betwmb"else parties,aid Am there ire no verbal vadastaaAahyf ins a"of the terms of this JSreeate.t.Boytr(s)aekaowltdgea tbat$ayerw (1)has nod this Agreemen4 uoden"ad■the terns of Wa Agreement,and has reeelvred a oomplrted,signed,and dated copy of this Agreement,ledudlagdw two attached Notices of Caocdl.dou an the date fQutwrittea above and(2)was orally Informed ofEuyer"sA&toea fed"Agreetnew-DOA1WSIGNTIDSCOA'IRACTNTHFAEARBANYBL NKSPACES. (RiiiodeltlawdSaks Om&)Noeiee roEayer.(1)Doaccslge.this Agreemmtif any of the spates isteadedforthe agreed terms to the etttmt of zhm available iatormadloa are le$w—lt.(2)Yom ate eadded to a arpyof thisAg oemmt at the time you sign it.(3)Yaumayat ray time pay oii the hU=t sidba2,ace due uader*bAgret'J>ot,nadi nso doing yoamaybecntidedm reaebt a pedal rebate of the iteance and 3asueance ehairps.(4)T6c setter has rb rIaht to mlft%funy toter your Premises or comob airy bmsch of the peace to repossess goods purchased under shisAgreemeat.(5)Yon ass,eaaret"Agretmew if it bas act bees tige ed as the Mau olboe or a branch am"of the sew provided you a**dw Scutt at his or her main office or branch offisesbowai she Apeeaaesibysegismiredoroap8cdauAv►hichshaIIbe posted cat law diaamlaai b of d a tbird calendar day after the day on vrhich the buyer sigus she Agreement.esctodiaf Sunday and any holiday oa which regular mail de iveaias we not made,five the aooampasyInnotice of easuetlationform forasaplasation of boyer'brhom. BuNv*)rehired dic ctmsumer education awftisln prffiWd trf the Rhode Island Cwttraam Reenrafkai ,vrWxWaW Hester' m f NewEngLod Bayer{.) 11-y-(ra) Siiphuurr f dtrct Alanaycr ;1�pnuun CMIM ±hmht Sue Vilmeasold Pont Verne of IYtxiu�t ALhna^;rr P&A N2tnc thine\3hthr Y09 TM KIYER(S),MAY CAATCU THIS TRINBACMN AT ACHY TIME PRIOR TO MMMGM OF THE THIRD WSWESS DAYAFPSRTHEI)ATE OFTHIS TRANSACTION.SUTM AITACEi M NOTTCB OF CANCEUAMON FORMS FOR AN WOPI AMMON OF THIS RIGHT. x-- - - N ---- _ - - -x - - - -CANCELILATICIN -- - - - --NaTIt AFt [ELt1TtAN - - - -� Deter ofTranowslon f 4 -You 1"W C noel t Gate ofTransaaoon q-Z"z.'141 .You rnzy carted this tran metion,without any po alo or oWgladutt,within this transaedon,wkhohr any ponaky or oblisaeiors withtm leaves busFtttxsdqs bum tfse above date.If you cancel,any ' tree businm days from due above darn H you tame',any property traded any paynmm made by you under do t yyeevvpptteettyy traded Ire arty prImenes made by you under tlhe t:ontraec or Sate,and a'7' instruutent executed t Contract or Stale,and any a Insu unant entatted by you will be rCttwrned Mieftirt t buslaoss days following I by you will be returned v4diln cm business dap foliarin8 receipt by the Seller of your camalWon notice.and any l eetriet by the Seller of your cancellation notice,and arty security interest arising otie of the t on ransacti will be seoa ty rrtttrest adiihv out of the transaction .1be canodudlfyoucanayyoumaitmalseavailabletodieSdkr I c; edifyoutancAyou mastmduenovWlabletotheSetler ac your rattdsoce,to wbsantiaAy as gtod a mAdon as when I at your residence in sukistanially as good candidon as when raceir"my Vads-delivemd to you wider goods delivered to you under �:d you�you�. �the et�dats of I So Contract or I reocin*4�ntWf you w1sN u�"PV with d inumcdom s CAmtraft of thB Saber reprding the rWxm slltpmettt of the gootts at the the Seller regard ft the ream,d9pnvent of the goods xkOw Seller's expense and risk if you do malmtita Moods wadishle Seller'sa and risk.Hrou do mate the goods m"lahle to rise Seller and the Seller doers not prole tlnm up vMWn ' to the Seller and tM Seger does not pkk Inman up wWn twcmtyr daps of the date of wtoe stion,you rrtsy ruin or t twenty days of die date of ormettat on,you may retain or dispose of the Sorb without any fnrdher oWigsdon.If you 1 of ithe goods witwut any furdter obligation.H you fail to make the goods avallaWe to tits Seller,or dyou agree I falfto nhake tits goods ara3abie to the Seller.or tf you es to return the foods ter due Seller and tail to do i%dwen you t to realm ties floods to the Seller and fail to der so,that yes nmwdn tiaLle for prforrnance of all~am under the I remain liable for tafion»ance of all obligations under the Contraa.To earned this tramsactior%nail or deliver a signed Cothtract To Cancel this transaction,tna3 or dtd'tver a t3peed and dated soPf of ti>b caiicdhton notice or airy other n and dated copy of this onceJladon notice or any odner writYennatioe,orsendateithgamto Rene"byAndersenof I wrkmnnosice,orsendate�Ie�mm Renewal brAndrrsmai Soudmen New England at36Albion Road,L; wl Ill 2 b5. i Soudtem New En2land at 26A1bion Road, t*j%Rl OUK NOT LATER THAN MIDNIGHT OF {NOT)LATER 1 MIDNIGHT OF -CS-I Nat*) CANCELTHISTRAHNSACTWM (CM CANCELTHISTRANSACTION. ags►arlpirw Irtnemeat trap the. RbA Cope%Ift &W Cyr:YdbW &W Cvplr.Pt& OM d QO}9 cc C-Wfi kU NOStAH LM £Z-i"OZ Southern New England Window d.b:a Renewal by Andersen' of SNE-[ Massachusetts-Department of Public-Safety Board of Building Regulations and Standards Construction SupervLi.or License: CS49M7 N. 7.LAMBS POND CIIRlug s Charlton MA 01507 IV Expiration Commissioner 09/08/2016 c¢T�ieY�(i'o,�zm�s�i,cue�,l�i o�C)vtaaa�c�u�etta . . ' • �. T' -Office o1'.Consumer Affairs 5nd Business Regularion' 10 Park'Plaza-Suite 5170 r Boston;Massachusetts 02116 Home lmproveinent,Contractor Registration f - f ReglatiaBtm: 173205 Type: supplement cardE�p SOUTHERN NEW.ENGLAND WINDOWS L•L� 11H001. �1eno>B' DENNISON BRIAN' 26 ALBION RD 'LINCOLN,RI 02866 Vpdue Add—and return urd.Mar4,rewon for•rhaugts }� f xGt o mrmu • - Address p Renewal p employment Lost Card of Co A161n R eadoep RgaNtloo Ureme or regNtration valid for Indivldai an only g ME 1liPROVQMFM CONTRACTOR before the expiration date.if found return to: N; Office of Consomer Affalro and Business Regalatbv �r bhatlpn 1732l5 TYpa•, 10 Pori,Plaza-Suitt 5170. • - Eaplratlon:.ONe/p18 Svppldnenl:nd .Boston,MA 02116 ' . 1} SOUTKERN NEW ENGIAND WWOWS LLC. 7 F. RENEWAL BY ANDERSON+ - . DENNISON BRUIN' ` 20 ALBION RD. /l VFW'RI Ued.—reury of valid wlWout signature The Commonwealth of Massachusetts Department of Industtzal Accidents Office of Investigations I Congress Sheet,Suite 100 Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/orga=at1on/>ndiv1dua1): SOUTHERN NEW ENGLAND WINDOWS LLC Address: 26 ALBION ROAD City/State/Zip: LINCOLN, RI 02865 Phone#: 401-228-9800 Are you an employer?Check the appropriate bog: 1.Q I am a employer with 20 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6- ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling slip and have no employees These sub-contractors have g. ❑Demolition working for me m any capacity, employees and have workers' (No workers' comp. insurance comp. insurance.* 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L Plumbing re myself. ❑ g pairs or additions y [No workers comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12 ❑Roof repairs employees_ [No Workers' 133A Olher WINDOW REPLACEMENT comp. insurance required.] 'Any applicant that checks box l must also fill out the section below showing their workers'compensation policy information. '• Homeowners who submit this affidavit indicating they are doing all Rork and then hire outside contractors must submit new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:.ARGONAUT INSURANCE COMPANY Policy#or Self-ins. Lic. #: WC927938352394 08/21/2015 � Expiration Date: Job Site Address:_ G /� /3 OCO Rgt 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 00.00 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.d0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the p'21 ains and penalties of perjury tliat the inft� Lormation provided abo v is and correct. Sienahl : N O lzte: Phone#: 401-228-9800 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD"� De/12/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY.OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the Policy(les)must be endorsed the terms and conditions of the . ff SUBROGATION IS WAIVED,subject to certificate holder in lieu of such endon endor certain Policies may require an endorsement A statement on this certificate does not corder rights to the seme s, PRODUCER Willisof Now Jersey, Inc. ry�ME• c/o 26 Century Blvd PHONE FAX P.O. Box 305191 -8 7- 45- 37a A/C No:1-888-467-2378 Nashville, TN 372305191 uOA AADRESS:certificateaerillis.com INSURERS)AFFORDING COVER GEE [2i INSURERA:Solective Insurance of SB INSURED Southara New Saglend windore LLCD/8/A Reaeral INSURER B:The Beacon Nutusi Iaeoraaceby Andersen26 Albion Road INSURERC• naut lbouranre Lincoln, RI 02865 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:WS29160 N NUMBER: IOO 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. LTTRR TYPE OF INSURANCE AD S POLICY NUMBER POLICY EFF P RACY EXP LIMITS COMYERCULLGENERALUABRJTY CLAIM"ME OCCUR EACH OCCURRENCE $ 2,000,000 O REPITED A I ES ocmmence $ 100,000 MED EXP iAm amp $ 10,000 8 2029459 08/10/2014 08/10/2015 PERSONAL&ADV INJURY $ 1,000,000 GEITL AGGREGATE LIMIT APPLIES PER: 71 POLICY I JECT ❑X UX GENERAL AGGREGATE $ 1.000,000 OTHER-, PRODUCTS-COMP/OPAGG $ 3,000,000 s AUTOMOBILE LIABILITY COMBINED SINGLE UMrT IANYAUTo acdderd $ 11000.000 ALL OWNED SCHEDULED BODILYINJURY(perperson) $ AUTOS AUTOS 8 2029459 08/20/2014 08/20/2015 BODILYINJURY(Pereoeident) $ HIRED AUTOS X• A �UTOS PROPERTY DAMAGE A X UMBRELLA LIAR )( OCCUR $ EXCESS LAS EACH $ 5,000,000 CLAIMS-MADE 8 2029459 08/10/2014 08/10/2015 AGG��� $ 51000,000 DED RETENTION WORKERS COMPENSATION s B AND EMPLOYERS'LIABILITY ANY X TUTE ER OFFICER/MEMBERE EXCLUDED? ? N N/A EA EACH ACCIDENT $ 1,000,000 (Mar4atuyInNH) 0000060028 08/21/2014 08/21/2015 H yes desa ibe under EL DISEASE-EA EM $ 1,000,000 DESCRIPTION OF OPERATIONS below C ork C ELDISPASE-POLICYUMIT $ 1,000,000 tatutory Limits or/� NC927938352394 08/21/2014 08/21/2025 .L Ba. Accident - $1,000,000 Limits - KC L. Disease Policy Lmt - $1,000,000 L Disoase Ea. Baployes - $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddlBonal Remarks SchadWe.may be allsched M mole apace Is nqutrW) 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. Southern BS LLC AUTHORIZED REPRESENTATIVE Albion Road fA K4 cola, RZ 02965-0000 ©1988-2014 ACORD CORPORATION. All rights reserved.ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 8R ID:6629625 BATCH.-Batch •: 79627 . r"" '! t� - A `,; •..Y�: s .,. .�`.. .,,..'�' h„S:.yJ n+v-f��-�•�''q�<-" ^•-•,'1�'h.,.Jr ��^ri,--.�+ t Assessor's office(;t;st''Floor): Assessor's map and lot number 8 a S of fNE to Board of Health(3rd•floor): Sewage Permit number - -00 Z 9ALIST&DLL i Engineering Department(3rd floor): rnea House number 'bso \e� Definitive Plan Approved by Planning Board 19 �Fo Yav d' APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only ` f� TOWN OF BARNSTABLE s • BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 12-CA M TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit accorrdingJ to the following information: Location �� ����� lL� "� r ✓Qt? In �Ic. �L F� Lt � van At Proposed Use, h Zoning District f Fire District "�/ Q �_✓r 1 e• Name of Owner 1 11 L M A 4, A 1' G I'o h Address Name of Builder kU ®(A! G'S O r Address 6OK q 3 14 UJ• �16&,An O�)`t-f'+ • ✓V):�. Name of Architect Address Number of Rooms Foundation - iU L®� {� Exterior lam/ G LeXA Aa- 'iRoofing �� P►? Q`��, Floors Heating i Plumbing Fireplace Approximate Cost CQo 0 0, 00 Area Diagram of Lot and Building with Dimensions Fee U / � t _ s OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License nn.S �� q MATTON, THOMAS A. A=215-005 No 331 73 Permit For Build Addition ! Single Family Dwelling y Location 63 Moco Road West Barnstable - Owner Thomas A. Matton Type of Construction Frame Plot Lot Permit Granted August 2 9, _ 19 89 Date of Inspection 19 Date Completed 19` S ° 2 j j de i.. � i I I �1 1 .'•�r:j.. j i.. SL tiFFFT , bo t , > ^ { I ! d .x .. T ' Assessor's office(1st Floor): Assessor's map and lot number �-2 SI a 65 swiv SYSTEM MUST BE ' O*TM E To Board of Health(3rd floor): INSTALLED IN COMPLIANQE d�Q� `� Sewage Permit number -3^ WM TITLE 5 Engineering Department(3rd rasa ,floor): i ENViRONFAENTAL CODE AND = BesNAB& E � House number '11p9.6\e�' Definitive Plan Approved by Planning Board 1gO � �EO��.A�®�� �� _APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only I " TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION-FOR PERMIT TO i TYPE OF CONSTRUCTION / YL a an 19 QCj TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location lD 3 Im0 GO' k c.Y W . /3o I? n ��.,�Liz. Proposed Use FC6 Ile- L LL,4 goo M Zoning District �- F Fire District `'�/ • �� - Name of Owner 1 h 0 Vet G41 \ m G 1' Address Name of Builder P—u IM 1�(A/at 50 In Address <Q•o• QO K qZ 4 U-)� \I A.f q 100A41 Ii kCi, Name of Architect Address Number of Rooms h C Foundation AJ Lo G 1� Exterior t-i LeA On' Roofing Floors `� � -� Interiors Heating Q( �"_ - . .,_.__.. ..... . .- Plumbing �=-�--�_..� _ -_-- • . Fireplace Approximate Cost 0� Area Diagram of Lot and Building with Dimensions Fee So / 9 9 J I _ 6 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License oQ e MATTON, THOMAS A, No 33173 Permit For' Build Addition Single Family Dwel1Jng d Location 63 Moco Road t, • West Barnstable , Owner Thomas A Matfnn • J' Type of Construction Frame "> Plot Lot Permit Granted August 29, 19 89 g Date of Inspection 19 Date Completed 19 0l Sz • r E 4 �.•. {V y PF a i .3 --1 ` r ; ;:J36 a� in1 11'29 ROCK WALL ti u7 . .4 0} DECK l It d- 4? � 5G± I--: N NOISE 14 Q 64 J +, LOT 5 M 150.08 MOC-0 ROAD APPR6VED /! 'OKHRHDC RES. ZONE: RF FLOOD ZONE: C/ ' , THIS MbF2TGAG•E INSPECTION PLAN IS FOR---- BAN *Q'St ONLY TOWN f• WEST -BARNSTABLE REGISTRY OWNER:THOMAS A t. HEIDA A MATTON DEED REF: 5297/18 BUYER: DATE: • 7/6/89 PLAN REF: Ij3/91 SCALE: I -= ere y certify that the buildinS %AA Of shown on this plan is located on ���' VANKEE SUPZVEY the ground - as shown and it P C0NSUL_TANTS position does eanrorm to the 70 RASPSERRY .LANE zoning law setback requirement of BARNSTABLE NMsM y MARSTONS MILLS and does not- lie within the special lgSS,da MASS 02648 flood hazard area as shown on N�SURVE'19� the u. d. . Uo d map dated s plan not- made from an instrument Paul A. Merithew, RPLS survey , not• tb be used for fences •et 5253 I I , : l Q T - Ld jL KL uj S�J . .. . . . . . o . . . . .. . . .