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Home My WebLink About0164 ARROWHEAD DRIVE X-PRESS PERMIT �FIKE Town of Barnstable *Permit# p� O 6 2007 Expires 6 months from issue date • ARNSTABLE Regulatory Services Fee v M"� Thomas F.Geller Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY t Not Valid without Red g Press Imprint 1 Map/parcel Number ® / 15 - Property Address co VResidential Value of Work a Owner's Name&Address (1 rYl S�WJ e- hG J `d H to So 5_�C&&r► Contractor's Name 02i"e �;'�-1 e p(0 u6I��q Telephone Number J� �-77 Home Improvement Contractor License#(if applicable) U�1 GJ�I Construction Supervisor's License#(if applicable) �,5 DQ U(0 Ll 3 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor dam the Homeowner `have Worker's Compensation Insurance Insurance Company Name _ • �"� �- L9 �5 �G-1� _ Workman's Comp.Policy# 10 QLA W �U`a NO -7 Permit Request(check box) ❑'Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: ope must sign Property Owner Letter of Permission. e rovement Contractors License is required. i i Signature Q:Forms:expmtrg uP�;•.ntanna t ne t;ommonweacrn of lnussacnuseecs Department of Industrial Accidents Office of Investigations 600,Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu'bers Applicant Information ]Please Print Legibly Name (Business/Organization/Individual): ,5(!g I►` �� V)o (`{Z� = Mi�Rw o-e-M e-1�S7 Address: 1 ` 9 hw�rc SLR c� City/State/Zip: Phone #: S o S 7-7 Are you an employer?Check the-appropriate bog: Type of project(required): 1.DI am a employer with 5 4. ❑ I am a general contractor and I 6. ❑ New construction employees (IL'and/or part-time).* have hired the sub-contractors 2.111 am a sole proprietor or partner- listed on the attached sheet, $ 7, ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13,❑ Other comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomnation' t Homeowners wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tcontractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'cornp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andiob site information. Insurance Company Name: R S 5 o c a-r-e a -�N a"_t>vN,�_� Policy#or Self-ins.Lic. #: A w C )o b 9 0 1 aoo-7 Expiration Date;5//3)07 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500;00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and'a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u penalties of perjury that the information provided above is true and correct Si ature: f Date:— 0 Phone#: i oS ?7 S— 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): 1d of Health 2.Building Department ICity/Towu Clerk a.Electrical inspector 5.Plumbing laspv . Boar etor �I Contact Person: Phone#: I - Y ~3. Homeowrer will pay lawrul collection expenses, including reasona le legal fees incurred by the Contractor as a result of the Homeowner's failure to comply with payment terms. 4. Contractor is not responsible for existing conditions of residence. 5. Contractor is not responsible for damage to such items as, but not limited to: sidewalks; driveways; patios; lawns; shrubs; sprinklers; and other such appurtenances. However, reasonable care will be taken. a, r. 6. All agreements are.contingent upon strikes, accidents, or delays beyond Contractor's control. 7. Homeowner is to carry fire, and other necessary insurance. Contractor's'.workers are.fully covered by Worker's Compensation Insurance. 8. Fencing, carpentry,painting,plumbing, electrical, dry wells, etc., and all other work necessary that is not contained in this contract, shall be the responsibility of the Homeowner. R1fGHTS TO CANCEL The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the Contractor in writing at his main office, or branch by ordinary snail posted, by,telegram sent or by delivery, not later than midnight of the third business day following.the signing of this Agreement. WARRANTIES The Contractor warrants that the work furnished hereunder shall be free from defects in workmanship for a period of two (2) years following completion and shall comply with'the requirements of this Agreement. In the event any defect in workmanship, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within two years after completion of any job, including clean-up, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced such damage or such defect in workmanship.as long as the owner has paid their,agreed contract in full. The foregoing warranties shall survive any inspection performed in connection with the agreed upon work. All warranties for product supplied by the Contractor under this Agreement shall be those given by the manufacturers of such product, which shall be and hereby passed directly to the Owner. Such manufacturer's warranties,the Owner may be required to register or mail in a warranty card or other evidence of ownership, and use of such product in order to activate such warranties. The Owner's failure to send in or register such documentation, which failure voids that manufacturer's warranty, shall not create any responsibility for the . Contractor to warranty such product. Note: Any changes in the contract during the duration of the project which results in additional monies due will be paid in full,to the contractor atthe time of the change. I authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be , performed on this job (i.e..permits, applications etc.) if necessary. �- U-7 'L "6 Barnstable Hou g Authority Date Brad Sprinkle .' 4 Date ✓ e -0ow//98CYOZCIfeaew 4�ii�GCl/J�CZ 2CG4NLG4 c Board of Building Regulations and Standards — i HOME IMPROVEMENT CONTRACTOR Registration 10.3757 Expiration 7/9/2008 Type P' 'ate Corporation SPRINKLE HOME'41VIPROVEM --NT INC. Brad Sprinkle e 199 Barnstable Rd. - Hyannis, MA 02601 Deputy Administrator � J lons BOARD OF BUILDING REGULATIONSLicense: CONSTRUCTIONSUPERVISOR Number CS 006643 Birthdate 10/08/1955 xpires 10/08/2'007 Tr.;no: 6638;0 ion -CS, Re tncted 00 BRAD K SPRINKLE 190 LOTHROPS LANE W BARNSTABLE, MA `02668 Commissioner MR, ram �CRTFC�T0"mm IssuE DATE osizliaoo7 PRODUCER S ISSUED AS A MATTEROF INFORMATION ONLY AND Bryden&Sullivan Ins Agency S UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE , XTEND OR ALTER THE COVERAGE AFFORDED BY THE Inc POLICIES BELOW. 88 Falmouth Road - -- ---_-- Hyannis,MA 02601 COMPANIES AFFORDING COVERAGE INSURED Sprinkle Home Improvement Inc 199 Barnsl'alile"Road""' COMPANY A A.I.M.Mutual Insurance Co " 'LETTER _.... Hyannis,MA 02601 b�Wfflffll. ERAGES ,. 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._____ CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION _ LIMITS- LTR DATE(MM/DD/YY) DATE(MMIDD/YY) GENERAL LIABILITY GENERAL AGGREGATE"�' -- r • - PRODUCTS-COMP/OP AGG. " =COMMERCIAL GENERAL LIABILITY " PERSONAL&ADVANIURY $ =CLAIMS MADE=OCCUR ` EACH OCCURRENCE S =OWNER'S&CONTRACTOR'S PROT, ., FIRE DAMAGE(Anyone tire) S _ MED.EXPENSE(Anyone person) 9; AUTOMOBILE LIABILITY COMBINED SINGLE ` .. LIMIT S ANY AUTO BODILY INJURY ALL OWNED AUTOS (Per person) S. . SCHEDULED AUTOS HIRED AUTOS " BODILY INJURY -'-- GARAGE.LIABILITY PROPERTY DAMAGE — -_- — EXCESS LIABILITY --__- -- --- - - - ---- - EACH OCCURRENCE UMBRELLA FORM AGGREGATE, X OTHER THAN UMBRELLA FORM - - g,F < ,�„s- - WORKERS '' COMPENSATION AND STATUTORY LIMITS OTHER EMPLOYERS LIABILITY X - HE PROPRIETOR/ ECEACH ACCIDENT S 500,000 A PARNERS\EXECUTIVE r. OFFICIERS ARE: - 7004943012007 05/13/2007 05/13/2008 '. EL DISEASE--POLICY LIMIT 50Q000 r INCL - EXCL EL DISEASE--EACH ' 500,000 EMPLOYEE COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE.EXPIRATION DATE BRAD SPRINKLE HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,"ITS AGENTS OR REPRESENTATIVES. 199 BARNSTABLE ROAD - _ HYANNIS,MA,`02601 AUTHORIZED REPRESENTATIVE