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Home My WebLink About0040 BIRCH DRIVE �--> ;, .�� i S Town of Barnstable *Permit# 00M�l 9S Fxplres 6 mondhs from issue date Regulatory Services Fee 3c;) 1 1 Cl X-PRESS PERMIT Thomas F.Geiler,Director Building Division Y`-- APR 2 4 2008 Tom Perry,CBO, Building Commissioner TOWN_ OF BARNSTABLE. 200 Main street,Hyannis,MA 02601 www.town.barnsfn le.ma.us Office_: 508-862-4038 Fax: 508-790-6230 EXPRESS PER HT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address [Residential Value of Work . Minimum fee of$25.00 for work under$6000.00. Owner's Name&Address C)1 D Contractor's Name o� �c�� Telephone Number Home Improvement Contractor License#(if applicable) .Construction Supervisor's License#(if applicable) ®O 1�UD J ❑Workman's Compensation Irmzance Check one: - ❑ .I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Named\�) ' fit►�� Workman's Comp.Policy# Copy of Insurance.Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to `5� a 1 \�s ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (ma)ci_um.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.historic,Conservation,etc. ***Note: Pro erty Owner must sign Property Owner Letter of Permission. A c y of the Ho eprovement Contractors License is required. SIGNATURE: Q:Forrm:expmtrg Revise061306 The Commonwealth ofMassachusetis Deparfinent of lndusidal Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.m ass.gov/dia Workers'Compensation Insurance_Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Maine(Business/Organization/IndMdual):. Address• -t City/State/Zip: vv\ u e PG1 Phone.#:�I�- � P I U`4 Are ou an employer? Check the appropriate box. -Type of project(required):• 1 I am a employer with (p 4. 0 I am a general contractor and I employees(full and/or part time).* shave hoed the stab-contractors 6 ❑Nett'construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet; 7. ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' 9. But1 ' ' addition (No workers'comp.insurance cep•insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner do' all work officers have exercised their I LEI Plumbing repairs or additions rnyself [No workers'comp. right of exemption per MGL 12Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] . *Any applicant bat checks box#i uarst also fill out the section below showing theirwario:rs'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. tContracton 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 providb their weTic 'comp.policy number. ram an employer that is provlding workers'compensation insurance for my employees Below WA'policy and job site information. Insurance Company Name:_ &LYA Policy#or Self-ins.Lic.#: Expiration Date:_ r I Job Site Address: `,t Zvb\Sktg1}11�:C'• City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date),. Faihrre to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of ct4r¢nal penalties of a fine tip to$1,500.00 and/or one-year imprisomment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against thq violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of ft JDIA fox insurance coverage verification. 16 hereb certi nde the pains. penalties of perjury that the information provided above is true and correct Sienature: (a� Date: _ Phone#-. � �— 1 •Q Official use only. Do not write in this area;'ib a completed y ctty or town af`tcial City or Town: Permit/License# Issuing Authority(circle one): X.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person• Phone#: 04/23/2008 18:18 FAX 6172272654' HTS ARCHITECTS 2002 To:Mr.A:Ypgt Page 2 of 2 2008-04-23 18:35:39(3MT) 15084370264 From:Toby Leary r'^ 'Z`Own ofBaarnstable, Regl�atory Sept ices ' Thomm Y.Genes,Dig ector TDM PI'M., $'ttilding COIU418sioner 200 Main Street, $Yates,l fA•02601 . �rto�,barns'table.ma.us Office: 509-852403 8 Pax: 54.8-750-5234 Propelty der Must Complete and Sign Tills Section If Using A 33ULder a.. Owner of the sub'ecr property . ) p Perty is all ma mn rela&e.to,work aurhoziud by this biuldin g perk app7icetinn for: . . .0040 fix;aA 4;5r w . , (Address o job , MA 8apa Omer ate , �rmt Dame • ' q.Fow�as.•Dwr�xp��sioN 1 � _ a Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massad-husetts 02108 Home.Improvement � tractor Registration Registration: 143942 Type: Private Corporation :.._.-7- Expiration: 8/17/2008 TOBY LEARY FINE WOODWORKfNC. TOBY LEARY 46 LAFRANCE AVE �. HYANNIS, MA 02601 = -- - - - Update Address and return card.Mark reason for changf r Address ! Renewal ri Employment Lost 0 DPS-CA1 w 50M-05tWPC8M 777777777> t y f �;'�`� �'0 �j O1 C $$ o � o a' v < 'Wag! GTE Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:'143942 Expiration: p 8/17/2008 Type: Private Corporation TOBY LEARY FINE WOODWORKING, INC. TOBY LEARY 46 LAFRANCE AVE HYANNIS, MA 02601 Deputy P tY Administrator J� eqmmzw� �� Board of Building Regulations and Standards . One Ashburton Place - Room 1301 Boston, Massl4chusetts 02108 Home Improvemenx. oractor Registration Registration: 143942 Type: Private Corporation ; Expiration: 8/17/2008 TOBY LEARY FINE WOODWORK� 1 TOBY LEARY if 46 LAFRANCE AVE L �, �r E, HYANNIS, MA 02601 �t , „m -- -...._._.. a� Update Address and return card.Mark reason for change. oPs-CAI 0 soon-05/06-PCe4so [� Address ❑ Renewal (_� Employment � �_Lost Card Licen`e or registration valid for individul use only befor, the expiration date. If found return to: Boar of Building Regulations and Standards One shh to Place Rm 1301 Boston, 108. _._.....: - ....- --- --- - ____ t valid without at e N-18-2008 1S:10 From:SANDPIPER INSURANCE 50879E3560 To:15087906230 P.1/2 DATII AGCNry CERTIFICATE OF LIABILITY INSURANCE 011lINIDDe zo0os08 PRODUCOR {506) 790-1919 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sandier Ialeuraunva Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Sandpiper F, rHOL,DER.,.T>II=TIFICATE DOES NOT AMEND EXTEND OR 12 Enterprise Road �i , ['TAL#I`st�s�H OE AFFORDED BY THE POLICIES BELOW. 14 anna.m MA 02601- E FR0 0 COVERAGE NAIC 9 . INSURED MRURBAA Western World:Insurance Tobey W. Loary Fine Woodworking, Inc. INeuRERO,A.1.G. 46 La ftaLnoo Avenue INRURER C. I I3 annl6 MA 02601- FINSURFR COVERAGES 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 . AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. uLI INBA INSRQODD TYPE oP INSURANCE POLICY NUMBER �DJITL' oplad dY1r DMA MM o ON LIMITS A GONCRALLIADIUTY UPPIL44072 12/14/2007 12/14/2008 ACM Or-Cx b 1,000,000 X COMMERCIAL GENERAL LlAfli ITY Hka erroa 6 100,000 CLAIMS MADE 1E OCCUR / I I I. MF.D UP(kw alls ww 6 5,O PEMOONAL 8 AOV INJURY 6 1,000,000 OENDRAL AGORL'GA 6 2,000,000 GEN'LAGGREGATBLIMrr APPLIES PER PRODUGT8 COMP S 2,000,000 OUCY MELOO AUTOMOBILE LIABILITY / / / / COMBINED SINQLC LIMIT 6 ANY AUTO lea aoaldaral ALL OWNED AUTOS / / / ODDLY INJURY. a t RCMEOULED AUTOS HIRED AUTOS / / / ./ SODILY INJURY NON-OWNED AUTOS (Par aoemem) PROPERTY DAMAGE (Per aoWdam) GARAGE LIA ILOY AUTO ONLY-eA ACCIDENT $. ANY AUTO / / / / OTHER THAN FA ACC 6 AUTO ONLY' AGO b P.XCMMMBRCUA LIABILITY I / / / 6 OCCUR a CLAIMS MADE A RELiATE 6 6 DEDUCTIBLE / / 6 orrpmm b WORKERS COMPENSATION AND WC 6716675 01/01/2000 OZ/01/2009 X L'MPLOYERS'LIABILITY ANY PROPRICTOWPAIMER/EXECUTNE E.L.EACHACCIOENT b 500,000 QFFICCRfMEMtJCRL'XCLUDf:O9 SL OIbP-18P--PAEMALOYEI:6 900 000 9p1!CIAL ROVies.daedhe 9/0 9Delaw LOIBFI�B)'-POLICY LIMIT 6 500,000 OTMBR D1IBCRIPTION Oil OPERATIONddAMTIONBNEMOLCaMXCL.USIONS A0080 BY ENDORNW9NTIBPOCIAL PROVISIONS CBRTIFICA7E HOLDER CANCELLATION ( ) - (508) , 790-6230 SHOU40 ANY OF THE ABOVE DOSCRIDW POLICIES III .CANCO"60 BEFORE THE EXPIRATION DATO THI:RCOP, TNC IBSUIN4 INBUR8111 WILL .ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE ClIMPICATB M04COR NAMED TO THE LOFT,Mff TOWN.'OF AARNSTABLE FA14UR8 TO 00 80 8HALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THO { INGU ITS A06NTB ORPIGPREBENY AUTNOR12EDREPAO AnVA HYANNXS MA 02601- %COIRD 2-6(200108) ORD CORPORATION 1988 . .IN5026(o,00p6• ELECTRONIC LASER FORMS,(NO-i0m327.4546 Pape i of 2 } Town of Barnstable *Permit# Ob 0 7 t of Expires 6 months from issue date Regulatory Services Fee -0> Thomas F.Geiler,Director. bp _ Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 t Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY i Not Valid without Red X-Press Imprint j Map/parcel Number r Property Address [Residential Value of Wor 0 0_e Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number 7 Home Improvement Contractor License#(if applicable) I Construction Supervisor's.License#(if applicable) C3Workman's Compensation Insurance �y a ry ti Check one: ❑ I am a sole proprietor R 4y L arri the HomeownerNn I have Worker's Compensation Insurance t 2OQ7 Insurance Company Name Lrtf rt e' S��IJ� � �' y l;8LE Workman's Comp.Policy# I Copy of Insurance Compliance Certificate must be on file. 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) C5"Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other todm department regulations,i.e.Historic,Conservation,etc. ***Note: P operty Owner must sign Property Owner Letter,of Permission. copy of the Home Improvement Contractors License is required: SIGNATURE: Q:Forms:expmtrg Revise061306 .t ' The Commonwealth of Massachusetts Department of.1ndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111, ` www.mass.gov/die ' Workers"Compensation Insurance Affidavits Builders/Contractors/Eleetricians/Plumbers _Applicant Information I" Please Print Lepibly Name(Business/Organization/tndividual): e— (6j (Al(f AA dress:�� C Q 1LE-ACE ' City/State/Zip: t ( Phone.#: ` Are you an employer?Check a appropriate box: :Type of project(required):. 1. I am a employer with 4. [] I am a general contractor and I hew construction . employees(full and/or part-time).*• have hired the sub-contractors2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ( Remodeling ship and have no employees . These sub-contractors have 8. ❑Demolition iyorldn for me in an capacity. employees and have workers' g Y P tY $ 9. ❑Building addition' ' [No workers comp:insurance.comp.insurance10.❑Electrical repairs or additions 5. [] We are a.corporation anal its eP required.] ' officers have exercised their 11. Plumbing repairs or additions ' '3.❑ I am a homeowner doing all•work .- • g p • myself[No workers'comp. right bf exemption per MGL 12,$Roof repairs insurance.re e t c. 152, §1(4),and we have no 4 ] d employees.[Nb workers' 13.❑Other comp,insurance required.] *Any applicant that checks box#1 must also fill aut the section below showing their workers'compensation policy information. t Fiomeowoera who submit this affidavit indicating they are doing all work and then hire outside contractors nw5t submit a new affidavit indicating such �Contnwtors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees, If the sub-contractors have employees,they must provide their workers'comp.polio number. I anc an employer that is providing workers compensation insurance far my employees. Below is the policy and job site' information. ,D A Insurance Company Na'me:�' "�� 1v �j,�jV 0,A-0 C6. C Policy#or Self-ins.Lic,# i d D `S G Expiration Date: I Jab Site Address: Y City/State/Zip:_� Attach a copy of the workers'compensation policy declaration page'(showing the policy number and expiration date). Fafiure•to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 thq violator. Be advised that a copy of this statement maybe forwarded to the.Office of" Investigations of thr.MIA for insurance coverage verification. • I do hereby r the pains and penalties of perjury that the information provided a ove•is true and correct Si afore: Dater D _ 47 Phone#• 1-�"!—iL � I Official use only. Do not wrlte.in this area, to be completed by city or town.offcciaG 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 In 6. Other Contact Person: Phone#: - • � ;�. `��1't7anr��aryn,�oea.`l� fl!;,,�,ufaac�rcatrl�d l a 1 Board of Building Regulations and Standards ' HOME IMPROVEMENT CONTRACTOR 1, Reglstratlon: 143942 Expiration! 8/17/2008 , Type: Private Corporation TOBY LEARY FINE WOODWORKING, INC. i TOBY LEARY 46 LAFRANCE AVE j ' HYANNIS, MA 02601 Deputy Administrator Town of Barnstable: e Regulatory Services ss�tsras�, P ;,uss Thomas F.Geiier,Direei r :&�;9616 Building DiYisioa Tom Ferry, Building Gomn-,issioner 200IVIain St?'eeL, $Ya, +s,i�S°-�02,O1 . ��.towu.barnstable.ma.us Office: 508-862-4038 Fa-.:: 50$=790-6230 Property Ow e_r,illust Complete and Sign--his Section if Using ABuil&r t, as Ovrner of the subject propcity hembyauthorize to 2ct on 117 be-=aj) in all m rters relat-;c to wow au horsed b_yt�1 is L�uil&rq pr--,-mit,apPi;c,.,�,on for.. . �. V8 (Address of b ) Sim Cr? Owner 1 l Date AM�r\ 9; � ( l�Pnni!vamp � - • J 9 QTORMSDWNE fIssroia U:-4 A��;' L; 1-r- L f -——--—-------—---------—---------------- N-- Q 4b LA5--F—A'--'Lt A V L 14 U Z "YANN!S- MA 0260-11•-0000 "FED 4 Or Internatio-nal Grio-up QffT�� CSC 6i 70r, p1pult-'Q Ira 49W VCIRK. N-At. -jLL Vitt!—_ W-Vmv ta AND F:11-APAI rAr1VT--R-q MAW 43 Y 1,IA CORPORATION NEW, ,OTHER INN RKKACES KOT SHOWN ABOVE SEE NAME AND A 0 E,R E-c S- -c C R ED)1";L E Fr 9 SI u 6 o' ITEM 2 POUCY PERIOD 1201 AAL Standard thoe at the insureds mallingaddress. FPOM 01/01107 To 011G11108 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability,lnsuranmc Pan'TWo of the poficV applies',to the work In each stike listed if-t ftern- 3>A, The limits of our liability under Parr Two are. Bodily Injury by Accident $ 500,000 each accident Bodily injury by Disease $ 500,000 Policy limit Bodily Injury by Disease $ 500,QQQ each employee C. Other Stator Insumnm Part Thirm all*e polite applim ta the sty -ff M-Fr-listed AK AL AR AZ CO CT OC BE FL GA HI IA ID- 11- IN' KS KY LA MF1 ME MI MU MID M5 MT NC NE NH NJ NM NV NY OK OR PA R1 SC SO TN TX UT VA Vt W1 ITEM4 The premium for this policy Will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration s108 OF Re- Premium Annual 3 Year ratineratton UA Annual ❑3 Year. SEE EXTENSION OF INFORMATION PAGE WC7754 TAXES/ASSESSMENTS/SURCHARGES a $1 ,012 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA TOTAL Eswm7m PREmmu $24,417 If indicated below,interim adiustments of aremium,shall,be made: Semi-Annually ❑ Quarterly Q Monthly DEPOSITIPREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM. SCHEDULE wc990612 01/26/07 PARSIPPANY 82 Issue Date Issuirigotfice Authorized RepmentMIve we 00 00 al 39967 '!\(.SUR- 1— S COPY