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HomeMy WebLinkAbout0050 CAPTAIN COOK LANE � c�,;� �o,� zN 1 O t Town of Barnstable �.. Expires 6 mon , m issue date Regulatory Services Fee Z::._:.. •fir, ` _ Thomas F.Geiler,Director p.fp MA Building Division Tom Perry,CBO, Building Commissioner . 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us -Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number -7'( Property Address�5c) 0 0 c✓ l QoL n I_ _ o 02V P 3 J_ Uu Residential Value of Work' * 1 /OGG S Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address J70 YI !^o '�U �-,SCYI f Ak— Contractor's Name pr• a Telephone Number S(7Ss 7 7.5--l 1,18 Home.Improvement Contractor License#(if applicable) 103 7 5 7 Construction Supervisor's License It(if applicable) S (0 y Ianan's Compensation Insurance E T Vo Check one: JUL. 5 2010 ❑ lain a sole proprietor ❑ I am the Homeowner TOWN OF BARNS TAB�,� ®Thave Worker's Compensation Insurance Insurance Company Name Q,-no Gi ajtA -j--naLksS , ,tz r� Workman's Comp.Policy# 7 W 4 9 4 a U(oZ Odd Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(heck 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 #of doors Replacement Window oor sliders.U-Value (maximum.44)#of windows f *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, l A of Improvement Contractors License&Construction Supervisors License.is • equir SIGNATURE: Q:\WPFILES\F0kMS\bui1ding permit foiins\EXPRESS.doc Revised 090809 The Commonwealth'ofMassaehusetts Department of Industrial Accidents Off ice of Investigations. 600 Washington Street Boston,MA 02111 www.mass.gov/dia` Workers' Compensation Insurance Affidavit:,Builders/Contractors/Electricians/Plumbers Ayylicant Information 1 i Please Print Legibly Name(Business/Organization/individual):S n r;►)ILI2 ttLwe_ n fOV2.M2�� Address:— l99 �in rh5 btu City/State/Zip: ha VI A'5 M Oa(PO Phone#: _404_ -17.5 ' 1-7 7 3 Arree,yyou an employer.?Check the appropriate box: Type of project(required): U 1. lam a employer to er with—�— 4• ❑ I atti'a general contractor and I 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 workingfor me in an capacity. employees and have workers,' Y P , tY• t =< 9. ❑Building addition [No workers'comp.insurance comp.insurance. 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] ' officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ 8 eP myself.[No workers'comp, right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,_§1(4),and we have no emmployees. [No workers' 13. Other.P6�nfD2 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. tContractors that check this box must attached an additional sheet showing-the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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. 1 I Insurance Company Name: Qssoc.%-a GA. -S,- kuSt f i C"S Policy#or Self-ins..Lic.#:aLAX, 700 9 9 q 3bl kb[e) Expiration Date: 0( _ Job Site Addressr t Co D �t F'1 Or r)� City/State/Zip:�V�k2r et l�ei rn Oo�& 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 violato a advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA46k 0 era a verification 1 do hereby certify h a 14&eA allies of perjury that the information provided above is true and correct. Si nature: Date: Phone A ' 75' Ofjlcial use only. Do not write in this area,to be completed by city or town ofj'IciaL 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#: k . r Town of Barnstable Regulatory ServYces t Thomas F.Geller,Director ` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma xs Office: 508-862-4038 Fax t 508-790-6230 Property Owner Must complete- and Sign This Section If Using ABuilder as,Owner of the subject property `hereby authorize act on my,be half, in all matters relative to work authorized by this building permit application for. I,AU�i i i✓1 �OO k C r�IP ✓�(c('�� (Address of Job) S, . of Owner I? I UI C � o`er IT/9 � Print Name /�114 If Properly Owner is applying for peixnit please complete the Homeowners Licetise Exemption Form o.n the reverse side. " (1+Ff1 R M C•f1 WIJF.R PF.R MT.CC1f1N COR�7® — DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE OP ID DS - SPRIN 1 01/05 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS.UPON THE CERTIFICATE Bryden Sullivan Ins Agency.. HOLDER.THIS CERTIFICATE.DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone: 508-775-6060 Fax:508-790-1414 �INSURERS AFFORDING COVERAGE NAIC:# INSURED - - INSURER A: Assoeiated-Industiies of MA - -!INSURER 8:-- — -- ---------}- — Spprinkle Home Improvement Inc. INSURER C 199 Barnstable Rd INSURER o _ Hyannis MA 02601 INSURER E: - 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. - LTR INSRE TYPE OF INSURANCE POLICY NUMBER' TCMMID IYYYY)DATE(MM/D IY DATE MMIDDIYYYY Ii DATE MM/OD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ _ COMMERCIAL GENERAL LIABILITY' - i - PREMISES(Ea occurence) $ CLAIMS MADE OCCUR I MED EXP(Any one person) $ — _— iPERSONAL&ADV INJURY $ GENERAL AGGREGATE i$ GEN'L AGGREGATE LIMIT APPLIES PER: j I PRODUCTS-COMP/OP $ POLICY PRO- JECT LOC i AUTOMOBILE LIABILITY" COMBINED SINGLE LIMIT ANY AUTO f I (Ea accident) $ ALL OWNED AUTOS - I BODILY INJURY SCHEDULED AUTOS j (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS i ` (Per accident) $ PROPERTY DAMAGE I$ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT. $ EANY AUTO 'OTHER THAN EA ACC $ I L.. AUTO ONLY: AGG $ EXCESS I UMBRELLA UABILITY- EACH OCCURRENCE $ OCCUR F—]CLAIMSWADE AGGREGATE $ I — DEDUCTIBLE $ RETENTION $_ is WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIV♦.7YIN AWC70049430.12010 I 01/01/10 01/01/11 E.L.EACH ACCIDENT s500000 OFFICERIMEMBER EXCLUDED? — (Mandatory In NH) E L:DISEASE-EA EMPLOYEE $.500000 VIf yyes,describe under SPECIAL PROVISIONS below E.L.DISEASE,POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SPRNKHO: DATE THEREOF,THE ISSUINGINSURER WILL ENDEAVOR TO MAIL 1"0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, Inc IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax #508-775-1350 MargoREPRESENTATIVES. 99 Barnstable Rd. AUTHORIZED REPRESENTATIVE anni Ba Barnstable 02601 Kelley A.Sullivan ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD // O(fice t Co m°"a airs' 411-s eg-In"n. License or registration valid:for individul use only HOME IMPR01fENIlrNT CONTRACTOR before the expiration.date. If found return to: Registration: 03757 Type Office of Consumer Affairs and Business Regulation VSU MM Expiration: 12 Private Corporate! 10 Park Plaza Suite 5170 Boston,MA 02116 9,zl Brad Spnitkle H anrtis, If11 U24 =•/ Y ��<•%' Ui� ersecreti Not valid without sign 'tore Massachusetts- Del}.0 tment of Puhlic $afet� Restricted to: 00 Board of Building RE ,ul,itioitti xnd rvisor License St�indarrls 00- Unrestricted Construction Supe - 1G-1 2 Family Homes License: CS 6643 Restricted to: 00 i I BRAD K SPRINKLE; ':. Failure te.possess a current edition of the 190 LQTHROPS LANK i`' I Massachusetts State Building Code W BARN3 LE, MA 02668 is cause for revocation of this license. i - Refer to! WWW.Mass.Gov/DPS Expiration: 10/8/2011 J Commissioner Tr#: 5478