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Home My WebLink About0054 CAPTAIN COOK LANE �� /.- C�o� Cr,�. t , of T KKEram, Town ®f Barnstable Permit# aO L l Expires 6 months from issue date saxxsrnstE, - Regulatory Services Fee 1 v MASS. Thomas F.Geiler,Director �p 163g• A,4 lFo►,+A� Building Division Tom Perry, Building Commissioner 200 Main Street, ,Hyannis,MA 02601 Office: 508-862-4038 ' Fax: 508-790-6230 EXPRESS PERM[T APPLICATION - RESIDENTIAL ONLY Not Valid without Red&Press Imprint Map/parcel Number a1",A r"► (Jr� Prope Address Residential Value of Work Owner's Name&Address D k `\, oA-Z �7 Contractor's Name 1 Telephone Number p PP GC), Home Improvement Contractor License#(if a licable)CS Construction Supervisor's License#(if applicable) orlanan's Compensation Insurance a RESS pE1� Check one: � , ❑ I am a sole proprietor 3UL 2 8 20�$ ❑ I am the Homeowner have Worker's Compensation Insurance TOWN OF BAR��?rLF Insurance Company Name Rl,tlVl Qq-601D-006 — Workman's Comp.Policy# oL� y 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 l ' D/Replacement Windows. U-Value - (maximum.44) '" ~ �7 *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Cms rvation,etc ***Note: Pro e Owne roperty Owner Letter of Permission. c me Im ve' t ontractors License is required. Signature Q:Forms:expmtrg o e.,;yen;znnz The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunibers Applicant Information t ' n! Please Print Lezibly Name(Business/Organization/Individual): mil/ �,IMI t✓t()tW�C`t1 Address: (�C( 5tr 10w City/State/Zip: UA°l i'1 l5 Phone#U Are u an employer?Check the propriate box: Type of project(required): Are a employer with 4. ❑ I am 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 workin for me in an capacity. employees and have workers' g Y P h'• 9. ❑Building addition [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 officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp, right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 152, §1(4),and we have no 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 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. $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: l o Policy#or Self-ins.Lic.#: Expiration Date: ( (, Job Site Address: CkLptatn City/State/Zip: I,tIe ►V 1 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$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$250.00 a day against the violator. dvised that a copy of this statement may be forwarded to the Office of Investigations of the D raze verification. I do hereby certify u rWmq a s an Ides of perjury that the information provided above is true and orrect Si :ature: Date: Phone#: 1 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i A ORD. CERTIFICATE OF LIABILITY INSURANCE OP ID DS DATE(MMmarrrr) SPRIN-1L 05 09 08 PRoouceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone_ 508-775-6060 Fax: 508-790-1414 INSURERS AFFORDING COVERAGE NAIC# ---- _ NSURERK Associated Industries of MA -- ----_--- : - NSURER B . Sprinkle Home Improvement Inc. NSURER C. 1B9 Barnstable Rd vSURERD: Hyannis MA 02601 ,P��URER c COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NERD TTPE OF N-SURARCE POLICY NUMBER POLICY EFFEC7IVF PCLICY EXPIRATION - DATE MMIDO/YY) DATE IMMATDfYY) LIMIT$ GENERAL LIABILITY EACH OCWRRENCE $ i COMMERCIAL GENERAL LIABILITY I - PRFJYJSES(Ea bccurence) t3 I CLAMS MADE L 1 OCCUR NIZOEiP(Argrmeperson; ; --_— PERSONAL&ADV N.UPY $ GENERAL AGGREGATE g GEN'L AGGREGATE;IMIT.4PPUES PER:POLICY PRODUCTS'COMPIGP AGG 14 PRO- - - i JECT r�LOC I AUTOMOBILE LIABILITY - i , I (Ea amEU SINGLE UNIT AN'f AVTO (Ea 3CCWen[) �g ALL OWNED AUTOS (� BODILY INM1IR'f I S 1 I SCHeM'ED AUTOS . - � � I (Perpemn) III 41PED AUTOS - - NON-OWNED AUTOS _ - BOOILV 9JLJR1' i (Per w0dent) �- - PROPERTY DAMAGE„ IS - (Per acc!dent) GARAGE UABIUTY ' AUT O ONLY-EA ACCIDENT ; ANY AUTO r I I OTHER THAN EAACC 14 MJTG ONLY: AGO $ - EXCESS.'UMBRELLAUASIUTY 'EACH OCCURRENCE I$ ' OCCUR CLAIMSMADE AGGREGATE g r , 1 DEDUCTIBLE _ $ �4 REJENTON WORKERS CCMPENSATION AND WC TA OT `� IEMPLAYERS'UAS!UTY TCRY UMiTS ER AJJVPRGPRIEroRPARTNERE%EaJr!V +AWC7 0 04 9 43 012 00 8 I 01/0(08- DESCRIPTION Ol/O1/09 E. EACH ACCIDENT sSOOOOO JFFICM.NEMSER E%CUZED7 IfyeS,aeecabemaer L.DISEASE-EA EMPLOYEE Is 500000 SFECWS PROVISION:belowSEASE-POLICY LIMIT I4500000 OTHER OF OPERATIONS/LOCATIONS/VEHICUESI EXCLUSIONS ADDED BY ENDORSE MEN T/SPECIAL PRO VISIONS - CERTIFICATE HOLDER CANCELLATION SP_RNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Sprinkle Home Improvement, Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL Fax #508-775-1350 N.argo Mack IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 199 Barnstable Rd. • _ - REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE Kelley A.Sullivan ACORD 25(2001/08) OACORD CORPORATION 1988 - - -� -f�/2P l/71I'�r,(Yrcusl,2GLl2 U� l�l rrdttLfltl�'GGfci `h ' '` � . '- l3o'a�d of t3u�IdmgYRegu1 itlons and St�ndarda w� •!•'' '• a Const�uct'ion Supervisor License rrCF 4 License CS F6643� i � i t ` Ezprration 1,0/8/2009`�F Tr# 9427 � ` , Resfri, tizon 00 k ?..•�. y c zx f x a i: BRAD K SPRINKLFr W BARNSTABLE MA 02668 Coiimissione e s X 74 l?D yb+IrL(73'Y,IG�CY.t�� r/r ��Y•JOfGC 11.lE3f'��d �y , .y _ Board of Bnidmg Regulations and Standards-` x Y s _ �OME IM!PRO CONTR�4GTOR f ;Reg anon 1s03757 t Expiratio /912008 t / Typ#e Pnu Corporation, � SPRINKLE HOME IMPROVEMENT z,r �Hannls NIA 02601 Deruty Admmistiator .. Z q''3 t S Licenseror registration valid for mdrv�d'ul useaonly .k beforexthe exp`ratton date If found return to ' Board"of BuildmgRegulat�ons and Standards �. One Ashburton Place Rm 1301E �, Q Bostori;'Ma 02108 k - Not uand wrthout sig ature�� d y ¢ zr` � x � x i• w " ,p� ✓sae Toomvrnoouuea�i o�✓�Gczddacreuaett`d �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR- RegistraX ofr 103757. Esc /9/2010 Tr# 271033 ' o iu to Corporation , SPRINKLE HOME 1 Elr/kE INC. r Brad Sprinkle Lh . . 100 Barristable R . Hyannis,MA 0 01 u ,r Admfmstrato'r r are cone ent upon strikes, accident 'or delays�eyond Contractor's control: S: All agreementsg p 7. Homeowner is to carry fire, and other necessary insurance. Contractor's workers are fully covered by Worker's Compensation Insurance. z 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. - RIGHTS 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 Ownerr-notifiesthe Contractor in writing at his main office, or branch by ordinary mail posted,.bytelegram 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 and shall comply with the requirements of this Agreement. In the period of two(2)years following completion 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 at the time of the'change. I authorize Sprinkle Horne Improvement to act on my;behalf m all matters relative to the work to be performed on this job(i;e.permits,applications etc.)if necessary: Pattie Kautz Da Brad K. Sprin le Date Celebrating 62 years in.business!!,