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HomeMy WebLinkAbout0072 CAPTAIN COOK LANE _ � rJ j Town of Barnstable �� idC��,�y� Qy (, *Permit# Regulatory Services EFeees6;rr°,rtlrs r°mrssrredale .tanRvsr�sr E. : �— y loss. 1639- ,�� or. � Thomas F.-Ceiler,Director. 8 fz-1�l�a Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 62601 www.town.barnstab le.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL .ONLY Not Valid Withorrl Red X-Press Imprint . Map/par el Number {.}YaAM1'.S Prop rty Address r"/1/ C(njl - Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Nam e & Address Contractor's Name,_lAlh e S ��pAl Telephone -----� hone Number Home Improvement Contractor License #(if applicable) ;W/ntion Supervisor's License#(if applicable)orkman's Compensation Insurance Check one: ❑ ipKa sole proprietor El/am the Homeowners.r ❑ I have Worker's Compensation Insurance ' Ss Insurance Company Name JG ee.�. d!? t Workman's Comp, Policy Co of Insurance Comp liance- PY p Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will'betaken to ❑ Re-roof -urricane nailed) (not stripping. Going over existing layers of roof) ❑ R ide #of doors Replacement Windows/doors/sliders. U Value 0, _ (maximum .35) # of windows *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 Leiter of Permission. A copy of the Home Improvement Contractors License & Construction Su required. pervisors License is _� SIGNATURE: Q:IWPFILESIFORMSIbuilding permit formsTXPRESS.doC Revised 072110 The Carr't'rrroirive lth of1' assachuseits r` ,•. — Departinerit cr,,►`'Indust"riai-AcciVenft �; .. . Office of bivestigatiolds 600 Washington S'tree fi Boston, A14 0211 Massgovldia o . Vorkers' Ccmpen'sa ion Insurance_Affidnit: Builders/+Cart:ti-actoi-&/Electiricians/Pl.umbers Applicamt Information Please hint Le "hl-v Name (Business/Orga17izati soG Cityt` te/ ip Phone#": " S ri a an employer?Check he appropriate box: Type of project(required): 1. I am a employs r .th 4 I am a general contractor and I erxrplvyees(lust and/or paTt=:time). have hired the sub-contmctors. 6- ❑New stnrchon I ElI.am a sole proprit for orparixrer- listed on the attached sheet. 7- em d bng ship and have no l T These sub-contratstors have employees 8. 0 Denwlifion -working :for me in any capacity., employees and have workers' comp.msurance, o workers �camp,insastance 1�- 9. .D.Building addition, 5. We are.a co, orations.and its 10.❑Elec required:] rptrical repairs or additions 3:❑ :I.ain a.homeou ner doing.a11 work afficers have ex,e a6sed their 11:Q Plumbing repairs or additions thyself [No workers'camp: right of exemption per MGL 12.❑Roofrepairs insurmce:requtiec.]T c- 152, §1(4),and we have no employees. {No wo6rers' 13.0 ether comp-.insazranM required-1 •Any applicamt thatdl ches box#1.mnst also fill out the section bel",showing#heir workers'compeusati.onpohcy inforimtian t Hameoermers who submit this afEda"indicating they are doing all wmt end then hire oautsidecontmuors mast submit a neW aHidnit indicating s=LL tC'onirac:iors th2i check his.band must attached=sdditiotmd sheet showing the name of the sub-cmtractars and stare whether or aot'those entities h2v-e employees. If the si b-contsactars:have employs;.ttey.m st provide their workers'comp.policy number. lam an emp7o}per that is providing workers'compensation salon inswr ance or 11V,t;ftfrpk'lees. Below is the pulicy an.d,jou sits+ infor ntatirrdt Insurance Company Name-_ f-IRCO l/ AWV14 Policyor Mf� ins.1_.1c.-9: �] �' Expsatian Date: Q Job Site.Address: ! CADas Y` 41 City/Stat&r ip:(�Jl�>! rl eAoo •b a6 2 Attach a copy of the workers'-compensation leers'compe.�tsa'tion policy declaration page..(stromdng the policy cumber and esph4lon date). Failure.to secure coverage as required under Section 2.5R.of MGL c,.152 can lead to the imposition of criminal penalties of a fine up to$1;500.00 andfor ane-year imprisonment,as well as civil penalties in the fbrm of a STOP'WORKORDER and a fine of up to$250.00 a day against the violator. Be advised that a'copy of this sWement maybe forwarded to the Office of Investigations of the D.IA for insurance coverage verification. I do heroky certify under thepains andipenalffes nfpeduty that the if forrnrrlrcrrt.prm�ided above is true and correct Si"tmature: Date Phone#: official 111'e:ar.ily. Do not.t,rite in finis area,to be cosipleted by citt or tota�n official O'tv or To'"111: Permit/l kense# Issuing Authority(ch-cle one): 1 Board of Health 2.Building Department 3.City/To-vim Clerk 4.Electrical insp=P'lumbing. 6. Other Contact Person: Phone#: 6 AtfC'-?-Rf CERTIFICATE OF LIABILITY INSURANCE OP ID SR DATE(MM/DDIYYYY) 140ONA-1 10/05/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI. 02838-0001 Phone: 401-769-9500 Eax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED Moon Associates Inc. INSURER& National Grange insurance Co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURERB: Beacon Mutual DBA Gutter Heimet 'Roofinq DBA Moon Works INSURER C: 1137 Park East Drive INSURERD: Woonsocket RI 02895 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTRINSIRE TYPE OF INSURANCE POLICY NUMBER DATE(MWDD/YYW) DATE(MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000.000 A X COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISS ESE""'L nce) $500000 CLAIMS MADE FxE OCCUR MED EXP(Any one.person) $.10 0 0 0 PERSONAL&ADV INJURY $10 0 0 0 0 0 GENERAL AGGREGATE $2000000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2000000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY. COMBINED SINGLE LIMIT ; $ 1000000 A X ANY AUTO BIS26619 09/16/10 09/16/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS 'BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR ❑CLAIMS MADE CUS2 6 619 0 9/16/10 09116111 AGGREGATE $ 0DEDUCTIBI E $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION X TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN I B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ 28586 10/01/10 10/01/11 E.L.EACH ACCIDENT $500000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below E.L DISEASE-POLICY LIMIT $50 0 0 0 0 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MOONASS DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO'OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR' REPRESENTATIVES. AUTHORIZED REPRESENTATIVES ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - Oka � . �mter z ? ft- Ttg'-28W-8 r z iv on _ {LION _ . rr dr,. r` JAM-' 11-3 Aoi t tlrd 1 � �-�•`:8 PAID€F ROB Nov 121010:4$a Jim 508 699 3938 p.2 1137 Park'm DrWe Ili.Res.F r2 w-jo 9tM:aP Mown I V.: ilY9Dlfe:ket 4thMe lshno Q2�5 i� - rce"-.K%a2Y1SivA,nasniv.eani.`- [ay0i37S•86fifi ;� 1At7.Mrrt551Sfh1aar.Assxanez SI Purdna3er(s)Name instillation Addne s: '7 2 MaNngAddreisa S At'71Z — Horne Phone• s 28 "77L 45) CeY Phone: " a J Email: Year Home Bust_1 S T 7`Customer inimk: Tam Paid inTorm of- 13F3_�f 1 7+9/3 L _ Me,the above putctaseris,I'kric aser[sr)and the ownWs)ol the p•ope•ty located at the above instal ation address. wet v jamdy andacaseraliyagrew to:ontrad with moon Assxlees,Inc.['A4dornvwis"J is fcmish,deliver.and Insta I of el mate•ials at c:escribed in-ft agrecTentAg-eement`,dhe atta:ied Spec Sheets)and dagram[s)wh'ch a-e hrxoorated he•eia by reference well made a pa-t wreef.A CompleWn Certificate will be fte-alted for ail jobs at the end of ft irstallatlon. Order Au nW der Number. Order NLrtber: Project ype, _� tr�_ �jestTvpe: FrojedType: Agreemen:Ansunt 5 �3 A;•ewentArount S - Aileeme-tArroint S l Less Deposlt� S ��� Less Depos t# S_ i less Dep%0 $ 3alance fkaeO�Con Ciadara $,� _ l Balawe 74*On Com:c tor; S _ Bala%e 0.re On Camp etinn $ Il b'brum377rf�e.rvneanawdw Or+zaclm_ Ilaw 33L01Aeigme-dM0rrA,euFvauYJx fAo»1e3:1%D1A MWeHA+�urtd6e.7rr�.m Indieaei Pr0wA ltrAadmd For na wri Irtdkah Pagtent 11~ForBalmie andicate VawmaA ttbod For Batprxe f L Due at Time of Installation: Dye at Tune of InSfiB11WID: - Due at Time of Installation: �•/1/ Esz.Start Date. Est.Completion Owe. Es:.S.a't Da_m 4t Gann edon om Est Start Date: Fst.CoroPle4an Date. -7 DEP05fT/PAYMENT OPTIONS ISWUactto full weraotion an9cir credaepPrvrall I t.Check,Cathhee et check ar Niamey Order a o 1.lbsndng t'Aadepyr•.bie to 1400nwols; Aard�7G�DD 2� t 1i3�3 Apawd Code l31/�'1 2.Credit CaW rcrekj Visa Mas:erCa-d Ciscaer AccE Apwo at Code_ A:Ct6 Eta Date _Se_t Cod@ VWeapp±MsooV�er.r�-crtdrargeV•eryeee.ucaeoZuAso heaeawa^m.rt icy dated aaarcztaari dd la:cdnca da0on sun kaardoa31 ai0gFYrtd aheot. it it Weed by and betsivion the parties that this AAgreMaeM t:CnstitnRes the entire understanding between the paroes,aondthert are no verbal undersur dptgt changing or modNying any of the terms of this Agreentignt Purcheser[sj hereby aduso%dedges that Pyrithaserts)1)has read the front acid reverse of this Agreement and has received a completed,signed,and dated copy of this Agreement,including the two ssccompattytng Notice ad Cancellation funnr on dw date fustwrittm aboveand at was orally iolormad of hrsjrherright to canal this transaction:00 NOT$KN TINS aINTRAC iF THME ARE ANY BLANK SPACES. P ts. Purd aser NWonwaeYcS. n Sigraturt. Si$satura S grature Print Name Print Hane Prirt Yams YOU,THE BUYEft[S),MAY CANCELTHIS TRANSACBON AT ANYTIME PRIOR TO MIDNISHr OF THE THRtD BUSINESS DAY AFTER THE DATE OF THIS TRANSACiICK SEE THE NOTICE OF CANCELLATION FORM 6EIA101 FOR AN EXPLANATION OF THIS RIGHT. if4W OF CANCEL bona OF CANCELLATION pate of Ttansatdion —� 'JV Date of Transaction / o You may cancel this transaction,without my pesky or obligation, You may cancel this trarmaction,without any peoakV or obligation, within three business days from the above date.if you carwA vW within three business days from the above date. If you canal,any property traded in,any Payments made by you under the Connect or property traded in;arty paymerds made by you under the Cootrad or Sale,and any negotiable instrument executed by you will be tettirned Sale,and any negotiable instnmtent tmecuted by you will be returned within 10 days tollaamtg moMpt by the Seger of Your carxeRathsn.ssrithin 20 days f*11"rhg receipt by the Seiler of your cancellation notice,and any security Interest imbb g out of the transaction v'II be notite,and any Security interest aching ion out of the transact will be a neeled.If Yet cane,you most make evadable W the Seller at you► cantelel.R You cancel,you must make available to the Seiler at your residerrce,in substantially as good nnrditioa as when recdved,say residence, In substankWir as good condition as when received, any goods delivered to you under this Contract a Sph or you may,if you goads tielivered to you under this Contract or Salk of you may,it you wish,comply With the instructions of the Seller regarding.the return, wish,comply with the Instructions of the Seller regarding the realm sh4mient of the goods at the Sellers expense and risk,If you do make[ shipment of the goods at the Sellers expense and risk.If you do make the goods available to the Seller and the Seiler does not pick then up Was goods available to the Seger and the Sailer does not pith them up %t eb 30 days of the date of Your Notice of Cancellation,you may.within 20 days of the data of your Notice of Cancellation you may retain m d'rspese of the gouda without any further obligation.H you retain or dispsam of the goods whhout any horther obligation.0 Yea fail to mate the goods available to the Sella,or H you agree to retum fall to make the goods available to rite Seller,or if you agne to teearn the goods to the Seller and fail to do so,then you remain Cathie for the goods to the Selleir and foie to do so,thtn you remain liable for performance of a0 obligations under the Contract. To cancel this performance of aR obliesdares under the Conbmwx To tancel this transaction, rawl or deliver a signed and dated copy of this transaction, mall or deliver a used and dated copy of this cancellation notice or any other wrnm notice,or send a tehellrom to cancellation notice or any other written rnotioe,or send a telegram to MOONWORKSy 1237 Park East Drive, Woonsocket/, Rhode island NWonworks, 1137 Park East Drive, Woonsoduet Rhode Island 02095,NOT LATER THAN MIDNIGHT OF I/`f J=1 U (Date). oms,NOT LATER TITAN MIDNIGHT OF I HEREBY CANCELTHIS TRANSACTION. I HERERY CANCELTHIS TRANSACTION. Consumers Signature Date I Consumer's Signature pate REP W E R rarr.►� , o r c ':'I•E_ ?'aacy..[:j.. ,.h:..t:..,. '.r... i'.Warr !y.a.: -t, :6;p w:.j t;.%-N Ir" 4 �v I F --vit -t;7. r-ez �41, So I 9 wq *rs t•r. 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