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HomeMy WebLinkAbout0364 CASTLEWOOD CIRCLE of stt>=r� `Town of Barnstable *Permit f0� �P` O Expires 6 nzonths rotn issue Regulatory Services Pee BARNSYASLS, 1639' Thomas F.Geiler,Director -PEES FERMI pJED MA't� Building Division QC 1 1 3 2010. Tom Perry, CBO, Building Commissioner 200 Main'Street, Hyannis, MA 02601yQv1/ 'Q B,ARKS ALE. , www.town.b arnstab l e,ma.us Offee: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Nlap/pat-cel Number_C*DT3 �2 prop" y Address CrWi C'�_ ! (} Residefltial Value of Wort._ Q. Q 5 Minimum fee•of,25.00 fo work under$6000.00 Chvner`s Name&Address -- _ - �p�(�k tA/c/ �191y? _ Contractor's Name � L ®�/�,. Telephone Number I Ionic Improvement Contractor License#(if applicable) ) Ztioii Supervisor's License#(if applicable) 9��an's Compensation Insurance Check one: ❑ 1 am.a sole proprietor ; m the Homeowner I have Worker's Compensation Insurance Insurance Company Name Q,; (� Workman's Comp. Policy Copy of Insurance Compliance Certificate must be 6n 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)' ❑ Re- de Replacement Windows/doors/sliders:U-Value Of (maximum.44) *•Where required: Issuance Of this permit does not exempt compliance with other town department regulations,i.e.Historic, onservation,etc. ". ***Note: Property Owner must sign Property Owner Letter of Permission, i A copy of the Home Improvement Contractors License is required° c f•WPHLESU C)R(vl,Muilding permit fomislEXPRESS.doc The Coininomverzhh nfl wssr dwJ etts Deprrrtinew of 1ridustrial.Accidenis r— Mice of Im5estigatiqrm 600 Washington Strut r y Y6'3171'.AIYlSSgo9�,✓dIfT ATorker-s' Compensation Insurance A.f'fi-davit:'Builders/{C'an:tz-actoi-s/E1ec-tticiieins/Plumbers hcant Information 1'lense Pr iut Legibly Name. (&isinem/0r9aurz11 /e/ G Address: 37 94 City/ te/zip:U//0QA/. d Plibn,e d . AXI u an employer?Check the ap'proprinte boa.: T e of ra' t d' , uir�e :. I am a general contractor and I p { ~1. jn a employer v��i.th ❑ � . . employees(fun and/or part tim ).* have hired.the sub-contractors 6_ ElNcanstn.Tctiou I❑ I am a sole propri6lor orpartnfr- listed on the attached sheet. y. E414emodeling shipand have 1 These sub-contractors halle ' no:employees oyees 8- ❑.Detnohttion working .for me in any capacity. ernploy'ees and have tvoskers' corn insumnce.1 9. ❑.Building addition jNo�,orkers' camp.ins�usance p- re aired] 5• ❑ We are.a corporation and its 10.❑Electrical repairs or additions 3.❑ Lain a.homeoumer doing all work afj.cess have exercised their 11:0 Plumbing repairs or additions myself [No workers':oiainp. right of exemption per ATGL 12.❑Roof repairs insurance required.]F c- 152, §1(4)„and.we have no employees.[No workers' I I❑ Other comp.insurance required.] ;Any apppEcaut tUt checks box#1.mast also fill out the section below showing flveiTwnrkers'caugpensati.an policy inforriaatfaa. Homeowners who submit this affidavit indicating they are doing alt work and then hire outsidecontmciur3 mast sabmit..a uew..9ffs a-,it indicating sgch tContrac:tors ttart check this:box must attached an additional:sheet shoa+ing the rime of the sub-contract ws gaff siBre whether or not Those entities have enrpoyees. Ifthe sat--contactor have empl gees,theymust provide their wurkers'comp:pahcy number. Ittnl nit atp.toyer flint is praifidirtg rdro.>kars' r�t7rxv¢rtsnhvn 'risrtr�tr for my t�dtr�*alol�eas :Belong is the pa&U -raid jab site informrrdmi, Insurance Company Name: eii k Policy*,or Self--ins.Lic.-9: ( o Expiration Date: / Jots Site Address: �� c,40"WcOn C" �o 1. J �CitylStatel7ip: Attach a cagy of the iTorkers'compeirs.i-don palit:3>d cl:atration page(shoming the poticy'rrum er and u-ation-date). Failure to secure coverage as required under Secliou 25A of MGL c.. I52 can lead to the imposition of criminal penAties of a fine up to$1.,500.00 and/or one-year imprison ent,as well as civil penalties in the form.of a STOP WORK ORDER and a fine of up-to$250-0'0 a day against the violator. Be.advised that a copy of this statement may:be fwwarded to the Office of Investigations of the D.IA for insurance coverage verification. I do h.ereky r rtrfy under thepahis xandp. enfilfies L?flaer,jetty Mat the itt,,forinafianprm�idf d.a.bow es fro.e atd correct., Si tare: .- Date: Phone#: l 6 O c.7W use only: Do not write hi this area,to,be cottipletod by cit}or town ofcial Litt°or TostM: PermitlLicense# Issuing Authmity(circle one): 1.Board of Health 2.Building Department 3.City/Fo-tim.Clerk 4,Electrical Inspector 5.Plumbing Inspector° 6.Other Contact Person: Phone#e 6 1 DAT10/05 lY0 CERTIFICATE OF LIABILITY INSURANCE OP ID sR 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 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED Moon Associates Ing. INSURER A: National Grange Insurance co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURER B: Beacon Mutual DBA Gutter Helmet Roofing . DBA Moon Works INSURER C: 1137 Park East.Drive INSURER D: 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 MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - - LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY - EACH OCCURRENCE $ 10 0 0 0 0 0 A X COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISE�S(Eao ccurence) $500000 CLAIMS MADE X❑ OCCUR MED EXP(Any one person) $ 10 0 0 0 PERSONAL&ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: -_ .. PRODUCTS-COMP/OP AGG $2 0 0 0 0 0 0 POLICY PEa LOC AUTOMOBILE LIABILITY - COMBINEDSINGLELIMIT $ 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 1 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 $ F1 EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR CLAIMS MADE CUS2 6 619 - 09116110 09/16/11 AGGREGATE $ DEDUCTIBLE $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION - - X TORY LIMITS ER AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN L8S86 10/61/10 10/01./11 E.L.EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? El (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5 0 0 0 0 0 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $5 0 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 REPRESENTATIVE ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD xr tMVIMP, MEN7. M4 ter_ IN AAMM AS lt husob;bDeparlawnt of thabok sarell Board(W BuRding " s and rds Ccmetmotion Supervisor i �Uponse U : C Rear' <. RNM J 48 PIN } CUMBERLAND, ._ �3. : OSM r 508 746 4656 _ P.81 .. ?. WaorsMllL flF,ode hhnd 02694 ' V eV.r::aaL9ilaT>9 pninka0ea,ar lfK? '�"• .. . f e 'r'f'�, cars-,nGmg273i{alaw Affalrp+l-rl. •+bl''� € �. yy M�yt ����� ��� anus wet:essszeo+avaoara utr: � t •� a� Purdww(r)Name: sekellad,a,Address; A011 C'"ti�Yr,eg&Qg cigc%P Melling Address: aV d�+€+Q Nome phonic: f eeRPhooe: y 'a��f!i1/ E+wsil: /� �•. Year Nome awit: /gam' CuAomer lnk;als: Ta:a PafdmToem ot` nJ,t $/� __. U?. I,'We,the above p'archaser(s)(°Futrtuofigsp and the owners)oftha property looted atthe above Installation address,herebypdnoy and sevetaByagrs. t.s caatmtl with Moon Associates,Inc.('Moonworkr')to furnish,deriver,and install of all materials as described in this agreement('Agrtermnri,the attached Sped Sheet(s)and tllailim t(s)which are Incorporated herein br reference and made a part hereof,A Completion Certificate will be esecuted:ot as jobs at 69 end of the installation. Ortlor NYm ( Order Humber Order Number: — P QIKI Type. /.JirrOonlS DaavC,( RojectTrl>e Pro)ectType: _ - AgreenentAnfount s/() S7 AgreementAmoutt S _ AgrwmantAlowR $ Less�eposltr - $all. Less Oepodtt _S Less Depcsitt Ral_ante Oueon Completion S O Balance out,on Completion$ 0alame0va On Completion$ 'lNaa:r.."13x e'ALRelMatano,ra aw.pJn weuP a. iiwNi'Nn)TtW MKneManian,aw+pa^r.eMwt MAlalmwn iaxa. Fpeanant a,.aw aewo+ramm�- ilndkslo,paymem Method ForeataMor Indleate Payrnsot Mdl.W Fara-Wrn `Indicate PipnamMethud Per aalam l Dueat Ameaftnstaltatbn: Ore aTTlmedlnstdFatlpn: Dueet Thmeotbmlbmts:- - - EA.SUrt Gate: Est Completion Date: Eat Start Date: EA.Cemplei,m bate: ESL Stad Date: ,Etc Camptetion Data: DEPOSIT/PAYMENT OPTIONS6ue}sa eo rundr mauon Wle.rredtq,pranq- - i 1.Check,Cashices Check or Money Order Cka S.Hnaaetug I (Merle payable to Moonworksl Aura Appruval Code,_` i t Credit CatIr(dr ) V,Sa kiwteCard DqW er Actt it - Approval Code . Lit Date-7��JJ SeCUrf Code rpaalsetoscae MCaroaietod"i,P dx re`rleeud aedlf yard fertN aia hsmc,me �P T�i,,,r_ ry BaomsrohnocedteaMarM wo,trle�plrNnolsauelusn anetre aba.r - It It ftmod by and between the parties that this Agreement(onuttuht the amhe undardandla between the Part*%and there are no verbal u ideum&ngs dwnging ormod'dVIM any d me tarms of"d.Agreement RarhssenW here tV aitnowtedgll SMt➢atdaser(al 11 has read the honl and reverse of this Atmeme d and has received a completed,signed,and dated copy of this Agreaawnt.including the two acmmparrying Notice of Caacehation fomt,on the date Post wrlttee-hove and 2)was amity informed of kh/he right m darnel the trorewttlon,tall NOT SIGra TKM CONMCT If THERE ARE ANY W"SPACES. _ - Purchaaer purchaser // gnat r! 4sf{J�iJJ Signaturosinat.re .. /h/ Qt/1 RCC/CtvaP.� / .iJ �niylarw,y - - Pini Nave Mnl Name ham Name - YOU,THE RIYER(SL MAY CANIULYWS TRANSACTION AT ANY TIME PRIORTO MIONWHTOF THE THIRD BUSINESS DAY AFTER THE DATE ON THIS TRANSACTION.SEETHE NOTICE OF CANCEttATWN FORM BELOW FOR AN EXPLANATION OF THIS RIGHT..: - NOTICE OF CANCELLATION - - NOTICE OF CAFFEWATION Date d(Transactio n Date of Transaction You may cartel this transaction;without Arty penalty or obligation. You may cancel this tradeaceion.without any Penalty of obligation, within three business days from the above date.It you canal,any wNhiru three business days from the above data If You cancel,any property traded in,any payments made by You under the COMIact of Property traded he,anY Payments merle by You under the Contract an _ Sale,anq any regotiabk instrument executed by You will be returned Sale,and m twitotsable fratru runt ezwAted by Von will be rettrnr" - within St days to0owbtg racelpt by the Seger of your carate0ation within to days foPe"receipt by the Seger of Your cancellation _ notice,and any security)merest MOM out of the transaction wO be titian,and a"musity Interest aris)ryl tut of the transaoaan will be canceted if yore eancei,You must make available to the Seller at your aMelati H you cancel,you roust make available to the Seder at yout - realdenes,in substantially as good cohdition as when mcelved.any 1 residence,In substaistfatly as good condition os when recahed,any - goods dei(vered to you under this Contract at Sale;at Vats maY.N you goads dell mad to you under the Convacs or We;or you ralay,it You wnh,Comply with the instruct)otsa of the Seller regarding the reran wish,comply with Me Inswctlau of the Seiler repelling the Talcum shipment of the goods at the Sellers t use se and risk.If You do make shipment of the goods at the Sages sapame and risk.if you do make . pia goodL oraRable to the Seller and the Seller does tot pick them up the goods avaltable to the Seller and the Seller does pot pick them scat wnthln 20 days of the date of Your Notice at Caocellatksn,you may within 20 days of the date of your Notice of Cancellation,you may retain or dispose of the goads without arty further obligation.If You retain a dispose at the goods woout airy tutthad abligatlam It yuv - fail to mike the goods available to the Segef.at N you agree to return salt to make the goods"llibie to the Seller,ar R you agree to return the goods to the feller and fan to do so,then you remain gable for t the goods to the Sella and fall to do so,than You remain liable for paAeemanse of all obligations under the Cowart To Want this.per(ormeaw of all ONIgatlorH under the Caatracc To anal this ImrdecWp, rneR or deriver a signed and dated copy of this;transa ion, mall of deRYer a signed and dated copy of this tancellaUas notice or airy othet vrritten notice,of send a teiegnm to cancelled"mike of any other written nods,or send a telegram to MQONWORnS, 1237➢ark Fast Drive, Woonsocdat Rhode Island Moomwrles, 1137 Park East DHve, Woonwdket, Rhode Island 07M,NOT LATTRTNAN MWNIGHTOF (Data). OWS,NOTtATER THAN MIDNIGHT Of I HEREBY CANCEL THIS TRAseSACTTON. - I HEREBY CANCEL THIS TRANSACTWN. - Consumeessignabsre - Date I Consumer's Signature Date 1P.�B V3 E1Mftts! R E Pa:�W E R ..z✓ks nth M.+vw uric. :l tcliun iyd.r Clxvva Piri Cspy rr j,ri Sp.riJ,t l '