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HomeMy WebLinkAbout0052 CHERRY STREET 1� Cl-er Town of Barnstable - a .wus� rw Post.This Cac So That it�s Uis�ble Frorn the Street ing Approved:Plans�lulust be�Reta�ned on Job and this Card Must be;Kept v �" Posted Until`Final Irispe'ction Has BeenMade = �' 113ermit b �� Where a Certificate of Occupancy. s Required,sucfi Building shall Not be Oceupied until a Final Inspection has been made .. Permit NO. B-19-4212 Applicant Name: ARMEN SAFARYAN COREY AND COREY Approvals Date Issued: 12/20/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/20/2020 Foundation: Location: 52 CHERRY STREET, HYANNIS Map/Lot: 309-121 Zoning District: RB Sheathing:' Owner on Record: CAREY,JOHN J& M ISABELTRS Contractor Name: ARMEN SAFARYAN Framing: 1 Address: 52 CHERRY ST -GontractorLicense: 106102 2 HYANNIS, MA 02601 Est. Project Cost: $ 12,00&00 Chimney: Description: re-roof-yarmouth dump Perrriit Fee:' $61.20 Insulation: Project Review Req: Fee Paid: $61.20 Date. 12/20/2019 Final: Plumbing/Gas x t2 - a. � Rough Plumbing: = g g: ' Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six,,,' -t fter issuance. All work authorized by this permit shall conform to the approved application and th'01approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shalli be in compliance with the•Ibcal zon ng by laws and codes. . Final Gas: This permit shall be displayed in a location clearly visible from access street orroad.and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ., Electrical .. The Certificate of Occupancy will not be issued until all applicable signatu4s by the Building and Fire Officia-ls are provided orrthis permit. Service: Minimum of Five Call Inspections Required for All Construction Work: s 1.Foundation or Footingsy Rough: 2.Sheathing Inspection t_. 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work,shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards„are the property of the APPLICANT-ISSUED RECIPIENT o— �i � Vail Application number.. Fee .........................co .02�............................. " sn M o J� Building Inspectors Initials....................................... t659. '�°•� TO�i �C'2 (''OTC, DateIssued................................................................. OI9 Map/Parcel................�J...l......../.C)-./.................... T0Wi*1'<0F BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: Sa S-1,0 e 4e�7 Gt of of � NUMBER STREET VILL GE Owner's Name: J Phone Number S0 7 7S 3d? 74/ Email Address: Cell Phone Number Project cost$ Check one Residential `/ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ED Siding Windows (no header change) # F-1 Insulation/Weatherization Doors (no header change) # Commercial Doors require an inspector's review Roof(not applying more than I layer of shingles) 1 Construction Debris will be going to M4 o L& T41 C_*_an t; CONTRACTOR'S INFORMATION Contractor's name Arm ea Jam' o . - y. Home Improvement Contractors Registration(if applicable)# 1P3020C2 (attach copy) Construction Supervisor's License# l Lo 9z (attach copy) Email of Contractor c ho en number _Y'0 4? 7 ALL PROPERTIES THAT HA E STRUCTURS OVER 75 RS OLD OR IF THE SUBJECT PROPERTY IS IN .. . ......................................................... *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am -9.30 am or 3:30 pm-4.30pm.Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date P LICANT'S SIGNATURE Signature Date l a: o2 Z) All permit applications are subject to a build' g official's approval prior to issuance. COREY & CO: REY " The Roofers G6 67 SEA STREET APT#A4, HYANNIS MA 02601 PHONE 1-500 -775-0240 C ERTAINTEED LANDMARK LIFETIME - ALGAE RESISTANT ARCHITECTURAL TYLE October 15,2019 RE - ROOFING PROPOSAL JOHN CAREY 52 CHERRY STREET EM:joeizcarey62@msn.com HYANNIS,MA Tel: 508-775-3874 COREY & COREY hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of the Old Asphalt Roofing Shingles (One Layer)and The Old Rubber Roof from the Entire House.Re Nail All The Existing Sheathing as needed. Supply and Install CERTAINTEED LANDMARK AR: LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE RATED,COPPER/CERAMIC STONES for a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT,235 POUND,EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY,CATEGORY III HURRICANE, STORM/HURICANE NAILED (6 NAILS PER SHINGLE), MULTI-LAYERED,LAMINATED ARCHITECTURAL STYLE,FIBERGLASS BASED ASPHALT SHINGLES. COLOR:` .,' e Supply and Install 8" WHITE ALUM UM/HICK'S VENTED DRIP EDGE on All of the Eaves.` Supply and Install 8"WHITE ALUMINUM DRIP EDGE on All of the Rake Boards. Supply and Install CERTAINTEED WINTER-GUARD (Ice as Water Shield)WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves &Valleys Under the Step Flashings,on the Skylights and Chimneys. Supply and Install CERTAINTEED'S "ROOF RUNNER" SYNTHETIC ROOFING PAPER Supply and Install AIR VENT SHINGLE VENT H RIDGE VENT on the Entire Ridge. Supply and Install NEW ALUMINUM& NEOPRENE SOIL PIPE FLASHINGS Supply and Install NEW EPDM RUBBER ROOFING MEMBRANE TOTTALY ADHERED over'/Z" STRUCTODECK UNDERLAYMENT Held Down with Plates/Rubber Coated Screws on the Rear Porch Roof I. OR '."EY & COREY " The Roofers Supply and Install NEW RUBBER EDGE TAPE with CLEANER PRIMER on All of the Existing Rubber Roofing Scam and NEW C-6 WHITE ALUMINUM RAKE AND FASCIA AREAS. Clean and Remove Debris from work area after job is completed. TOTAL INVESTMENT ------------- $129000.00 POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards,Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$ 60.00 per Hour(For Each Laborer Involved). PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All the Roof Work is Scheduled for Completion Within 90 Days of Acceptance and the Deposits Received are Non-Refundable After a Three Day Cooling Off Period from the Date of Signing. Please Make Checks Payable to: COREY & COREY COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years and the Shingles your LIFETIME if the shingles becomes defective. CERTAINTEED Warranties the Shingles up to a CATEGORY III HURRICANE-130 MPH WIND WARRANTY. CERTAINTEED Warranties the Shingles to be Algae Resistant for a Full 10 Years. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: tO . Q I ACCEPTED BY: SUB TT X o ARE A AFAR AN HO OWNER COREY chi COREY HIC # 183202 CSSL# 106102 The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING ALITHORITI'. Applicant Information Please Print Leaibty Name(Business/Organization/Individual); �i+� �� • � —_T Address: 67 City/State/Zip: �/t n<7,'s A/ Phone k S G 7 7 Y (� Are you as employer?Check the appropriate box; Type of project(required): 1 g am a employer with employees(full and/or part-time).* 7. ❑New Construction 2. 1 am a sole proprietor or partnership and have no employees working for me in any capacity.(No workers'comp.insurance required.) 8. ❑Remodeling 3.0 I am a homeowner doing all work myself.fNo workers'comp.insurance required.]t 9. ❑Demolition 4.FJ I am a homeowner and will be hiring contractors to conduct all.work on my propeary. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I I-❑Electrical repairs or additions proprietors with no employees. S.O I am a general contractor and I have hued the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13- Roof repairs 5-D We are a corporation and its officers have exercised their right of exemption per MCsL c. 14.❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box/r 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. :Contactors 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 isprov&ing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: 74' Policy#or Self-ins.Lic.#: A/C Cp �f /�"� c G/ Expiration Date: Job Site Address: C 5' 7' City/State/Zip: /7 � 0,2 6'!�� Attach a copy of the workers'comp ation policy declaration page(showing the policy nu er and expiration date). Failure to secure coverage as required under MGL c. 152,$25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DU for insurance coverage verification. I do hereby certify. and penalties of perjury that the information provided above is true and correct Si ature: / ;/ //'✓{'�'�� Date: 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#: AC40" CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD"YYY) `1- 9/13/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder-is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ashley Paiva NAMEastern Insurance Group LLC PHONE (800)333-7234 1 FAX No: 233 West Central St E-MAIL ADDRESS:apaiva@easterninsurance.com aiva@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC i Natick MA 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURER BAssociated EmploVers Insurance Armen Safaryan, DBA: Corey and Corey INSURERC• 67 Sea Street INSURERD: Unit A4 INSURERE: Hyannis MA 02601 INSURERF: COVERAGES CERTIFICATE NUMBER2019-20 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP POUCY NUMBER MIOD MMlDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 9520046441 9/18/2019 9/18/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 % POLICY 0 JECaT F1 LOC PRODUCTS-COMPlOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE umrr $ Ea MINED ANY AUTO BODILY INJURY(Per person) $ AUT OS SCHEDULE AUTOS - BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS eracddent $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLgIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PE OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE B OFFICERIMEMBER EXCLUDED? FN]NIA E.L.EACH ACCIDENT $ 1000000 (Mandatory in NH) W0050050150912019A 9/18/2019 9/18/2020 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below F i DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John Koegel/APAIVA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025onidmi toBoard of Building Regulations-and Standards .License: CSSL-106102 Construction Supervisor Specialty ARMEN SAFARYAN 67 SEA STREET APT A4- t HYANNIS MA 02601 T a Expiration: Commissioner 10/02/2020 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement�Contractor Registration Type: Individual �, Registration: 183202 ARMEN SAFARYAN ; p�iration: 09/13/2021 DB/A COREY AND COREY 67 SEA ST APT A4 � HYANNIS,MA 02601 t, f Update Address and Return Card. SCA 1 Co 2OM�M-05/177 Vlze tOanUnza7uvea�o�G��GaGda�uaelfa -- ----- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:.IndMdual before the expiration date. If found return to: Registration,� Expiration Office of Consumer Affairs and Business Regulation 183202:- -09/13/2021 1000 Washington Street -Su'te 710 = Boston,MA 02118 ARMEN SAFARY,6�7—r$Z D/B/ACOREYAND'CO F—A-ML� i '� t`'1 EN SAFARYAN 3sy 67 S 67 SEA ST APT A4•'-;;� -;, HYANNIS,MA 02601 _ Undersecretary Not valid ignature l f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ParcelI Application # Health Division Date Issued Conservation Division A;�o A �ationlFe Planning Dept. ®� ermit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �� ��cr✓�� S _ Village Owner Address Telephone Permit Request c. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family (a/ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new - First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑.existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Mike McCarthy Construction Address PO Box 52 License# West Dennis, MA 02670 Cell (508) 2$0-6964 Home Improvement Contractor# CSL-58633 HIS,'-1 69393 Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 21 1 FOR OFFICIAL USE ONLY APPLICATION # • 4 DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116- Home Im rovement Contra p `� � ctor Registration Registration: 169393 Type: Individual �� ` Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY MICHAEL MCCARTHY - P.O. BOX 52 — WEST DENNIS, MA 02670 ' ' e.Update Address and return card.Mark reason for change.g SCAT Co 20M-05/11 [� Address ❑ Renewal ❑ Employment ❑ Lost Card �e tpa7rv�rao�ztvealCl a��,aaaac�to� License or registration valid for individul use only Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: VExpl egistration: ,• 4'69393 Type: Office of Consumer Affairs and Business Regulation a- 10 Park Plaza-Suite 5170 ration` fi 15r2617 Individual a � Boston,MA 02116 MICHAEL MCCAR'fE l•:- t MICHAEL MCCARTHY WNo 6 RANGLEY LN. ;_SOUTH DENNIS, Undersecretary ith/signature e, Massachusetts Department of Public Safety �f` ;. Board of Building Regulations and Standards License: CS-058633 ; Construction Supervisor MICHAEL J MCCARTHY-.,,s, P.O.BOX 62 . WEST DENNIS MA 026T0 ►l^^^ Expiration: Commissioner 04/10/2018 The Commonwealth of Massachusetts _ Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02II4-20I7 wim.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl-Y Name (Business/Organization/Individual): Mike McCarthy Construction Box 52 Address: West Dennis, MA 02670 City/State/Zip: Cell 08)#280-6964 _ 14IC-169393 Are you an employer?Check the appropriate box: [7. ype Of project(required): 1.Pfam a employer with 5 employers(full and/or part-lime). ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in . Remodeling any capacity.[No workers'comp.insurance required.]3.�I am a homeownerdoing allwork myself.[No workers'comp.insurance required.)t . ❑Demolition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑i am a general contractor and i have hired the sub-contractors listed on the attached sheet. These sub-contractors havc employees and have workers'comp.insurance.t 13.❑Roof repairs 6.r]We are a corporation and its officers havc exercised their right of exemption per MGL c. 14.DOtber b✓(.f 152,§1(4),and we have no employees.fNo workers'comp,insurance required.) •Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy in forrnal ion. t Homeowners who submit Ibis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraclors that check Ibis box must hay: an additional sheet showing the name of the sub-contractors•and slate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 1'/I Policy#or Self-ins.Lie.#: V1AJL- 1W -( G 1 D'I Expiration Date: )2 )If- I! Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c:152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t a s enalties ofperjury that the information provided above is true and correct: Si ature: Date: Phone#: (Sc�k1 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#: DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/07/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:,If the Certificate holder is an ADDITIONAL INSURED,the policy(ies)must.be endorsed. If-SUBROGATION IS WAIVED,subject to... the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 01962-001 NQM€ACT Bryden&Sullivan Ins Agcy of Dennis Inc XF.'fo.E,n: (508)398-6060 No,: . (508)394-2267 . PO Box 1497 %Sss' So Dennis,MA 02660 INSURERAFFORDING COVERAGE NAIC# INSURERA• A.I.M.Mutual Insurance Company -33758 INSURED INSURER B: Michael McCarthy Construction Inc IN RER C P O Box 52 INSURER D: West Dennis, MA 02670 IN R RE: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE I SR POLICY NUMBER MMIDDIYYYY AWS LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMI E Ea occurrence) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ OLICY RCOT OC AUTOMOBILE LIABILITY NED EOMBI c �iderdl NGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PPROPERT IDAMAGE $ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ REXCESS UAB CLAIMS MADE AGGREGATE $ yyoRKDEEDg�p RETENTION $ yy�g7Alp, 7� 7� $ AND EMPLOY8LIABIIITY Y/N X TORY LAMITS OER AONYIPRPRI ETOR/PARTNSR/EXECUTNE� NSA VWC-100-6017656-2015A 12/15/2015 12/1512016 E.L.EACH ACCIDENT $ 1,000,000.00 A O (Mandatory in NH) ED7 E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 D9$sC4 PTION It below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ff more space Is required) CERTIFICATE HOLDER CANCELLATION Cape Light Compact PO Box 427 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable,MA 02630 THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRO)IISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved.. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD F5 /< f Town .of]Barnstable Regina ry Services Ricbard'P.Scali,Director ,ems' lBuildina Division. Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable maxs Office; 508-8.62-4038, Fax: 508-790-6230 Property Owner Must Completeand-Sibn This Section. If Us na .Builder. T, v V% as 0%mer of the subject property ^mot r � .+}-K , •.),»a ,� q hcre'by auto �: 0.act'oon my.behalf, in all mamas relative to work authorized by this building permit application_for. A G >_ (Mdres's,*o:Job) *Pool fences and alarms are the responsibility of the-applicant. Pools are notto be filled orutilz d before fence is.inastalled and all final inspections are performed and accepted_ Signavore:o Plicant_ �0Gr 14 Print Name Print Na= / v Z2=6 Z—/(, Daze ` e Q:FORMS OVNI ERPMAISSIONPOOIS 40 0* Town of Barnstable *Permit# q `F E.v Tres 6 monthsI rom issue dale n , s,,BLF ' Regulatory Services FeeBA - v� MAS& Thomas F. Geiler, Director t plfD �' ESS PERMITBuilding Division JUL 2 8 2009 Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 TOWN OF BARNSTAB�' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number '309 l zz Property Address , Q 't [✓]Residential Value of Work (814010 440 ` Minimum fee of$25.00 for work under$600.0.00 Owner's Name& Address Contractor's Name .� L r elephone Number ]U �5 .7 7 — �7 Home Improvement Contractor License#(if applicable) ( � "7 5 Construction Supervisor's License#(if applicable) Workman's Compensation Insurance Check one: t ❑ I am a sole proprietor �❑--,�I am the Homeowner Ca . t have Worker's Compensation Insurance Insurance Company Name I V V 0_Q —T IIJ S t 3.A OLM_K� " Workman's Comp. Policy# W i '-A `30 1 `2:LV Q Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: erty must sign Property Owner Letter of Permission, o en, Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFIL;ES\FORMS\Express\EXPRESS PERMIT.DOC Revise06O4O9 J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 ��•�'�. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address. I9 �T oDQ C1 City/State/Zip: oiv, �,D M R Phone.#: '�3 0 8 -7 ? S — 17`7 Are you an employer? Check the appropriate box: Type of project(required): 1.P?f employer with PY �I am a em 4. I am a general contractor and I employees(full and/or part-tirn.e).* have hired the stab-contractors 6. ❑New construction .2. I am a sole proprietor or partner-' listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑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. XContiactors 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. n Insurance Company Name: Policy#or Self-ins. Lic. M W 9 00 q\VJ 01 Z (3 O 9 Expiration Date: Job Site Address: 5 a City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number Ind expiration date). Failure to secure coverage as required under,Section 25A of MGL c. 152 can lead to the imposition of crLmingl 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 the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insuranLaaaverage verification. I do hereby cerli d aims enalties of perjury that the information provided above is true and correct Si ature:X Date: Phone#: Offccial use only. Do not write in this area, to be completed by city or town officiaC .City or Town: Perrrit/License# Issuing Authority(circle one): i.Board of Health 2.Building Department 3. Ci.ty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'_compensation for their employees. Pursuant to this statute, an employee is defined as ".:.every person in.the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a.license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.' Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)narne(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pernut or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" the.applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. he Office of Investigations wo»id like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts De:padment of Industrial Accidents Office of Iuvestigati.ans 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777740 Revised 11-22-06 www.mass.gov/dia one iko uId of lit il"ctint RQgulahons:enrd Stand If ds •` Construd#.6n Supervisor Li 'ense Leense: CS 6:64:3 ati:an 1:078/2009 Tom` 9 27 <Expar Restriction 00 BRAD, bPRINKLE 1`go LOTHROPS LANE el VV BARNSTABLE,MA 02668 (6in-fl sioini t I , 1 0.0--3�;QOpxef enclose`clspace s ; ti { 1;A-Mas6nry only .I 1°G_ 1 2 Fa=mi1�'Ho�es i 4 h1re to-pos ess a cur rent ediGican'of r1i'e F:� M•assachusefts State=�Bnlidin�;trode , . i is e'a:use for r.evoeatto-a of th> dii eoSie: '!/fit:: (ii.;:;72.i1Gi.1•PLLiN'.CLC/�. ��✓���d;r�,i;`are:Je�,erG ' Board:of,I UildingRqulafi.ons an&S6irfd'a1 eT a ia; HOME IMPROVEMENT CONTRACTOR Fi:, RegestraUon 103757 691pirateo0 7!9/2010 M 271033 Type. Private Corporation SPRIiJ t E HOME IMPROVEMENT IN:C. Bratl Sprinkle 199 B:amstables Rd: �-`. : ' Hyannis MAA2601 Admm)stratot° _ License or registration valid for individul use only before the expiration date. If found return to: t Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,.Ma.02108 Not valid without Sig ture - I ��r 1- F�QiI: :���FiiGri�►�9:�I�I:ua:u�ul��ul�:u �f 12/31/2008 14:18 Bryden & Sullivan Insurance Donna Seviour-►Margo 1/2 ACORN CERTIFICATE OF LIABILITY_INSURANCE oP OATE(MNV00l SPRIN-1 12/31/0/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden Q Sa- li.van Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. Hyannis MA 62601 Phone: 508-775-6060 Fax: 508-790-1414 INSURERS AFFORDING COVERAGE NAIC N INSURED INSURER Associated Industries Of MA' INSURER R Rrinkle Home Improvement Inc. INSURERC: 9 Barnstable Rd INSURER0: 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 BEENREDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSRO TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE MM/DD/YY GF,NERAL LIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY PREWSE5(Es Dccurence f CLAIMS MADE r_1 OCCUR - NED EXP(Any one person). f PERSONAL L AOV INJURY It - GENERAL AGGREGATE - f GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGO SJEC - POLICY7 PROT LOC - AUTOMOBILE LIABILITY .. - COMBINED SINGLE LIMIT (Ea accident) f MY AUTO ALL UVNED ADTOS - .. BOOILYINJURY f (Per person) SCHEDULEDAUTOS HIRED AUTOS Y BODILY INJURY f NON-OWNED AUTOS _ _ (Pet accident) PROPERTYDAMAGE .f . (Per accident) GARAGE LIABILITY AU70ONLY.EAACCE)ENT f MIYAUTO - OTHER TWIN EAACC S . AUTOONLY. AGG f EXCESSNMBRELtA LIABILITY EACH OCCURRENCE It OCCUR EI CLAWS MADE AGGREGATE f f DEDUCTIBLE f RETENTION f f WC STATLL I O H. - - WORKERSCOMPENSATIONAND TORY LIMI7S ER EMPLOYERS'LIABILITY A AWC7004943012009 01/01/09 01/01/10 E.L.EACH ACCIDENT s 500000 ANY PR07sR1ETORIPARTNEAlDD:CUTNE - -. OFFICER/MEMSER EXCLUDED? E.L.DISEASE•EA EMPLOYEE f 500000 d yes.describe under i SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT s 500000. OTHER - - DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION . SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSVINO 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 SO SHALL Fax #508-775-1350 IMPOSE NO OBLICATIONOR LIABILITY OF ANY KIND UPON THE NSURSR,ITS AGENTS OR Margo Mack 199 1'arnstable Rd. REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED RE/RESENTATIVE lKelley A.Sullivan ACORD 25(2001108) O ACORD CORPORATION 1988 HOME IMPROVEMENT SINCE 1946 ISPRINKLE SPRINKLE HOME IMPROVEMENT,INC. Celebrating 63 Years in Business! 199 Barnstable Road•Hyannis,MA 02601 •508 775-1778.800 244-1778•Fax 508 775-1350 Email-sprink@comcast.net Website address: w-ww.sprinklehome.com Property Owner Must Complete and Sign This Section I, John Carey , as Owner of the subject property\"� hereby authorize Sprinkle Home Improvement to act on my behalf, in all matters relative to work being done on my property (i.e, permits, . applications, etc.)-if necessary. .52 Cherry St., Hyannis, MA 02601. . , Address of Job 6/19/09 S' n re of Ow r Date S" John Caret/ Print Name Town of Barnstable Permit# OptHE tqf� Expires 6 m nths from issue date .� Regulatory Services Fee BARxsMMA = v Mass. 0$ Thomas F.Geller,Director �plFn►u+`� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 X-PRESS PERMIT Office: 508-862-4038 FEB 17 2009 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ARNSTASLE Not Valid without Red%Press Imprint Map/parcel Number 3 o ` —A-Z—' Prope Address Value of Work esidential Owner's Name&Address Q 5t Telephone Number '.)-U Contractor's Name-9p� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) nwa "anIs Compensation Insurance Check one: ❑ 'I a sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance Insurance Company Name rr,, Policy# -1U U 14rt Q Z GNU Workman's Comp. 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' Replacement Windows. U-Value (maximum.44) 1 �jCLVVv t-C7UY e, *Where.required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop e n�n'ust sign Property Owner Letter of Permission. om ement Contractors License is required. Signature Q:Forms:expmtrg Revise053003 I 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/Plui ibers- ,pplicantInformation �? Please Print Legibly Tare(Business/Organization/Individual): J 1�''' yk n^s p �' - ,ddress: 'ity%St to/Zip: M(&- Phone.#: 7 Vain an employer?Che4ppart-. appropriate box: Type of project(required): a employer with 4. I am a general contractor and I 6 E]New construction employees(full and/or me).* have hired the sub-contractors listed on the.attached sheet. 7. ❑Remodeling ] I am a sole proprietor or partner- These sub-contractors have ship:and have no employees employees and have workers' 8: ❑Demolition working.forme in any capacity. 9. ❑Building addition [No workers'comp,insurance comp• insurance.t required.) 5. We area corporation and its ME] Electrical repairs or additions ] I am a homeowner doing all work officers.have exercised their 11.[]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 13. Other employees: [No workers' comp. insurance required.] applicant that checks box#1 must also:fill out the section below showing their workers'compensation policy information. neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rectors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have iyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site -motion. d, _ ante Company Name: OA J Pr L f1 y#or Self ins.Lie.#: 6U LAct q%)t 2� Expiration Date: tite Address: .-!v' 6afnC-) `atote City/State/Zip: l Q :h a copy of the workers'compensation policy.declaration page(showing the policy number and expiration date). re.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ip 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 to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the Office of - ti ations of the DIA for' a e verification. rereby certify Ir he an enalties of perjury that the information provided above istrue and correct. tore: J .Date: ficial use only. Do not write in this area,to be completed by city or town officiaL ty or Town: Permit/License# wing Authority,(circle one): 3oard of Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector ntact Person: Phone#: t: t30ard'of Building RcguCaaums an'dsStantlar<Is Construction Supervisor Li,cens'e License: CS 5643 { � E.x-piration: 1002009 Tr#' 9427 t: Restri'cti.on: 00 BRAD.K SPRINKLE 190 LOTHROPS LANE '`•' !% 1N.BARNSTABLE. MA 02668 Conrmi'ssiolle), ^ 0.0-3$,000 cf<enoloSed space' 1 A-1Vlasonry only ., 1G- Y 2 l amity Hames p Failure to:possess a,current edtron o#>'fhe Massachusetts State Binldtng Code I A is cause for revocation of.thts licen's;e: ii ,..li..rt�u.J[tacG Board of Building Regulatrons and Stari:dards HOME IMPROVEMENT CONTRACTOR Registration: 103757 Expiration: 7/9/2010 Tr# 271033 Type: Private Corporation SPRINKLE HOME IMPROVEMENT, INC. Brad Sprinkle 199 Barnstable Rd. Hyannis,MA 02601 A'ilmrnistra-to'r License or registration valid for individul use only before the expiration date. 1f found return to: - Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,.Ma.02108 FNotvaglhidwitt Sig lure 12/31/2008 14:18 Bryden & Sullivan Insurance Donna Seviour4Margo 1/2 ACCRD CERTIFICATE OF LIABILITY INSURANCE OP — DATE SPRIN1 12/3/31/08 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 Associated Industries DL MA INSURER B: Spprinkle Home Improvement Inc. INSURER C: 199 Barnstable Rd INSURER.D: 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. INS POLICY EFFECTIVE POUCY EXPIRATION LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMrDD/YY) DATE IMMIDD/YY LIMITS GENERAL LIABILITY - - EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence S - CLAIMS MADE 17 OCCUR MED EXP(Arty one person) S PERSONAL B ADV INJURY S GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S POLICY ECaT LOC AUTOMOBILE LIABILITY COMBINED SINGLE OMIT S ANYAUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS _ BODILY INJURY S NON OWNED AUTOS (Per accident) PROPER.TY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT s ANYAUTO OTHER THAN EA ACC S AUTO ONLY: - AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE Y ? OCCUR ❑CWMS MADE AGGREGATE S DEDUCTIBLE g RETENTION S g 'NC STATU. OTH- WORKERS COMPENSATION AND TORYUMITS ER EM LUI PLOYERS' BILRY A ANY PROPRIETOR/PARTNER/EXECIITNE AWC7004943012009 01/01/09 01/01/10 E.L.EACH ACCIDENT S SOOOOO OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s 500000 9 yes,describe under ' SPECIAL PROVISIONS below E.L.DISEASE-POUCYUMJT 1 s 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Y 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 SO SHALL Fax #508-775-1350 Margo Mack IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 199 Barnstable Rd. REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE lKelley A.Sullivan ACORD 25(2001/08) O ACORD CORPORATION 1988 • sly Town of Barn-stable Regulatory Services r � nUsg�Bi'E Thomas F.Geiler,Director En ���� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property-filer Must Complete and Sign This Section If Using A Builder as Owner of the subject.property hereby authorize QEnLk j aAaapvynTto act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) / P `Signs of er J Date Ja A k% ✓ , Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION �oF'THE r�� Town of Barnstable Regulatory Services swtuvMsM Thomas F.Geiler,Director _ HAS. 16s9. .•�A Building Division rfD MA'1 Tom Perry,Building Commissioner 200 Main.Strget,_)Ryannis,MA_02601_ vvww.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to- be, a one or two-family-dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family.dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION .The Code states that: "Any homeowner perfommrg work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuring the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a.form currently used by several towns. You may care t amend and adopt such a fomr/certifrcation for use in your corrvrrunity. Q:forms:homcexempt II Engineering Dept. (3rd�loor) Map O Parcel . . �`P'ermit# ' G 6 J House# Date Iss Fee S s f �19 '�`� E SARNSTASLE. 16 TOWN OF B TAB 'F° `°�� ARKS LE Building Permit Application' Pro eet Ad ress vL. Village—' Owner ry,, Co N ddress61 Telephone •Permit Request .First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: _Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Namem 1 C114P Telephone Number 617 786 06 6/ � Address Al License# o 6 ? d 9 c1 621 C9 Home Improvement Contractor# 12- -5-of r Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 12-7 A7 BUILDING PERMIT DENIED OR THE OLLOWING REASON(S) FOR OFFICIAL USE ONLY _ PERMIT NO. c?' � ► _ ` . DATE ISSUED. .ti n MAP/PARCEL NO. ADDRESS { •,;' 1 VILLAGE- OWNER .: DATE OF INSPECTION: a •• f "} _' FOUNDATION FRAME 1 INSULATION FIREPLACE ` — t, x ELECTRICAL: ROUGH '. FINAL PLUMBING: ROUGH `+ f FINAL - GAS: , , ROUGH FINAL FINALBUILDING DATE CLOSED OUT. ASSOCIATION PLAN NO. s �` { t `w. TMe rQL CJ i _'f�°♦ - The Town ®f Barnstable 9 �' Department of Health Safety and Environmental Services . BuiIding Division 367 Main Street,Hyarmis MA 02601 Ralph Cmsse^Office: 508-�90-6ZZ7 f Building Comm Fax: 508-790-6230 For office use Only Permit no. Date . i AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL a 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition,et one bolt not moref an than fourn to any dwelling units orng to owner occupied building containing registered contractors, with structures which are adjacent to such residence or building be done by certain exceptions,along with other requirements. Type of Work: Est. Cost Address of Work• Owner's Name Date of Permit?plicnition: %0 a I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: _ OWNERS PULLING T�P�CABLE HOME nYIPRO OWN PERMrr OR �'r WORK DO NOT HAVE CONTRACTORS FOR AP ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c- 142A SIGNED UNDER PENALTIES OF PERJURY I h reby apply fora permit as the agent of the own r: v 21 Registration No. Date Thc• CunlIrruirtrc111111 o :)tastiuchuscnr Depurtnrrrrt of ludiutrial Accidcuts 608 !f uahitt(;tim Street .'�'- �.�'.�-• � �:. Bustult. .11uaa: (IZIII «'orl:cm' Compensation Insurance Affid:ti-it �L[tlic�inr information --- — Plcnse fR1NT le;;i�ii'y • v ^c. i n W l/ del/ 6 � hon • d b r� t�. S' ,� e 1 am la homeowner performing all wort:myself. I am a sole proprietor and have no one working in anv capacity I am an empiover providing workers' compensation for my employees working on this job. cmmtnn\• n•Imc- atltlrrcc• errs•• nhnnc�• . in-irnorr rn noilC\'t2 I am a soic proprietor. -eneral contractor. or homeo,ivner(circle otter and have hired the contractors listed beiow who the �oilowing %vorkers• compensation polices: comonn\• nnmr- nddrrv— cir'• nhnnc a• in<irrnnrr rn nniic\' emmn7mV nnrnr• atillrr«• rite•• nhnnc t�• incrrr^nrc rn - neite�'d tio_n Attach addi al sheet if neces�arv: �'�•;�,-._... -..�:'•^.ii►.ii.�.�•�. ".... --.......: •....._.�..�«:. • '...�..�-:-:�.� ":,.w...:..% F:uiurc to secure curcmcc as required under=tton_cA of AIGL 152 can iead to the tmPostnon of crtmtnai Penait►es of a line up to S1.500.UU anutur unc cars' impnsonmcnt as 1%'cil as ci\it penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand thgt a cop} of this swicnicut ma\ lic furivnrdcd to the once of In\•estications of the DIA for coverage verification. /!t0 irrrCnt CL'rrtll' «cr t/1L P�lis anti Petra! 'cs ojperjun•t/lat the information provided above is tru ttd correct Si^^atur OMe �� Z L c 7 Print name Phone>r ' officiai use unly du not\s•rite in this area to be completed b�•cin•or tots•n official ', • E• cin•nr tn\cn. Permit/license ra: r-13uildin",Department OLicensinc Huard L ti- check if immediate respunse is required OSeleetmen's UfGcr 1.. ,. Clticaith Department E. contict person: phone st- rtUthcr Information and Instructions Massachusetts General Laws chapter 15_ section 25 requires ail employers to provide %vorkers* compens:ttttn�rt "iati�'". an ejnpturee is defincd as ever} person in the scn'rcc of :ultrthcr unQt:r emniovees. As quoted from the contract of hire. express or implied. oral or writtcn. An employer is defincd as an individual. partnership. association. corporation or other Impf entitY. or any two or the Foregoingen__nued in a joint etlterprise. and including the legal representatives of deccascra�\npioyer, or-.!,,., recci%*er or trustee of an individual , pannership. association or other Legal entity, employing. employees. Hmve,.'c owner of a dwelling_ I1C1uSC having not more than three apartments and who resides therein. or the occupant of:ite �d��cllin�� hoetse f anotlier who employs persons to,do maintenance,;construction or repair work- on such dwell in_ or on the __rounds or building appurtenant thereto�shall tnot becauseiof such emplovment�b'edeeM`eLf to be ::n MGL chapicr !5Z section 25 also states that eti-erg- state or local licensing ngency shall withhold the issunil.ce 9, of a license or hermit to operate a business or to construct buildings in the commollivealth for sny leant who lens not Produced acceptable evidence of compliance with the insurance covers-c required. AcLa ..ionnlly. neither the commonwealth nor any of its political subdivisions shall enter into any contract for ale pertIJrnlz::ce of public wart: until acceptable evidence of compliance with the insurance requirements of this be: prccc:;ted to the contractin-a authority. ApIriicants Pl c 'Iii In the wori:ers* coin perlsaliotl affidavit completely, by checking the box that applies to your situation z:' suc2 ivin_ company names. address and phone numbers as all affidavits may be submitted to the Departmcm of r I I Sirial accidents foi- confirmation of insurance coverage. Also be sure to sign and date tile aMdavit• Tile - ,at it should be returned to the cin' or town that the application for the permit or license is being requested. 0 :he Dcparnne::t of Industrial accidents. Should you have any questions regarding the "law" or if you are req::: .0 obtz:n a «'orkcrs' con;pensatiorl policy. please c-11 the Department at the number listed below. C ii, �)r Fwxns Pie_-_ �e 'urc ala: the affidai,•it is complete and printed legibly. T11e Department has provided a space at the 5on..c.- dl - aa� it for ou to fill out in the ez-ent the Office of Investigations has to contact you regarding the applic-n:. F be _ : to fill in the permidlicense number which will be used as a reference number. The affidavits may be .turn: -ae Deaarzme:lt by mail or FAX ullicss other arrangements have been made. Tire Offce of Investigations would like to thank you in advance for you cooperation and should you have any que_: piease do not hesitate to _'ive us a call , Tire Department's address. teiepilone and fax numbe.. TIIc Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston. Y[a. 02111 fax T: (617) 7,27-7,749 ni:unc =. :61 -.) :-- '900 406. '0° or _ . . n _ � -�..s� 1.P� ✓1LG V/OmYrIL�YILU/CIII.NG O�✓[�CQd6Q�/L000(niLIA r. z s OEPARTNENT OF PUBLIC SAFETY CONSTRUO,jq SUPERVISOR LICENSE = Nunbe : Expires: =a NLCHA L.:a�NURFHY � `1�.�.,►�t�u�, 1 BARIIA Bit . DORCHESTER, NA 02124 . � - ✓iEe V/o9»iptO�fuleaUli o� c�ut6e�b - HOME IMPROVEMENT CONTRACTOR lo Registration 125015 Type - DBA Expiration 09/26/99 All Service Contracting -7f, ffewa.el J. Murphy ADMINISTRATOR IN Cranch St Quincy MA 02169