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HomeMy WebLinkAbout0097 CRAIGVILLE BEACH ROAD 97 TEE, Town of Barnstable *Permit# b ~p Expires 6'months issue date Regulatory Services Fee * snruvsrns[.e, 9c6 1639." Thomas F.Geiler,Director ITBUilding Division O C T 2 9 200 JI'om Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 OWN OF BAR NSTABL&ww.town.barnstable.ma.us Office: 568-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number. 2( 4 /116 001 Property Address -4 it v L 6 F C V Residential Value of Work -19 3 DO Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 9Ql3Efz1 W, IELMORF, q65 CtA 4ILL go. , 6UM70tV, Or 06Li3-+ Contractor's Name pAt'C f_TT E Ul t.j*ys t =rJ G, Telephone Number 5oa"L Z$-OUO 1 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Lis g 5 Cr Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name i�MAR tGA�-�uQ�GN Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. 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 #of doors Replacement Windows/door sliders -Value r 30, (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: /,A y Owner must si n Property Owner Letter of Permission. y of a Home roe ent Contractors License&Construction Supervisors License is e i SIGNATURE: C:\Users\decollik\AppDEffa\Local\Microsoft\Windows\Tcmporary Internet 11 \Content.0utlook\ TGU5QO\EXPRESS.doc Revised 090809 r a ■ • BARNSfABM 9� ,.� Town of Barnstable ArE p�A Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder ' 1 12 V 1 n L�'`�� ,�. , as Owner of the subject property hereby authorize `An�� - �c�LL�e425, tJC. to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) U -,)-5 v Ire of Owner bate 16AV lb 1SLvhC Print Name l If Property Owner is applying for permit,please complete the homeowners.License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 °T�ze i�omvazaizusealCl oaaoa�ivavlta ? - -.. —--- d Board of Building Regulatio s and Standards Construction Supervisor License 00-35;000¢f enclosed space 1 License CS 48859 I. 3 IA-Masonry only, I -1-2 Family Homes ratla� 212212010 Tr# .15566 • ' R s ett, 1,G u Failure-to possess a current edition of the l- Massachusetts.State Building Code is cause for revocation of this license. ROBERT R PADG �� 1 184 SCHOOL tR COTUIT,MA 02635 Commissioner — lee V/007��reo�zevPa�l/ o��ac�ivaetta _ . __ _ Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' Board of Building Regulations and Standards Registrafion:N 100131 One Ashburton Place Rm 1301 I ELp7- Ea 6f9/2010 Tr# 267799 Boston,Ma.02108 'I_-Type;_ Private Corporation PADGETT BUILDERSkNC Robert Padgett l PO Box 133/184 Scfiool`St� ...�, Cotuit,MA 02635 � Administrator Not valid with t signatu e I . . 4 .(LC�� EieJlii��a ��abEf. " 'a4 K�ri� rn .I° J h ,'�+ K f r f J.i 5 3 VCb,ft �[i l•i'eJiF�t�.T S 4 4 $�' d T X 'Ed✓ S. 3Ey.k .{ A y ' a }, E' x% Sf!ll4 U.fr l i w e F r; '`r ;' -+y ,� X 9 x - $ x � .�" r , u t �, 14xi i1�17 t!l/� w - a r i�ar ': nlupens�> on Issnran+cx davlE r ud -SI�vn call sdPiaim be A�picant Inf®ra> €�n � ` .Pies Futy Ie ADG 'TTL'�c�11�-ERS ,,LNG ryY ` S .e ,.y; ,,, �, 4 Y .� 1;1_�� x., I 33 t 8N �Nooi. 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CERTIFICATE OF INSURANCE DATE(MMIDD\YY) 06-03.09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MYCOCK INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 20 SCHOOL ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 437 COMPANIES AFFORDING COVERAGE COTUIT,MA 02635 COMPANY 297SB A AMERICAN ZURICH INSURANCE COMPANY INSURED COMPANY B PADGETT BUILDERS INC COMPANY ' PO BOX 133 C COTLIT,MA 02635 COMPANY D COVERAGE 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 COMMON 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 19 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFT: POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE WMADDIYY) DATE LIMITS GENERAL LIABILITY GENERALAGGR EGA TE COMMERCIAL GENERAL PRODUCTS-COMPIOP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&S CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ ' MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ - SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE . $ NON-OWNED AUTOS GARAGE UABILITY ANY AUTOS AUTO ONLY'-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ c AGREGATE$ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKERS COMPENSATION AND A EMPOLYEWS LIABILITY US-0574N648-09 06-01-09 06-01-10 STATUTORY LIMITS X THE PROPRIETOR EACH ACCIDENT $ 100,000 PARTNERSIEXECUTIVE X INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL ti DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OFOPERATiONStLOCATIONSIVEHICLESRRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CORTIPICATE ISSUED TO THE CERTQ+ICATE HOLDER APPECITNO WORKERS COMP COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF BARNSTABLE,BUILDING INSPECTOR -EXPIRATION DATE THEREOF.THE ISSUING COMPANY WILL ENDEAVOR TO MAIL,o DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT. 367 MAIN STREE r FAILURETO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES ' HYANNIS.MA 02635 AUTHOR¢PI)REPRESENTATIVE ACORD 25.5(3/93) W A Bolinder Padgett Builders Inc. Subcontractor Insurance Information Excavation n's Excavating ing P O89 ox 0 p 0Mashee, A 26 49 WC90A 945 Foundation B Colony P. O. x 469 Cotuit, 02635 WC000246 Concrete Flatwork CJ Be co P.O. Box 8 Sandwich, 02563 Framer D M Construction, Inc. 5 Bea Dam Way, P. O. Bo 90 S. Dennis, 02660 WC231S35140 Roof/Sidewall Todd DeBerry 228 Wood Street Middleboro, MA 02346 6KUB 0381BO9007 Electric Mike Ostrowski, Inc. dba Barnstable Electric 40 Village Drive East Sandwich, MA 02537 08 WECTJ0645 Plumbing Spencer Hallett Plumbing&Heating P. Box 61 Cotuit, 02635 WC 176-70- HVAC e Comfort Man 67 strial Drive Mashpee, A 02649, WC 176-70- Insulation Pimental dba:Ace Insulation 12 We m Shores Drive Carver, M 330 TBA WC 1609 n Padgett Builders, Inc. Page 1 updated 6/02/2009 Padgett Builders Inc. Subcontractor Insurance Information Drywall ntury Drywall Inc. P. O. x 572 Hyannispo , A 02647 WC500249901 Finish Carpentry Kempton Nickerson Building&Remodeling 13 This Way Osterville, MA 026555 WC990610 Painting Brothers Enterprises P. O. Box 2061 Hyannis, MA 02601 WC2315359289016 Padgett Builders, Inc. Page 2 updated 6/02/2009 ACCRD. CERTIFICATE OF INSURANCE DATE(MM\DDIYY) 06-15-09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INSURANCE AGCY CAPE COD HOLDER. THIS CERTIFICATE DOES NOT AMEND.EXTEND OR PO BOX 960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE EAST SAINDWICH,MA 02537 COMPANY 29BJH A TRAVELERS INDFMNTCY COMPANY INSURED COMPANY 8 DEBERRY TODD A. COMPANY 228 WOOD S'IRM C MIDDLEBORO,MA. 02346 COMPANY D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWRHSTANDM ANY REQUIREMENT,TERM OR CONNnON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIM THIS CERTIFICATE MAY BE ISSUED OR IMAY PERTAIN,THE INSURANCE AFFORDED BY THE.POUCIEB DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OFINSURANCE POLICY NUMBER DATE(MMkDDIYY) DATE LIMITS GENERAL LIABILITY GENERALAGGREOATE $ COMMERCIAL GENERAL PRODUCTS-COMPiOP AGO. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Anyone fire) $ MED.EXPENSE(Any one person' $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Pwson) $ SCHEDULE AUTOS BODILY INJUP.Y(Per Accident! $ HIREC AUTOS PROPERTY DAMAGE NON-OWNED AUTOS $ GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AOREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY U9-0019N04.A-09 01-12-09 01-12-10 STATUTORY LIMITS X THE PROPRIETOR( EACH ACCIDENT $ 100,000 PARTNERS'EXECUTIVE INCL DISEASE-POLICY:IM!7 $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100,C00 OTHER DESCRIPTION OF OPERATIONSILOCATKNISIVEMCLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERMFICATE ISSUED TO THE CHRTIFICA,E HOLDER.AFFECTING WORKERS COMP COVERAGE. THE WORKERS COMPENSATION POLICY DORS NOT PROVIDE COVERAGE FOR DEBERRY TODD A. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE PADGE'IT BUILDERS INC. - EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR 70 MAi 10 - DAYS W RITTEN IJOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT PO BOX 133 - -- - FAILURE TO MLSUCH"NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE CCAiPANY,ITS AGENTSCR REPRESENTATIVES. COTUIT.MA 02635 AUTHORIZED REPRESENTATIVE ACORD 255-5(3193) Charles!Clark Y FICATE OF LIABILITY INSURANCE 06ilz/2009 PRODUCER (SOS)$$8-2766 FAX C508)633-0909 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Ipsurance Agency of Cape Cod Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 480 Rte 6A HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 960 E Sandwich, MA 02537 INSURERS AFFORDING COVERAGE NAIC# mumm Todd De Berry INSURER Harleysville Worcester ans Co 229 Wood Street INSURERS: St Paul Travelers Middleboro, MA 02346 WaURETR c: INSURER a -- N6URER I-' . COVERArgES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERRA 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. INSR ADCI'L TYPE or-mauRJINCE POLICY NUMBER FOUCTEFFECTIVE POUCYEXPIRATION LIMITS GENERAL LIABILITY CJB M91 08/07/2008 09/07/2009 EACH OCCURRENCE a 1 0D0 00 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED� $� 100,00 CLAIMS MADE ®OCCUR MEDEXI i�u+Y Peril A _ PERSONAL L ADV INJURY 16 1,000,000 GENERAL AGGREGATE 6 2 0DO 0O GEN'L AGGREGATE LIMIT APPLIES PER: PRODLCY3 COMPIOF AGG 3 2,000,000 POltCY P LOC o AUTOMOE ILE LUUBLRY COMBINED SINGLE LIMIT ANY AUTO (Eaaeddenl) 5 ALL OWNED AUTOS - BODILY INJURY s SCHEDULED AUTOS (Per person) HAED.AUTOS uootly INJURY s NON-OYWNED AUTOS (Par Kd&nW PROPERTY DAMAGE $rPer&%idenl) OARA05LIAMLITY AUTO ONLY-EA ACCIDENT 3 ANY AUTO EA ACC S OTHER THAN _ AUTO ONLY: AGO S EtCESSiUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE ! DEDUCTIBLE 6 RETENTION 6 S WORKERS COMPEN90WN AND TO BE ISSUED 01/12/2009 01/12/2010 WC 6TATu oTH- — EMPLOY8R6'UAI0IJTY S ANY PR PRI T R+PARTNERIEXC•C C UTN .DIRECTLY BY CARRIER Et EACHACaOENT s �1 OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA SMPLOYE 3 I OO OO 11 yes.desmW under , SPECIAL PROMSIONS balm E.L.OISEA3E•POLICY LIMIT 6 S00,00 OTHER j DESCRIPTION OF OPERATIONS f LCOA11ONS f VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIO a CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 96 CANCELLED BEFORE THE e OPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOUR NAMED TO THE LEFT. Padgett guilders Inc. r BUT FAILURE TO NAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY PO Box 133 OF ANY KIND UPON THE INSURER,1T8 AGENTS OR REPRESENTATiyeS, Cotuit, MA 02635 AUTNOXIZEO a fiNTATIVE ACOIRD 26(2001186) FAX; (508)539-0557 wACORD CORPORATION 1988- -- Client#• 11149 2 ARNE A C-ORD,. p� MM1UDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE DATE( 06/03/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis,NIA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED - INSURER A: Harleysville Worcester Insuranc _ M.Ostrowski,inc D/BIA INS!J ER : Associated Employers Insurance Barnstable Electric INSURER C 71 Lothrop's Lane 1Ns'JRERc: _ West Barnstable,MA 02668 INSURERS: COVERAGES THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED.ABOVE cOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REGUIR RENT,TERM OR CONDITION 0=ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI iCH THIS CERTIFICATE MAY BE ISSUED OR NtAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNS.EXCLUSIONS AND CONDITIONS OF SUCH POLICES-AGGREGATE LIMITS SHOWN AWAY-IAVE BEEN REDUCED BY PAID CLAWS. POLICY EFFECTIVE ��— L?R NEW 'TYPE OF INSURANCE POD POLICY EXPIRATION POLICY NUMBER ' DATE NWDDIYY DATE MM/D LIMITS A GENERAL LIABILITY CBOMO113 107/19/08 OT119109 EACH OCCURRENC-E $1 000 n00 X COMMERCIAL GENERAL DABIUTv i GAMA�E TO RENTED i $1 OO OOO CLwMS MACE ®CCCUR Mi D( EXP Am;one 1 ( persar 1 $5 000 PERSONAL&A.DV INJURY $1.000 000 _ GENERAILAGGP.EG.ATE s2000000 GENTAGGRFGATELIM!TAPRY.IESPER: PP,ODLICTS v COMP'OPAGG $2000000 7 -1�CLICY E0T LID(-, AUTOMOBILE LIABILITY COFAEINED SNGLE LR.ti!T ANY AUTO j (Ea acddenl) $ AL,-OWNED AUTO: EODILY NJURY S214EDULEDAUTCS i (Per person) 41RED AUTOS BODILY NJURY $ NON-COWED AUTOS - 1 - (Per accident) - PROPERTY DrAlAAGE (Per accident) $ GARAGE LIABLTYAUTO ONLY.EA ACCIDENT $ A"JY AUTO I OTHER THAN EA..ACC $ AUTO ONLY: ACC: $ EXCESSAPABRELI A LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTICN $ $ B WORKERS COMPENSATION AND WCC5000804�012009 101(15/09 01115t10 X QU STATU- OTH- EMPLOYERS'DABILnY j E.L.EACH ACCIDENT $500 OOO ANY PRCPR!E"TOiLPARTNERfEKECUI;dE OFFICERIMEMBER EXCLUDED? N(� E.L.DISEASE-EA FNPLOY $500,000 fyyeess des,r tx�unc er SPE(:IAL PROVISIONS' . I E.L..DISEASE-POLICY LIMIT 1$500,000 OTHER l I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT i SPECIAL PROVISIONS Job: 107 Parsley Lane Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE CESCRISED POLICIES BE CAWEL LED BEFORE THE EXPIRATION .Padgett Builders IDATE'HEREOF,THE ISSUING INSURER YWLL ENDEAVOR TO MAIL 1 n OATS WRR'TEN PO Box 133 iNOTICE TOTHE CERTIRCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL COtuit,MA 02635 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,rTS AGENTS OR REPRESENTATIVES. AUTHORIZED PRESENTATIVE ACORD 25(2001108)1 of 3 #5S8337/M58336 LS1 o ACORD CORPORATION 1988 ACORQ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/03/2009 PRODUCER (508)997-6061 FAX (508)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 439 State Rd. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 0. Box 79398 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Keisser Rocha & Kleber_ Gulmaraes dba - INSURERA: Peerless Insurance_ Brothers Enterprises INSURERB: Arbella Mutual Insurance PO BOX 2061 INSURER c: AIM Hyannis, MA 02601 INSURER D: 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. INSR DD' POUCY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YYYV DATE MM/DD/YYYY LIMITS GENERAL LIABILITY BHO 53349462 04/11/2009 04/11/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY D T PREMISES Ea occurrence $ 100,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000 9 000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $" 2,OOO i OOO POLICY PRO= JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS HC 189 306 04/17/2009 04/17/2010 BODILY INJURY B X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) 300,000 PROPERTY DAMAGE $ (Per accident) 2 50,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION ! AND EMPLOYERS'LIABILITY X TORY LIM TS ER C OFFICER/MEMBER ER EXCLUDED? JOTH ECUTIVE Y/N WCC5008243012009 05/02/2009 05/02/2010 E.L.EACH ACCIDENT $ 1,000,O00 (Mandatory in NH) LISTED PARTNERS ARE E.L.DISEASE-EA EMPLOYEE $ 1,000,000 yes, under S PRO INCLUDED FOR WC COVERAGE. SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 . OTHER r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ` SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 Padgett- Builders IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR P.O.BOX 1333 REPRESENTATIVES. Cotult, MA 02635 AUTHORIZED REPRESENTATIVE Krista Hartford ACORD 25(2009/01) FAX; 508.539.0557 C 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD lRogem ODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE a Gray Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Box 1501 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW South Dennis,MA 2660 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY i INSURED M Kempton Nickerson 13 This Way Ostervllle,MA 02655-0000 i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEC,NOT WITHSTANDING 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 THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 00 LTR TYPI OF I SLIRANOI POLICY NUMeIR POLIOY IPPIWM DAM POLIOY RIPIRATION VAT! A �1NDEMPLOYERS'LIABILTTY I f LIMITS E PROPRIETOR/ HE IOFFICERSARE:NCL a EXCL❑ 7423525 3/0212009 =212010 I ATUTORY LIMBS THEIR ICwampAppIla oMA DomlanaONy. EACH ACCIDENT S 100,�gqI ISEASE POLICY LIMIT $ 500,00q ISEASE-EACH EMPLOYEE S 100,E CRIPTION OF OPERA 11ONWEHIOLMOPECK ITE IRE:M KEMPTON NICKERSON IS COVERED BY THE WORKERS COMPENSATION POLICY. I CERTIFICATE HOLDER ANCELLATION PADGETT BUILDERS INC SHOULD ANY OF THEABOVE DESCRRIED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF.THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 12 PO BOX 133 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BUT COTUIT, MA 02035 I FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY.ITS AGENTS OR REPRESENTATIVES. j AUTHORIZED REPRESENTATIVE I i I i I t TOWN OFBARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# Health Division Date IssuedZ/_2 Conservation Division Fee Tax Collector Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village _ hlYXIW/f)X5A4,eT' Owner e5S ",eIS� ,f'6WZ,,171 Address Telephone 0&e/Z13 Permit Request — 0 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost S axi Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No -If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes dNo On Old King's Highway: ❑Yes J(No Basement Type: Vull ❑Crawl ❑Walkout ❑Other _\Basemkt 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 BUILDER INFORMATION Name_ Telephone Number Address_ Z9 /r& License# _C 5 O 63,_5�3-7 Home Improvement Contractor# Worker's Compensation# 6ZZ20D��1u ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOCJ.�LU SIGNATURE DATE > FOR OFFICIAL USE ONLY «' G PERMIT NO. DATE ISSUED , MAP/PARCEL NO. F, ADDRESS ,, VILLAGE OWNER ..r ' ti DATE OF INSPECTION: FOUNDATION FRAME INSULATION / i t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL • FINAL BUILDING F DATE CLOSED OUT , ASSOCIATION PLAN NO. r , I" I :--: --- The Commonwealus of Massachusetts �i -- :=.3 De ailment o Industrial Accidents Office nffnyest 92011s �: --a 3 � 600 Washington Street Boston,Mass. 01111 Workers' Com ensation Insurance davit ��� /��j�� . name: location: Z4 E /l city / / Y/�S?/�_�l/)e27* phone ,?7��,-7719 ❑ I am a homeowner performing all work myself. ❑ I am a sole;)=rietor and have no one worldrig in any capacity �am an employer providing tivorkers' compensation for my employees working on this job. comnnnv name: .7�dj6 2,1Z-)K- 1 / city: phone•#:. 221, - R Z149 insurance co. nnlicv# ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have , the foIlo«ing workers' compensation polices: comranv name: address: :•;:: :•:.:,.:. city phone* insornncecn. comnnnv name: :::::,...... address: phone insurance co. :... Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a One up to 53300.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herebv certify under the pairs and penalties of perjury that,ahe information provided above is true.and correct. Si=ture Date ,441 A'_'9 _ Print name Phone# ni ofncizl use only do not write in this area to be completed by city or town oOloal dtv or town: permit/lIcense q ❑Building Department (]Licensing Board ❑ check if immediate mpontse is required ❑Selectmen's Office ❑Health Department (conutact person: phone/!; ❑Other�� (mum 9,95 PJAi - - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for th:� employees. As quoted from the "law", an employee is defined as every person in the service of another under any ca.�.: 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 o: the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receive7 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 c. building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa. 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,neither.the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work mt? acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. , ----------------------------- Applicants ' Please fill in the workers' compensation affidavit completely, by checidng the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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 permit 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. City or Towns 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 is the permitllicense number which will be used as a refereace number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Deparaneat's address,telephone and fax member. The Commonwealth Of Massachusetts Department of Industrial Accidents amce of Iavesduadons 600 Washington street Boston'Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 erL 406, 409 or 375 The Town of Barnsta e Department of Health Safety and Environmental Services p Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other, requirements. O� Type of Work: Estimated Cost D�U Address of Work: Owner's Name: Ags ldzye z .�ylbGlTY �iC''� Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied 00wner pulling own permit Notice is hereby given that: OWNERSTULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME EVWROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Q Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav DEPARTMENT OF PUBLIC SAFETY CONSTRUCTIOµ SUPERVISOR LICENSE ' Number Expires: Restr iced To 80 VID R COX, t PO BOX 4:81 S YARMOUTH, MA 02664 S. .V � n #'G + o`./tlaaoaclEuaella HOME IMPROVEMENT CONTRACTOR :Registration 4100497 `+TY a INDIVIDUAL Xp .06/18/00. r� �Eiration � k -r�S�, ,� �„r• t'�--2� i" a C OX �� = °'I19' -AVENDER LN: 383F` YARTMOUTH MA 02673 t s } gpMINIg1pA70R :-