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HomeMy WebLinkAbout0177 GREENWOOD AVENUE __I,�`] ��-per,w�c� � �F�. ,_ Town of Barnstable Building , .". '�:` :., p �,:���' `"" `�";ti�'= fir. "d <i � � u� �^�x � .'*z '� �,' ',. �� � ��." ,.: � '. � �.. .•�� �x.,� c Post This Card So Thatit is Uis�ble?From the Street Approved Plans�Must=be,Retamed on Job and,this Card Must be Kept • lAR1W'[ABLi. - '��''" , 6"9 =PostedUntil,Final InspectionHas.Been Made ' �� 3 Permit e° Wheiea Certificate.`of Occu anc`:is Required,such Building shall NotbekOccupiedunt�l afinallnspection has:beerimade x$ Wes_ r p Y .F.._, ._.� w •,.. . .. N -> , Permit No. B-19-1933 Applicant Name: SPRINKLE HOME IMPROVEMENT INC. Approvals Date Issued: 06/12/2019 Current Use: Structure Permit Type: Building Addition/Alteration-Residential Expiration Date: 12/12/2019 Foundation: Location: 177 GREENWOOD AVENUE,HYANNIS Map/Lot 288-068 Zoning District: RB Sheathing: Owner on Record: BECCHI, MARY C&FRANCO TRS s Contractor Name SPRINKLE HOME IMPROVEMENT Framing: 1 W INC. Address: 44 STRAWBERRY HILL AVE#12B Contractor License 103757 2 STAMFORD,CT 06902 w ," Chimney: Description: Install opening to fit new construction on gable end of home Est Protect Cost: $2,000.00 Permit Fee: $85.00 Insulation: Project Review Req: v Fee Paid: $85.00 Final s Date:' 6/12/2019 y Plumbing/Gas M s c Rough Plumbing: � - d ,3i � w�i- -BuildingOfficial Final Plumbing: O This permit shall be deemed abandoned and invalid unless the work authored by this permit is commenced within s�xmonthsxafterissuance. Rough Gas: All work authorized by this permit shall conform to the approved application and fhe approved construction documents for whiich"this permit has been granted. All construction,alterations and changes of use of any building and structes`shall be in compliance with the local zoning by laws and codes. Final Gas: ur This permit shall be displayed in a-location clearly visible from access street o*r;hoad and shall be maintained open for public mspection for the entire duration of the work until the completion of the same. i urn Electrical 'J, Service: VC The Certificate of Occupancy will not be issued until all applicable signatures by the Buildrog and Fire®fficials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Works; Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Per•ons contr s 'ng 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 I q33 Aw&atloa Number.. , 6 XAS& F®it Fee........... ......................Dder Fee........................ I" Total Fee Paid...................... TOWN OF BARNSTABLE Pew .. . . ............ BUILDING PERMIT iAPPLICATION L lap.......01....W......................,.......... -4..............:..... Section 1 — Owners Information and Project Location Project Address l)7-veo-,nLtx�)L-)d a�-e— . yl-llage Owners Name1��0(1 Owners Legal Address_ i4 CItY S4-00 �n State 'L� Zip 0(0-- SL Owners Cell# �3 I �' _ '�3 E-mail c C.o� I Section 2—Structural Use Single/Two Family Dwelling El Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Section 3—Type of Permit o $, 40ew Construction Move/Relocate Accesso Structure❑ • ❑ ry El Change oQse CIO LJ Demo/ entire struct=e ❑ Finish Basement ❑ Family/Amnesty/Amne i ( ) y sty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ 'Sprinkler S ❑ Addition ❑ Retaining wall ❑ Solar -Renovation ❑ Pool ❑ Insulation Other—Specify F— Section 4—Detail Cost of Proposed Construction 9 00D Square Footage of Project Age of Structure Z Dig Safe Number •-- '4 #Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist❑ WFCM Checklist ❑ Design Last updated:ll/72017 Section 5 o Work Description Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage, ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑.Heating System ❑ Masonry Chimney ❑Addhelocate bedroom --water-supply 1 ❑_Public _ ❑_Private Sewage Disposal ❑ Municipal ❑ On site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility- 16 ro,O-A ( LI I am using a crane C Yes �No Section 7—Flood Zone Flood Zone Designation - - J Within or adjacent to a wetland,coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area.Sq.Ft f S Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes . 0 No Lad upddc&11rZ2017 i I Notes Arty changes in qhe contract during the duration of thepm}ect�vinah nults in adclitionai monies due will be paid in f ffto-the contractor at.the time of the eliange_ 1 authorize Sprinkle Home Improvement to act on my.behalf in all matters relative to t1dwork to be perfamle onthis job.(i.e,penmits,applications etc.)i necessary: Authorized Signature Dater Contractor Signature Date France Beocan Brad Spnntde Regsira n number ,�. Greenwagd Ave,Hyenn�,MA t]2�1'` I TS AQ Ar - SI' ST All 1 °2z D1 j I SP.RIN-1 ACO!?O" DATE(MM1DDNYY1) f� CERTIFICATE OF LIABILITY INSURANCE 01/03r2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAtIO W 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 poll cy(ies)must have ADDITIONAL INSURED provisions or 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 tconfer.ri hts to the certificate Bolder in lieu of such endorsement s PRODUCER 5.08-776-6060 C T CT Kelley A.Sulllvan Bryden&Sullivan Ins Agency PHONE 508-775-6060 F 50.8-790-1414 88 Falmouth Road aq No,Ezt: A/C,No -.: YIAIL Hyannis,MA 02601 Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NGM Insurance Company 14788 INSURED: INSURER B:Associated Employers Insurance Sprinkle Home Improvement Inc 199 Barnstable Rd INSURER c: .. Hyannis,MA 02601 INSURER D; INSURER E: INSURER F: _ COVERAGES E THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED.TO THE INSURE.D 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 JNSURANCE:AFFORDED BY THE1 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 NSR TYPE INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS' A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE : 1,0009000 PAP 07/01/201181 07101/2019 DAMAGE TO RENTED CLAIMS-MADE,a OCCUR 600,000 . X Business Owners ." 19400 MED EXP An one'arson PERSONAL 8 ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:_ GENERAL AGGREGATE S' 2,000 000 X .POLICY❑JECpo .:�"T LOC PRODUCTS-COMP/OP AGG '21000A00 OTHER: A AUTOMOBILE LIAB(LnY COMBINED SINGLE LIMIT 11000,000 (Ea agoenl� ANYAu7o M1T2646X 07/27/2018 07/27/2019 :BODILY INJURY Pere n AWNED SCHEDULED AUR�TEgOS ONLY X AU ��TOS WW p BODILY INJURY(Per accident) X A�TOS ONLY X AUTO ONY Pe�acEcJRde t AMAGE A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE ' `'I i000i000 EXCESS W_iB CLAIMS-MADE ` CUT2640X O7/01/2O4S O7/O1I2O18 AGGREGATE 11000,000 DE D X .RETENTION$ 1;0000 B WORKERS COMPENSATION z PER OTH AND EMPLOYERS LIABILITY ER CC50650167472019 01/01/2010 61/0112020 500 000 ANY PROPRIETORIPARTNER/EXECUTIVE' Y f N E L.EACH ACCIDENT OFFICERMIEMBER EXCLUDED' N❑ N:I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $00,000 de under DES R ET 5 :L DISEAS -P LI L 00,000 DESCRIPTION OF OPERATIONS!LOCATIONS VEHICLES(ACORD 1019 AddRional Remarks Schedule,may fae aRached If more space Is required) Home Improvement Contractor''.. CERTIFAN I C CELLATIONL: . `SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED :IN ACCORDANCE WITH THE POLICY PROVISIONS. Sprinkle Home Improvement,Inc 199 Barnstable Rd. Hyannis,MA 02601 AUTHORIZED REPRESENT /�� � JN i.1A ICI KelleyA.Suliivan ACORD 25(2016/03) . c01988=2015 �t(;Sft O I rights reserved. The ACORD name and iogo are registered marks of ACORD a/&m r Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston,Massachusetts 02108 Home Improvement=Contractor Registration jr TYPE, Coryorahon YI4 # RegIshatlan:; 103757 SPRINKLE HOME IMPROVEMENT,INC. , } E1pIrahon:. 07/OB(2020 1.99 BARNSTABLE RD. � � 1" HYANNIS,MA 02601 9 r _ Lodate Address andReturn Card. - - SCA 1 0 2OM-05117 - - Cl/re 1('lMfl�nMtUIC(L[IIL C�F%�L¢d6n�u6r.�J . Office of Consumer Affairs&.Business Regulation HOME IMPROVEMENT CONTRACTOR _ Registration valid for Individual use only - - i TYPE-Porppation .before the expiration date.If found return to: Rernstrafiorl- Expiration Office of Consumer Affairs and Business Regulation 103757 07/08/2020 One Ashburton Place-Suite Boston,MA SPRINKLE HOME IMPROVEMFNf,INC. � � - rs.. BRAD K.SPRINKLE 199 BARNSTABLE RD"" HYANNIS,MA 02601 `' Undersecretary Not valid Sl attire :a Constructlori SuperUlsor - - - commonwealthofMassachusetts,. Bta ed: BuillifingsofanyusegroupWhichContain Division of Profe55i0nai L1Censufe liestitI=35,000 cubic feet(691 arc fn*M)of endosW ' Board of Building Regulations and Standards space. Co n struiori'Stt pervi sou CS 006643 " EISAires: 1 01081,20 1 9 A. BRAD K SPRINKLE .n , 199 BARNSTABLE ROAD 4 WANNiS MA 02 Ot r ' 71 1 `� ' ' Figure to possesst.a eullmd edition of the Massachusetts State Bullding Co4e is cause to revocation of this tkease. For WonrldiM about Uft Reme { � CAn iBtTj 77{T-3FOG or visit vrvrwattat;sgov/dpi Commis,sionet. I The Commonwealth of Massachusetts Department of Industrial Accidents _ d 1 Congress Street,Suite 100 Boston,MA 02114-2017 s� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. } Avolicant Information Please Print Legibly Name (Business/Organization/individual):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Barnstable Rd. City/State/Zip: Hyannis, MA 02601 Phone #:508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 1 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ repairs re airs These sub-contractors have employees and have workers'comp.insurance.$ 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] I / *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. tContractors 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. 1 Insurance Company Name: A.I.M.Mutual Policy#or Self-ins.Lic.#:WCC50050167472019A Expiration Date: 1/1/2020 Job Site Address: �9/ ULLt�.S?J�-'c City/State/Zip:, d Attach a copy of the workers'compensation policy declaration page(showing the policy.num 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 sta ment may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde he nalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 508 775-1778 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#: Section 9—Construction Supervisor Name aMLM—rM Telephone Number s Addres `'/ ` i� dY��� State `r r j'l zip 61-6ab License Number License Type Eamon Daie Contactors Emas1 30(1�k C2-1 Cell# u I understand my responsisiblifies under the rules and regulations for Licensed Cautraction Sq=visw in accordance with 780 CMR the Massachusetts State Building Code. I undm3tand the construction inspection procedures,specific inspections and doctmmentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signattue Date (o/-)�1 Section 10—Home Improvement Contractor Name �Q - elephone Number Address f qi a/)1&b&)City LL,20 L4 State Zip U l -f— Registration N T— er - Eq ation Date 2ty -- -- ------ I understand my respomslxWes under the roles and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State CoNtheerstaad eam faction inspection procedures,specific inspections and f docmmeatafim regWred of Barnstable.Attach a copy of your H.I.C... Side Date Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I I understand my responsibilities under the roles and regulations for Licensed Canstrnction Supervisor in accordance with 780 CMR the Alwsac usetts State Building Code. I under3tand the construction inspection procedures,specific inspections and docmmentation requaed by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Si e Daxe -5 Print Name �� r n � Telephone Number sI) -77 S—/7 E-mail permit to: Y� C �' 0 f � Last updated 11/7,2017 Section 12—Department Sign-Offs ° Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ J For commercial work,please take your plans&ecdy to the fire depoftent for approval Section 13— Owner's Authorization I, , as Owner of the subject property hereby authorize to,a.ct on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner date Print Name r.astupaatma:11/72017 Town of Barnstable *Permit# Expires 6 months from issue date s Regulatory Services-, Fee Q3�. sexxsresra, �"t"M �' Thomas F.Geiler,Director �® _ �� big• �`MA'1 • B it 'dI n Division u Tom Perry,CBO, Building Commissioner `' 9 3 0 4 200;Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN Office: 508-862-4038OUM NA - EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY p Not Valid without Red X-Press Imprint Map/parcel Number?b d Property Address 1 C1 rCQfN NLe—.' ti`,C Aa l S )§-Residential .Value of;Work Minimum fee of 25.00-for work under 60$ 00.00 Owner's Name&Address �(p�,^ CCU I..CG,v\Y\CSY1 �� C. C� �s Act Q ��� � C ac��o3 ,'1 T M1 Contractor's Name S�(i!1 I �Telephone Number 501� --7 7.5 11-1 Home Improvement.Contractor License#(if applicable)_ 1 0 3 757 Construction Supervisor's License#(if applicable). C,S- (gip.(o(n y 3 *Ko'rkman's Compensation Insurance Check one:. PRE IT ❑ I am a sole proprietor ❑ lam the Homeowner❑ 23 2014 I have Worker's Compensation Insurance ') `� Insurance Company Name - L Workman's Comp.Policy#_ y� q 1W -.a b l BAR TABLE 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 cz, 42�Replacement Windows/doors/sliders.U-Value o _ (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: Property Owner must sign Property Owner Letter of Permission A copy of the Home Improvement Contractors License&Construction Supervisors License is reouired SIGNATURE: QAWHILESTORMS\building permit forms\EXPRESS. c Revised 090809 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AQDlicant Information Please Print Legibly Name(Business/Organization/Individual):- Sprinkle Home Improvement Address: 199 Barnstable Road City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext.10 Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with 10-12 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' ' comp. insurance.'- required.] Building addition (No workers comp. insurance P• required.] - 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.F� Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' I bt0thercomp. insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have mployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site :formation. isumnce Company Name: A.I.M Mutual Insurance Co. olicy#or Self-ins. Lic.#: 7004943012014A Expiration Date: 1/01/2015 )b Site Address: `—]-7 C,ree-n Wopd AveCity/State/Zip:�t .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under i t ofperjury that the information provided above is true and correct i ture: Date: (0. �r 1 lone#: 508 775-1778 Ext. 10 Offwkd 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#• _ a $ AL $ Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis;MA 02601 www.town.barnstsbie.ma.us Office: 508-862-4038 Fax: 508 790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Frah C c as.Owner of the subject.propeny . I' hereby authorize Sprinkle Home Improvement y to act on my behalf, in all matters relative to work authorized by this building permit application for: I� 2, . l�t Gcd1V1l _ S (Address of job) .. i G S e 0.f,0vAer D to • 11 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. r C:\Usm\d*wUikWpplaMU-calUvlic—ft\Windo—s Temporary Internet FiICS\ContentOutlook\DDV87AAZ\EXPRESS.doc Revised 072110 SPRIN-1 OP ID: DS q�aRO CERTIFICATE OF LIABILITY INSURANCE F DATE(01/14/1414l14 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 1 ranrLAKfANT If the Certificate holder Is an ADDITIONAL INSURED,the POIICy0es)must be endorsed. If SUBROGATION IS WAIVED,subject the terns and conditions of She Policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th a Certificate holder In lieu of such endorseme PRODUCER Phone: 508-775-6060 00 TACT Bryden&Sullivan Ins Agency NANIE: 68 Falmouth Road Fax: 508-790-1414 PHONE -- FTpY'--—------ - Hyannis,MA 02601 Kelley A-Sullivan ADDRESS: _ _ INSUREI(S)AFFORDING COVERAGE — I -NAIC p INSURED Sprinkle Home Improvement Inc. — INSURER A:Associated_ Industries of MA 199 Barnstable Rd INSURER e: Hyannis,MA 02601 INSURER C: INSURER D: -- - _- INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER:THIS IS TO REVISION NUMBER: CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO` INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI. THE TERM.^.: C EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAW CLAIMS. I ISR TR TYPE OF INSURANCE AUDL RR P Y EFF POLICY EXP -'-- POLICY NUMBER MAAIDD YY/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE ;$ ( COMMERCIAL GENERAL LIABILITY rMXMAM TO RENTED PREMISES Eaoccurrerue $ CLAIMS MADE OCCUR I MED EXP(Any one person) $ ---+--- PERSONAL&ADV INJURY $ - -i GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1$f � $ ---- PRODUCTS-COMPIOP AGG POLICY PRO- LOC � I $ _----------f AUTOMOBILE LIABILITY CO BIW SINGLE LIMIT I$ ANY AUTO I BODILY INJURY(Pe ALL NED SCHEDULED AUTOS I BODILY INJURY(Per acddent)I$ HIRED AUTOS NON-OVIMED I PR PER DAMA E AUTOS Perecddent) $ UMBRELLA LIAR OCCUR 'g EACH OCCURRENCE I$ EXCESS LIAB CLAIMS-MADE I i AGGREGATE ;$ DED RETlimn S ---- WORK m COMPENSATION $ AND EMPLOYER$LIABILITY Y f N �STATU- OTH- 1 A►n PRpPRIETOwPARTNER(EXECurIVE WC40070049432014A 01/01/14 I 01/01/15 - --ry (�OFRCERIMEMBNEHR EXCLUDED? NIA E. EACH ACCIDENT _-- $ 500,- yyeeaa ) E.L.DISEASE-EA EMPLOYE $ 500,G0 DESCRIPTION OAF OPERATIONS below E.L.DISEASE-POLICY LtMtT $ 500,00 i I ESCRIPTI)N OF OPERATIONS/LOCATIONS VBUCLE8(Attach SRO Tf.AdCRUO W Remarks Schedule,N more space Is required) artificate issued dfor insurance verification purposes. I ERTIFICATE HOLDER CANCELLATION SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Sprinkle Home Improvement,Inc ACCORDANCE WITH THE POLICY PROVISIONS. Margo Mack 199 Bamstable Rd. AUTNOPJ=REPRESENTATIVE Hyannis,MA 02601 Kelley A.Sullivan I ©1988-2010 ACORD CORPORATION. All rights reserved. -ORD 25(2010105) The ACORD name and logo are registered marks of ACORD Unrestricted Buddwgs off?RYuxC scam►ess dma 35.000 , BMA which _:rtciO -,ed spy aCn� C(991JU )Of a. ..._.. zr;. « ..._5l BBAD K t "F!Urp To Ppa,.M a �didOn I"Lommwn Ir AL atate Bwiding Cage rs cause for a' MA: www Msss.Go,ypos Om m of e'oasaaer ARi1hs&Bosiaas Rerulstioo License or rrgomration valid for iadividal use only um CONTRACTOR before the expiration data if found return to: 103767 Type: Otlfee of Coasumu Aft$and 8nsiaeas t4 Pnvaoe Camarawr 10 Park Pbtm-Suite 5170 Regalatian T� "'"'W-LE HOW NPROVEWNT INC sexton.MA 02116 'fad Spnat A9 Saf#MMWD Rd rd'uUs MA 02801 t adwseercta y Not valid crltbo*aicaature �INME r ti ,Town of Barnstable, *Permit# k 3 7 Expires 6 months from issue date t BAMETPABLE, : Regulatory Services Fee 639 �� Thomas F.Geiler,Director A�EO MA't s 0 .. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 & t7r n m Office: 508-862-4038 .�, Fax: 508-790-6230 APR EXPRESS PERMIT APPLICATION - RESIDENT AL ONLY Not Valid without Red X-Press Imprint I UWN_01=B SAD(c- (', L -af-�:��,.�:; Map/parcel Number� e j � �25 S I�Z Property Address X [BIesidential Value of Wor 4��Q Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address '�nt.e-mo_-) ®SE 017 S"4&V1 Ra Contractor's Name i r_- . Telephone Number 6-09 23.7 742 . Home Improvement Contractor License#(!applicable ` mP ) . III �lG Construction Supervisor's License#(if applicable) 7 S� Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I m the Homeowner Mlf-have Worker's Compensation Insurance Insurance Company Name /J Workman's Comp.Policy# A- W C 7 Q 11 `I SO L2 a O Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will PP g g ) be taken to k ❑Re-roof(not stripping. Going over existing layers of roof) 2"Rke-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. ** Property Owner Permission. — - ' ✓ me rovement Contractors License is required. Signature Z b (j W n e-r 61 Q:Forms:expmtrg `l Revise063004 -071 P �,/�aooacfivaek'a Board of Building Regulations and Standards License or registration valid for individul use only HOME IM OVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Re 'aSti__ ftf� 9�1069 One Ashburton Place Rm 1301 ota S/2006 Boston,Ma.02108 M1 ihvidual NEIL S.TANGE NETANGER --- --IL — <r — PO BOX 1291/66 s FORESTDALE,MA 02644 Administrator 'Not valid wit u signature _ P r t .B arnstale RetYlatory Services :. . ... .. . . . ; � saaxsrAsu, �.•=Z'p,oriias F:.Geiler,=Director• ;;r�..•, . 143 � ding•Division -To' lif y;`BiUding Commissioner , - - "200 Main Strect, $ymmis,.MA 02601 - .�w l Aown Barnstable;ma,us Fax. 508-790-6230 Offloc 508-862-4038 " Property Owner Must Complete and Sign This Section If Using ABuilder 6 C.Gtt (� ,as CVner of the eject property to act on wIbeh4f j hereby onze: , in all matters relative to work authorized by this binding permit application for 4� (AA cldres s of Job) 2-3 Signature er Print U husetts Commonwealth o The Common Massac e f ��. - Department of Industrial Accidents p' :_- __ Office oflnvestigations - 600 Washington Street, 7rh Floor Boston,Mass. 02111 Workers'Com ensation Insurance Affidavit:Buildin lumbin lectrical Contractors name: Qi address: "v —7 �/ 7 city 'C (� 3r P ❑ ���1 state: I ' y zip' 4 Z 0�`1`Y ohone# `emu 10 ` ! 1 L work site location UUH address): ❑ I a homeowner performing all work myself. Project Type: ❑New Construction 216emodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition . .... i.i>F" ' '� .7JPs xr�:xt�:l:t':v�'O .'� '.d Y}�:.:�_:'": h A�N e?;'' `;'•?.�'{^a.2L":•: .,�rl a•:::.. `a;.Ya.`+ ❑ I am an employer providing workers'compensation for my employees working on this job. d company name, address' _.".'..........__.......--..._... city insurance co. 81111111111 HIM11 I 1 10111# MEMO I ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: .co .name•-- _ address: 4 city: phone#• insurance co. company name: t address: city. phone M insurance CO.. . of # Failure to secure coverage as required under Section 25A of MGL 15.2 can lead to the imposition of criminal penalties-of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. ]understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. , I do hereby certi under the a n penalties of perjury that the information provided above is VtrendcorrectSignature DateZ Print name Phone# Z official use only do not write in this area to be completed by city or town official ' city or town: permit/license# ❑Building Department QLicensing Board ❑check if immediate response is required ❑Selectmen's Office ClHealth Department contact person: phone#; ❑Other (mv'ised Up.2003) I Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 section 25 also states that every state or local 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,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'in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, 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 retumed.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. 4 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 in the pennit/license number which-will be used as a reference number. The affidavits maybe 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. IN- The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 ,