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Home My WebLink About0021 HARBOR ROAD (�0 z�r - 'own of Barnsta ble *Permit# O 4 °ly Expires 6 months fton,!ssw date Regulatory Services Fee Y awatvsrns[.e, v MASS. Thomas F. Geiler,Director i639 Building.Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601, 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 Property Address •. h'` ['Residential Value of Work . Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address X_ F42-1 t Contractor's Name i-� :SSQ "t"3Zt1�7tfl.. y�t.�io vTelephoneNumber Home Improvement Contractor License#(if applicable) Abi�36,5_ X-PRESS PERMIT, Construction Supervisor's License#.(if applicable) � �✓,$^�, Workman's Compensation Insurance' ��A 19 2010 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABL I am the Homeowner ' [ have Worker's Compensation Insurance' Insurance Company Name „ J,66,crl, /_0,17L,�1, Workman's Comp.Policy.#, b/C2 -31 6' *3 16 3 .0.7 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) e-roof(stripping old shingles) All*construction debris will be taken to 1 3:.1 iyj5— ❑Re-roof(not stripping.`Going over existing layers of roof) t , �Re-side .. #of doors Replacement Windows/doors/sliders:-U-Value (maximum .44)#of,windows _ *where required'.,Issuance of.this fpermit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. . ***Note: . Property Owner must Sig?Property Owner Letter of Permission. A copy of;the Home Improvement Contractors License& Construction Supervisors License is required. r SIGNATURE: Q:\WPFILES\FORMS\building permt formS\EXPRESS.doc '• . Revised 090809 The-Conimomvealth of Massachusetts .Department of Industrial Accidents " Office oflnvestigations 600 Washington Street ti Boston, MA,02117 -� fvwiw.mass.gov/dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): ffexrr&Ps Address: Cla)�b j y f IF— City/State/Zip: - Bpj.exr - Phone#: Are ,y/ou an employer? Check the appropriate box: Type of project(required): 1.L✓J 1 am a em to er with ;�N 4.;El am a general contractor and I P Y _ _ 6: ❑New construction employees (full and/or' art-time) * have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. .70 ❑ Remodeling ship and have no employees These sub-contractors have g, 0 Demolition. . Workingfor me in an `ca acit employees and have workers' Y P Y, 9.,.❑ Building addition [No workers' comp. insurance comp. insurance,$ required.] '5. ❑ We are a corporation and its ]0.❑ Electrical repairs or addition 3.❑ I am a homeowner doing all work s officers have exercised their I LE]Plumbing repairs or addition myself. o workers',com right of exemption per MGL 12. Ro repairs P P Y [N ❑ insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other (,!)IAIw comp.insurance required.] *Any applicant that checks box 41 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. lContradtors 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 pro viding'workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: ski A �1� Policy# or Self-ins.Lic.#: t�G l S�f{( j'� 6 Lq Expiration Date: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal'penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fin of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIN for insurance coverage verification. I'do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature' ��1��.t.�-vim Date• cg� In /20 . I Phone#: 9 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: t� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. , Pursuant to this statute, an emploj,ee 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 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,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-contractor(s)name(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 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. 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 permiUlicense number which will be used as a.reference number. In addition,an applicant that must submit multiple permiVlicense 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 may be 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 i I Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/die To: G H DUNN INS AGCY INC: DEBORAH From:,Anne Chandler'' 8-05-09 7:50a® p,:3 .of 3 1 CERTIFICATE OF LIABILITY INSURANCE DATE(dkN�DDKYYY) 8122009 PRODUCER G H DUNN INS AGCY INC ° THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 191 MAIN ST ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BUZZARDS BAY,MA 02532 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (508)759-3132 INSURERS AFFORDING COVERAGE NAIC# INSURED PERSSON CONSTRUCTION INC INSURER A:LIBERTY MJTUAL GROUP 22 COLONY AVE INSURERS: BOURNE MA 02532 INSURER c: INURM D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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,EXCLUSION AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LUSTS - - GENERAL LIABILITY EACH OCCURRENCE ; - COMhdRCIAL GENERAL LIABILITY ORENIPREMISES aft 0 -0 $ CLAIMS MAIX OCCUR MEDEXP(AnyonspeWl ; PERSONAL&ADV[NAM ; GENERALAGGREOATE $ GEN'LAOGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGO ; POUCY PRO- LOC AUTOMOBILELtl181LRY - (�B COMBINED SINGLE LIMB O O ) ; ALL OWNED AUTOS -. w SCHEDULED AUTOS f ILA URY $ HIREDAUTOS BODILY INJURY. ; NON•OWNEO AUTOS. (Per acdd-1) PROPERTYDAMAGE S (Par accident) - OARAGE LIABRJTY - AUTO ONLY-EA ACCIDENT ; ANY AUTO EAACC ; OTHER THAN AUTO ONLY: AGO EXCESS)UMBRELLA LIABILITY - - EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE ; DEDUCTIBLE ; RETENTION $ $ A WORKERS COMPEAND EMPLOYERS'NSATION YIN WC2-31S-363103-019 8/2/2009 012010 ✓ %ySTAT - OTH- U ANYPROPRIETORIPARTNERIEXECUnVE - E.L EACH ACCIDENT $. 50 00 OPFICERIMEMBER EXCLUDED? a �� 0 (Manddorytn NH) E.L.DISEASE-EA EMPLD $ s�cIArc a AL PRe roar E.L.DISEASE-POLICY UMrr 500000 L PRovISIONs earobr OTHER DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLE8 i EXCLUSIONS ADDED BY ENDORBEMENTISPECIAL PROVISIONS The Workers'compensation policy provides coverage only for the state of MA as noted in section 3A of the policy. IF LD9RCAN ELLATtON . - SHOULD ANYOFTHEABOVEDESGUBEDPOUCIESSECANCE2LEOfflam"THEEXPI NATION �. . TOWN OF HARWICN DA7E7IMEOF,1HE1S8UWG14URERVALLENDEAVMTOMM 7 DAYS WRB'TEN v 732 MAIN STREET EFT NOTICETOTHECERnRCATEOMERNAM 70THEL ,BI/TFALURETODOSOSNALL HARWICH MA 02W,,.. IMPOSE NO ODUGATION OR LAA13JU Y OF ANY.KNIO UPON THE 1NsURER,Its AGENTS OR . . AUTHORIZED REPRESENTATIVE Jeff Eldridge 0 ACORD 23(2009/01) 01988.2009 ACORD CORPORATION. All rights reserved. C4sT W., 5509972 CLIGM COW,.1207112 Anne Chandler 9/5/2009 7:49,11 AM Pnge 1 of 1 - Persson Construction Inca 22 Colony Ave. Bourne,MA 02532 Phone: (508)759-8959,' Fax: (508) 743-9303 PROPOSAL SUBMITTED TO: ' PHONE: DATE: STREET: i �;J JOB NAME: ARCHITECT: Qi t i 11 CITY,STATE AND ZIP CODE: .,JOB LOCATION DATE OF PLANS: We hereby submit specifications for: Strip off old siding'shingles and clapboard' p d'from left gable end of house.- I, Install new white cedar clear shingles over an underlayment of Tyvek paper. Shingle exposure will be approximately.5" to the weather, and fastened using j galvanized sidewall staples: Replace outside trim on 3 windows in.the same wall that is to be shingled. Install 3 new white Harvey replacement style windows in the same openings. All windows will come with energy-star rating, half screens, and grids. All debris will be removed to the dump. ' MA HIC#102365 MA CSSL#99507 We Propose hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: ($5,025.00)`five thousand twenty f ve dollars. Payment to be made as follows:$1,,675.00 down,balance on.completion. Any work preformed beyond the scope of this contract vnll be billed separately Authorized Signature: as extra work. This includes conditions which could not be foreseen the - contractor. In the event the customer does not keep the payment terms,work - shall cease,and customer agrees to pay any legal fees incurred to collect payment.work progress is subject to weather conditions. Note:This proposal may be withdrawn if not accepted within 30 days. Acceptance of Proposal=the above prices, specification,and conditions are satisfactory and are Signature: /p= hereby accepted. Payment.will be made as outlined. Date of Acceptance: . 3�/I /4. Signature: s 411 j ZLOZrLI L uoileaidx3 �' `3N�nO9, - Z£SZodW No,o�ZZ 3(1N3nd 1. � 1N3� .. . S , . a` ,,• s 2l -IS SO.:asua�il" LOS66 .. tll a suo0 > UO}D .a /�11ni�adS 10sinaad'nS,n9}o P troS _ sox"PuraS Pu t t'• .o luaus tl3a-Silasnu t'SSr�N ��a3rS a�l�lnd - ,per J -Board of Building Reoula{ions and Standards - b 1- _ License or registration,valid for individul use only - g HOME IMPROVEMENT CONTRACTOR before the expiration tion a e. If found return to: .Board of Building Regulations and Standards _ • = Registra O 102365 Ex nation One Ashburton Place Rm 130I F p yp 7/1/ 010 Tr# Boston,Ma.02108 . `, T e =P,nvate Corporation 1� t � 271191 L� PERSSON ROOFINffi Dp -,YING:INC. t Kent Persson 22 COLONY AVE - 0 BOURNE, MA 02532, "Administrator Not valid without signature a