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HomeMy WebLinkAbout0251 HINCKLEY ROAD i� �o 1605( a Tt ; Town of Barnstable *Permit# ? Expires 6 mondis from issue date Regulatory Services Fee s sAhiv ,t$z$; rasa ;0� Thomas F.Geiler,Director = Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT'APPLICATION RESIDENTIAL.ONLY ii Not Valid without Red X Press Imprint Map/parcel Number .3 1 6 ®7 Property Address ?s 1 t✓�C M A 03601 FResidential Value of Work' a 00 _ Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 00-Y�A 2Jqg-r J(Po Is�Y) cS�r-e-d <Sj1reAIZ6 61.r MA n IS 4S_ Contractor's Name S O r,A I(I e_ Telephone Number SOV`7 7.5'1118 Home Improvement Contractor License#(if applicable) 10 3 '7 S 7 Construction Supervisor's License#(if applicable) (y orkman's Compensation Insurance 8 Check one: �"" .RESS IT ❑ I am a sole proprietor El am the Homeowner . C LLl 9 201 3 9Thave Worker's Compensation Insurance TOWN N OF BA NS AB LE Insurance Company Name Q,-ncic-�� Zn&tS4-r ts mlp Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) J Re-roof(stripping old shingles).All construction debris will be taken to (a(MOL." I rC4VI S4 1Y �/j ❑Re-roof(not stripping. Going over existing layers of roof). ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value. (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 co mprovement Contractors License&Construction Supervisors License is eq ' ed. SIGNATURE: Q MPFILESTORMSIbuilding permit forms\EXPRESS.doc Revised 090809 Town of Barnstable Regulatory Services Thomas F.Geller,Director., Building Division - Tom Perry,Building Commissioner 200 Main Street,Hyannis MA 02601 www.town.barnstab i e.ma.us Fax: 508-790-6230 Office: 508-862-4038 .. Property Owner Must Complete and Sign This Section If Using, ABuilder I; ee lc��r r ,as Owner of the subject property hereby authorize."ISA QroVewuA to act on my behalf, in all Matters relative to work authorized by this building permit application for. O�Sl ( i e ROCA i -(Addre s of rob 10.,M Signature of Owner Date T-e-qelc,c,-►r Print*Name If Prot)ekty Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 04z(.)RM.q-nWNRRPF.R WTR.g1nW The.Commonwealth of Massachusetts Department of Industrial Accidents a Offlce of Investigations 600 Washington Street Boston,.MA 02111 www.mass gov/d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t Please.Print Leelbly Name(Business/Organizadon/Individual) S�,-6 Y-12 tt lme— �rn 4,rpV -Mere Ad&ess City/State/Zip: 4 OcZ(PQ Phone#: Sn 7,7 • l-77 3 Are youan employer?Check the appropriate box: Type of project(required): 1.I� am a employe with�, . 4 Q I am a general contractor and I 6. Q New construction employees(full and/or part=time).• have hired.the sub-contractors 2.Q I atn a sole proprietor or partner . listed on the attached sheet. 7• Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for the in any capacity. employees and have workers 9 Q Building addition [No workers'comp. insurance comp.insurance.]Q 10. Electrical airs or additions required.) 5. We are a corporation and its reir ❑ 3.Q I qu homeowner doing all work officers have exercised their. 11.Q Plumbing repairs or additions myself.(No workers'comp. right of exemption per MGL 12.gKoof repairs insurance required.]t c. 152,§1(4),and we have no .employees.[No workers' 13.Q Other comp.insurance required.] *Any applicant that checb box 01 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, tConoactors that check this box must.attached an additional.sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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 thepolley and Job site Information. Qssoc�-ZCL�C-LInsurance Company Name: Policy#or Self-ins.Lic.#:AWC, 700"q9 q 301 2b10 Expiration Date,,:(( nt Ol Job Site Address: 4 i" t t e\ �Ocxgl City/State/Zip: tt�a M A 5. 0A 09601 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sf�iiic coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to SI 500.00 and/or one-veer it risotunent,3s 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 may be'forwarded to the Office of Investi ations of the DIA for insiuvrfSOcoverage verification. 1 do hereby certify i th and penalties of perjurythat the Information provided above Is true and correct. Si tur C.- Phone 1#: 7-57- Offlcial use only. Do nott write In this area,to be completed y city or town offic1aL 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`(�J CERTIFICATE OF LIABILITY INSURANCE oP DATE(MMIDDfYYYY) 3PRIN-1 01 05 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bzyden & 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 III INSURED INSURER A. Aeooustod Induetrio• of tM ' --__._ --- ----- . i INSURER B - I Sprinkle Home Improvement Inc. 199 Barnstable Rd.. Hyannis MA 02601 (INSURER a _. _.- -_ _ _---- •--r ---- 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: LTR NSR TYPE OF INSURANCE I POLICY NUMBER �IDPATE M- AaTE MMI LIMITS ` GENERAL LIABILITY EACH OCCURRENCE S i COMMERCIAL GENERAL LIABILITYi. !. PREMISESEa OCwrenau). S __ CLAIMS MADE OCCUR - ! MEO EXP(Any one Person)—j S� _ PERSONAL&AOV INJURY ,I f i I GENERAL AGGREGATE I S _-- GEN'L AGGREGATE LIMIT APPLIES PER;i PRODUCTS-COMP/OP AGG f — POLICY PRO JECT• I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I.f +(Ea accident) ANY AUTO �— ALL OWNED AUTOS I z w,., :I - BODILY INJURY I S - i (Per person) SCHEDULED AUTOS I HIRED AUTOS 4• 'BODILY INJURY 1 S ' (Par accident) --- NON-OWNED AUTOS - I I PROPERTY DAMAGE IS (Per accident) I _ t GARAGE LIABILITY I.. AUTO ONLY-EA ACCIDENT S — t ! ANY AUTO 1 OTHER THAN EA ACC $ �. AUTO ONLY: AGG $ I. EXCESS'I UMBRELLA LIABILITY ( EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGATE S I DEDUCTIBLE I j— ---------r---- ^ RETENTION WORKERS MPEN$ATON ; ! TORY LIMITS ER I _ AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVFD AWC7004943012010 O1/01/10 01/O1/11 E.L.fu+CHACCIDENT $SOOOOO OFFICER/MEMBER EXCLUDED? L_J E.L.DISEASE-EA EMPLOYE $500000 (Mandatory In NH)If as OeaaiUe wWer =y I ! SPECIAL PROVISIONS'Delow I E.L.DISEASE-POLICY LIMIT $SOOOOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SPRNKHO 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 Sprinkle Home Improvement, Inc IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax #508-775-1350 REPRESENTATrVES. - Margo"Mack AUTHORtZED REPRESENTATIVE 199- Barnstable Rd. Kelley A.Sullivan annis MA 02601 ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All fights reserved. The ACORD name and logo are registered marks of ACORD , J1 office�t o�me ' airs r�siue" ss7tJ19.2 r License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR. before the expiration date.,If found return to: Registration: 103757 Type: Office of.Consumer Affairs and Business Regulation Expiration: / 12 Private Corporatic: . a 10 Park Plaza-Suite 5170 , y — Boston,MA 02116 S KLE HOME' T;7NC. Brad Sprinkle i ;r 199 Barnstable Rd �� , yy Hyannis,MA 02601 '� UoBersecretary Not valid without sign ture Massachusetts- Department of Puhlic �:Ifct� Restricted to: 00 Board 4 Buildin�o Re��utati�rns ;rr�tltandurtls 00- Unrestricted Construction Supervisor License. I-1 2 Family Homes Licenser CS 6643 Restricted to: 00 BRAD K SPRINKLE ; ' Failure to possess a current edition of the 190 L6fHR0PS LANE-~' Massachusetts State Building Code W BARNS.TQB LE, MA 02668 is cause for revocation of this license. Refer to'. WWW.Mass.Gov/DPS Expiration: 10/8/2011 _ ('uumisioncr Tr#: 5478 i - °FIKE Town of Barnstable *Permit# Expires 6 m ont ,fr q i s r(e date Regulatory Services Fee l BARNSrABLE, : Thomas F. Geiler,Director A.�� Building Division TFD MA't Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 62601 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., Q 0 7 Property Address JS tYla ei 001A tLVl S (Y)A 0<esidential Value of Work 14k16'Q 'r Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address C-' I CAGL►- C nde c t)aV(A r Contractor's Name—, 0,-AUE 14y(w_ 1^0%"e m, 4 Telephone Number YD'S• -7 7 5 - l Home Improvement Contractor License#(if applicable) 103 75 -7 �Vorkman's Compensation Insurance °° IT Check one: ❑ I am a sole proprietor O C T 9 2009 ❑ I am the Homeowner l�have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name nit;-�0. c� (��.� MA Workman's Comp.Policy# 0uI r,- 7Q0 `t 9 '4 30 l a Qd� 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/doors/sliders.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: Property Owner must sign Property Owner Letter of Permission. ' A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Revise020108 ' 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/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): So &Y\L TM01-0 .e.'W1�_✓-� Address: 9 Po-r(AC,4-a_W �OOA City/State/Zip: 4 v 6%,n V\ M, Phone#: '7 7 5- 7 .7 Are You an employer?Check the appropriate box: Type of project(required): 1.91 am a employer with C 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition' working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5..ElWe are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp: c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.® her iyt ee comp. insurance required.] lo�J *Any applicant that checks box#I 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. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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: 4SSoC.i CJ� T.vvA_l,.ST r t cls cl� MN Policy#or Self-ins.Lic.#: G UX- _7QO 99 y 130[oZC F Expiration Date: Job Site Address: U(1C12J Qd.P __ City/State/Zip: A&hA S, (Yl W.�c�� 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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance caucrage verification. I do hereby certify r t ins enalties of perjury that the information provided above is true and correct. Si ature: Date: id s " 0 9 Phone#: 5 o s ' Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SEP-16-2009 15:oe EGENERA INC P.02 �THEF, Town of Barnstable' O Regulatory Services Thomas F.Geller,Director Building Division Tom Perry,Building CommUsioner 200 Maid Strut.Hyannis,MA 02601 www.town.barnrtable.ma.us Office: 508-962-4038 pax: 508-790-6230 ,Property Owner Must Complete and Sign This Section If Using A Builde I, David Tegelaar as Owner of the subject property her6yauthoiize SPRINKLE HOME IMPROVEMENT, INC. to act on.ray baLd, in all matters relative to work authorized byP this building permit applicatkn for. 251 HINCKLEY RD., HYANNIS, MA_02601 (Address of Job) , 9 11W09' Signature of Owner Date DAVID TEGELAAR Print Prame Ifkropegy Owmer is applying for permit please complete-the Homeowners License. Exemption Dorm on the reverse side. Q:FORMSrDWN1=RPI:RMIS9IDN - - . TOTAL P.02 r Massachuctts.- Dcirirtmcdt of Public Sufeh' Board of Building Rq;ul`ations,.lnd.Standards Construction Supervisor. License �ic ense: CS 6643 I Restricted.ta 00 BRAD K`SPRINKLE i 19010THROPS LANE W BARNSTABLE, MA 02668 ✓-' - y!f -` Expiration: 10/8/2011, vnunissiuner Tr#: 5478 Restricted to: 00 00- Unrestricted 1G-1 2 Family Homes t1 Failure to possess a current edition of the Massachusetts State Building Code its cause for revocation of this license Refer to: WWW.Mass Gov/DPS; �%, Po�»ino�uuea i'o�. aao .coell� Board of$wilding Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regist l* 103757 - 9l2010 fr# 's71033 Corporvt[or - S�R11tIKLBii© ,11WG ' a Brad SPit%le t Bai atisb f7t1: ., siarirs,lOQE L irense rregi r - - -before the'expirationi date:,if found return"to Board of guildmg egpiat►ons and Standards bue Ashburton Puce RnI:1301 $pstoq,)tIa 0208, ;Not valid wit outsi zture . f �. 12/31/2008 14:18 Bryden & Sullivan Insurance Donna Seviour- Margo 1/2 ACpRy. CERTIFICATE OF LIABILITY INSURANCE OP ID DS DATE(MW00 VYYY) SPRIN-1 12/31/08 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 of MA INSURER D Sprinkle 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. I POLICYEFFECTIVE POUCY EXPIRATION- LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE IMM/DD/YY) DATE IMM/DD/YY LIMITS GENERAL LIABILITY - EACH OCCURRENCE S COMTdERCIAL GENERAL LIABILITY . - , PREMISES Es dccur;nce S CLAIMS MADE OCCUR r TOED EXP(Any one person) S PERSONAL 8 AOV INJURY $ GENERAL AGGREGATE S CEML AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGO $ POLICY IE LOC AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT y ANY AITO (Es accident) S ALL WINED AUTOS ° BODILYINJURY (Per person) S SCHEDULED AUTOS HIRED AUTOS - BODILY INJURY NOWOWNEDAITOS - - (Per accident) S- PROPERTYOAMAGE S (Per accident) GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EAACC $ AUTOONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S y I ; OCCUR Q CLAIMS MADE AGGREGATE $ _ DEDUCTIBLE RETENTION S WORKERS COMPENSATION AND - TH- TORYUW9 S WC STATU OER EMPLOYERS'LIABILITY 'a` ANY PR06RIETOR/PARTNER/EXECUTNE AWC7004943012009 01/01/09 01/01/10 E.L.EACH ACCIDENT• S SOOOOO OFFICER/MEM8ER EXCLUDED? - - - _ E.L.DISEASE-EA EMPLOYEE 4,500000 a yes,descrlue under - SPECIALPROVISIONStelew - E.L.DISEASE-POLICYUMYT S 500000 . OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - - CERTIFICATE HOLDER CANCELLATION SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 #i508-775-1350 IMPOSE NO OBLIGATIDNOR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Margo Mack 199 'Barnstable Rd. REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE AUTHORIZED A.Sullivan ACORD 25(2001/08) O ACORD CORPORATION 1988