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HomeMy WebLinkAbout0054 HYANNIS AVENUE J /7 �✓� �- ���� �. -- - - �I Town of Barnstable *Perj-, I�'�JExpirefrom•su I ' Regulatory Services, Fee • anxxsrABl , 9� Richard V.Scali,Interim Director 161 i0rfp�,t6 Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.tbwn.bamstable.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 i Tforl.Property Address U Fk1A L Q Residential Value of Work$ 17,OUCH , b- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address (c� ci-wv-\ (�)^ ��—T- Contractor's Name Telephone Number S-P<d- 77& C Ww�► v� Home Improvement Contractor License#(if applicable) Email: Ay1`�kU►1" Construction Supervisor's License#(if applicable) — d ' ❑Workman's Compensation Insurance b� Check one: a ❑ I am a sole proprietor DEC ` ❑r-�/I am the Homeowner r E 2 I� 1 have Worker's Compensation Insurance J'✓w/v ' oL- - ®16 N Insurance Company Name ArA Workman's Comp.Policy# �G �r�! l�(� 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ' ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to (SX,n.4� f�-c ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Vee-side Replacement Windows/doors/sliders.U-Value b 2`� (maximum.35)#of windows .{,► #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 me Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit fo \EXPRESS.doc Revised 061313 � C f The CommonweaM of Massachusetts Department of Industrial Accidents f irke of 1westigations 600 Washington Street y Boston,M4 02111 wmv.mass.govfrlia Workers' Compensation Insurance Affidavit: BtmlderslContr-acirrrsTAectridans/Phimbers Applicant Information Please Print Legibly Name Uasi�xhganizatinnu&idaaty I ar Address: �� r4b>-,. (-.-CA:�.,� Ci lStatel t✓ UL66� fY 9; - Phone;g_ e �' Awl employer:'Check the appropriate boa: Type of project(rewired): 1. L a employer with / 4. ❑ I am a general contractor and I p * have hired the sub-=tractors 6- ❑New construction employees(fish andlorpOrt-time). ,��( 2.El am a sole proprietor or partner- listed on the attached sheet. 7- M4(emodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity- employees and have workers' g- ❑Building addition [No workers' comp.insurance comp-insurance.I 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 L E]Plumbing repairs or additions myself. [No workers'comp- tight of exemption per MGL 12.,❑Roofre pairs insurance required.]B c.152, §1(4k and we have no employees.[No workers' 13.❑Other comp_insurance required.]` ;Az yap applicant that checks box#1 mast also fill out the section below showing dL&woakers'compensation policy in&rmxdou_ &amsowners who submit this,afdm i Aksting they ne doing all weak and their hire outside contaactors mast submit a new affidavit indicate suet tContractors That check thi s box must attached am additional sheet showing the rime of the sub-contractors mud stale vhe&u or not those entities have employees. Ifthe sub-contactors have employees,they musrprouide their workers'comp.policy number. -Taman employ r that is prm idi►e g it�orkers'eangmisation insurance for my eerptoy ees. Below is the policy and job site iRfitrRtatIt7l6 . Insurance Company Name: 7 6/6'. cl_�Y 1 CC, Policy 4 or Self--ins.Lic.g: 12-Z t✓C - `7LO Fxpiration Date-- F I`t A —7 Job Site Address�0 4!dm !.4.fi t tA.r_ , a; City/State/zip: /T ja4A-'S �r-4 Arch 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 o€MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STUP WORK ODDER and a fine ofup 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 coverage verification. I do hereby ceeWfy,under the and penalties of petjztrt.that the i►�ormation provided above is hue aced correct r Si Date: / J Phone if: b Official we only. Du not write in this area,to be completed by city or town officiat City or Town: PerndtUcense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 I � DATE(MM/DDNYYY) ~ Ac�® CERTIFICATE OF LIABILITY INSURANCE 11/21/20 16 THIS CERTIFICATE IS ISSUED"AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to { the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsement(s). i PRODUCER CAOM E:NM Nancy Bums I N CLEARY INSURANCE INC. PH E . (617)723-0700 Fax GNE l A!C No E-MAIL ADDRESS: nbums@clearyinsurance.com 226 CAUSEWAY ST. INSURERS AFFORDING COVERAGE NAIC# BOSTON MA 02114 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER 8 SANDY NECK BUILDING AND REMODELING LLC INSURERC: i INSURER D: 84 MINTON LANE INSURERE: 1 WEST BARNSTABLE MA 02668 1 INSURER F: ! COVERAGES CERTIFICATE NUMBER: 105117 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I 1Y EXP �TR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDPOLIDY� MMIDDfYYYY LIMITS I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ { ' CLAIMS-MADE OCCUR DAMAGE (REM c l PREMISESS Ea occurrence) $ MED EXP(Any one person) $ N/A _ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY jECOT- LOC PRODUCTS-COMP/OP AGG $ , OTHER, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accid nt i ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident $ } AUTOS AUTOS ) # NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ i $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ REXCESS LIAR HCLAIMS-MADE N/A - AGGREGATE E $ RED RETENTION$ $ WORKERS COMPENSATION a X STATUTE OERµ AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE E.L EACH ACCIDENT $ 500,000 ' A OFFICERIMEMBEREXCLUDED? N!AN/A NIA R2WC760743 08/14/2016 08/14/2017 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govnwd/workers-compensafonfnvesfigaUons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVEDESCRIBED POLICIES B R S E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWII Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 06010 Daniel M.Croy,CPCU,Vice President-Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r tiTown of Barnstable Regulatw* Semees . yMAS& Thomas V.Geiler,Director Building Division Tom Perry, Building Commissioner 200'Main Street, Hyannis,MA.02601 www.tow.n.barnstablema.us Office: 508-862-4038 Fax: 508-790-6230 Property.Oamet Must Complete and Sign This Section �I If Using A Budder f O*Uer4of the�6*ect property. hereby authorize (y 101,��1. ` . 2S� to act on iity be' . izi al matters relatrveao work authorizedby this building permit application for. {Addtess:of Job) ='T— l� of Date` Ptint Name If PropertyOwner is a for permit please,complete lete the Homeowners License PPS P P _ P .. Exemption Form on the reverse side. o Massachusetts Department of Public Safety .. Board of Building Regulations and Standards License: CS-090335 QJi ltl�°® 11. ° 36•-004930868 Construction Supervisor This card acknowledges that the recipient has successfully completed a i ANTHONY M NESE 10-hour Occupational Safety and Health Training Course in 84 MINTON LN Construction Safety and Health ' WEST BARNSTABLE MA 02668 1 ! Anthony Nese r--Jzu� nn '' Expiration: -- deter Rice 66873 8(ti/2014 l.� { Commissioner 1 (Trainer name—print or type) (Course end date) 1/09/2018 \ F c:llce U/1nrcrtaueeccl!�o�P/l�ics�tcr�tc:te/!5- ` � '� '-,`�' - ' Office of Consumer Affairs&Business Regulation t . HOME IMPROVEMENT CONTRACTOR ` RegisVation178731 -Type: "' MISAFETY CERTIFICATE Expiration "5/13/2018 Corporation Anthony Nese SANDY NECK BUILDING&REMODELING LLC f .1 Has completed Excellence In Safety Elevating Work Platform& i .s Construction Forklift Operator Training at Shepley Wood Products, ANTHONY NESE r t 84 MINTON LANE � '' Hyannis,MA. W.BARNSTABLE,MA 02668 Undersecretary Richard Hughes.C.E.C.M. August 17,2006 + Trainer Training date i Commonwealth of Massachusetts q Department of Public Safety License: HE-128057 Hoisting Engineer l ^, ANTHONY M NESE 84 MINTON LNy WEST BARNSTABLE MA 02668 = � CA,( zu� L Expiration: ' Commissioner 11/0912018 -7 HYANNI.S AVENUE N 2 G°3 G'00"E po 155'.(DEED s APN 287- 1 25 �4 .®.-- 32,550±5F s EX15TING LOT COVERAGE'= 15",I % . ^? Ll__I PROPOSED LOT COVERAGE 17.0% s £" f ro 0 0 � . O - O i I COVERED PORCH s 0 O 4' HIGH (MIN.) C.L. i O rn r Q FENCE W12 SELF- 0 rn No; 54 LATCHING GATES. 2 STY. WD R. 0 max . x COVERED PORCH PROPOSED ROPOS D Gam- IG' X32' IN-GROUND POOL o - 1 . 33.,5' _ 14" COPING N N r w I 6, SHELL GAR. x 155'(DEED) _ x DRIVE{ S25943'00"W' IPRIVET HEDGE -~ ,; .; . f EDGE.OF TRAVELLED-WAY---- !( -- _ NEKTON `AVENUE I H ERE BY;CERTIFY THAT, TO THE BESTI OF MY KNOWLEDGE, . i - AND IN MY PROFESSIONAL OPINIPN, THE LOCATION OF THE PROPOSED SWIMMING POOL; AS SHOWN HEREON, CONFORMS WITH THE HORIZONTAL SETBACK REQUIREMENTS OF Tf1E ZONING �,-- 1BY-LAW-_Of_THE._TOWN OF BARNSTABLE! SITE PLAN _JOB No.-:-I-I'12£5 ` ! IN: i +,, DATE:, I GNOV I t K SCALE: 1 = 30,' BAW TABLE ` (f1YANNIS PDRT)� MA PREPARED FOR TIM:OThY SHAY ,: ,' of{_'HARD COD r j hood 4 Son, inc. s t No 35031 land surveyors engineers: 1.8 route Ga - 5andwich,"ma 025G3 Ph: 508.833.7100 Fax: 508:838.71101 APPLICANT INFORMATION r may' , (BUILDER OR HOMEOWNER) Name Telephone Number 5OX IS At 3 f s+ Address ��'� (f'u e� ��. License# Y y,� � a V.U_� ak !3 x Home Improvement Contractor# IIV � r� � r. Worker's Compensation # ;t ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE T 's TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map '� ,7 Parcel /a Application # ��� Health Division �! Date Issued Conservation Division Application Fee ,. 60 Planning Dept. r Permit Feea Date Definitive Plan Approved by Planning Board T Historic;- OKH Preservation/Hyannis Project Street Address Y 4A 17� Village A,& ;r o 0-1'f Owner 4( Address ,o:f er if e- Telephone 0 _ 710 .� `7.-6 Permit Request AepM e de-/ jk-4' e n Et Plb 6d-61 i1 e-7-S Q�R-'fi `Ft0:n 0 4() U 11,k L4 144 e,e- /?-e-iv y- l o-p r c n i614 rgav-- Lrs-yiilfa- d- I-e-rs Cat Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Q "0. "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 d ,s Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full UErCrawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing new Total Room Count (not including baths): existing new First Floor Room Count GO Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/c stove:Q YesxQ No Detached garage: ❑existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑exis ing ❑mew maize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: P ell Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name L-/ Telephone Number 776 r`Address t? License # 0 Home Improvement Contractor# r Worker's Compensation # `-1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Z4-r7 k SIGNATURE DATE FOR OFFICIAL USE ONLY t , - 'APPLICATION# L . DATE ISSUED V MAP/PARCEL N0. ADDRESS VILLAGE " OWNER DATE OF INSPECTION: FOUNDATION FRAME ®ram �� �f -o87 INSULATION FIREPLACE 3 ELECTRICAL: ROUGH FINAL } PLUMBING: ROUGH FINAL GAS: ROUGH FINAL =4 FINAL BUILDING ' 'z DATE CLOSED OUT ASSOCIATION PLAN,NO. , ' The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations a + d 600 Washington Street �< Boston,MA 02111 www.mass.gov/dia Workers}Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/OrganizatiowTndividual): . la, 44 Address: City/State/Zip: F4 , 1��G1. 0 iS3d Phone.#: $ .Are an employer? Check the appropriaV ox: :Type of project(required):. 1,❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on the'-attached sheet. 7. [d Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers'$ 9 Building addition comp. insurance, [No workers comp.insurance 10.❑Blectrical repairs or additions required.] 5. We are a corporation and its- p '3.❑ I am a homeowner doing all work officers have exercised their l l.[]Plumbing repairs or additions myself.[No workers'comp. right 6f exemption per MGL 12,[]Roof repairs insurance.required.]t c. 152, §1(4),and-we have no 13.❑ Other employees. [No workers' comp,insurance required.] *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ar 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. Insurance Company Name: Policy#or Self-ins.Lic,#: - Expiration Date: Job Site Address: n � f1JUP cfU City/State/Zip: AAA . 1 S3ol 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 covera e verification. �do hereby ce u der the pains and penalties of perjury that the information provided above is true and correct. i afore: Date: Phone# , Sti�J 9S� 3/ sue, r0fjiclalonly. Do not write in this area, to be completed by.city ar town offcciaG n: Permit/Licensehority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a' joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §251C(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 ehapter.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 cornnpl aace 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-,it necessary,supply sub-contiactor(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 cf 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town 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:. (�Commmwealth of Massachusetts Departnmt of Indust al.A.ccidects Office of Investigations 600 Washingtoli Street B.ostonx_MA 4211 t TO. #617-727-4500 ext 40,6 or 1-977 MASSAFE Fax#6.17-727-7749 Revised 11-22-06 • www.mas,­,_gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors(EIectricians/Plumbers A licant Information Please Print Le 1 /2L7` -/Jlv w� Name (BusiersOOrgazuzfion/Individuo): ,A Address: / City/State/Zip: �Pfh{�iiy7l•e �. F2-0 re you an employer? Check the appropriate box: Type of project(required): a employer with 4- ❑ I am a general contractor and I 6. ❑Hcw construction employees(full and/or part_time).* bavc hired the sub-•contractors I am a'sole proprietor or partacr- listcA on the attached sheet 7. 1modeling ship and have no employees These sub-contmctors bavo 8. ❑Demolition employees and have workers' working for me in any capacity. 9. ❑Building addition o workers' ;nc��rancc comp.insurance t comp.� 5. ❑ Wearc a corporation and its 10_❑E1.cctricalrepairs or additions rC quircd-] officers have I mucised their 11.0.Pl=bing repairs or additions 3.❑ I am a homeowner doing all work - mysclf-[No workers' comp. . right of exemption per MGL 12 ❑Roof repairs in_sux-ance required_] t c. 152, §1(4), and we havt no 13.0 Other employees. [No workers' camp.insurance required.] *Any appl;ont that chccl5 box#1 must also fM out the section below abowing their workers'co on policy infmrmli n- t Homcownut who gubmit this RMdavit indicating tbey arc doing RM work and then biro outside eont mr-tom must rubrn;t a nrw affidavit indicating eueh- tContractors thxt cbcckthis box must atiacbcd an additional rhmt showing the name of the sub�oniractrna and stale wbctha ornot thosd rntitics Nava cmployecs. If the sub-contractors have mW1a)ccg,thry nrurt pravitib their workers'comp.po'bcy ntunbcr. I am an employer th.id is providing workers' compensation insurance for my employees. aerul-v is the polity and jab site information. r Incnrancr,Company Namc: Policy#or Sclf-ins.Lic. #: Expiration Datc: Job Site Address: / City/State/Zip: Attach a copy ofj4-,1,1r111r0 �11npeMati=policy declaration.page(showing the policy n er and"expiration date). ' Failure to sccurc t:overagc as required imdcr Section 25A of MGL c. 152 can lead to the imPosid0n of crin,;nal penalties of a 5ne lip to$1,500.00 and/or onr-year imprisonment, as writ as civil penalties in the form of a STOP WORK ORDER and a filar, of up to$250.00 a day against the violator. Bc a.dyiscd tbat a copy-of this statamerit may be forwarded to the Office of Inycsti ati°ns of the DIA for insurancc coverer c verification. I do her certi un the pauts•and penalties of perjury that the information provided above is true and correct Si strut: �wti� Date: / Phone# officw use only. Do not write in this area, to be completed by city or lawn official, City or Town: PermitUcense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other . 'Contact Pergola: #: Massachusetts Genera] Laws chapter 152 requires all employers to provide workers'compensation for their employees: pursua ,t to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written_" ' An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing_engaged in a joint cntcrprise, and including the legal mprescatatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employccs. However the owner of a dwelling house having not Mort than three apartments and who resides therein, or the occupant of the l iwdling house of another who employs persons to do maintenance,construction or repair work on such dwelling house )r an the grounds or building appurtenant thereto shall not because of such.employment be deemed to be an employer." v4GL chapter 152, §25C(17 also states that"every state or Iocal licensing agency shall withhold the issuance or -enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any Lpplicant who has notproduced•acceptable evidence of compliance with the insurance coverage required." VdditiomaIly,MGL ohapter 152, §25C() states`Neither the commonwealth nor any of its political subdivisions shall rater into any contract far the performance of public work until acceptable evidence of compliance with the ins-urance cquircmenfs of this chapter have been presented to the contracting authority." LPPlica.nts Rase fill out the workers' compensation affidavit completely,by checking the boxes that apply to.your situation and, if eccssary,supply,rob-eontractor(s)name(s), address(cs) and phone numbers) along with their cerEficate(s)of auraucc. Limited Liability ConVanics'(LLC) or Limited Liability Partnerships (LLP)with no-cmaployces other than the wcmbtrs or partners, are not rcgtTircd to carry workers' compensation inanance. If an LLC or L12 does have nployecs, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial ceid,nts for confirmation of insurance coverage. Also be cure to sign and date the affidavit. The affidavit should returned to the city or town that the application for the pc�it or license is being requested,not the Department of idustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' ,mpcnsatiort policy,please call the Department at the nurMber listed below. Self insured companies should enter their :If-kMU-anro license number on the appropriate line. ity or Tow i Officials ease be sure that the affidavit is complete and printed legibly. The D cpartmcnt has provided a space at the bottom 'the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant case be sure to Ell in the permit/license number which will be used as a refcrcnce number. In'addition, an applicant rt must submit multiple permit/license applications in any given year, need only submit onp affidavit indicating current licy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or Nm)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the. plicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit,must be filled out each ir.Where a home owner or citizen is obtaining a license or permit.not related fo any business or cormncrcial venture ;, s dog license or permit to brim leaves etc.) said person is NOT required to complete this affidavit t Office of Investigations would l0ce to thank you in advance for your cooperation and should you have any questions, aso do not hesitatx to give us a call Deparfinent's address, telephone-and fax number. The C&mmonwealth of Ma.ssac-huse#s Dcpartrmrit of Industrial Accidents Office of Investigations 600 Washing�aa Street Boston, MA 02111 TO. # 617-727-490.0 ext 4.06 or 1-877-MAS.SAFE Fax# 617-727-7749 11-22-o6 vrww.mass.gov/dia RightFax C2-2 8/20/2008 8 : 25 : 24 AM PAGE 3/003 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 08-20-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE EDWARD A GRAZUL INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 337 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDINGCOVERAGE MARSTONS MILLS,MA 02648 COMPANY 28Y2K A HARTFORD GROUP INSURED COMPANY B R L T CONSTRUCTION INC o COMPANY m Cs. 31 MANNI CIRCLE C 33. to CENTERVILLE,MA 02632 COMPANY " D C COVERAGE C2` > THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN�-ATED, x=' NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATEMAV BE ISSUEDBR - MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUC POLICIES. " LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �D Jtil CO POLICY EFF POLICY EXP (,� Q' LTR TYPE OF INSURANCE `'POLICY NUMBER DATE(MM\DD\YY) DATE. MITS _ I r GENERAL LIABILITY GENERAL AGGREGATE $ rT1 COMMERCIAL GENERAL PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one tire) $ 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 LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-1051C045-07 12-24-07 12-24-08 STATUTORY LIMITS X THE PROPRIETOR/ " EACHACCIDENT $ 100,000 PARTNERS/EXECUTIVE X INCL DISEASE. POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF BARNSTABL.E - EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUT ATTN:BUILDING DEPARTMENT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF 200 MAIN.STREET ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25-5(3/93) Ramani Ayer Town of Barnstable y��pF THE Tpwyon Regulatory Services Thomas.F. Geiler,Director MAS& Building Division PTfD► � Tom Perry,Building Commissioner . 200 Main Street; Hyannis, MA 02601 ym-w.town.b arnsta bl e_ma.us fice: 508-862-4038 Fax: 509-790-6230 HOKEOWNER LICENSE EXEMPTION Please.Print DATE G 701 SS (( I 10B LOCA I70N: T T tf,3 ^rl ; �� �/1c`I ,Oa r n u mb cr street village "HOMEOWNER": >�o+ O ► 5b�'�' ,Jdt- ; ( 3 qne `home phone# work phone# CURRENT MAILING ADDRESS: �i It SIP lartA bo ro 114a 6 3 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of sir units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. bE)~TNITION OF HOMEOWNER person(s) who owns a parcel of land on•which he/she resides or intends to reside, on which there is, or is intended to- . be, a one or two-family dwelling,_attached or detached structures accessory to such use and/or farm structures. A one home in a fwo-year period shall not be considered a homeowner. Such person who constructs more than "homeowner" shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building;permit.JSection 109.1.1) The undersigned"homeowner"assumes responsibility for compliance.with the State Building Code and other applicable codes, bylaws,rules and regulations. Me undersigned"homeowner"certifies that be/sbe understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and -equirem ts. signature of Homcown .pproval of Building Official Note: •Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the tate Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is rLquirrd shall be exempt from the provisions 'this section(Section 109.1.1,-Licensing of construction Supervisors);provided that-if the homeowner engages a persons)for hire to do such )rk that such Homeowner shall act as supervisor:" Many homcownas who use this exemption air unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q, Iles&Regulations for T.iccnsing Construction Supervisors,Section 2.15) This lack of awamncss often results in serious problems,particularly Icn the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would Wtith a%sensed pervisar. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilitirs,many communities a of this as part of the permit u application, i the homeowner certify that hr/she tmdastands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by .mil towns. you may care t amend and adopt such a fom✓certification for use in your community. • t mEr�s• Town of Barnstable R R Regulko ry Services • BARIi5Ta8LFi y IMAM& Thomas F. Geiler, Director �'°rFa►u�a�� - Building Division Tom Perry, Building Commissioner 200 Main Street; Hyannis, MA 02601 www.town.barnsta ble_ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign ThisSection If Using A Builder I , as Owner of the'subject property hereby authorize to act on IMy behalf, in all matters relative to work authorized by this building permit application for: (Addtess of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please,complete the Homeowners License Exemption Form on the reverse side. uo Jr- \n y Z J N zl- J l d J J " ' , .�-/Svv� {UrGFfIZ 6'U �� lS �� _; �.. t ' .� �� �o� � i�v ,� Y� �rL� it IV atAA CA.) ( Nrw6 rL,pal'� yvo 9IVr N G orc� AA G L��LS E9 Po F w �.° NOTE: I M ® 0 - CONCEPTUAL PLANS ONLY, op—to_ NOT FOR CONSTRUCTION. FIELD VERIFY ALL DIMENSIONS Hudroom - (A AND EXISTING CONDITIONS PRIOR TO FINAL DESIGN • �— AND CONSTRUCTION. - - .11 INTERIOR FURNISHINGILJ Li Li Li L SHAY S 7 . III1111 IIINII 33"Rai. ee is"F11. 36"Dk - EXletinc.]. 811der SUMMER Bp— Dnua. RESIDENCE 54 Hyannis Ave. Hyannisport,MA I.. open — to Hell - 11 O O O 111am B1c,.pw. " . FF1 11 :11 PROPOSED 0 0 B Re ee ELEVATIONS Broom Food Food 36" 36° 19"w 36".— closet PanvU Pantry Drw Dnu vert, oyj.wI Kitchen `eY+s ten9 12"w door Mudroom KITCHEN INTERIOR ELEVATIONS PNB Interior Design,Inc. stone Cwntertop stone cowntenwp 94 Pleasant Northboaught Street 01532 ® ® � F..•508-393-3866 F:508-393-9648 � I� lil l ! I � Il� ii Outalde 1alarld IB"w DW 36 Blnk IB" 4i6I08 Tranh Beae Cab. /��/ /t Pe' Pullout _ ^K-2a 'VVOS ISLAND ELEVATIONS 8.011. va^=r=o^ PNB sr-Id' NOTE: CONCEPTUAL PLANS ONLY, NOT FOR CONSTRUCTION. FIELD VERIFY ALL DIMENSIONS 411 ��-6u 4�-0�4u -10�4,I 8�-IO�II 9��IIII AND PRIORTIO FNNAL DESIGN NS AND CONSTRUCTION. 8'-IOQs° INTERIOR FURNISHINGS --- ------- SHAY Electrical. ,_ _ - - SUMMER �Y service/ Ibo ,_ T I Meter LAUNDRY IL, Q RESIDENCE DR - 54 Hyannis Ave. Q j 0 Hyannisport,MA T m I itl x r— _— Add new wall, r S, door and hooka. `n PROPOSED ---- chen Kit 'v -------------- --- _ d - MUDROOM ___ Mudroom 4 New ench =� KITCHEN I? x. seat:open iV belo ' ® I. I I.Q `C � r i star _Ed MeterPantryPantry Closet Closet closet PNB Interior Design,Inc. ge 4'-10"x 3--2% Chan . S-S II I sw or l-10 4 I " " " 94 Pleasant Street g. -10 9-O. Northborough,MA 01532 T.•508-393-3866 P 508-393-9648 4/6/08 SK-2 l/I/08 P N B oF� rTown of Barnstable *Permit#,;065N�Q J OExpires 6 m onths rom iss e date Regulatory Services Fee saaxsrast,e; Thomas F. Geiler, Director v Muss. 4> i639. Building Division PrFb��a - Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Noe ha lid without Red X-Press Imprint Map/parcel Number 7 t a Property Address �� �1 (/Q.o� � ) � . Ott i G f residential Value of Work 7 g (/� `� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ,S,-AA_ e . Contractor's Name k L7— GQ/trj r 111L 5"/4/0d 6 —Telephone Number=5_6 9`7 7( '91 l fy Home Improvement Contractor License# (if applicable)_ _3�y_ p2 F [ Workman's Compensation Insurance PERMIT Check one: ®PRESS ❑ I am a sole proprietor. ❑ ram the Homeowner AUG 1- 9.2008 FIK have Worker's Compensation Insurance Insurance Company Name n� TOWN OF BARNSTABLE Workman'§Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) f at['n�e-roof(stripping old shingles) All construction debris will be taken to S� ( �c� ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) ­Z1 *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc ' �1 r- ***Note: Property Owner must sign Property Owner Fetter of Permission. A copy of the Home Improvement Contractors License is required. Crt � SIGNATURE: Q:\WPFILE_STC)P,M,I\building permit forms\EXPRESS.doc The Com"tnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ' Boston, MA 02111 www_mass.gov/dia Workers' Compensation Affidavit:Insurance Adavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LetTibly aD1e(Business/Organizaiionlfndividaal): d �he Address: (e — City/st telZip: & b/��+e �/(Q �� Phone.#: 7^7 6 Are you an employer? Check the appropriate bwc Type of project(required): 1. am a employer with 4 ❑ I am a general contractor and I 6 ❑New construction employees (full and/or part.timc).* have hired the stilrcontractors 2.❑ I am a sole proprietor or partmr- listrA on the attached sheet 7. ❑Remodeling ship and have no cmployces These sub-contractors have. g, ❑Demolition" oyes and have workers' working for me in any capacity. empl e 9. [] Building addition [No workCrS' comap.'ir gmame Comp-insurance$ S. F] We arc a corporation and its 10-[]Electrical repairs or addific required} . officers have exercised tbcir 1 L❑Plumbing repairs or additir 3.❑ I am a homeowner doing all work myself [No workers' comp. right of exemption per MGL 12-E]Roof repairs incnranCe r t P. 152, §1(4), and we have no egnu�d} employees. [No workers' 13.[]Other comp,inch cc required] "Any applicant fhat rhxla bar#1 must also fill out the section bdorw showing their workr_-rs'eomp=nr4on policy infmznation- t Honxowoat who submit this affidavit in6ieating fbey arc doing2M work and thrn hire outside contractors west mbinit anrw affidavitindirafing such XCrnitiactnrs that chmv this box amst atbArd an additional sheet showing the name of fhe sub-cont a� and of ttn whether or not thosd cntitics have cn-[pioycrs. if the sub�onb-act am have rcnployces,they must provi&their wmIrcxz'camp.policy nttmbcr- I am an emplayer that is providing workers`compensation Insurance for my employees. HeLaw is the polity and job site information.- G�G is i-ance Company Na=: Policy#or Sclf-ins.Lic.#: Expiration Date: fobSitc Addrt ss: it Q A/5c City/stddzip: Attach a copy of the workers' compensation policy declaration age(showing the policy number and etrpiration dau Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ai Eno tip to$1,500,00 and/or one-year m'prisonment, as wrU as civil penalties in the form of a STOP WORK ORDER and a of up to$250.00 a day against the violater. Be.advised that a copy of this statrmcrit may be forwarded to the Office of 1nvmti9atiDns of the DIA for invura-n_ce coverer e verification. I do hereby certify the pains" en of perjury that the information provided above is true and correct Phone# 57 � 7 7% O pedal use only. Do not write in this area, to be completed by city or town of ceiQL City or Town.: Permit/License# Issuing kuthority(circle one): L.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.PInmhing Inspector 6. Other R:ightFax C3-2 4/23/2008 9:04 :37 AM PAGE 3/003 Fax Sarver ACOR®. CERTIFICATE OF INSURANCE DATE(M*DD?YY) 34-2'_-:.08 PRODUCER THIS CERTIFICATE IS ISSUc.l AS A MAYTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT•iFICATE ;DWA3D A GR.A7.i,i_INS AG('11' HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTENT:OR Y+)BOX 3_7 AL.TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CUI:9PANIE'S AFFORDING COVERAGE I,fLaRSi'ONS MILLS, tR 02C48 COMPANY 2S1' I; A .fj,.kKIT.OR.D GROUP INSURED COMPANY B it L T CONSTRL'CTJ.OPI INC . COMPANY. : 31 MLANN[CIRCLE C C'ENT-,RVJ?..LF.,MA 02632 COMPANY c COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURAMCE LiSTEO BELOW HAVE SUN ISSUED TO THEiNSUPED HAIt3E:D ABOVE FOR THE POLICY PERIOD iN01CATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR COHDITK7N OF AtiY CONTRA.^,?'7i7 OTHER DOCUMENT WN'H RE_PECT TO WHICH THIS CERT3iCATE MAY Br:ISSUED OR MAY PERTAIN.THE INSURANCE AFFORCEO BY THE POLrNES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS.EXCLUSIONS ANY:CONDITIONS CF SUCH POLICIES.LIMf_lS:?NO'NN MAY HAVE BEEN REDUCED BY PAW CLAIMS. - CO POLICY EFF POLICY EXP LTH TYPE OF INSURANCE POLICY NOMBER DATE(MM?DD%YY) DATE(MGttDO%YY) LIMITS r.;EtiERAL AGEIG,'EGA.TE � GENERAL LIABILITY PRODUCTS-COMPrLIP AGu. CC`A`AERCIAL GENERA_LIABILITY PERSONA,.3 ADV.IN.ILRY S CLA:4rr5 MADE �.JC•:LlR.- OWN'ER'S&1 CONTRACTOR'S PROT.- iREi DAMAGE o FiRED.APiiA,G�(Anyoreius;' MED.EXPENSE(Any one peo-,un) S AUTOMOBILE L.IABILi7Y COM9INED SINGLE LIMIT 3 ANY AUTO ALL O. JNED AUTOS' BODILY I.\,IUR' (PeY ParsuFj SChED%JLE AUTOS BODILY J�_URY;Per Accida-m) a PROPERTY DAl%/A(3E $ TIRED A.1TOS Ov OWNED AUTOS GARAGE LIA601_I'rY AUTi7ONLY-EA ACCIDENT 5 A','Y A--iTO:i CT:-iER'rNAN AUTO ONLY: EACH ACCIDE0 S AGREGATE S EXCESS LIABILITY E,ACI-0l_GURRENCE I..MERELLA FORM � P- OTHER THAN .-A UMERE_ FORA AG BEGAT WORKER'S COMP_:NSAriON AND A EMPOLYER'S LIABILITY U8 105?C.:046-07 122 12-2n..Q? - '3-Ofi STATUTORY_li.4TS EACH AGCt DENT 100,000 T:+E PROPRIETOR/ a 51)0 rt:r :lARTNERS'EY.EC,UTiVE < INCL DISEASE.POLICY LIMIT ,.,,_• .)- -,FF!CERS ARE: EXCL . DISEASE EACH SiVPi.OYO° OTHER DESCRIPTION 0. OPERATIONS!LOCATIONSIVEHiCLES!RES7RiCT10NSiSPF.CIAL ITEMS i3F°I_ACF_S.4NY PRIOR CF:RTIFfC4TF,[BSI-;fiCt'TOTHF.CFR_l'iFfCATE HOLDER AFFECTING t:V'�?KERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD-AtJY' r fH=.niiOVE U?SCF:IEF.'�-CLIC ES BE CANCFLLEGB`�FCR_=THS ['0 WN 11I'Ii r;rd S�':=��(.). Th+ERrOP HF.c:U'NG COP)"ANY A'U FND AV04F Nh-,.l'. . - )Ale til i•ilf.tliNCT:., iJ-I;��Uc.-IrICAII_HOLGL-RNnPA-JIOTN..,_--i,_�I il�{ :Ii't.;IIDINGDEPAIR, \TEN_17 FriP_ RttCy'Fit_SUCHNSHALLIvt?OSFNCQELIGAT+CNGRLRSitT'r "0). KAU-�:STREET - K!ND UP:itJTHe CUP,IFANY,'I_:':AGENTS CR 4EPR53c!•! ATiVFS. I])',�NNIS,MA 0260I AUTHORIZE?REPRF.o"r.NTA73VE ;ccstD 25 I�; ) Kar a-ai.Aver Island Sid' andRoofin N� h . PRI, a division of RLTConstruction,Inc. Proposal To: August 18,2008 Tim Shay 54 Hyannis Rd. Hyannisport, Ma. We are pleased to submit the following specifications and estimates for re-roof. Remove existing cedar roof and flashings. Install copper drip edge and pipe flashings. Install 18" red cedar shingles using stainless steel fasteners. Clean up and haul away debris. We hereby propose to furnish material and labor - complete in accordance with the above specification, for the sum of $49,800.00 PAYMENT TO BE MADE AS FOLLOWS: Payment in full due upon completion All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the above specifications involving extra costs will be.executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance. RLT Construction,Inc. carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature ;' a Start Date: Signature 31 Manni Circle Centerville, Massachusetts 02632 Telephone 508.420.5243 and 508.833.5249 • .fax 508.420.1776 • Emai(caperoofer@caperoofer.com i ✓/ZB tsllI�/112002C!/PO��UGQ.QdCLCfjlC6P�(Q, Board otBuilding Regulations and Standards t r HOME,IMPROVEMENT CONTRACTOR f Re&tr` Io-, 134286 { Expiration 10/22/2009 Tr# 13342Ei f - T;ype DBA> I ,RLT CONST. IN DBq k'SLgND S.�DING&ROO.FIN F BONNIE TAYLOR 31 MANNI CIRCLE t CENl ERVILLE, MA 02362 p , Administrator • a