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HomeMy WebLinkAbout0009 LAFAYETTE AVENUE g ����y��� ��� t Application number..... .'.. . .. 3 � . e Date Issued.......��!�°�� BAWNSTABM 1639� �0 ,���` Building Inspectorsslnitials..i .............................. Map/Parcel......02 g.................. ..................... T-6WN Co . OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATEERIZATION . PROPERTY MORMA1 TIO`N Address of Project: .rac 2 c- 411 NUMBER STREET VILLA Owner's Name: Phone Number o2 O/- 410 Email Address: Cell Phone Number 229-7 7S'- Project cost Check one Residential V1 Commercial „ OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Se Ka Oc-Aac Date: TYPE OF WOE Siding U� Windows (no header change)# 7 0 Insulation/Weatherization Doors (no header change)# Commercial boors require an inspector's review J Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONITRACTOWS INFORMATION Contractoesname (�d�un i�enn�so✓� - sov 2�n �PsJ Fr,��rva Home Improvement Contractors Registration(if applicable)# !7 3 2.i-L (attach copy) Construction Supervisor's License# 01 S­7 0� (attach copy) Email of Contractor A Sw r 4 qi #,1a6 •COAi Phone number Il01— Z 2 R -190D ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY/S IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. f k . 1 1 APPLICATIONNUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00arn-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLLT STOVES * Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOwNEWS LICENSE EXENTTION Homeowner's Name: Telephone Number Cell or Work number I understand any responsibilities sunder the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE °Signature Date_10" All permit applications are subject to a building official's approval prior to issuance. 4 t Renewal Agreement`Document and Payment".Terms bvAndersen. - Aw Renewal By Andersen of Southern New England'. Linda Woodwell . Legal Name Southern New E6gland Windows,LLC ` 9 Lafayette Ave RI #36079,:MA#173245,CT'#0634555, Lead Firm#1237 " Hyanrnsport,M' 02647• wixoow RE rLACEMIENT 10Reservoir'Rd LSmithfield,RI02917, H:(201)410-8076- w Phone'.866-563-2235 I Fax:•40.1,-633:-6602 ilsales®re'newalsne tom', C:(508)7:75-3647 w • f - Buyer(s),Name: Lihda.Woodwell ,. `Contract Date. .0 77 Buyers)ScreetAddress 9 l.afa ette Ave;_H annls ort Y Y P. , MA 02647' Primary Telephone:Number: (201)410 8076 Secondary Telephone Number (508)775 3647 Primar 'Email:'Ioodwell@gma11 eoni .' Sec onda ` Email t Y Buyei(s)'hereby.iointly and.'severally agrees to purchase the products and/or,services.of Southern New Englind Windows LLC d/b/a Renewal By Andersen of Southern New'England("Contractor");in'accordance with rhe'terms and coriditi ris;described in this Agreement Document and Payment.Te'rms,any docuitients listed iti the Table of Contents,and any other document attached to.'this Agreement' Document,the•terms of which are all agreed to by the parties and'incorporated herein by reference;(collecfively,this"Agreement ) r Buyei(s)hereby:agrees to sign a completion certif cate after Contractor has•completed.all�work uiider.this Agreement. , otal Job:Amount r $13,664 B si nin this A'reement, ou acknowled a that the..Balance Due,and:the Amount T Y g g g Y g t Financed must be made by personal check bank check',credit;card or:cash Deposit Received $4 624 ` Balance Due $9,040 Estiriiated Start x t Estimated Completion Amount F►nancedi 10 to'12 weeks 10:to 12 aWeekS. 0 . Method of Payment: ,CreditaCard A. WeY schedule ninstallations based on the date of the signed contract-and secondarily on the datein which,we'om lere th ethnical"me em is-The installation a to at we"areproviding at'tliis time is only an estimated We will communicate an ofPieialtdate. ` +` 'and time'at a laterdate Rain.and 6' me,' atherare the most cottimon•causes for:. . delay, n i' Notes'#Deposit of$4624 up:'front','baFance due upon install m r f Buyers)agrees a'40nderstands that this Agreement, the entire understandings between the parties and that there are no verbal understandings changing:or modifying any.of the:terms of this Agreement.No alterations to or deviations from this Agreement will be valid w.ithout.the signed,`written consent of.both Bi yer(s) and Contractor` Buyer(s)hereby acknowledges that Buyers) I)has:read this -Agreement, understands the terms'of this Agreement;and has received a completed,signed,and dated copy of iiiis Agreement;including the.two attached Notices of CLwell'auon,.on the date first writteti above and 2)was orally informed of Buyer's right to cancel,this ' ' Agreement: NOTICE.TO BUYER: Do'not sign this contract if blank You are entitled-to a copyiof the.contract at the time you sign r .. a .. .... ... - . • V3� YOU;-THE 9UYER; IVIAY.CANCEL.THI5 TRANSACTION AT ANY TIME`NOT.LATER THAN MIDNIGHT OF 09/20/2018.ORTHE.THIRD BUSINESS.DAYAFTER.THE DATE OFTHIS•TRANSACTION;` 'WHICHEVER:•DATE IS LATER.SEETHE ATTACHED NOTICE OF CANCELLATION FORM FOR AN . EXPLANATION'OF THIS RIGHT Legal Narne:Southern-New England Windows,-LLC " q• 1 ' dba:Renewal By A s of Southern New.England "-. Buyer(s) r py�• b" a x Signature of Sales•Person ., ;:`.RSignature Signature:.,.• ' Paul 6 boy ?Linda Woodwell Print Name of Sales Persona: Pnnt Name'.`' " Print Name ' UPDnATED .09/17/18' .'` �T ,° a Page.2 / 13 Wr Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home lmprovement-Contractor Registration ._- - - - Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS,LLG- Expiration: 09/18/2020 10 RESERVOIR ROAD =_= _- SMITHFIELD,RI 02917 - Update Address and Return Card. CA 1 0 20M-05i17 •_��F �CYi7/)7.!'/�lL'P.O,G��/.�,;('�Zr/l,I//.CLJCl� ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Renistritio_n._ Expiration Office of Consumer Affairs and Business Regulation ;173245 _ 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW-'ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretary wbu tlau Without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consfra Ct bn`Supervisor E CS-005707 _ pires: 09/08/2020 �. RIAN ® DENNISON 8 BLACKWELLy®RIVE ; CHARLTON MA.-, so7 Commissioner , The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 ' Boston,K4 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): la/7 �n ��fplr/tf Address: City/State/Zip: Phone#: 41 p !—Z2,-q f OO Are you an employer?Check the appropriate box: Type of project(required): i. lam a employer with e;+0+ 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. EJ Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.F�I am a homeowner doing all work myself[No workers'comp.insurance required.]' 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 1 LQ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.r7 I am a ❑Roof repairs general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.* 13. J 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. her W i/1 O G✓ 152,§1(4),and we have no employees.[No workers'comp,insurance required.] rr /a <-et•_ts *Any applicant that checks box#1 must also fill out the section below showing their workers compensation police information. }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 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 mP employees. Below is the policy and job site information. Insurance Company Name: '-`f e-/n CA S lei C. (;D&I I)a'n�/ — Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: "/ L a -t g t/P_ ? /e City/,State/Zip: ;$ or-f MA Attach a copy of the workers' compensation policy declaration page(showing the policy number 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer under the pans and penalties of perjury that the information provided above is true and correct Si2ruatur Date: V" 3 Phone;" 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#: CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYr) 12/29/2017 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 CONS TITUTE A CONTRACT BETWEE N THE ISSUING AND THE C U NG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polic ies must be end the terms and conditions of the y( ) endorsed. If SUBROGATION IS WAIVED,subject to policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). - PRODUCER CONTACT CoBiz Insurance, Inc.-CO NAME: 1401 Lawrence St, Ste. 1200 PHONE .303-988-0446 (A/C,No:303-988-0804 FAX Denver CO 80202 ADDRIESS, COMaiI cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC p INSURED ESLERCO-01 INSURER A.Acadia Insurance Com an 31325 Southern New England Windows, LLC. INSURERS:Firemens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 3 t452 10 Reservior Rd INSURER D Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1252851165 REVISION NUMBER: THIS 1S 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. INSR ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER MMIDDMM/DDIYYYY LIMITS POLICY EFF POLICY F1(P - A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/112018 1l7/2079 EACH OCCURRENCE S 7,OOD,ODD CIAIMS MADE X OCCUR PREMISES SES EWIAGE TO aENTOc"E ante S 300.000 MED EXP(Any one person) 510,0DO 1 i I PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ; i GENERAL AGGREGATE S 2.000.000 XF71 DOLICY JECT L�' LOC PRODUCTS-COMP/OP AGG S 2 000 000 .. OTHER: 11 I I IS A AUTOMOBILE LIABILITY. I I N CPA315S 28 I 111l2018 1/112019 COMBINED SINGLE LIMIT 1 Ea aeddentl 1 1.000 COD X ANY AUTO ! i BODILY INJURY(Per person) is ALL OWNED SCHEDULED I. AUTOS AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS I Per accident s S A X UMBRELLA LIAB X OCCUR i CPA315672e j 1/1r<u18 I 11V2019 EACH OCCURRENCE 510,000.00D EXCESS LIAB CLAIMS-MADE j I AGGREGATE 510,000.000 DED I X I RETENTION S 111 � S B WORKERS COMPENSATION WCA3158729-20 1/112018 1/112079 X I PER - OTH- AND EMPLOYERS'LIABILITY YIN $7ATUfE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ E.L EACH ACCIDENT S 1,000,000 OFFICERIMEMBER EXCLUDED? N 1 A (Mandatory in NH) If yes,descnbe under E.L.DISEASE-EA EMPLOYEE,51,000,000 DESCRIPTION OF OPERATIONS be]— I E-L DISEASE-POLICY LIMIT 51,000,000 C Pollution Liability 7930073340000 ( 11112018 I 111r2019 I Each occurrence S1,000,000 Claims-Made Policy Aggregate S1,000,000 Retroactive Date 06120121113 Deducfibie 510.000 - I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FQr`%g'Ml$onal Purposes AUTHORIZED REPRESENTATIVE '� ©198a-2014 pCORO CORPOtiA7\0�• A\\rvghis reserved. \o o ate tecj\steted mat\cs of NCO?D _..nn�ameana 5 .-- W 4 a = , fi - �* Expires 6 months from issue date egIatory Services gee ' Thomas F Geiler,Director wn ; { (, Y =gBu duig Division r P nil rn erry,CBO, `$. ding C To -Per 4,200 Main,Street,,Hyannis:Na 0260 I r 4 www.town.ba nstabl i ma.us>. �. t y Office: 508-862-4038' Nh ' F e Fax 508-790-6230 s EXPRESS°PER11�lCT APP CA`FI®N RESIDE uNot Valid without Red X-Press7inprint z` Map/parcel Number'' c r s Property Address Residential, _Value of Work „`J , Nfimmum fee Of$25 00 for work under 56000 00 ° r b Owner's Name&Address 3 Contractor's Name r y' Telephone Number l/ t 4Y k Home-Improvement Contractor License#(if apph cab>>le) y lI0�D9 . rF? � �A Y y •.F. Y �... a Icable t / ction Supervisor's License#(n` pp ) Constru 77 , Q�VJorkman'.s CornpensatlonInsurance ± 'aieck one t � FEB 20�2 fr I ain a sole piopnetor _9 I am the Homeowner x .� [�]%I have Worker's CompehsationInsurance ' ` O OF RARNST�►RLE Insurance Company Name 's Cob Policy# (J U�3�7 D/t l� t. "��workman � • Copy of Insurance Compliance Certificate must be on file _ .. s Permit-Request(check box)`t " ❑,Re roof(stepping old shingles)`;All construction debris will be taken to Re roof(not stripping, Going over %existing layers of toot) ` [] Replacement Windows/doors/sliders U Value: ";(maxmzum 44): ' , *Where required: Issuance of ttus permit does not exempt compljance with other town-departrnent regulations 1..e Historic Conservation,etc ti : Pr. e " Owner must si µ`Pro er Owner Letter of Permission , I ty gn r p ty , opy of the`Home—Improvement Contractors License is required , SIGNATURE: " Q Forms:expmtrg i vise061306 . ACORO® DATE(MM/DDIYYYY► CERTIFICATE OF LIABILITY INSURANCE 1/25/2012 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(les).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 certificate holder In lieu of such endorsement(s). PRODUCER cO Er Erica H.O-Connor HART INSURANCE AGENCY,INC. "A"aE` 243 MAIN STREET PHONE (508)759-7326 ac N.:(508)759-7366 PO BOX 700 EA DRESS: BUZZARDS BAY,MA 025320700 INSURE S AFFORDING COVERAGE NAIC# INSURER A; ARBELLA PROTECTION INS CO 41360 INSURED EJ Jaxtimer Builder,Inc INSURERI: ARBELLA PROTECTION INS CO - 41360 48 Rosary Lane ARBELLA PROTECTION INS CO 41360 Hyannis,MA 02601 wsuRER c INSURERD: ARBELLA INDEMNITY INSURANCE COMPANY 10017 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MWDDMW/ A GENERAL LIABILITY - 8500042039 01/01/2012 01/01/2013 EACH OCCURRENCE $ 1000000 COMMERCIAL GENERAL LIABILITY DAMAGE PREM SES Ea occurrence)TO RENTED $ 300000 CLAIMS-MADE ry OCCUR MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $ 1000000 v .GENE RALAGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2000000 POLICY PRO- LOC $ B AUTOMOBILE LIABILITY 21662400004 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT 1000000 E_aaccident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accideni) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS R I AUTOS Per accident $ C UMBRELLALIIB OCCUR 4600042040 01/01/2012 01/01/2013 EACH OCCURRENCE $ 2,000,000 EXCESS LI1B CLAIMS-MADE AGGREGATE $ 2.000,000 DED RETENTION$ $ D WORKERS COMPENSATION 0053890111 01/01/2012 01/01/2013 WC STATU- OTH- AND EMPLOYERS'LIABILITY. TORY LIMITS EEL ANY PROPRIETOR/PARTNER/EXECUTIVE Y= N/A E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space is required) , CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE '200 MAIN STREET' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HYANNIS,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTHORIZED REPRESENTATIVE :' oe ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD y o 9 =f Office of Consumer Affairs and VUSness Regulation 10 Park Plaza -'Suite'5170 Boston 5 Massachusetts 02116 Home Improvement Contractor Registreion Registration: 110609 Type: Private Corporation Expiration: 11/3/2012 Tr# 205399 E J JAXTIMER, BUILDER, INC ERNEST JAXTIMER , - �: 48 ROSARY LN " HYANNIS, MA 026-01 �T 1; r Update Address and return card.Mark reason for change. 1f J E] Address Q Renewal 7� Employment Lost Card DPS-CA1 is 50M-04/04-G101216 Office�f o er" f r�usines 'on License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: �.1.10609 Type: Office of Consumer Affairs and Business Regulation Expiration: c1_I 012 Private Corporation 10 Park Plaza-.Suite 5170 —_ — Boston,MA 02116 E K TIMER, Bl7fLEfts _7 ,ERNEST JAXTIMER ; 48 ROSARY LN HYANNIS, MA 02601 ; . Undersecretary Not valid without signature x a Massachusetts-Department of Public Safety Board of Building Regulations.and Standards 'Construction supervisor �� License: CS-003251 . ERNESTJ R�-` 48 ROSARY:TANS HYANNIS M1 02601" i of-,�.•J1 �fa�` Expiration Commissioner 01/14/2014 .f M1 � of s r + BARNSTABLE. ' ALASS 1659. cb$ Town of Barnstable � �TfD h1p`f R Regulatory Services Thomas F.Geiler., Director Building Division t Thomas Perry, CBO; Building Commissioner 200 Main Street, Hyannis, MA 02601 wWw.town.barnsta ble.m a.us O Mce. 508-862-403 8 Fax:-50 8-790-623 0 Property Owner Must Complete and Sign This Section If Using A: Builder, I, IJ� � L1%✓ , as Owner of;the sub)ect property . . hereby allthDriZe J `L / to act on my e bh alf, , in.all"matters relative to work authorized by this building permit application for: J (Address of job) G� I Z ignature of Owner ate L'►(I d a W.d od we 11 Print Name If Property Owner is applying.for permit,:please complete the'Homeorvners License Exemption Forma on the reverse side. QAWPFIUEST0RMSIbuilding permit forms\EXPRESS.doC Revised 072110. The Commonwealth of Massach usetts f,- Department of Industrial Accidents Office of Investigations � } 600 Washington Street r Boston, MA 02111 - y' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f L / Please Print Legibly 1 Name (Business/Organization/Individual): •J. y Y_/ /�LP� ��� l(�t?(fir /o � . Address: gOs City/State/Zip: G[f2 /(;f 5 m6 426,0 / Phone#: (508) /7 1 .9 4 l Are you an employer? eck the appropriate box: Type of project(required): E 1. I azn a employer with aO 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. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' ' [No workers' comp. insurance comp. insurance.$ 9 ❑Building addition �required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions ❑ 3.El officers have exercised their I am a homeowner doing all work 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other 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 or not those entities have employees. lf.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.#: Oft, Expiration Date: Job Site Address: to City/State/Zip:_*1 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D A for insurance coverage verification. I do hereby c e�thepainsand�enalties of perjury that the information pt ovided above is 1ruu a d correct. Si afore: Date: CT/ Phone#: 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#: " Town of Barnstable *Permit# } -PRESS PERMIT Expires 6 months from issue date . Regulatory Services Fee APR 8 2008 Thomas F. Geller,Director Building Division TOWN OF BARNSTABLE g Tom Perry,CB0, Building Commissioner 200 Main Street,Hyannis,MA02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNU'T APPLICATION - RESIDENTIAL ONLY �f Not Valid without Red X-Press Imprint Map/parcel Number I D � Property Address Pi t Zl A29 11 oesidential Value of Work `i .3,00Q Minimum fee of$25.00 for work under$6000.06 Owner's Name&Address TIC( �tJd Contractor's Name J � (i(( � U , (n L. Telephone Number CM)M Y- 4 J I Home Improvement Contractor License#(if applicable)_ t Q "1 Construction Supervisor's License#(if applicable) V O P*orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name r-- Workman's Comp.Policy# u00& / -01 -?00 o Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) G4- ihar�se �nCc.�) �`�A �Re-roof(stripping old shingles) All construction debris will be taken to 1 ac&2 bew9 6*, S-kr— ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value. (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pr rty Owner must sign Proutrty Owner Letter of Permission. e rovement Contractors License is required. SIGNATURE: Q:Fornas:expmtrg Revise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston,MA 02111 SJev'6a www.mass.gov/did Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �J J"nm l B��l a . l Address: City/State/Zip: Aft 02/o I Phone:#: Are you an employer?Check the appropriate box: Type of project(required):. /1 am a employer with ?jd 4. . I am a general contra 1.Ltd ctor and I �. &. Q New construction . employees(full and/or part-time).* have hired the sub-contractors 2.. I am a sole proprietor or partner- listed on the attached sheet. 7. [modeling - These sub-contractors have g, Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑Building addition o workers comp.insurance comp.insurance.$ . � � Electrical repairs or additions its, 10.❑ eP required.] 5. � We are a corporation and 1 3.❑ I am a homeowner doing all work officers have exercised their 1 LFI Plumbing repairs or additions myself.:[No workers comp. right of exemption per MGL . � 12.❑Roof repairs insurance re uired. t c. 152, §1(4),and we have no q ] 0 employees. [No workers' 13. Other 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. 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. Insurance Company Name:_ '�=- • �• � — Policy#or Self-ins.Lic.#: (0 Lo 7��,( Oy P Expiration Date: ra 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$1,500.00 and/or one-year impnsonment,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 maybe forwarded to the Office of Investigations of the 19A for insurance coverage verification. I do here4cerrer the pains and penalties of perjury that the information provided above is true and correct. Si attire Date: — Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: : Permii/Licerise# Issuing Authority(circle one): 1.Board of)health 2.Building De'artrnent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:. .. Phone#: Client#:2093 2JAXTIMEREJ ACORD. CERTIFICATE OF LIABILITY INSURANCE 0DATE 3/17/8D ) t PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION { Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyanough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA Acadia Insurance E.J.Jaxtimer Builder, Inc. INSURER B: Ernest J.&Marie T.Jaxtimer INSURER C: 48 Rosary Lane INSURER o: 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. INSR LTR TYPE OF INSURANCE POLICY NUMBER DAB EFFECTIVE DATE MMIDD OLICY EXPIRATION LM1 TS A GENERAL LIABILITY CPA010264814 01/01108 01/01/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED $20 000 CLAIMS MADE a OCCUR MED EXP(Arty are person) $5 000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OOO OOO POLICY EP GT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS ° (Per person) HIRED AUTOS GODLY INJURY NON-0WNEDAUTOS - (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGG $ A ExCESSIUMBRELLA LIABILITY CUA010264914 01/01/08 01/01/09 EACH OCCURRENCE $2 000 000 7X OCCUR CLAIMS MADE AGGREGATE s2,000,000 DEDUCTIBLE $ X RETENTION $O A wORKERs CoMPENSAnON AND WCA02045501..1 01101/08 01/01/09 we s""MITATU- o R T R EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTE NO E L EACH ACCIDENT N $500,000 OFFICER/MEMBER EXCLUDED? E_L DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. E.J.and Marie Jaxtimer are included under the workers compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ' Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL in DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #51277 LS1 0 ACORD CORPORATION 1988 • Board of Building Regula ons and Standards .One Ashburton Place= Room 1301. Boston, Massachusetts 02108 -Home Improvement�tractor Registration � • -- Registratio n 110609 1l ` �* Type Private Corporation i11/3/2008 Tr!/.,124739 E J JAXTIMER,.BUILDER, INC <r #� y ERNEST JAX 4 - (� Expiration:, ' rt TIMER _r - 48 ROSARY LN . 4 _ w HYANNIS,`MA 02601 '; g — — y ' Update Address aiid return card.-Mark reason foi:cliange. DPS-CA1 `i'a 50M-05/O6•PG8490. _ Renewal- Employment Lost Card lier(L,r� _ �11 Boa d of B�i�ldl g�Regulat►ons and Standard - _ n l l ri Constructlon Supervisor License f, .' - -- CS 3251 Xi }� /2010 Tit 13629 e� T J JAX t,iti p I a a ERN .S _ + j I A•Y`. rl �`�` ���G-� I i HYANNIS MA 02601 " Cori►missiongr s i Ir t HE r Town of Barnstable Regulatory Services 9 $ Thomas F.Geller,Director 9. V OTED MA'S a� Building DIYISI®Il Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Tire:. 508=862-4038 Property ®wrier must. Complete and Sign'This Section If Using A Builder as Owner of the subject Pr oPertY hexeby authorize �-�t ( L /- J to act on my behalf, in all matters relative to work.authorized by this building permit application for. (Acfdress of Job) Signature of Owner Date e Print Name a Q:FORM5:0VTN-ERPERNMSION TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION , Ma ® O Parcel (J s 4 o ee p .Application#_ Health Division ' Conservation Division ,' Permit# Tax Collector Date Issued Q1Qb 0 Treasurer Application Fee Planning Dept Permit Fee %® _7 r S� Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner= k r7 d a Iya o () / Address l r. Telephone Permit Request 114'teei l r- 11W6 — Ak rkh i Gk�6 1.� AI&O paw&fYZI Milt- 19W9 . /2�?.l� -A-160 C Square feet: 1 st floor:existing proposed 2nd floor:existing proposed _ Total new Zoning District Flood Plain Groundwater Overlay Project Valuation .!�'761 00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 0 No On Old King's Highway: ❑Yes O'No Basement Type: ❑Full 0 Crawl ❑Walkout ❑Other { Basement finished Area(sq.ft.) Basement Unfinished Area(sq.ft) : Number of Baths: Full:existing new Half:existing new Clu Number of Bedrooms: existing new Total Room Count(not including,baths):existing new First Floor Room Count . Heat Type and Fuel: ❑,Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size ` Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ,❑No If yes, site plan review# 7 , Current Use° Proposed Use ' S1ecic BUILDER INFORMATION J Name � ay--h- 17 - &/ uze , 10C Telephone Number Address /'D �0Sa a License# Home Improvement Contractor# PO+✓61 Worker's Compensation# O ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO - SIGNATURE DATE rF FOR OFFICIAL USE ONLY t ; PERMIT NO. D DATE ISSUED 3 MAP/PARCEL NO. ADDRESS VILLAGE OWNER z DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT U , ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Department of hidusti ial Accidents Office,of Investigations 600 Washington Street Boston,M4 02111' www.mass.gov/dia ' ' ensation.Insu rance Affid avit: Builders/Contractors/Electricians/Plunabers Workers' ComP W Anylicant Information Please Print Lei ibly Act- (�L iismess/or 'on/Individual)' � . I �•� Name(B �ti Address: g 05 Ltl� City/State/Zip: k O2& hone Are you an employer?Check the appropriate box:. Type of project(iequiied): 1r5 4. []�'�!am a general contractor and I 1.[[TI am a er�loyer with a. 6. ❑New;construction * : : . have hired the sub=contractors employees (full"and/or part tune). 7. . Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ g ship and have no employees These sub-contractors have 8. :❑ Demolition working for mein any capacity.' workers' comp.insurance. .9. ❑ Building addition [No workers' comp.insurance 5: ❑ We are a corporation and its 10.❑ Electrical repairs or.additions .. . required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL A.❑ Plumbing repairs or additions c. 152, 1(4), and we have no. myself.'[No workers' comp. § 12.11 Roof repairs insurance required:]t employees. [No workers 13.❑ Other c?mp.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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'-comp.,pohq infosrmtion. I am an employer that is providing workers compensation insurance for my employees.*Below is the po&yand job site. information. Insurance.Company Name: t • T.C . Policy#or Self-ins.Lic.#: 54o'o Co ri 20 oZo6 Expiration Date: / Job Site Address: City/Stat4ip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to,secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOPVORK ORDER and a line of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to.the Office of . Investigations of the DIA.for insurance coverage verification. I do hereby certify u er the pains andpenalties of perjury that the information provided above is true and correct: Si attire: Date:: a �® Phone# Official use only. Do not write in.this area,to be completed by city.or town official City or Town: Permi icense# 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#: 1 Board of Building Regula ons and Standards One Ashburton Place - boom 1301 Boston, Massachusetts 02108 Dome Improvement4.Contractor Registration Registration: 110609 Type: Private Corporation Expiration:. 11/3/2008 Tr# 124739 EJ-JAXTIMER, BUILDER, INC. _-- - -.-- -- ERNyEST JAXTIMER ^ 1 - 48 ROSARY LN; �} z HYANNIS, MA 02601 Update Address and return card. Mark reason for change �J Address Renewal Employment Lost Card DPS-CA1 0 50M 05/0fi PC8490 i 7: i I I � r rl��y �';,� ✓fie�am�tn�;anweall� a� Qutfztico�(�a ' �'�; BQARtJ OFIPUILDIi�G EGIJ�ATION qq I! I I �r License t;OI�JSTRUCTION UP �tV150R P1 l` l li Numlisx, CS! 00328,fl I I: -9 tfe 01 14)1956: S pi Tr.no: 12839 6 /14b8 RstY[�et- I[rr 00 ERNES?J JAXTI(VIE1tZrJ I' 48 ROSARY LANEti HYANNISi MA 0260I �..._ G` �✓ �t; '; i. COm� idrler iss , �TME •-LV rTu V1 JJCLAAA7LKRJiV Regulatory Services K Thomas F,Geller,Director ��bpr fD► `. Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town,barnstable,ma.us free: 508-862-4038 Fax, 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL a 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which'are adj scent to such residence or building be done by registered contractors,with ce±tai*s exczptious,along vszth other requirements- Estimated of Work: Estimated Cost_ 9 Address of work: Owner's Name: Date of Application: I hereby certify that Registration is not required for the following reason(s): Work excluded by law FIJob Under$1,000 []Building not owner-occupied _: []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT FORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A, SIGNED UNDER PENALTIES OF PERJURY I hereby app-y for a permit as nt of the owner. -� amd Date Contractor Signature, Registra'onNo. OR Date Owner's Sipatuie Q,,,,fnes.form-,homeafndav Rev, 060606 r�oFS ; � Town*of Barnstable p Regulatory Services Thomas F:Geiler,Director E1► "1 wilding Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Vice:. 508-862-4038 Fax: 508-790-6230 Property ®wrier Must Complete and Sign This Section If Using rA,Builder as Owner of the subject property hezeb7 authorize act on m7 behalf in all matters relative to work authorized b7 this building p erroit application for: (Address of Job) r. • tore of e ate Print Name Q:FOR MIS MS:OWNEK?ERSIOId ' • Client#: 2093 .4 .2JAXTIMEREJ DATE(MMiD AGOR®TM CERTIFICATE .OAF LIABILITY INSURANCE" 01117/07°1"rr' s M oDucER THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO'RIGHTS.UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 West Main St. PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING.COVERAGE NAIC# INSURED :.INSURER A .Acadia Insurance E.J.Jaxtimer Builder, lnc. Al' INSURER Bi Ernest J. & Marie T.Jaxtinler INSURER C: ' - 48 Rosary Lane 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 I POLICIES.AGGREGATE LIMITS SHOWN MA HAVE BEEN P.EDUCED'BY PAID CLAIMS. - INSR D' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MM/DD/YY DATE MM/DD/YY ,A..^:.. `GENERAL LIABILITY CPA010264813, . ., 01/01/07 01/01•/08 - EACH OCCURRENCE' $1:-000 000- )( COMMERCIAL GENERAL LIABILITY • - DAMAGE TO RENTED PREMISES'Ea occurrence $2504000 CLAIMS MADE O;OCCUR 1 y:r. MED EXP(Any one person) $5 000' PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE- : $2 000.000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG s2,000,000 PRO- �,.. POLICY JECT LOC AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ri ALL OWNED AUTOSF BODILY INJURY, BO I URY $ SCHEDULEDAUTOS (Per person) - HIRED AUTOS " BODILY INJURY $ NON-OWNED AUTOS.~ (Per.accident) - }. PROPERTY DAMAGE $ (Per accident) o GARAGE LIABILITY ;i AUTO ONLY-EA'ACCIDEN,T S. ANY AUTO .e '. OTHER THAN. EA ACC $ a AUTO ONLY: AGG' $ A EXCESS/UMBRELLA LIABILITY CUA010264913 01/01/07 01/01/08 EACH OCCURRENCE $2 000 000 X OCCUR . El CLAIMS MADE a AGGREGATE $2 000 000 �DEDUCTIBLE �0. $ X .RETENTION $O $ ,. WC STATU- OTH- A WORKERS COMPENSATION AND: Y WCA020455010 01/01/07 01/01/08 T Y I T ER EMPLOYERS`L'IABILITY "«• .. E1,EACH ACCIDENT. - $500,000 r- ( ANY PROPRIETOR/PARTNER/EXECUTIVE, OFFICER/MEMBER.EXCLUDED?,:', :, E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under .:.,. - - SPECIAL•PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER r W k j•, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Bussmann m } r Operations performed by the named insured subject to policy conditions , and exclusions CERTIFICATE HOLDER '` CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE.EXPIRATI( Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTED 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL .Hyannis,MA. 02601 - _ IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #46052 LS1 O ACORD CORPORATION 1' AF2�i�A.w� �l p •,s,, !- F 3 �. 'rr j �;, IT Q�i l{ !L 11t5T I —IN kFl"I OR ' I J � 1Af lipt1D I ` �a• RAM I. it EXI$:T :WINDOWS Nt!W �FILWINbQ i5. WPH2O,32 Uj H2O32 18, L°+, TENS= CUSTOM k CMILLE$: f LE'•.S - - 7777 r__...__ T" N UJ;. K I T C>41 :;1-A Y CJ UT II.O:CATE REF t NEW, ' iS AND E EXS .. 'REMOVE, 1' CUUNt:tR/CAS s" — T' STEP DOWN NEW ,PANTRY TO PATIO (.2) --_-Y - NEI1J 2.0 RS . -NEW CLOSET L� ---- W/ STORAGE l NEW C:O. TO �i� PINETTE UNDER EXIST RESID: '`=; - A I A OF EXIST WALL _ ,• STACKING W/D• FOR 'BOX WIND, - I E EXISTING RESIDENCE ciNFILL WHERE RE STEP DOu TO GRADE WDH2012 W01,12O1 t -O 111 -ALL %SF,4'{� 7 r / / J 3 . t � K Pdt�0IV 14 4- sr • � — 4 s � d l � � � "� ; I a 1 t 1 — x 1 rt i kh 777`L� _• .1 7 t ll r1Fr 1 ! 7 Iltt,�+7 4 + t a f�5 �� raw. � *��sti•f 4d�W� � r,.`k w ull . Z s!-] . - 'IST NNOR.-L ".WHrwRE REQ:) i Omov 11 ^+- 6 :r PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: 10/02/06 TIME: 15:35 ------------------TOTALS----------------- PERMIT $ PAID 205.00 AMT TENDERED: 205.00 AMT APPLIED: 205.00 CHANGE: .00 APPLICATION NUMBER: 20063610 PAYMENT METH: CHECK PAYMENT REF: 38379 J Town of Barnstable *Permit#1Q656 3!010 Expires 6 months front issue date ®®® Regulatory Services Fee $ X-PRESS PERMIT Thomas F.Geiler,Director OCT 0.2 2006 Building Division Tom Perry,CBO, Building Commissioner TOWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us )ffice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint O /parcel Number A 0176 ,erty Address -ILA�yt4Av- ffida n n po�T Lesidential Value of Work, (960 Minimum fee of$25.00 for work under$6000.00 ier's Name&Address V W V V tractor's Name ,��I ��.� J � �, ��(� l � UI Telephone Number l �J��; 1 1 49/ ae Improvement Contractor License#(if applicable)_ Q t�Q Cl mcftrSupri ls hicerrse-#���appliealrie) I)i� 2�c 1 i Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ am the Homeowner [i]I have Worker's Compensation Insurance rance Company Name C, :kman's Comp.Policy# 50 0 )-0 iy of Insurance Compliance Certificate must be on file. nit 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) [T Re-side Pa ICIIA4 [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: P Owner must sign Property Owner Letter of Permission, y of the rs License is required. INAtVRE: ,=:expmtrg se061306 SINE r Town of Barnstable Regulatory Services 9B&AM MASS.'E Thomas F.Geiler,Director 16.39. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I. L/4&, Wood W4 �� , as Owner of the subject property hereby authorize E •,J J 9nte Ut I64 o act on my behalf, in all matters relative to work authorized by this building permit application for: ` t Z4 (o u(�_ t�?.f�,�/�i'S Porgy; /L1k . (Address of Job) Aym& f, wjydjwe_� S-eW 2- 6,6 Signature of Owner 6ate Lih�la /� Wy�cl���r Print Name Q:FORMS:OWNERPERMISSION 91te omwwwweqla ` Board PE of Building Regula ions and Standards i; _ One Ashburton Place - Room 1301 •` Boston. Massachusetts 02108 Home Improvemerrr� tractor Registration A Registration: 110609 i Type: Private Corporation Expiration: 11/3/2006 E J JAXTIMER, BUILDER, INC: ERNEST JAXTIMER 48 ROSARY LN HYANNIS, MA 02601 Update Address and return card.Mark reason for change. DPS•CA7 Co soon-oaroa-cioizis Address Renewal. Employment Lost Card I 1 . _ � I ICI ��i� i iii� ': ✓/xe -� ' ecell/ o� ac�ivaelta �FY t i F } �" BOARD OF BUILDINGrg i EGULATIONS I License CONSTRUCTION SURVISOR V I j, r umlie� rth fi` 003251:, I` = Bi atf 4,1956 s . ai $+ pii5 01/142QS Tr:no. 12839 ResI AP tricted; I ERNEST J. JAXTIJR �':r {` 48 ROSARY LANE<,r HYANNIS, MA 62601 _r' i . Commissions—r1 :� 1r}r f i' The Commonwealth of Massachusetts { Department offridustrial Accidents Office.of Investigations I' A - e 660 Washington Street Boston,M4 02111 - 11 0-4 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auiplicant Information Please Print Legibly ' r c Name (Business/or ganizationadividuat)• .:-J �1 l—=�?,- , 3(A' l L-D I .fQ l ., Address: ilL l 0 hone# ( 1�.�� Are you an employer?Check the appropriate box.: Type of project'(regnired)-- 1.( I am a.employer: )�� 4. am a general contractor and Y . 6. ❑New construction employees (full and/or part time).* have'hired"the subcontractors 2.[] I am a sole proprietor or partner- listed on the attached sheet $ 7. Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for mein any capacity. workers' comp.insurance: 9. E] Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its -•. 10.❑ Electrical repairs or.additions required.] officers have exercised their 3.D I am a homeowner doing all work right of exemption per MGL ll: Plumbing repairs or.additions 4 ,and we have no myself. [No workers comp. c.152, _ §1O 12.❑ Roof repairs . insurance required:] t employees. [No workers-. 13.❑ Other - .. comp:insurance required] Any applicant that checks box#1 must:also fill out the section below showing their workers'compensation policy information: .. N ' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cofactors must submit a new affidavit indicating such tcontractors thatcheck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp..pohgy information. . I dm an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site. information. , Insurance-CompanyName: �' ' fi•C . Policy#or Self-ins.Lin#: 5'00-O(a 7 o2O oU(No Expiration Dater 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$1,500,.00 and/or one-year imprisomment 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 maybe forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certify un er the pains and penalties of perjury that the information provided above is true and correct. . Signature: Date: ' /0(, Phone# O,f j`icial use only. Do not write.in this area,to be completed by city.or town official. City or Town: PermitUcense# Issuing Authority(circle one): 1.Board.of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector .5.Plumbing Inspector 6.Other Contact Person: Phone#: It � .� :, LJ'� ' Cam vYl.� C..�•/� -►�3 �' �`�" ;1 I' !, i ma + Li �+ _ _o s . Lp ff �__. ' . C - --------__ f� II kL 1 W4 i{