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Home My WebLink About0131 LAFRANCE AVENUE 3 � `3ivr�nc�e �, �� — — -- � � — . . . _ Town of Barnstable *Permit# 6 Expires 0 months from issue date —-:- -: :Regulatory Services Fee 9� 1�� ThomasY.Geller Director .. �Eo' ,ts __. ...._.. :.. _:..._.:.� ...::..._:�..BuildingDivision- k-PRESSMel° ..:�._,. Perry, Building Commissioner JAN 1 0 2005 '*3 .200 Main•Street,• Hyannis,MA 02601-- Office: 508-862-4038 TOWN OF.BARNSTAB LE. Fax:'508-790-6230 . EXPS.�: �RN7IT�A �LICA'TION = RESIDENTIAL ONLY. Not Valid without RedX-Press Imprint Vlap/parcel Number Property Address tr f t residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address, 9,4�ftA Ji�(4e J�"It Contractor s Name f Telephone Number 7r q Home Improvement Contractor License#(if applicable) / J 7 2 Construction Supervisor's License#(if applicable) ®®�t-�� 1 • 1 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner K,I have Worker's Compensation Insurance Insurance Company Name �� Worlonan's Comp.Policy# T,7 �� '7 °^ •—(� Copy of Insurance Compliance Certifica e'must be on file. Permit Request(check box) 9 Re-roof(stripping old shingles) All construction debris will be taken to a �{ ��Q ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this penTat does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pr perty wne must sign Property Owner Letter of Permission. ome Im irov ent Contractors License is required. Signatur Q:Forms:expmtrg Revise063004 The Commonwealth of Massachusetts Department of Industrial Accidents - -_ Office offnuestigations 600 Washington Street, fh Floor Boston,Mass. 02111 \ Workers' Compensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors A" hca �tParanam . IN ,ii: e name: address: ci r state: zi : hone# �6 work site location full address): JtANA1 cl ❑ I am a homeowner performing all wor myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole ro rietor and have no one working in any ca aci . ❑Buildin Addition I am an employer providing workers' compensation for my employees working on this job F. Com:"an Ft name address. x, x ,.fir, a 7, �.,,jc^ x r r ❑ I am a sole proprietor,general contractor,or home caner(circle one)and have hired the contractors listed below who have the following workers' compensation polices x cord pany"naive. ad'd'ress. cites; _: nnone#: insura`nee"co, companv.name. . address. city; ' " alone.#. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as ', penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement y fo a to the Office of Investigations of the DIA for coverage verification. I do hereby cesd u d the ains d penalties of perjury that the information provided above is true and correct Signa a Date P3 Print n c 1,l Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# []Building Department' []Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone#; ❑Other (revised Sept.2003) • s A; Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or,on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. • , MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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.. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided aspace at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: , The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 .01/134"2005 11:22 5087789312 BARNSTABL-E HOLISING PAGE 01/03 MIKE MONCEAU (508) 178-9797 - PROPOSAL 77 Traders Lane Cell (508) 367-2646 W, Yarrrouth, MA 02673 Lic, No. 0,06670 Ddte: Proposal Submitted To: Mailing AdGress Work to be performed at: Name: Ur- —4 5tret',t' street: 7, 1" f city. City:_ _f. State: Zip code: Stale, Zip Code: _ Home Phone; , `� -®� Work - - AIMES/Suggesticns. IL r We Hereby propose to furnish the materials and perform the labor necessary for the completion of r "rL� shingle' (b) Removing old r of, install new roof with a - a estimate (�) sq. This price will include a yaor warranty on workmarship, new alumi- num drip edge, 15# felt-underlovment, roof vent collars, instail :ce and water barrier arour.d chimney, valleys, nail Loose boards, clean gutters, total clean up cnc removal of all debris. Color of roof is to be 2. Venting - can be critical on certain homes ,a) Install ft. of Cobrc continuous ridge vent $ (b) Install ft, of Hicks vented drip edge on soffit. $ (c) Do not wa t t6 upgrade venting . (d) Other qil material in guaranteed to be as specified, and the above work to be performed in accordance with the specificotions submitted for above work and completed in a profess`oncl workmanlike. manner for the sum of $_ 0()r" ; with payments to be de f Ifows: Deposit of $ C ► Balance due upon compl l*on. Respectfully submitted ACCEPTANCE OF PROPOSAL We ress le the right to r�apl:.r e any rotted or bf0kon roof or trim The above prices, specitications and conditions are boards. 7ni5 wiii be en extra ost above the cjuote roof price, The sdtisfactory and ore r:e.eby accepted. you cre charge for this will be,it neede . $50/hr.plus m.aterlals,All aveements o jthorteC to do fhe work a, specified. Payment wll, C0n-irgSrs7 upon,of,;,;Jd5nto Cr delays beyond-Our control.Outstond- be rnooe as oullined obo��e ing balance a7,ler 30 days vJ11 lr cur 1.5%finance V org�per m th. Owner to remove all vajobles from wolls.Liobllity Insurance on all Date: above to be teiccr.out by, Mike Mongeau f Rightfax Norcross 5/28/2004 7:56 PAGE 003/003 Fax Server 05-27-04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BRYDEN & SULLIVAN INS HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR P.O. BOX 217 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. SOUTH DENNIS MA 02660 COMPANIES AFFORDING COVERAGE COMPANY 75BKG A CONTINENTAL CASUALTY COMPANY INSURED COMPANY " MONGEAU, MICHAEL-. B 77 TRADERS LANE COMPANY WEST YARMOUTH MA 02673 C CUMPANY D y k�JIL ES» # THIS IS TO CERTIFY THAT T HE POLICIES OF SU t IN RANCE LISTED BELOW L HAVE"BEEN ISSUED TO THE"INSURED"NAMED IABOVE 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. - CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LT DATE(MWDD\YY) DATE(MM\DD\YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE a OCCUR. PERSONAL&ADV.INJURY $ [ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY $ NUN-OWNED AUTOS (Per Accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY - (LIB7480X760-9-04);, 03-04-04 03-04-05 STATUTORY LIMITS r THE PROPR EACH ACCIDENT $ 1Q0 000 IETOR/ INCL PARTNERS/EXECUTIVE DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: RX EXCL DISEASE--EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES,RESTRICTIONSISPEOAL kMS 'THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOL R CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION' DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE DAVENPORT REALTY 20 NORTH MAIN ST LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR SOUTH YARMOUTH MA 02664 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE AGQRD 25 3i93..: MAY 2 8 2004 J