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HomeMy WebLinkAbout0402 OAKLAND ROAD i �� i i i i i i f 1 Town of Barnstable *Permit# Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee Thomas F.Geiler,Director JUL 2 7 2007 Building Division -� TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.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 9,rj 1 y©� r q c n,� Property Address 4d"- V a k l a.&I, kd�I a"/1 h! S '-/4 62*01 006 Minimum fee of$25.00 for'work under$6000.00�sidential Value of Work Owner's Name&Address boa 04,k 6ZA_"C 4011 &V_1tLW_,S) 1-114 Da&o/ Contractor's Name 1F.j .j a 5_hM L{- , 6GU' Telephone Number (6_2� HomejImprovement Contractor License#(if applicable) 11 Q( 09 Construction Supervisor's License#(if applicable) Workman's Compensation Insurance y Check one: ❑ I am a sole proprietor ❑ I am the Homeowner PTI have Worker's Compensation Insurance Insurance Company Name A, E. I •C Workman's Comp.Policy# 6-000(0 7d.01 9,06.E Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to /rt a mxo r-S S (� ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. opy o e Home Improrv�ement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of1Mlassachus. etts . Department of industrial Accidents Off ce°of In>vestigadons , 600 Washington Street Boston,,AM 02111 ',M ,••� www.mas&gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Anulicant InformationPlease Print Legibly Name (Business/organization/Individual):` ; J lds�rlq K�- D i , ' .�Q l Address: s - L . LL \ city/State/Zip: .,. -�- �.�.1 S ; kk. 0�''Pbone#: � 1�. :� ) �� �' 4q " . Are you an employer?Check the-appropriate box:. Type of project(required): 1.[-.I am a 1 4. am a general contractor and I. employer with � � 6. New construction employees (hn and/or Part-time). . have hired the sub-contractors 2.[] I am a sole proprietor or partner listed on the attached sheet $ T Iff Remodeling ship and have no employees These sub-contractors have 8. E3.Demolition working forme in anYcapaci�3 workers' comp.-insurance. ' g ❑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 11 ❑ Plumbing repairs or additions 1 4 myself [No workers comp. ,.;,c. 152,§ O,and we have no 12.E Roof repairs insurance required.]t employees. [No workers' . 13,� Other comp.insurance required.] *A ya pplicant that checks box#i must also fill out the section below showing_their workers'compensation policy information: `• t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contmctors must submit a new affidavit indicating such tContmetm that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp.-policy a)r1riatiom I am an employer that is providing workers'.compensation insurance for my employees.*Below,is the policy and job site. information. n Insurance-Company Name: Policy#or Self-ins:Lic.#: 5-00.0&rl 020 02®O l :l Exprratron Dater Lo Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and vpiration 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,.06 and/or one-year imprisonment, as well as.civil penalties in:&e 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 thepains.andpenalties ofpedury that the information provided above is true and correct. signafore: ll Date: Phone 4VIcial use only:: Do not write in this area,to be completed by city.or town:official City or Town: : PermiMcense# Issuing Authority(circle ones 1.Board of Health 2.Building(Department 3,City/Town Clerk:4.Electrical Inspector.S.Plumbing Inspector: 6.Other Contact Person:' Phone# s Board of Building Regula ons and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 ]tome-Improvement;Contractor Registration Reqistration: 110609 ._ t { Type: Private Corporation I Expiration: 11/3/2008 Tr# 124739 E J;JAXTIMER; BUILDER, INC. ' ERNEST JAXTIMER s 48RQSARY LN; — — HYANNIS, MA Q2601 - -- - ., Yl +r k Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card DPS—CA1 0 50M-05/06-PC8490 a Bt�biR O��¢UILDi G E ,�1LP�TI0 1 `' r ilk 4 ieense i;Qf S�RUCTION UP V1 1'SOR ,';' Nufiibo., 003251` 4� �I flirt R -'14-1956 iT r rs .i i^ :I:d :�.OW 1.4 ,� ,1. 8 Tr. 12 , !p no: 839 �.. • s i 7 l ti i r, ERNEBT J,JAXTIM �� � '.>P�,';' r 48 ROSARY LANE° C NNi c, Hy, S; MA 02601 a �✓ 4 g COm Itsioner ;...ffi •i„ 'n-1 .r Client#-2093 2JAXTIMEREJ DATE AG®RD- CERTIFICATE OF LIABILITY INSURANCE 01/17/M07 M1DD1YYYY, ;Z:ODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling S 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 INSURERA Acadia Insurance E.J.Jaxtimer Builder, Inc. INSURER B: Ernest J.8r Marie T.Jaxtimer INSURER C: 48 Rosary Lane INSURER o: Hyannis,MA 02601 INSURER I- COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING IANY 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 1 POLICIES.AGGREGATE L!PA!TS SHOWN MAY HAVE BEEN REDUCED RV PAID C AIMS, POUCY EFFECTIVE. POLICY EXPIRATION LIMBS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE M DATE MM/DD A GENERAL LIABILITY GPA010264813 01/01/07 01/01/08 EACH OCCURRENCE $1 000 000 DAMAGE TO RENTED $2SO OOO X COMMERCIAL GENERAL LIABILITY PREMISES CLAIMS MADE a OCCUR - - MED EXP(Any one person) $5 OOO PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2,000,000 POLICY F1 PEROO- LOC AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO - - AL•L.OWNED AUTOS BODILY INJURY (Per person). SCHEDULED AUTOS .HIRED AUTOS BOOILYiNJURY^' $ (Per accident) NON-OWNED AUTOS ' PROPERTY DAMAGE $ (Per accident). GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY CUA010264913 01/01/07 01/01/08 EACH OCCURRENCE s2,000,000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 DEDUCTIBLE X RETENTION $O $ A WORKERS COMPENSATION AND WCA020455010 _ - 01/01/07 01/01/08 IT wC STATU- O R -EMPLOYERS-LIABILITY "` E.-L.EACMACODENT $500,000 ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $SOO,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Job:Bussinann Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATK Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �_ DAYS WR{TTE! 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES..; AUTHORIZED REPRESENTATIVE LS1 © ACORD CORPORATION T ACORD 25(2001108)1 of 2 #46052 JUL-27-2007 12 : 12 PM KENNEDY PINK SNACK BAP 5087757039 PACE 02 t f Barnstable ` gory Services ; .;. iaitrl ng�M*fon g;.;; U410 sV"t, Hytgoctae,XA C260 i SOU62.4038 41: 508-7*1 Z" 71 Cofti*,.twand,Sign This Section 'U'Udhi A guilder as Churns 0f the subject PTO?" bt►sobpBuda to act ap any on tad► m 2al9dve to V03k ed-by-&s building permit appliemtioa for sig>sAmm of Oeaaor � Y2 .Prat Name y I i