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HomeMy WebLinkAbout0150 SEVENTH AVENUE (HYANNIS) r .� own of Barnstable *Permit 0 . 0 w � *Expires 6 mo from issue date Regulatory Services Fee BARNWABM MASS. �, AY 20 se39.�,�5 R' hard V.Scab,Director F BARNSTABL N o Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,.MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:'508-79M230 EXPRESS PERMIT APPLICATION.' -, RESIDENTIAL ONLY ® Not Valid without Red X-Press Imprint Map/parcel Number �� - Property Address J�� � /�T� /�f/1✓ Q 2— G%t— �n esidential Value of Work$ (, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 6w Contractor's Name ( /M /A C2 /yet/?.-2-Cz3 Telephone Number: 7 f 1,1217 0 Home Improvement Contractor License#'(if applicable) Email:` . 7 ;cwj OCX ege Construction Supervisor's License#(if applicable) ®el&I'93 Korkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I 4pi the Homeowner ERI—have Worker's Compensation Insurance y Insurance Company Name X" ..7;JS Workman's Comp.Policy# R r.C,`Z7 i 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) a-side [tj�eplacement Windows/doors/sliders.U-Value SU A4MCkibmaximutn.32)#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 Home Improvement Contractors License& strid on Supervisors License is requi SIGNATURE: � =� G(,II v if l/ C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook Sc Revised 040215 (7:1911te' W04n','�Wlnwewl e' CZ/4 6�' X, e,4,ej, Office of Consumer affairs and Business Regulation 10 Park Plaza Suite a 170 Boston, Massachusetts 0211.6 Home Improvement Ct�xtrae.1 to Registration . Registration 184370 x ' Type: Private Corporation _ Expiration: 1011,12015 Tr# 244672 EMERGENCY CONTRACTORS LLC ' - r ...... .... SCOTT GLAUISH . 73 IYANNOUGH RD" _._. . _ .... HYANNIS, MA 02601 e ['Pdatc:'address and return card.E41ark.reason for change. r Address :-' Renewal E✓rnplovrriew Lost Card $CA t -3 2t8—W11 _. i ..r�*+.,, ~✓f7���tttttx4=5zt<ustrjl�e�r:�r�trrr:�tttrllE:+ ,, � -4 Office of Coasurner Affairs&:Business Regulatirtn. License or registration valid for indtvtiltaE use only IMPROVEMENT CONTRACTOR bef n the etc iration Ache. If found return.to: ,;�OEbtE eegistration: i° 4370 Type Office of Consumer A,Mirs and Business Regulation xpiration t6112615 Private rorporaticn. , 10 Park..Plaaa-Suite 5170 Boston,:NIA Q21,16 EMERGENCY OONTRAGTORS LLG',' SCOTT £3LAOISN 73 tYANNOUGH.RD a HYANNIS,€UlA o2601 r'ndei 5ecretar° Not Valid wit signature I Contract - Detailed Pella Window and Door Showroom of Centerville Sales Rep Name: Howard, Scott 1600 Falmouth Road Sales Rep Phone: 508-771-9730 Centerville, MA 02632 Sales Rep Fax: Phone:(508) 771-9730 Fax: (508) 771-8270 Sales Rep E-Mail: showard@gopella.com Customer Information,-:, Project/DelIvory Address OrOerInfornnation'; s Emergency Contractors,LLC SH-Puchkoff Residence Quote Name: Vinyl 5-7-15 73 lyannough Rd 150 Seventh Avenue Order Number: 182 HYANNIS,MA 02601-2060 Lot# rl Quote Number: 5506014 Primary Phone: (508)889-8741 WEST HYANNISPORT,MA 02672 Order Type: Non-Installed Sales Mobile Phone: County: BARNSTABLE Wall Depth: Fax Number: Owner Name: Payment Terms: 2%15/Net 30 E-Mail:,randy@emergencycontractors.com Emergency Contractors, LLC Tax Code: MASS Contact Name: Owner Phone: (508)889-8741 Cust Delivery Dater None Quoted Date: 3/12/2014 Great Plains#: EMECON Contracted Date: Customer Number: 1006368672 Booked Date: Customer Account: 1001879081 Customer PO#: Customer Notes: 5-7-15 : Line#. Location: fl utes - 10 A _ item Price Qty Ext'd Price Vinyl Windows/Doors By Pella, Double Hung,29,25 X 45.75,White $229.12 8 $1,832.96 1 Non-Standard SlzeNon-Standard Size Double.Hung,Equal +g Frame Size: 29 1/4 X 45 3/4 Q PK# General Information: Standard,Vinyl,Nail Fin,4 3/16", 1 5/8",2 9116" Exterior Color/Finish: White 708 Interior Color/Finish: White Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: White Screen: Full Screen Grille: No Grille, Wrapping Information: No Exterior Trim,No Interior Trim,4 9/16",6 3/16",Pella Recommended Clearance,Perimeter Length=150",Glazing Pressure= 130. Rough Opening: 29-3/4"X 46-1/4" For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 5/7/2015 Contract-Detailed Page 1 of 5 Customer, Emergency Contractors, LLC Project Name: ,SH-Puchkoff Residence Order Number: 182 Quote Number: 5506014 Line#' Location: " rl U es 15 B Item Price Qty Ext'd Price Vinyl Windows 1 Doors By Pella, Double Hung,26.5 X 41.5,White $216.15 5 $1,080.75 1:Non-Standard Size Double Hung,Equal Frame Size: 26 1/2 X 41 1/2 ~ Q PK# General Information: Standard;Vinyl,Nail Fin,4 3/16", 1 5/8",2 9/16" . Exterior Color/Finish: White a• „_ 708 Interior Color/Finish: White Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: White Screen: Full Screen Grille: No Grille,. Wrapping Information: No ExteriorTrim,No Interior Trim,4'9/16",6 3/16",Pella Recommended Clearance,Perimeter Length=136",Glazing Pressure= 150. Rough,Opening: 27 X 42. Line# : Location: A t rl u es R ; 20 B-T ` " emp Vinyl Windows 1 Doors By Pella, Double Hung,26.5 X 41.5,White Item Price Qty Ext'd Price $292 40 1 $292.40. =.,n 1:Non-Standard Size Double Hung,Equal Frame Size: 26 1/2X 41 1/2 I V 'a PK� General Information: Standard,Vinyl,Nail Fin,4 3/16", 1 5/8';2 9/16" Exterior Color/Finish: White , 708 Int rlor Color/Finish White Glass: Insulated Tempered Obscure Low-E Obscure Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior. Hardware Options: White Screen: Full Screen Grille: No Grille, Wrapping Information: No Exterior Trim;No Interior Trim,4 9/16',6 3/16",Pella Recommended Clearance,Perimeter Length=136 Glazing Pressure= 205. Obscure Glass Style: Pattern62(Standard) Rough Opening: 27"X 42" Customer Notes: Obscure Glass For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pellas website at www.pella.com g 9 9 Printed on 5/7/2015 Contract-Detailed Page 2 of 5 Customer: Emergency Contractors,LLC Project'Name: SH-Puchkoff Residence Order Number: 182 Quote Number: 5506014 Y Attributes Line# Location: 25 C Item Price city Ext'd Price Vinyl Windows I Doors By Pella, 3-Wide Double Hung, 69:5 X 43.5,White $691.82 1 $691;82 uz a a 1:Non-Standard SizeNonStandard Size Double Hung,Equal s ! Frame Size: 15 1/4 X 43 1/2 General Information: Standard,Vinyl,Nail Fin,4 3/16",1 6/8",2 9/16" �15:Zr �52�'f PK# Exterior Color/Finish: White r•: 708 ' Interior Color/Finish: White Glass: Insulated Low-E Advanced Low-E.Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: White Screen: Full Screen Grille: No Grille, Vertical Mull 1: FactoryMull,'1/2"Standard Mullion,Frame To Frame Width: 0.5" 2:Non-Standard SizeNon-Standard Size Fixed Direct Set Frame Size: 38 X 43112 General Information: Standard,Vinyl,Nall Fin,4 3/16",1 5/8",2 9/16" Exterior Color/Finish:White , Interior Color/Finish: White Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Grille: No Grille, Vertical Mull 2: FactoryMull,1/2"Standard Mullion,Frame To Frame Width: 0.5" 3:Non-Standard SlzeNon-Standard Size Double Hung,Equal Frame Size: 15 1/4 X 43 1/2 General Information: Standard,Vinyl,Nail Fin,4 3116", 1 5/8",2 9/16 Exterior Color/Finish: White Interior Color/Finish: White Glass:.Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: White - Screen: Full Screen 1 Grille: No Grille, Vertical Mull 1: FactoryMull, 1/2"Standard Mullion,Frame To Frame Width: 0.5" " Wrapping Information: No Exterior Trim,No Interlor Trim,4 9/16",6 3116",Pella Recommended Clearance,Perimeter Length 226",Glazing Pressure=50. Rough Opening: 70"X 44" For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 5/7/2015 Contract-Detailed Page 3 of 5 Customer: Emergency Contractors, LLC Project Name: SH-Puchkoff Residence Order Number: 182 Quote Number: 5506014 Thank You For Purchasing Pella® Products PELLA WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for;complete details,taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture within the wall system.Neither Pella Corporation nor'PELLA WINDOWS INC will be bound by any other warranty unless specifically set out in this contract. However,Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress)information does not take into consideration the addition of a Rolscreen[or any other accessory]to the product. You should consult your local building code to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. Variations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. INSYNCTIVE PRODUCTS:in addition,Pella Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. This order is made especially for you,the customer.No cancellations are possible after 3 business days of signing this order.This agreement becomes a binding contract only upon review and acceptance by authorized Pella Windows&Doors coporate representative in Fall River,MA.All promises of shipment are estimates only,and our best efforts are used in every case to ship within the time promised,but there is no guarantee to do so.Seller shall not be liable for any direct,indirect or consequential damage casued by delay in shipment.The customer represents that the window/door sizes and specifications shown on this order are correct and may not be changed or cancelled.The Scheduling Department will call you with your delivery date. WE PROVIDE TAILGATE DELIVERY ONLY,PLEASE ARRANGE TO HAVE ASSISTANCE ON SITE AT TIME OF DELIVERY<< >>FOR REPLACEMENT PART ORDERS PAYMENT IS REQUIRED,IN FULL AT TIME OF ORDER<< . >>COD PAYMENT.IS REQUIRED AT.TIME OF DELIVERY UNLESS ALTERNATIVE TERMS HAVE BEEN PREVIOUSLY ARRANGED<< For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 5/7/2015 Contract-Detailed Page 4 of 5 .. Customer: Emergency Contractors,LLC Project Name: SH-Puchkoff Residence Order Number: 182 Quote Number: 5506014 7 Project Checklist has been reviewed Y -Order Totals - Customer Name (Please print) Pella Sales Rep Name (Please print) Taxable Subtotal' $3,607.93 Sales Tax @ 6.25% $243.62 Customer Signature Pella Sales Rep Signature ' Non-taxable Subtotal $0.00 Total $4,141.55 Date Date_ Deposit Received $0.00 Amount Du® P,141.551. Credit Card Approval Signature w For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 5/7/2015 Contract-Detailed Page 5 of 5 COMMONNiTA:LTH OF 'MA.SSA.CHUSETTS 'OFFICE OF C ONSUMER AFFAIRS AND ' BUSE\TESS REGULATION 10 Park Plaza—Suite 5170,Boston MA 02116 (617)973-9700 FAX(617)973-9799 www.masS.goV/consumer DEVAL L.PATRICK GREGORY BIALECKI / GOVERNOR SECRETARY-OF HOUSING AND ECONOMIC / TMOTHY P.MURRAY DEVELOPMENT. LIEUTENANT GOVERNOR BARBARA ANTHONY UNDERSECRETARY Request For Supple merit ry ffiC Cards It is recognized that some construction firms may have a need for additional identification card(s)for oficers,partners, o r other key employees as means of identification in dealing with building officials, potential customers, and the hke. Additional iD cards will be issued upon proper completion and submission of this form along with a$10 fee for each additional card requested (CERTIFIED CHECK OR MONEY ORDER). The registration number will be the same as the original applicant registration number,and the ID card will list the name of the applicant and the name of the individual to whom it is.issued. The address of the individual should be the address at which the person is based(Le., a branch office, main office,or home address). Cards will be issued only to officer's, partners,or employees of the registration. THE REGISTRATION AND THE NAME OF THE RESPONSIBLE WDFVIDUAL WILL STILL HAVE THE JOINT AND SEVERAL LIABILITY FOR WORK CONDUCTED AS NOTED INMGL c.142A AND 780 CMR R6, AND WILL BE RESPONSIBLE FOR THE WORK OF THE INDIVIDUALS ISSUED A SUPPLEMENTARY CARD THE HOLDERS OF THE SUPPLEMENTARY CARDS WILL NOT BY REASON OF BEING ISSUED SUCH A CARD ASSUME SUCH LIABILITY, THESE CARDS ARE ISSUED AS A CONVENIENCE TO THE REGISTRANT. Additional Home Improvement Contractor identification cards are requested for the following individuals: PLEASE TYPE OR PRINT-LEGIBLY NAME TITLE, ADDRESS SOCIALSECURITY# C q SC E i CJT(�,A'►"bf� 16 a . y 77f r(L� YA AA,( /&A-N N!,S . /`T A D2 tots . I hereby authorim the issuance of supplementary cards to the above—named INDIVIDUALS WHO ARE Elv2LOYED BY THE HOME IMPROVEMENT CONTRACTOR REGISTRATION IN THE CAPACITIES NOTED. I understand that the registrant will be completely responsible for the work of the individuals, and will be responsible for'the proper use of these cards and their return if the status of the individual(s)with the registrant changes. SIGNED UNDER THE PFTIALTIIS OYPERJURY: s coRegistration/Businessme; ( T �t� Registration b By: (`� ,.,, � 6//S o i e of the registrant ' Title Daft P ase return this form along,with flee appropriatefees(SI0.00 PER CA AD)to the address above ' r E cial Use Only: tion Number: d By: Date: 1 s epartment of iblic ::-afety ' Scarp' of Ouilding Standards ?-i,-,=nse: CS-086693 eASIMI RO J BA12 2OS: 14 JEREI LANE . .MARION MA 020738 i ' Commissioner. 09/11/2015 tie�po�n�na�u�sea,�ri�C�aa�ac�coleGf License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation egistration: 163,028 Type: 10 Park Plaza-Suite 5170 ^ Boston,MA 02116 xpirationr; 5tg120# Individual WE,- l CASIMIRO J.BARR'OS K', r CASIMIRO BARRO �'��f_; '- 14 JEREI LN. �`f MA 0273 MARION of valid 8 without si nature , g Undersecretary 1 � Ap 9R m 73 Fyannough Road/Route:28, Hyannis,MA 02601 * 508-775-1120 *Fax 774-470-1575 x EMERGENCY CONTRACTORS LLC —ASSIGNMENT AND AUTHORIZATION TO PAY The undersigned, herein called: claimant, has authorized and ordered from Emergency. Contractors LLC the materials and/or services as agreed upon. This agreement shall not be considered a release and/or proof of'loss. Claimant hereby assigns to Emergency Contractors LLC any unpaid.proceeds due or to become clue;" under the claimant's policy with the insurance company to pay direct to Emergency Contractors LLC;or to include Emergency.Contractors LLC name on-check or draft. In the event that Emergency.Contractors LLC claim herein is:not covered by, or paid by, insurance company, claimant agrees to pay Emergency Contractors LLC within sixty (60) days after work has been completjed. Claimant understands that Emergency Contractors LLC is working for them, and not the insurance company or the adjuster. Payments remaining due and payable after claimant has received payment from the insurance company, shall:bear interest at a rate of one and one-half (1-1/21l6) percent per month. In the event of;breach:by claimant of any of the conditions of this agreemen#,.Emergency Contractors LW shall be entitted'to recover,:as^additional damages,:attorney's fees,costs and any other collection expenses reasonably.attributable to said breach. If payment is not received, within 60 days; collection. action will commence without further notice to claimant. Date: Claimant's Signature* E? 33� 675 Print name:-5 7 — Phona 7"' �? Address ! ' !/ h��l aZ:6' 7 insurance Agency/Agent ICT' Toll Free 866-888-7750 www.emergen!gycontractom.com The Commonwealth of Massachusetts Deparhnent of Industrial Accidents Office of Investigations .600 Washington Street Boston,MA 02111 wrvin niass.gov/din Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers,. Applicant Information Please Print Let~ibly Name(Busineess/Olganirdtiondadividinal): EACI C6,myt ►C YAP-S, LLC Address: 66ik�t 2- City/State/Zip: A-M N Is 0? O®1 1 .� �175 PLO Aree you an employer?theck the appropriate box: T� of project r ; 4. I am a eneral contractor and I } P ] ( Nm7d) 1.EdI am a employer with� ❑ g 6- ❑New construction employees(full and/or part-time)' have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet- 7- ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition w for me in an capacity- employees and have workers' working y aP h' ,9. Building addition [No workers'comp-insurance camp-insurance required-] 5- ❑ We are a corporation and its 10-❑Electrical repairs or additions 3_❑ I am a homeou mer doing all work officers have exercised their I LE]Plumbing repairs or additions myself-[N o workers' right of exemption per NIGL insurance s c-152; tu §1(4�and we have no 12-❑Roof repairs 13-Other GJ/� employees-[No workers' �vl ¢g,S1➢�IPI comp-insurance requited.] •Any applicant that checks bm-g1 most also fill out the section below showing their workers'compensation policy information t Homeonmets who submit this affidatn i&cumg they ate doing all wmk and then line outride couoactors most submit a new affidavit indicating such :Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must pmvide their,watke n'comp.policy number_ I ant art empigyer titat is prm idirig nrorkers'compensation insurmace for my enipfoyees. Below is the policy and job site information. . Insurance Company Name: AM C L)�� ` Co Policy#or Self-ins.Lic.#: 2( C 27 as— Expiration Date: � 1 Job Site Address: /5P City/State/Zip- P-rH.4 .2- 72 Attach a copy of the workers'compensation policy declaration page(showing the policy nuu&er 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 chil penalties in the form of a STOP WORK ORDER and a fine of up to$250_DO a day against the violator- Be advised that a copy of this statement may be fbm arded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceo9pn ns and penalties of perjury that the information provided abme is true and correct r- Si tune: Date: Phone#: 7S—/ ?lam Official use only. Do not write in this area,to be completed by tytp or town official. City or Town: Permit/License# Issuing Authority,(circle one):` 1.Board of Health ?Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: .DATE(MMIDDIYYYY) - - ACORO CERTIFICATE OF LIABILITY INSURANCE 03 03 2015 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 certificate holder in lieu of such endorsement(s). . PRODUCER - NAME:NTAC DOWLING&O'NEIL INSURANCE AGENCY PHONE FAX (A/C,No): 973 Iyannough Road nooRess: P.O. BOX 1990 INSURERS AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: AmGUARD Insurance Company INSURED - _ INSURER B: Emergency Contractors LLC INSURERC: 362 Yarmouth Road INSURER D INSURER E: Hyannis MA 02601 INSURERF: 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 LIMBS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ "AMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR - - MED'EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY - COMB N D).NGL. LIM - - Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED - - PROr ac TY DAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR - EACH OCCURRENCE.- $ EXCESSUAB CLAIMS-MADE AGGREGATE- $ DIED RETENTION$ $ WORKERS COMPENSATION -. WC STATU- X OTH - A AND EMPLOYERS'LIABILITY Y/N - R2WC627175- 3/3/2015 3/3/2016Ll.Tr ANY PROPRIETORRARTNERIEXECUTIVE E.L.EACH ACCIDENT S 1,000,000 N/A OFFICER/MEMBER EXCLUDED? Y❑ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 -- DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE,DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED 14 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ���s new ���� Q * "Town of Barnstable *Permit# a of Expires 6 months from issue date 22 2014 Regulatory Services Fee sna.Vsr�tE. v ,°a'M Richard V.Scali,Interim Director BARNSTAKE Building Division 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 Map/parcel Number a q O(-Q Not Valid without Red X-Press Imprint Property Address f 50 7fN I-Vf. b)96�- I7VQ✓?hwSWol-f Pqn D Z L.,r7 a Ff Residential Value of Work$ b 0. 00 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Jr�e y c Fb C_h Y—U FF /sv fir" A v-e— Wes �- H y,)� v,ylisaQE E. Mr+ . 0 z0 a Contractor's Name /Y/;L-eh C Telephone Number 5D0 "ZZJ- 77 Home Improvement Contractor License#(if applicable) /Cv S-'/y 7 Email: >'7J��G1 e o G,c- 3 / Cc Ct y✓14, .C U/1 Construction Supervisor's License#(if applicable) 09(7 F a>Y ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor U,,J,am the Homeowner l ha, Worker's Compensation Insurance Insurance Company Name. �Ct✓ C.�-� Workman's Comp.Policy# 2 /U/ Q yy Copy of Insurance Compliance Certificate must accompany each permit. Permit Req st(check box) _ [VRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Zs _D,�� �XCO ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (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: nrequired. er m sign Property Owner Letter of Permission. Ho a Improvement Contractors License&Construction Supervisors License is SIGNATURE: T:\KEVIN D\Building Changes\EXPRESS PERMIT\ Revised 061313 4/ oFTMEti Town of Barnstable Regulatory Services MASS. Thomas F. Geiler,Director 16596 1� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:.-508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder OFF , as Owner of the subject property hereby authorize V-C Gz.C o C/AC_ to act on my behalf, in all matters relative to work authorized by this building permit. Ae (Address of Job *Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed d all final inspections are performed and accepted. Signature of Owner S- tare of A t Print Name Print Name Date Q:FORMS:OWNERPM MISSIONP00LS 62012 11lightfax C3--1. 3/28/2014 10:05:40 AM PAGE. 3/004 Fax Server AC Z` CERTIFICATE OF LIABILITY INSURANCE 03- -- _ 03 2A-2014 IHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEt#IIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE I AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN I THE ISSUING INSUREH(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,certaln Policies may require an endorsement. A statement on this certificate does not comer tights Io the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT HUB IN'f ERNATIONAL NEW ENGLAND P H0.N f\HOF - - '•---- 26S ORLEANS ROAD A.0 tt� EU: FAX NORTH CHATHAM,MA 02650 -' LAlC No: INSUREntS)AFFOH97r7G COVERA INSUHEHA.TRAVEIFRSPr'OPFRTYCASUALIIY CU CF A!.1FR. A _._ INSURED -- lHEODOHE F#ITCHCOCK UBA T I.HIT V+SUBER a 933 FAL 140U I H ROAD 'NSURER c_ HYANNIS,MA 02601 NPUHERD: _ - i _ _--- _. tVS111TER E INSURER F A $ _ CERTIFICATE NUMBER 0 UMBE ' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHS-IANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT CR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUFO OR MAY PER IA7N, THE: INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI I IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 'ABBE SUR " TYPE OF INSURANCE POLICY.EFF POLICY EXP - llA INSR YND POLICYKU130EA GENERAL LIAM try - .__ hStfIDU'YYYY) A16L'DDIYYYY). lJlL11S EACHOCCUiREr., t:f..CfP.1 F.RGIAL GENERAL I IARILRY UAfAAGE TORFNTEO ..-1CU1:f.IS-t+ACE OCCUR t'lf Rli £ ---.- MEDEXP(Arfl,neP,rsonj £ f.-'i,SONAI S AOV 1,;!I1RY £ . _GFNI AMREGATELUAR AaPLIESPEn: .GENERALAGGRFGATE S _POLICY PRO• — PRODUCTS•CO`.fP�OP A^G dECI LOC AIIIOA!D8ILC UA8I11I Y.... ANY AUTO O.`.±a1N[U S'NGLE LIfd1T 3 -a arc.lc,e ALL CV/NFpAUTOS SCIIFD111.E0 BOCsLY I;ilUNY(P,r P'rsOn} £ --- HIRED I'MIO 1300ILY Irt•1�1HY(Per accdtj) --• H�tEp AUTOS t`UT Os`lScD AUTOS rr70PE�YGAL+A3Ee 1,1Y az�.Enl! FANY RI FI IA L(A8 CESS LIAR EACH OCCURflEttC>CI AP.IS-f.!ADE ....._._R D RFTF.MIp1;SRS COMPENSATI011 ---- E PLOYERS'LIABILITY X WC STA7U- pTe:,O;'fiIETOR:PARTNCRrCAECUT rvF"INTORER H.1Ar:A10ER E%CLUOEUT ❑N rt/AE.L.EACH ACCIDENT $1,000,000 ay„,tt11! 03.26.2014 03.26.2015 --.--.. If yes•[eeal?7C urdel 2E 101644 E.L.DISFASE-CA13.1PLDYEE 51,000,000 •DESCRIPT IOt!OF OPEnAT 10.V S bo-rN '--— __... _ E.L.DISEASF. FOLICYLIMiT S1,000,000 DESCHIP110NOFOPERAIIDItS/LOCATIONS I VEHICLES(AllachAr:ORD101.Additional RomsksSetodula,11noro Space lsrer(t;bed)Hl'ICti(;OCK,THFODORE is covered by the Yrorklfrs'compensaliun policy. ERT1FICAlE HOLDER AN ELLAT10N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIHA110N DATE THEREOF`, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUlM0RI7.ED RF.PRESEY.TATIVE -"-- ACORD 25(2010105) The ACORD name and 1090 are registered marks ofACORDCORPORATION.All rights reserved. Office of CousArner-Affalrs,&�)�Usi o-�Su-id:ri� -aau;a�io�ls .98,OME IMPROVEMENT CONTRAr-TOR,.. gistration: 165907 Type: _:Cerise: CSSL-099828 T 'u CONTRACTOR, e* R ACTOR ss - Ty" v piration: 41612014 Private,Co ratio ti TED L HITCHCOCK --.§TRU- SERVICE C T CKI%N CTION SERVICE INC. 55 LISA LANE w: West Barnstable MA 024668 THEODORE ITCHGOCK 55 LISA LANE WEST BARSTAB MA 02668 Und secretary 06101/2014 Restricted To: License or egistration valid for in ividul use.only before th expiration date. If found etur7i to: Odice.o Consumer Affairs and Busin sRegulation" 10 Par Plaza-Suite 5170 Post n,MA.02146 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS valid wit out-signature Office of Consumer Affairs&Business Regulation License or registration valid for individul use only �,'-F k4=FNOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: r' Registration: 165907 Type: Office of Consumer Affairs and Business Regulation -` : Ex gyration: 4/6l2016 10 Park Plaza-Suite 5170 p Private Corporatic•i TL HITCHCOCK CONSTRUCTION SERVICE INC. Boston,MA 02116_� THEOOORE HITCHCOCK 55 LISA LANE WEST BARSTABLE,MA 02668 Undersecretary Not valid wi i e The Conunonlvealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washingtoit Street Boston,M.4 02111 ' wwiv,tnass.gov/dla Workers' Compensation Insurance Affldavifi Builders/Contractors/Electricians/Plumbers. Applicant Information Please Print LegibIv Name(Business/Organization/individual): �i �l'h coo K Address: ,5�5- Lrser,,_ L A7N-.E, w pt re)sI-e, City/StatelZiP: d ' Phone#: . S-07 z 7 's 7 ?6 Are you an employer?Check the appropriate box: Type of project(required): 1,l_�1 t 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 ate a sole proprietor or partner- listed on the attached sheet t 7. ❑RemodeIing ship and have no employees These sub-contractors have 8. ❑Demolition working for meld any capacity, _ workers'comp,insurance. - g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required,] officer's have exercised their ` 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work 'right of exemption per MGL I LE]Plumbing repairs or'additions myself.[No workers'comp, c,152, §1(4),'and we have no 12•❑Roof repairs insurance required.]t employees,[No workers' 13,❑Other comp.insurance required] *Any applicant that checks box#I must also fill aut the section bclowshowing 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and theirworkers'comp.policy Information. lain an employer that Is providing workers'compensaflan hisurance for my employees Beloip i s ilie policy and Job site irrformaflorr. � I Insurance Company Name: ✓l�.d j Policy#or Self-ins.Llc,'#: 15 l O 1(p (4 LA ExpirationDate: ? 7— e [ t S Job Site Address: 1570 _74"Ipryt W 0 a Citylstate/Zip:_&6 Attach a copy of the workers'compensation policy 4eclaratfon page(showing the policy number and expiratlon date). Failure to secure coverage as required under Section 25A ofMGL 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 coverage verification. Ida hereby eertlj «nder t ze pales Rnd penallles_a{.aect,�xy that Me Information provided above fs true and correct. Signature: Date' Phone#: Offlelal use only. Do not write in thls area,to be completed by city or fotvn offlciaL My or Town; PermitUcense# Issuing Aufbority(circle one); 1.Board of Health 2,BuildingDepartment 3,CityiTown Clerk 4.Electrical Inspector 5.Plum binglnspector 6,Other Contact Person: Phone#: Information and Instructions 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 havhig 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, §25C(6)also states that"every state orJocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a buslness`or to construct buildings ln.the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 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 compliance 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,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(,)along with their certificates)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. Man 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 afiidavlt, 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'havo 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 of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding tho,applicant. Please be sure to frll in the permit/license number which will be used as a reference'number. In addition,ari applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary,)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. Anew 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 foryour 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 Mamsaohusetts, Department of Industrial Aoeidents Office of Investigations ' 600 Wuhington Street Boston,MA.02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 www,mass.govldia r