HomeMy WebLinkAbout0052 SIXTH AVENUE (HYANNIS) sa S��c-ram ��
1QS79
of ME ram, Town of]Barnstable *Permit#
' p0 Erpires 6 months om issue date
Regulatory Services. Fee S --
\. (RAR STARLE,p - -
110C
Al . Thomas F. Geiler,Director
i67q �—
�0 m
U MP
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 T� /Vol,
wtvw.town.barnstable.ma,us - OTC 009
Office: 508-862-4038 508`'790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLYST�4
Not Valid without Red X-Press Imprint
Map/parcel Number /
Property Address c !�/ Q , 2.2
�]Residential Value of Work 6-0 Xh Minimum fee of$25.00 for work under$6060.00
Owner's Name&Address y, Z5,7,,.,r`"e 1
Contractor's Name_ ���M6� 5 Telephone Numbers l •(} ��
Home Improvement Contractor License#(if applicable) l Y a7 n 3 as�S a
1✓ Construction Supervisor's License#(if applicable) C S ( �j c)`
\91Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name � .
U h
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box).
Re-roof(stripping old shingles) All construction debris will be taken to I(y Sse� �Vjhs 6�
❑Re-roof(not stripping. Going over existing layers.of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement C tractors License&Construction Supervisors License is
r red.
SIGNATURE:
I
C:\Users\decollik\AppData\Local\MicrosoR\Windows\Temporary Internet Files\Content.0utlook\4STGU5Q oc
Revised 090809
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tHE�Ytio�
t3AR\'S?A$tiE, '�
` Town of Barnstable
.
Regulatory Services
Thomas F.Geiler,Director
r Building Division
Thomas Perry,CBO
Building Commissioner.
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section ,
If Using Builder
A it r
,
I,x '50"/' 3✓.-Ji5e r ,as Owner of the subject property
hereby authorize' /t C, ti to act on my behalf;
in all matters relative to work authorized by this building permit application for:
sdx 14V L r,/ �19�i n/tSpon i
(Address of Job)
Signa e of Owner Date
Print Name i
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\ContentoiAlook\4STGU5QO\EXPRESS.doc
Revised 090809
j Client#: 9580 2KPRE
CERTIFICATE OF LIABILITY INSURANCE �;17/2009
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
.cling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
973 lyannough Rd., PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Western World
Kenneth Perry D/B/A INSURER e: Associated Employers Insurance
K.P. Remodeling &Construction
- INSURER C:
19 Guildford Road
INSURER D:
Centerville, MA 02632
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.
. DD
LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION -
DATE MM/DD/YY DATE MM/DD/YY _ LIMITS
A GENERAL LIABILITY NPP1203292 03/04/09 03/04/10 EACH OCCURRENCE $1 000 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
_ PREMISES Ea occurrence $50 000
CLAIMS MADE OCCUR - - - MED EXP(Any one person) $5 000
X BI/PD Ded:500 PERSONAL&ADV INJURY $1 000 000
GENERAL AGGREGATE $2 0O0 OOO
GEN'L AGGREGATE.LIMIT APPLIES PER: - - - - PRODUCTS COMP/OP-AGG $1 OOO OOO
POLICY PRO- _ -
JECT LOC � -
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS
BODILY INJURY -
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE _ $
(PeraccidenO
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO
- - OTHER THAN EA ACC $ .
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE -
RETENTION $
$
B WORKERS COMPENSATION AND -WCC5005450012009 06/13/09 06/13/10 XWC STATU- OTH -
EMPLOYERS'LIABILITY -
ANYPROPRIETOR/PARTNER)EXECUTIVE _ - E.L.EACH ACCIDC-NT;' $10,0.,,. OO .--L.
OFFICER/MEMBER EXCLUDED? YES E.L.DISEASE-EA ENaPLOYEE $1 OO' 00 1
If yes,describe under -
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $56tl-000
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Kenneth Perry is excluded from the workers compensation policy.
Operations performed by the named insured subject to policy conditions
and exclusions.
rr9 `
CERTIFICATE HOLDER CANCELLATION
- - - -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE.THE EXPIRATION
Town of Barnstable Bldg Div. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1171 WRITTEN
Attn:Tom Perry-Commissioner NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUTFAILURE TO DO SO SHALL
200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Hyannis, MA 02601 REPRESENTATIVES.
AUTHORIZED R PRESENTATIVE
ACORD 25(2001108)1 of 2 #S63247/M59064 / LS1 � O ACORD CORPORATION 1988
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:� taeh a,eogy otfhe��arlers ceivagertsfiora,poh dee9�aaatiflribeshoiiis the pi uuhea d e�p�atson date;
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rye aap.ta l £lQ,.+Qf3 tr�sli S oue.yetirt�p:nso e asp ell as ci l.p�att€es'k fhe.fGft O n TO.Ih�f� � RDUCritd'A ke"
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