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Home My WebLink About0119 STETSON STREET i op P # s04 -,Zz, I ! G i Ii I i 1 1, E Town of Barnstable *Permit# O �* Regulatory Erpires 6 mom •from issue date Services Fee • ►am , Mwss Q> 1639.A,0� Thomas F. Geiler,Director Building Division , Tom'Perry,CBO,.Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 5 08-862=4 03 ,8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Yalid without Red X-Press Imprint Map/parcel Number Property-Address_ —1 S �Y� S M-Residential Value of Work $Q`� $� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's blame Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License# if applicable A�g ❑Workman's Compensation Insurance.. - Check one: ❑ 1 am a sole proprietor ) b C SAR l y-...- -I am the Homeowner W1 have Worker's Compensation Insurance Insurance Company Name 1Man Workman's Comp.Policy# 3c �- 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 ❑Re-roof(not stripping. Going over ' existing layers of roof) ❑ Re-side [�f—Replacement Windows/doors/sliders.U-Value #of doors 1�3� (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 Orvner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is . required. SIGNATURE: Q:\WPF1LES\r-0 permit forms XpRFSS :n t The Commonwealth oftLMassachrrsetts Department.of Industrial Accidents Office.of Investigations ODD Washington Street Boston, MA 02111 >vfvw M4ss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual);�� Id ��e,l c S Address: (Ylw Cl / t S e _ �' at ZiP: Grf C, / Phone #: 7y G 7��lJ Are you,an employer? Check the appropriate box: 1.❑ I am a employer with 4. [�i am a general contractor and I Type of project(required): . employees`(full and/or par .* have hired the sub-contractors 6. 0 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 working for mein.any capacity. employees arid have workers' 8' ❑Demolition [No workers'_comp, insurance comp.insurance.; 9. [],Building addition required.] 5 ❑ We are a corporation and i.ts 10.[]Electrical repairs or additior. 3.E I am a homeowner doing all work. officers have.exercised their: m self.. I LEE Plwnbing repairs or addition y (No workers comp, right of exemption per MGL insurance required.) t C. 152,.§1(4),and we have no 12•E]Roof repairs employees. [No workers' 13.[]Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the sect* on below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing al]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, - am an employer that is providing workers'coin' ensation insurance for my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins..Lic.#: . (� !3 S'a Expiration Date: Job Site Address: JkZ/A City/Stale/Zip: 6 Attach a copy of the workers'compensation policy declaration a e showing the policy number and expiration date). Failure to secure coverage as required under Section 2.5A of MGL P g 2 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 STOP WORK ORDER and a fin( 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. I do hereby certify under the pains andpenalties ofpe)jury that the information provided above is True and correct Si attire: Date: - 3U- Phone N: :2?q— Official use only. Do not write in this area, to be completed by city or town official.. City or Permit/License# Issuing Authority.(circle one): ].Board ofllealth 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Numbine Inspector -- 6. Other 7HEr°��. Town of Barnstable • • Regulatory Service BAMSTAULP, s v� UAB& Thomas F. Gefler,Director Buildin lJi g vision : Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bainstable.ma.us Office: 508-862-4038 Fax: 508-790-6231 Property Owner Must Complete and Sign This Section If IJsing A''Builder Cas Owner of the subject property hereby authorizeIoI4 le j�1D to act on xny behalf, �in all matters relative to work authorized by tits building permit application fox: (Address of Job) ignature of er at me Print Narne If�'ropert Owner, is aPPlying.for permit please co lete the Hom.eovmers License Exemption Form on the reverse. side. - ri . Workrs': Ce� iQ ra heat b�fo5bui bers A Name `bl_ (Business/Orga�mzat«po�??�d�v� �. � ►!� /` Address: 4 ; Are yob aa':emplgper?E'heci tie approp ., a 1.❑ I am a employer.w'it 4 tit Igsx (TV 'ed00 ): employees( 1 and/or part- met:' c'h�cd' Nest coi�sfii>eon 2• I am n sole +09reT gas no s on shed'-3 ship a :have . �s�sumo g for me in a c, iacity, wores' oactms s } bIm [No kets' . ice s 0° isisrance. Q .1 n aco g add" of � � �� 3.❑ Iam3Ih or addifidw [l�o wo exs'comp,` I .or additim {U-� o€npoaa ` try > �tt' sc H0ni0Dwnas wbo Brt to } io l'mn ms c�loye�.,,t� 7 i1�QrkaT4'��D Ins�uance Company Name: Policy#or Self-ice.Lin cc Jclb Site.Addhs:�L J t� d ✓t. $�'— Attacli ' ' a csPF�the City� F same won date ` ,(�si'lore doA bf 1�{ryr�/''1 /� \Jr fine up tD$1,5"o�Y , 4-"*W r?v " � r i •" J of up $250.00 a -yeac as weli,as 'qy i Palies of a s< 9hT ' C �R'and a�.. tk hV of ti<e DIA fair cie coverage o '; D a 4ce of ydo herby widerth�.pwisrs c of,P ' eke rn �, , d kE con�ecx .PhM#. V .1 City or Town: ludmg Authority(drek one): i I.-Board OC$eaith Z.Buflft IN 6.Other " ' p` ! 'k' 4r�" r<$ Pinimbing�pedor {,k Contact Person! e i s sub- cor�t��•- �r L��'s �fa� C.ent---S ' - 1 kiZ�t Ella -i':.rti x} 1 71 . .'} �... f'+i ai i t I�ll'rr"idr-:> �� [ac7iil:la3l .; - 'r.l � �t i1•lal Sl - Lr:erhe: CS .77520 MANUEL A CRUZ < w r 181 GREEN:ST FAIRHAVEN,MA 02719 � " c E.<piratjon: 8/13/2010 1505 ��a fJcwra�rar�uurc�ll ti l . ,x,andu \ Board of Building Reguaons and Stards v License or registration valid for-individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 128654 Board of Building Regulations and Standards Registration: ' One Ashburton Place R 1301 acm Expiration: 50/2011 Tr# 284089 • Type: DBA Boston,Ma.02108 ADDITIONS PLUS zzMANUEL CRUZc/ 167 SOUTH MAIN STREET 2N ,,�, ,--, ACUSHNET, MA 02743 Administrator -Not valid with tit nature t. ( JCS icenseq Details Page 1 of 1 -fie Official Website of the Executive Office of.Public Safety and Security(EOPS) Aass.Gov Home Public Safety )apartment of Public Safety Licensee Complaints License Type Construction Supervisor License# 77520 - Restriction 00 Name Manuel A Cruz City,State,Zip Fairhaven,MA,02719 Expiration Date 8/13/2012 Status Current No complaints found for this Licensee. Back To Search tip://db.state.ma.us/dps/licdetails.asp7txtSearchLN.CSL.77520 9/29/201.0- 92. ZJomvrn1-1.&1c o�.�aaaac�ec aella: Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OdAE IMPROVEMENT CONTRACTOR before the esprration date. If found return to: Office of Consumer Affairs and Business Regulation Registration-:==},g688 10 Park Plaza—Suite 5170 Expira iq'i i f 8{2Q11 Boston,MA 02116 3 `Cp{ae;Susfeinent Card LOWE'S HOMES, JAYMI RODRIGCIEZ �' r 136 TURNPIKE RD:: [1T =�.Oa ga SOUTH BOROUGH,MA;01772 Undersecretary Not-valid without signature . . 1 oFIME r Town of Barnstable *Permit#ca A&6� Expires 6 ntoaths ro issue date ESS PE !Wgulatory Services Fee anexsrnet.e, : 'Thomas F.Geiler,Director . : PR 16 2009 Building Division C� 1p Tom Perry,CBO, Building Commissioner OF SARNSTABL2&Main Street,Hyannis,MA 02601 www.town.barnstable.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 Property Address54a_sc�Nj MA "" Residential Value of Work W O" Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 11 (1 D1 bQM1 Contractor's Name JLd b2A c-he--r Telephone Number jpE�^3L,)2 -142(a_ Home Improvement Contractor License#(if applicable) 111615 0 ❑Workman's Compensation Insurance Check one: ° ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name'� AJ X) ;ii ` Q 11 i r/Pt-fl Workman's Comp.Policy# Ll U CpQq n 3 H 5�Co30 ' Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris w tt'be taken to �5(,uyjj_ ) ,-,h ❑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. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:buildingperm its/express Revised 123107 Town of Barnstable BAMSTABM 63q 6 �{ Regulatory Services s . � n ° Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 as Owner of the subject property hereby authorize Q to act on my behalf, in all matters relative to work authorized by this building permit application for: (Addres of Job) Signature of Owner Date 7 Print Name Q:Foims:buildingpermits/express Revised 123107 I � ACORD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 10-02-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON'THE CERTIFICATE BRYDEN K SULLIVAN INS AG HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 FALMOUTH RD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW HYANNIS,MA 02601 COMPANIES AFFORDING COVERAGE COMPANY 232MY A TRAVELERS DIRECT ASSIGNMENT INSURED COMPANY B < LEIF BOTTCHER HOME IMPROVEMENT INC. COMPANY 825 CEDAR STREET C WEST BARNSTABLE,MA 02668 COMPANY D COVERAGE THIS IS TO CERTIFYTHAT 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,BHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE LIMITS GENERAL LIABILITY COMMERCIAL GENERAL GENERAL AGGREGATE $ CLAIMS MADE OCCUR. PRODUCTS-COMP/OP AGG. $ OWNER'S&&CONTRACTOR'S PROT. PERSONAL&&ADV.INJURY $ EACH OCCURRENCE $ FIRE DAMAGE(Any one tire) $ AUTOMOBILE LIABILITY MED.EXPENSE(Anyone person) $ ANY AUTO ALL OWNED AUTOS COMBINED SINGLE LIMIT $ SCHEDULE AUTOS BODILY INJURY(Per Person) $ HIRED AUTOS BODILY INJURY(Per Accident) $ NON-OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY 1 ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ a EXCESS LIABILITY AGREGATE $ UMBRELLA FORM, EACH OCCURRENCE $OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-0407M863-08 07-30-08 07-30-09 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERS/EXECUTIVE X INCL DISEASE;POLICY LIMIT $ 00,000 OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 100,000 y OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. "x. CERTIFICATE HOLDER 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 LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25-5(3/93) Charles J Clark f, '''�: k ys' 4 rg' egulatons a 'drS r 'ids N AG str` .O yes r � � Y perviso4 ere CS6 85 } N 2009 Tin#4124 116 F E BC}TTGHC t 825aCWK EDARS,TREET --�. �y WjBARNSTABLE MA 02668 Commissio eri r r� I I _ Board of Building Regulations and Standards License or registration valid for individul use only r HOME IMPROVEMENT CONTRACTOR before the expiration date: If found return:to- Registration: ' 111050 Board of Building Regulations and Standards • x cation y8/201 t Tr# 279079 One-Ashburton Place Rm 1301 44 x �YPe -DBN Boston Ma.02108 a 1= j LEIF BOTTCHER OME I IP:� WRACTOR LEIF BOTTCHER, -g _ 825 CEDAR ST I W.BARNSTABLE,MA 02668 ` Administrator of alid Without signature ' 02/21/2009 19:49 5083624262 LEIF BOTTCHER PAGE 01/01 The Commonwealth of Massachusetts Department of Industrial A.cciden.l!s ' Office of,Investigations 600 Washington Street .Boston, AL4 02111 www.mass.gov/dia. Workers' Compensation Insurance Affidavit: Builders/Contil-actors/El.ectricians/Plumbers Applicant Information Please Print LeQ1blV Nailie(Business/OrganizationAndividual):_LO-1 P -1, h,1 I- Address: of (� City/State/7i Phone #: Za Are you an employer? Check the appropriate box: Type of project(required): 1 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[] 1 am a sole proprietor or partner listed on the attached sheet, 7. [] Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y p h'� 9. ❑ Building addition [No workers' comp,insurance comp.insurance$ required.] 5. ❑ We are a corporation and its 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l LEI 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#I must also fill out the section below showing their workers'compensn,tion policy information. t HomewmerR 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-eontractins and state whether or not those entities have employees. If the sub-contractors have employees,they muat provide their workers'comp,policy num1mr. I am an employer that is providing workers'compensation insurance for my enpiloyces. Below is the policy and job site information. Insurance Company Name: t")ru r_ 11 n Policy#of Sel -ins.l.ic.#�: r'I Q�p "�Q� Expiration Date: �1 Job Site Address: .l lq�� _ _L)n �Cg_ ifl Art.f1L)I'S City/State/Zip: MA CA 2(a n l 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. 1.52 can lead¢o 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. I do hereby c_ert�fy u�n"d'er.Vm rru and penalties nfperjr;.ry that the information.provided above is true and correct Date: Phone __` ) a- . ,510,::2- a (n a- Official use only, Do not write in this area,to be completed by city, or town oj,!ricial City or Town: Permit/License#_ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electriical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: