HomeMy WebLinkAbout0030 STEVENS STREET �� S�e-ve � -S 7'—
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`Town of Barnstable *Permit# o% 0 3��0
Expires 6 months from issue date
Regulatory Services Fee
= RABNSPASM t o
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1619. Thomas F.Geller,Director
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Building Division ya Q
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
2\ I Not Valid without Red X-Press Imprint
Map/parcel Number 9 ! J 'kO
Property Address 3C 2kyy eYls VCA AV)t5
[Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address LZ taffl Z w A y1 7�C n
Contractor's Name Sprinkle Home Improvement Telephone Num 8 775-1778 Ext..10
Home Improvement Contractor License#(if applicable) 103757 PEP
Construction Supervisor's,License#(if applicable) CS 6643
JUN I . _
XWorkman's Compensation Insurance
Check one: op
❑ I am a sole proprietor RNST
El am the Homeowner ��
(� I have Worker's Compensation Insurance
Insurance Company Name Associated Industries of MA / A.I.M Mutual Insurance Co.
workman's Comp.Policy# AWC 7004943012012
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) UU
i Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to It t VM ot"A t Yct4 S,Ji'f'
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors,
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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 th ement Contractors License&Construction Supervisors License is
requi
SIGNATURE:
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet des\Content.0udook\DDV87AAZ\EXPRESS.doc
Revised 072110
The Commonwealth of Massachusetts Print Form J
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-20.17
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual,):.
Sprinkle Home Improvement
Address: 199 Barnstable Road
City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext. 10
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with '10-12 4. E] 1 am a general contractor and 1
employees(full and/or part-time).
have hired the sub-contractors 6. ❑ New,construction
2.❑ 1 am a sole proprietor or.partner- listed on the attached sheet. 7. Remodeling.
These sub-contractors have
ship=and have no employees 8. E] Demolition
working for me in any capacity. employees and have workers'' 9. 0 Building addition
[No workers'comp. insurance-.. 5. comp. insurance.
We are a corporation and its .❑ Electrical repairs or additions
required.]. ❑ r I0
p, 1
3.❑ 1 am a homeowner doing.alI work officers have exercised their I I. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 Roof repairs
insurance required.]t c. 152, §l(4), and we have no
employees. [No workers' 13.� Other
comp. insurance required.]
'Any applicant that checks box#1 must also till out die section below shoaling 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:
-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:
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.,
Insurance Company Name: Associated Industries of MA.TA.I.M Mutual Insurance Co.
Policy#or Self--ins. Lic. #: 7004943012012 Expiration Date: 01/01/2013
Job Site Address._, :eat_ns' H`� City/State/Zip: ,U,n n 1,S
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. 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 thara.copy.of this statement may be forwarded to the.Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u e e enalties ofperjury that the information provided above is true and correct
Si ature: Date
Phone#: 508 775-1778 Ext. 10
Official use only. Do not write in this area;to be completed by ch)p or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
DUAL Toww of-Barnstable
R_ egulatorye Services
Thomas F.,Geiler,Director
Building Division
'Thomas Ferry,CBO
..R . �+ Building Commissioner
200 Main Street, Hyannis;MA 02601
www.towubarnstable.ma.us
Office:.,568-862-4038 Fax: .508-790-6230
Property Owner Must
Complete and Sign This',Section
If Using AA Builder
I, SpQv� �tiSoirl ,as Owner of the subject property
Sprinkle Home, Lmprovement
hereby authorize to act on my behalf,
in all matters relative to work authorized by.this building permit application for.L GAN A
(Addressof Job)
`I -I Z
ature of Owner Date
� ZS6'
print Name
If;=Property Owner is applying for permit,please complete the,Homeowners License Exemption Form on-the
reverse side.
C:\UsersWecoi ik\AppDaUU=al\MicwsoMWindows\Tempon"intemet Files\ContenL.Oudook\DDV87AAZ\EXPRESS.doc
Revised'072110 p
12/ 2U/1U11 9 . 35 33 .AM 874:0 2 02/09 .
DATE(MXVDDrrM
CERTIFICATE:,OF LIABILITY INSURANCE iv2oi2oii
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rams QRRTIrlcavn Is INQm As A-w"M or, IarORAWxOr ONLY A COmrmRt no RSes" upon ram ¢alZrxC#TO AOLVER.:Timm CRRrmnc"s
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XIBUANCR DOas NOT COam'rlTorm A CONTRACT AW"Ua_Tas 1809XVe If80RSR(m)..AMORIila nPsssa7TATIVt OR FROOMM AND Tw
CmRTIrICATs aoL)RR. ,. ..
IWORTANT: xf the certificate holder im an ADDITIomAL' ImssRRD, the pol cy(sns)-sust be endorsed If moaROYRTIOm 29'fAIVRD, subject
to the tares and conditions of the policy, Carta III,pollciee say requIre.an-endCmwe ient. .A'statement on,thiscertificate does. not
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Rryden i Sullivan Ins,A ency .um
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Hyannis, HL ;02601 Imes in.
Immune is) wisaeae,cseuiios. suc• j
Sprinkle t IncMmum a, A.I.1[. Mutual 'Insurance Co 33758
Hcme;Z>Dpro emen --
Mains 9;
199 Barnstable'Road,' uoeaa C.
Hyannis, bft. 02601
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incl ❑ excl 7004943012012 R.L. •IseAal -s•LICT Lnu*, • 500 000
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CERTIFICATE HOLDER CANCELLATION*
PROOF Or INSURANCE
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HOME IMPROVEMENT CONTRACTOR
Registration: 103757 Type:
6643 Expiration: 1/9/2012 Private Corpurauc
SPRINKCi: HOME IMPROVEMENT INC;
BRAD K SPRINKLE y y '
190 LOTHROPS LANE ,
Naq 5phtln ie -
W BARNSTABLE, MA 02668
t nJcr.ccrrrn'�
L 100)X13
I.,r� „•,raraliun %alid for individul use(jolt
Failure to pu�.c..a current edition of thr het„rr rhrr%pir:Uion date. If found return Its:
Massachusetts State Building;(ode 1 riticc„t ("unsunu•r Affairs and Business Itskuiat,, l,
is cause for rc�ucation of this licrn�c' to 1'arti Plaza -..Suite 5171)
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