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Home My WebLink About0112 SUOMI ROAD suomx r Town of Barnstable *Pe 130 rmit �`' Expires 6 months from issue date Regulatory Services Fee a s • L►RN3rABLE • MAM Richard V.Scali,Interim Director i639. ,� •. DMA't� 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 ff ii Not Valid without Red X-Press Imprint Map/parcel Number 0 Property Address k-h,n t residential Value of Work$ 500 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address a Contractor's Name a(> zo h 2zsTelephone Numbe 999 Home Improvement Contractor License#(if applicable) mail:—Dh,a=1z as`o 6) p w. Construction Supervisor's License#(if applicable) c � 7 -�� ' �Vorkman's Compensation Insurance Check one: O C T 2 3 2013 ❑ I am a sole proprietor ❑ am the Homeowner have Worker's Compensation Insurance TOWN OF RARdVSTARLE Insurance Company Name ' Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ t(check box) [r✓] Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to r �y G� ❑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: Property Owner must sign Property Owner Letter of Permission. A copy of t)t Home Improvement Contractors License&Construction Supervisors License is uired. SIGNATURE: Q:\WPFILES\FORMS\building pe it fo RESS.doc Revised 061313 - Email: Trite C'ommanivealth of Massachusetts Departrnent of htdasoid Accidents Office of 1m4n igations .: 600 Washbigiaii Street Boston,MA 02-Ul YVi4'i rnasmgoWdia Workeis' Compensation Insnrani a Affidavit:Builders/+ContractorsfEiectricians/Rumbers Applicant Information Please print LeeiWy � n Name(ism WOrganization&&vidmi): Toa Adds : /�- D /�A l 9 � City/Stat&Zip: ) V Jr/ Phone 7� Are a an employer?Check t appropriate bow T of o ect(required): 4. I stir a coniractdu and I YI3e Pr' j . 1. I am a employer with ❑ l 6. ❑New cclIstructiou employees(full and/or part-time).* have hired the sub-contzscctors. 2_❑ I am a sole proprietor or partner- listed on the attached sheet. y- ❑Remodeling ship and have no employees These sub-oontractors have 8. ❑Demolition. w forme in an capacity. employees and have workers' working Y c iasurance.I 9. ❑Building addition [No workers' comp.insurance comp. required-] 5. ❑ We area corporation and its 10..❑Electrical repairs or additions 3_❑ I am a homeowner doing all work officers have exercised their I Lo Plumbing repairs or additions myself,[No workers'oomp- right,of ememption per MGL 12.. insurance required.]1 c.152,§1(4),and we have ua ❑Roof repairs employees.[No workers' 13.❑Other comp.insurance required-] *11ay agpH�nt that checks boa 91 matt also fill out the section below shooing ihek wadies''compensation policy infer mt m �Homeowners who submit ibis affidwit imEcstmE they are doing all work sad then hue outside cot<uacmrs must submit anew affidavit iaei Cahn such- lContkactors that check this bmc mast atu ched an additional sheet showing the name of&e snit-amWiclors and state whether arrow these w9 ties have employees. If the sub-coatmaors have employees,they must pmvide their warkus'comp.policy number. Ism an employer thatisprotd�e-rs'cogmyuw on ins trance for my omplayeas Below is diepArcy and job site information. Insurance Company Name: Policy*or Self-ins.Lie-#: �� , �� D/ . Expiration Date: ZP f �� Job Site Address: CitylStatelZip: 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 ofrriminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of fuvestigations of the DIA for insurance:coverage verifitation. I do Hereby ce under th pain nd as ofperjuty dtatdie information praiRded abrrve�ijs true and co)rrect t ��Si tore � Date: !` / Phone#: D, ciaL use only. Der not write in this area,to be completed by city or town offieiaL City or Town: PermitUcense If Issuing Authority(circle one): 1.Board of Health 2.Buff-ding Department 3.Cityfrown Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 having 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 or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in 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-contractors)name(s),address(es)and phone number(s)along with their certaficate(s)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. If an 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 affidavit. 711ie 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 have 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 the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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. A new 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your 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 Massachusetts Depaitment of Industrial AAcridents Office of kvestigatfans 600 Wasl i gtaa Street Boston,MA 02111 Tf,-I.A 617-727-49 00 ext 406 or 1-977 MASWE Fax# 617-727-7749 Revised 4-24-07 www.mas-s-gavldia Pro poal H.U.No.101135 OW Lie.No.025458 ROOFING AND SIDING, INC. PAUL KAZOLIAS P.O.Box 692297,Quincy,MA 02269 (617)471-2999 PR BMIITED TO/-I) PHONE DATE 6 C-(, i 0 STREET ' JOB NAME ice CITY,STA E AND ZIP CODE JOB LOCATION r O �,, ,/ ) ARCHIlfECT DATE OF PLANS J PHONE, Hang Tarps to Protect House and Grounds Strip Entire Main Roof Aluminum Dripedge on All Eaves Re-nail All Loose Boards with Galvanized Nails Vo Install Underlayment Paper Install Ice and Watershield 6'High at Lower Eavest1olle of � ! i e Counter-flash Chimney New Pipe Flashings Re-roof Same Areas Specified To Be Stripped Type of Shingles , Color of Shingles Clean all Gutters Upon Completion Remove all Excess Debris and Power Magnet Grounds )+ ✓' 1 Years Guarantee on All Workmanship and Manufacturers Warranty on Materials. Total Cost of Labor and Material Deposit Required Balance Due Upon Completion oploge er to furnish material and labor—complete in accordance with above specifications,for the sum of: Ilars($ Payment to be made as follows. All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above specifica- Signature tions involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes, Note:This proposal may e accidents or delays beyond our control.Ownerto carry fire,tomado,and other necessary withdrawn by us if not accepted within days. Insurance.Ourworkers are fully covered by Workmen's Compensation Insurance. 3creptante of propood - The above prices , specifications and conditions are satisfactory and are hereby accepted.You are authorized to Signature 0 ' do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature /e omvr�zaiuueal�o�C>�aac�zciaeC7.a. Office of Consumer Affairs&Business Regulation License or registration_valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: �1011,35 Type: Office of Consumer Affairs and Business Regulation xpiraUon 6/28E2014. Private Corporatica 10 Park Plaza-Suite 5170,. Boston,MA 02116 RAINBOW ROOFING&SI6ING`1NC Paul Kazolias V " J 67 ISLAND AVE. Quincy,MA 02269 Undersecretary of w thout signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards ` Construction Supen isur License: CS-025458 PAUL N KAZQLIAS PO BOX 69220 QUINCY M�} 022 �` Expiration Commissioner 04/09/2014 r. MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance frorn the Assigned Risk Pool Carrier(Travelers InderT►r►ity CO). Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. It this torm is Cully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of.the carrier's receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information referto the Certificates of Insurance section located in the Producer Community section of the Bureau's website (�ywtirti.:..v„:rl;}33 ,;�)rtl). t. Name, address, telephone number and facsimile number or email address of the INSURED: Name: --Rainbow Roofinq &Siding,-Inc: dba: Mailing Address: 67 Island Avenue P.O. Box 69-2297 Quincy MA 02269 Physical Address: Phone: (617)471-2999 Fax or email: Fax Number or Email Address 2. Name, address, telephone number and facsimile number or email address of the CERTIFICATE HOLDER: Name: Town of Barnstable Mailing Address: 200 Main Street, Hyannis, MA 02601 Physical Address: Phone: Fax or email: 508-790-6230 3. Name, address, contact person, telephone number and facsimile number or email address of the PRODUCER; Name: Albert J. Tonry&Co_, Inc. Mailing Address: 300 Congress Street Quincy, MA 02169 Contact Person: Janet G. Trefry Phone: (617)773-9200 Fax or ernail (617)773-9920 or c:erts a.tonry.corn 4. Policy Number, Policy Effective Date and Policy Expiration Date If a Certificate of Insurance is needed fior more than one policy term, provide the Policy Number, Effective Date and Expiration Date for each policy term. It the policy has not yet boon issued, you must attach a copy of the Notice of Assignment. . -Policy Number:— 6HUB5B309148131''� -Effective _ 6/14/2013 `, Expiration Date: 6 4/2614_N'-,, 6. List any special requests for optional coverages/endorsements(see Page 2 for listing of coverages available in the pool and the conditions of availability)or additional information(including changes in exposure not yet reported to the carrier)that will assist the carrier in the issuance of the Certificate of Insurance. NOTE:An additional insured(s)shall not be listed on any Certificate of Insurance unless such additional insured(s)is a named insured on the policy. None