HomeMy WebLinkAbout0046 UNCLE AL'S WAY z7L6
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Town of Barnstable *Permit# &d � �q
Expires 6 months rom i sue date
Regulatory Services Fee
spR►�ty-rpg�, : Thomas F.Geiler,Director
MASS,
EONa •� Building Division L{r O
Tom Perry,CBO, Building Commissioner �f
200 Main Street,Hyannis,MA 02601
www.town.bamstable.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 Gr 7 tf3 J
40
Property Adbtr ss &c
Residential Value of Work A0 ;S D Minimum fee of 25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name . at 46, .;?C_ J s 1 I ur, Telephone Number
Home Improvement Contractor License.#(if applicable)
Workman's Compensation Insurance X-PRES
C eck one:
Vza
I am a sole proprietor
❑ I am the Homeowner
JUN. (�Q$
❑ I have Worker's Compensation Insurance "OWN OF
RNSTAL
Insurance Company Name �,�(JG'l �s'bioP�"�Lj icSc� ir��s'
Workman's Comp.Policy# 00—2 3 6
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to C-
❑Re-roof(not stripping. Going over existing layers of roof)
ARe-side 4' � � .J�
❑ Replacement indows/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: r z G/zIll •
Q:Forms:buiIdingpermits/express
Revised 123107
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CONTRACT WORK SPECIFICATIONS
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'Mass HIC# 100468 RI HIC# 17166
M 01
Initialing this page indicates receipt of the CONTRACT TERMS
t .. l'
AND REQUIRED NOTICES as page 1 of this agreement F DN1S10 �Q� H1C#g°°'�`""7ssR1
est 1959
Owners Names h4lr! : A PK) 60 Getchell Way,Canton,
MA 02021 781-963-7900
Home Tel.NoL Li V,� 6� / ` 9
- 7
Bus.Tel. o. e-mail
Job Site Address LOwa, Ats ( MY ST Zip
Details of work to be performed and materials to be supplied follow
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Initials Acknowledging this page:Alumabilt, In Homeowner Homeowner p� C Date
HOMEOWNER: Do not sign this contract if there are any blank spaces. You have a right to a copy of this contract.
Page of
s
CO.t4TRACT TERMS AND REQUIRED NOTICESWELL
n� s
Notice:All home improvement contractors and subcontractors engaged in home improvement ;.
contracting,unless specifically exempt from registration b the provisions of Chapter 1 42A of the general 9 P Y P 9 Y P P 9 �
laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and .
status should be made to the Director,Home Improvement Contractor Registration,One Ashburton Division of �- 1C#IW468 MA 17166 Po n�I
Place,Room 1301,Boston,MA 02108. �`"°" est 1959
50 Getchell Way,Canton, MA 02021 781-963-7900
I/We hereby agree and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements
according to the specifications,terms and conditions,on the premises below described,which IMe represent that we have good record title in our own name.
Owners Names LL) P + JY h/ . r.1�4 A)
Home Tel.No. r rn el.No. ' e mail PI4 f0`!PA&O flfV/JA
Job Site Address CLA'. ALS IAA City °AWS ST Zip
Massachusetts Contractor Registration# 100468 Rhode Island Contractor Registration# 17166
Work Specifications described attached on pages: of of of
Permits:The contractor agrees to apply for and obtain all construction related permits(Building/Electrical/Plumbing)but shall not be deemed responsible for delays in
the work described in this agreement caused by regulatory,permit granting or inspection agencies,authorities or individuals.
Notice:The homeowner who secures his own permits will be excluded from the guarantee fund of MGL Chapter 142A.
Price:The contractor agrees to do all,work described by the contract for the total price of $
Notice: No agreement for home improvement contracting work shall require a down payment(advance deposit)of more than one-third of the total
contract price or the total amount of all deposits or payments which the contractor must make,in advance,to order and/or otherwise obtain delivery of
special order materials and equipment,whichever is greater. i �j= q0
Payment Terms: Advanced Deposit $ Payable on signing of contract ' Cam' /
Interim Payment 1 $ Payable aAl '" comet `y g
Interim Payment 2 $ Payable
Final Balance $ Payable. OA� r,
Security Interest: Yes No-To be held in the form of a UCC-1 form to be filed only if payment is not made on completion.
Notice:The contractor does not have the right to request payments in advance of the times set forth in this agreement,although,by agreement,the parties may jointly
agree to escrow any portion of the contract amount.In the event that it becomes necessary for the contractor to employ an attorney to collect any balance due
hereunder the owner agrees to pay in addition to the said balance,the costs of collection and reasonable attorney's fees.
Work Schedule:The contractor will not begin work or orcieS materials before the third day following the signing of this agreement unless specified in writing.The
contractor will begin work on or about __7 0 a (date).Barring delays caused by circumstances beyond the contractor's control,the work will be
substantially completed in 6weeks/days.The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that
are not avoidable by the contractor shall not be considered as violations of this agreement.The contractor shall not be liable for any delay or non-performance caused
by strikes,accidents,weather or any other contingency beyond its control.
Insurance:The contractor agrees to maintain workers compensation and comprehensive general liability insurance during the operation of this job to cover the acts of
its employees and or agents.
Warranties:The contractor warranties its workmanship for up to a period of seven years and assigns the rights to any manufacturer's warranties to the homeowner
after the substantial completion and payment of the contract terms.
You may cancel this agreement if it has not been consummated by a party thereto at a place other than an address of the contractor,which may be his
main office or a branch thereof,provided you notify contractor in writing at his main office or branch by ordinary mail posted,by telegram sent or
delivered,not later than Midnight of the third business day following the signing of this agreement.See the reverse side of this form for an explanation
of this right. This instrument and any and all other documents attached hereto and signed by the parties set forth the entire contract between parties
and may be modified only by a written instrument executed by both parties.Receipt of a copy of this contract and duplicate notice of cancellation and
explanation thereof is hereby acknowledged.
HOMEOWNER: Do Wfhe
f sign this contract if there are any blank spaces.
IN WITNESS WHERE .artiQhernto signed their names this )-May of 200�.
Alumabilt, Inc. Representativ Homeowner 2L
Accepted Alumabilt, Inc. Homeowner
Page 1 of HOMEOWNER: You have a right to a copy of this contract.
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individul a eo
istration vali 11 found return
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i ice the expirati Regulations an
heS°Te guildi place 9-0
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Board sl ou
One Ashhurt.
Boston,Ma'021p8
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Not valid witho
stguat e
✓fie�omvnzaruueai a� aQeac�ivaeba
? Board of Building Regulations and Standards
HOME IMPfIOVEMENT CONTRACTOR `
Registry i.;Qn 151245
CI E T '"3/2010 Tr# 266180 i
,v
G}� JW MALING COI j
JAMES MAILING X $a
4196 MAIN ROAD
TIVERTON,RI 02838
Administrator
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I
071
oard of Bwlding Regulations and StandarJ21
Construction Supervisor License
L Liceq$��CS 35196
j T4 12
JAME
j ratl'i�7 /,2010
aS W MALIN ,x �cJ - /1 i`4196 MAIN RDTIVERTON,RI 02878 Commiss
CERTIFICATE OF LIABILITY INSURANCE DATE(MMMWYYM
04/03/2009
0°U C781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE-CERTIFICATE
458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AWIEND,EXTEND OR
Whitman, MA 02382
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW..
Meaghan Walker INSURERS AFFORDING COVERAGE NAIC#
INSURED Alum3ibilt, Inc. INBuRERA; Western World 000071
C0 Ml Way INSURERS: The Travelers Tndemnity Company 2$6S8
Canton,
MAA 02021 INBUReRc, Penn America
INSURER D: Savers Property & Casual ty Ins 000203
INSURER E:
COVERAGIS
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 HER91N IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR TYPE OF INSURANCE POLICY NUMBER POLILYEFF11"VE POLICY EXPIRATION
LIMITS
0>;t�IEMLAWLITY REN OF NPP1082200 04/01/2008 04(01/2009 EACH OCCURRENCE s 11000,0
EX
COMMERCIAL GENERAL LIABLLrTY DM,
TO RENTED $ SO O
CLAIMS MADE a OCCUR MED EXP(Any one person) s 1 OO
001
PERSONAL&ADV INJURY IS 1.000.0
GENERAL AGGREGATE s 2,ON
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 1,O(w.OO
X PCUCY JPER LOC
AfrTOMO�Le Lu►BILITY EN OF BA4240701907SEL 04/01/2008 04/01/2009
COMBINED SINGLE LIMIT
ANYAUTO (Ee GCOAam) $ 1,000,OO
A"OWNED AUTOS
B
X SCHEDULED AUTOS (BODILYPNURY
X HIRED AUTOS
BODILY INJURY $
X NCN.OYVAIED AUTOS (ppr ecdtlenl)
PROPERTY DAMAGE $
(Par ecowru)
CAM"LIABIUTY AUTO ONLY-EA ACCIDENT >6
AN`(AUTO
OTHER TMAN EA ACC $
AUTO ONLY. AGG $
E CRSSWMBRELLA LABILITY REN OF SUB1015622 04/01/2008 04/01/2009 EACH OCCURRENCE s 1,000,00C
X OCCUR CLAIMS MADE C AGGREGATE - S 1.000.00(
$
DEDUCTIBLE
x RETENTION s la,o0
8
>6
WORKERS COMPENSATION AND REN OR CCO002363 04/01/2009 04/01/2009 x rvC 8 ATU- x OTH.
EMPLOYERS'LL41UUTY 'TS
O ANY PROPRIETORMARTNERIEUECUTNE E.L EACH ACCIDENT 5 5O0 OO 01
OFFICEWMEMBER EXCLUDED? OFFICERS INCLUDED If Yee,desmbs under E.L.DISEASE-EA EMPLOYEE S 5001 OO
SPEC PROVISIONS below E.L.DISEASE-POLICY LIMIT S O 5O0 QQ
THER
DESCRIPTI N OF OP TION§J LOCATIONS I VEHICL�S I EXCL ONS ADDED BY ENDORSEMENT i SPEC AL PROVISIONS
perationst IOMe improvement: TnstalUpation of windows, doors, vinyl siding
T12ER cANCELLATION
SHOULD ANY OF THE ABOVE 13ESXAUD POLICIES BE CANCELLED BEFORE THE
EXPIRATON DATE THEREOF,THE ISSUING INSURER WILL EnrAVOR TO MAIL
Al umabi 1 t Inc 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Rita BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO COUGA noN OR LIABILITY
SO Getchel l Way OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Canton, RA 02021 AUTHORMEDREPRESENTATIVE
ACORD26(2001/08) Fes: (781)963-7986
CACORD CORPORATION 1988
TO 39vd NOSVW NOSVW ZE8ZLpbT8L Eb:ST 80OZ/EO/bO
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �j Please Print Legibly
Name(Business/Organizationflndividud):
' Address: � �� �+��/�,o// �,27C�, •
City/State/Zip: 0,,10611 Phone.#:
Are you an employer? Check the appropriate bow Type of project(required)-
1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction
employees(faill and/or part time).* have hired the sub-cont actors
2�I a.m a sole proprietor or partner- listed on the attached sheet 7. Remodeling
�s$rp and have no employees These sub-contactors have g. Demolition
wo for me in employees and have workers'
ring �Y���� ;n��nce,t 9. ❑Building addition
[No workers comp.-msurance �-
r ] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their 11.0 Plumbing repass or additions
myself[No workers' comp. right of exemption per MGL 12.❑Roof repairs
rance ram]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that ehwAm box#1 mutt also fill out the section below showing their work='compm ration poH y information.
t Hamwwners who submit this affidavit indimti g they are doing all work and then hire outside contractors must subrnit anew affidavit indicating such.
tConttactars that check this box maut attached as additional sheet showing the name of the sub•contracton and state whether or not those entities have
employees. If the subtnnhactnrs have anployees,they must provide:their workers'corn.policy mmnbar.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information. / /
Ins,ti=ce Company Name: JAv ' 0,�0�6 cXs y
Policy#or self-ins.Lic.#: 6LZC ,9 6 3 Expiration Date: y/Zq?
Job Site Address: J6 el- 115' 4 City/Statemp: /7G/�i,qw a Mv-, 4�60l
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 tip 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 cove r ge verification.
I do hereby certi under the pains•and penalties of perjury that the information provided above is true and correct
Signature:,,- Date: b� 0
Phone
Official use only. Do not write in this area,to be completed by city or town officlaL
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#:
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 reprtsentatives of a deceased employer,or the
receiver or tmstee 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 local 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,it
necessary,supply sub-contractors)name(s),address(es)and phone numbcr(s).along with their certificate(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. Bp 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. 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 have any questions regarding the law or if you are required to obtain a worker'
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 Tow-p 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 on;affidavit indicating current
policy infozmation(if access Y)and under Job Site Address"theaPPlicai should wri
te"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'pemmit not related io any business or commercial venture
(i.e.a dog license or permit to brim leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would lice 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 C6mmonwealth of Massachusetts
Dqm nent of Industrial Accidents
Office of luvestiptions
600 Washington Street
Boston,MA 02111 ,
W. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia