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Town of Barnstable .*Permit# —C YJ
Expires 6 months from issue date
a Regulatory Services Fee
;l3AENSIABI E, « .�i 17 f
Richard V.Scali,Director
Aet Building Division
, Tom Perry,CBO,Building Commissioner
TOWN OF BARN TABL
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
ExP"SS PEFMT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
n
Property Address �� e V V
].Residential Value of Work$ ® Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address ` V
Contractor's Name Telephone Number '50S
Home Improvement Contractor License#(if applicable) Email: -3 `�
Construction Supervisor's License#(if applicable)
1KWorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
Vj,I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) U
K,Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to To o J f
❑Re-roof(hurricane nailed)(not stripping.. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical'&Fire Permits required. x
*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.
copy of th me Impr ement Contractors License&Construction Supervisors License is
quired.
SIGNATURE: V17L
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe F
Revised 040215
: I
2Tie Comrxnoinveakh gfMassacltrisetts
Department of1'ndustrial Accidents
Office of Insw igations
600 Washington Street
Bosun,-41A 02111
f4'F nnmaxs�govldia
'Workers' Calmpensation Insurance Affidavit:BudldersiContracturslEIectr clans/Plumbers
Applicant InfennatiGn Please Print LezibIy
Name(Busme�mim ionadividad): \� •e
Address: �,••
1 •
City/statelzip J c Nl \e P.bene
Are you an employer?Check the appropriate box: Type of project(required):.
1.P am a employer veith '2�S 4- ❑I am a general contractor and I 6. ❑New consttuetica
employees(fa andlor part-time).* have Hired the sub-cone ackxs
2.❑ I am a sale proprietor or partner- listed on the attached sheet. 7- ❑Remodeling
slip and have no employees. These sub-contractors have 8. ❑Demolition
wvod7ng for me-many capacity- employees and have we dcers' 9. ❑Building addition '
[No u%nkers'camp-insurance corny_incnrancr~1
required-] 5. 0 file are a corporation and its 10❑Electrical repairs or additions
3_❑ I am a homeowner doing all work officers have exercised their 11_❑Plumbing repairs ar'sdtiitions
myself [No workers'comp- fight of exemption per 1'MLGL 12.❑Roofrepairs
insurance required.]1 c.152, §1(4h and we have no
employees.[I:tilo worzers' 13.❑Other
comp_insurance required_]
•Any applfcsat&at cheda box#1 mast also fal out the section below showing their vnxkers'compensation policy i15rnL1Mom.
I homeowners who subaait this affidmq t indicating they are doing all weak and then hire Gutade contractors mast submit anew affidavit indicating ssuIi
(Contractors that check this box must attached an additional sheet showing the natae of the sub-coat wAxs and state whether.or not those entitias have
employees.Ifthesuh-contra=m have emplopee%the =nt pinide their workers'comp.policy nmaber-
I a»t an ersplop•Yrr cleat is pr�zding yt�orkers'carrrperrsatiort i�isurartce f br�i}*enrplay�es SeIo�v is fits pnticy an,J job site
itforaratiori ,
Insurance Company Name:' \� �V C�
Policy#or Self-ins.Lic.# ETcpiratioa Date:
Job Site Address: C�- �� citylState/zip:
Attach a copy of the workers'coumpensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required.unties Section 25A of MGL c- 152 can lead to the impos�on of criminal penalfi s of a
fine up to$1,500-00 andror one-year iniprisonmerk as well as civil peualties,in the form of a STIOP WORK ORDER and a Ene
of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations the DIA for insurance coverage verification.
I do hereby erti under t a penalties oefper,jury that the inf brmai ou prm ded aboiv is true and correct
Si�ature: Date: _
Phone
Official use only. Do not write in this area,to be completed by city or town ofj'iciat "
City or Town- PermidLicense#
Issuing Authority(taint:one):
1.Board of Health 2.Building Department 3.Cityl ToiOn Clerk d:Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 reggaes all employ=to provide workem'compensation for their employees-
p to this sbtati-,aa.e nployee 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 mdividual,partnership,association,corporation or other Iegal 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 occzrpant of the -
d-FdIi g house of anofher who employs persons to do maintenance,construction ion or repair worm on such dwelling house
t
or on the grounds or brnl�appurtenant thereto shall not because of such employment be deem,ed to be an employer."
MGL chapter 152,§25C(t7 also states that"evefy 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
appliea t who has not produced acceptable evidence of compliance with the im mran ce.coverage required-"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor nay of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the immn7aace._
requirements of this chapter have been presented to the contracting authoiityf
A_pplicaats
Please fill out the woikers'compensation affidavit completely,by chedl®g the boxes that apply to your situation and,if
necessary,supply sob-contras tars)name(s), address(t and phone numbers)along with their ceriifrcate(s)of
ncrararce. Limited Liability Companies(LLC)or Limited Liability-Par rierships(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 regoired. De advised that this atftdayit may be submitted to the Depar[ment of Industrial
Accidents for confsrmatioa of film ice coverage- Also be sure to sign and date the affidavit. The affidavit should
be retnmed to the city or town that the application for the permit or license is being requested,not the Department:of
Fndn ctri al 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 pried.legibly. The Department has provided a space at the bottom
of the affidavit for you to fill ouf in the event the Office of Investigations has to contact you regarding the applicant-
Please be sure to fi11 in the pen itllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple peu Wlicensa applications in any given year,need only submit one affidavit indicafiag current
p olicy i afbrroation Cif necessary)and under"Job Site Address"the applicant should write"all to cations in (crty or
awn)_"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 counrn m-cial venture
(Le. a dog license or pennit to bum leaves etc.)said person is NOT required to complete this affidavit_
The Office of Investigations would at to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call-
The Departments address,telephone and fax number-
The C�a.mmQnt tll of Massach. us-
Degaztmeat of 1 medal AociJeats
Off ce Of ve ig�t io.
6�-��in�tQn t
oslr�n�MA G2111
Tf,-L 4 617-'27-4AG c-xt 406 or 1-977-MASSAFE
Fax 9 617-727 7749
Revised 4-24-07
} 1�t Massachusetts -Department of Public Safety y
�f Board of Building Regulations and Standards
Construction Supervisor
y License:CS-035037
ter,r r.ti
„. DEAN F STANLEYV-
i . 359 CAPTAIN LI3
Centerville MA 01632 Iae
Expiration
�,•�, �19 01/19/2016
Commissioner.
License or registration valid for individul use only.„
y I before the expiration date. If found return to:
Office of Consumer Affairs&Business Regulation
(EIOME IMPROVEMENT CONTRACTOR Type: I. Office of Consumer Affairs and Business Regulation
egistration 132149 10 Park Plaza-Suite 5170 .
_ expiration 11428/2016
Individual I Boston,MA 02116
DEAN F.STANLEY i
DEAN STANLEY 1
359 CAPT.LIJAH RD g 'I of valid witho signatu e
Undersecretary
CENTERVILLE,MA 02632 I
' I,
mac® CERTIFICATE OF LIABILITY INSURANCE DA�,MM/DD,YYYY,_.._._.
11/26/2014_
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEN,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVI.
OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements.
PRODUCER 'CONTACT
NAME
NORTHWOOD ESHBAUGH INS PHONE FAX
540 MAIN STREET (AIC,No,Ezt): (A/C,No): ,
E-MAIL
ADDRESS: _
HYANNI S MA '02601 ' INSURER(S)AFFORDING COVERAGE NAIC#
I
-27JDD INSURERA:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
INSURED INSURER 8:
DEAN F STANLEY BUILDING INSURERC:
CONTRACTOR INC , -
359 CAPT LIJAHS ROAD INSURERD:
CENTERVILLE MA 02632 INSURERE
INSURER F:
COVERAGES CERTIFICATE NUMBER. �' REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 SHOWN MAY HAVE
BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR j - POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBERR MMIDD (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE S
I DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence 5
I
CLAIMS-MADE OCCUR MED FRCP An one person) S
I PERSONAL&ADV INJURY S :..
1 GENERALAGGREGATE S
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG
POLICY PROJECT LOC i S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident S
ANY AUTO A(C1FtI82ULED BODILY INJURY Pet erson S
ALL OWNED NON-OWNED BODILY INJURY Per accident 5
AUTOS AUTOS PROPERTY DAMAGE
HIRED AUTOS Per accident S '
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAO HCLAIMS-MADE j. _ AGGREGATE 5 '
IDEDI IRETENTION S S
WORKERS COMPENSATION I WC STATU- OTH-
A AND EMPLOYERS'LIABILI TY (7PJUB-2E49857-5-14) 10-08=14 10-08-15 X TORYLIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT S 100,000 OQQ
OFFICER/MEMBER EXCLUDED? Y/N
,(Mandatory in NH) E.
NIA 'ELDISEASE-FJ+EMPLOYEE 5 100,OOQ
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMITS 500,000
DESCRIPTION OF OPERATIONS ILOCATIONSNEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) , -
I
I
I
I
i
C:SR-LIFICATE'HOLDER ( CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREFD,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE:
` POLICY PROVISIONS.
DEAN F. STANLEY
BUILDING CONTRACTOR, INC.
Fax and Phone 508-428-3466
dstan359@yahoo.com
H.I.C.License#032149 Mass License#035037
June 2,2015
a
Sheila Burns
Birchill Rd.
Centerville,MA 02632
ROOF PROPOSAL
1. Remove all asphalt shingles.
2. Re-nail boarding as needed.
3. Install new 8" aluminum drip edge and new vent flanges.
4. Paper roof with 151b. underlay paper.
5. Re-shingle with 30 year Architectural style shingles by Certainteed.
6. Vent main roof area with Cobra Roof Vent.
7. Repair damaged vinyl siding.
.8. Remove all debris from premises.
Total Estimate: $5900.00
Payments: One half upon start of work and one half upon completion.
Sign r
r
Signature: a;
BABIST&BLE
HABB.
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION
TO THE INSPECTOR OF BUILDINGS:
-T-he-underslgned hereby applies for a permit according ^the following information:
Location
Proposed Use
Zoning District Fire District
Name of Owner Address
Name of Builder Address
Name of Architect Address
Number of Rooms Foundation
Exterior Roofing
Floors Interior
Heating Plumbing ..../..
Fireplace Approximate Cost ./?
Difinitive Plan Approved by Planning Board 19Sf.?...r^E ^5^
Diagram of Lot and Building with Dimensions
I hereby agree tp conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name.
Small,Alan
No ...Permit for
single fami^dwelling
Location'^.!
Centerville
Owner
Type of Construction
Plot Lot #12.
Permit Gronted 19 66
Date of Inspection ....19
Dote Completed 19
PERMIT REFUSED
19
Approved 19