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TOWN OF BARNSTABLE E,NPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY FORMATION Address of Project: 3 k ,3 re z .-Ne r L o . lIP P NUMBER STREET VILLAGE Owner's Name: 5 �� i•se -�j ,( ( Phone Number ' 7 7 -/, (e Email Address:� /e_/x /h�l 2 �� , / Cell Phone Number 1-75'-0 7 P 3 Project cost S f�._90�— Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: S e r �-f(Q��Q C'�.-��-� Date: TYPE DE WOE (l Siding U Windows (no header change)# S Insulation/Weatherization 17 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) nn Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name f�rtan ��n�,'so� - Sov ��n Wei Fps (�,� 1,11./)JowS Home Improvement Contractors Registration(if applicable)# 17 3 2-q,5 (attach copy) Construction Supervisor's License# Z S 7 07 (attach copy) Email of Contractor $L,)ee� J. C M Phone number 1101- z Z R -�900 ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATIONNUMBER.........................................................- *For Tents OnlY* Date Tent (s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4:30pm. Commercial events may,require Fire Department approval. *WOOD/CO.AL/EELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand any responsibilities under the rules.and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the'Town of Barnstable. Signature Date . AIAPLICANT9S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. a Renewal Agreement Document and Payment Terms Andersen. dba:Renewal B Andersen of Southern New England Y B Steve&Louise Howland Legal Name:Southern New England Windows,LLC 38 Bremer Ln. RI#36079,MA#173145,CT#0634555,Lead Firm #1237 Centerville,MA 02632 WINDOW OE MCEMENT 10 Reservoir Rd I Smithfield,RI 02917 - - H:(774)696-0538 Phone:401-349-1384 I Fax:401-633-66021 sales@renewalsne.eom C:(508)579-0783 Buyer(,)Name: Steve & LOuise.Hovuland Contract Date. 08/09/`19 Buyer(s)Street Address: 38 Bremer.Ln.,,Centerviille, MA 02632 Primary Telephone Number: (774)696-0538 Secondary Telephone Number: (508)579-0783 Primary Email: steye.howland22@gmail.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms.of which are all agreed to b 'the parties and in herein by reference(collectively,this"Agreement"); Buyer(s)hereby agrees to sign a completion:certi cate'after Contractor has completed all work under this Agreement. Total Job Amount: $10,904 By signing this Agreement,you acknowledge that the Balance Due,and the.Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $5,452 Balance Due: $5,452 Estimated Start: Estimated Completion: 6-8 Weeks 6=8 weeks Amount Financed: $10,904 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are proyiding'at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: 50% deposit-GREEN SKY; 50% balance due upon completion-GREEN SKY Buyer(s)agrees and understands that'this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the.signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed;and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first writien'above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled'to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 08/13/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT Legal Name:Southern New England Windows,LLC' dba:Renewal By An of Southern New England Buyer(s) pp . DVMwtiQlr{qG�.,A. Signature of Sales Person Signature Signature Chris Hutson Steve Howland„ Louise Howland' Print Name ofSales Person Print Name Print Name UPDATED: 08/0.9/19 Page.2 1 12 Office of Consumer affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 021.18 Home I mprovementl Contractor Registration 4Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS, LLC Expiration: 09/18/2020 10 RESERVOIR ROAD SMITHFIELD, RI 02917 scn 1 0 zom•osin Update Address and Return Card. b�i/- -/- Office of Consumer Affairs Business Regulation m HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reaistiation. Expiration Office of Consumer Affairs and Business Regulation 17.3245.=___ 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW E_NGLANQ WINDOWS,LLC Boston,MA 0211 V BRIAN DENNISON 10 RESERVOIR ROAD Q SMITHFIELD,RI 02917 Undersecretary dv �., without signature r %.00mrnon e_alth. of i'viassaehd'setts - Division of Professional Licensure Board of Building Regulations and Standards srtsr� tapervisor 4 CS-09 707ED>p i res: 09/08/202.0 SRIAN ® DENINISOIV 8 BLACKWELL-RIVE CHARLTON MA a 1507 1 COm"ssioner , The Commonwealth of 6AIassaehuselts Department of Industrial Accidents 1 Congress Streets Suite 100 Boston,MA 03114--2017 www massgov/dia A'arkers'Compensation Insurance Affidavit.-Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER_�MIZNG AUTHORITY. Anglicant Information Please Print Leeibly Name(BusineW.Or_zanization/Individual): S QG-the I-/1� t��(d� nQ�t Address:—to o -S Vol r iz bi Ci /State/Zi : m l n e- R! 0Zg / !� tY p S �►'(7 � 7 Phone#: Are you an employer'Check the appropriate box: 1. 1 am a employer with �'�employees(full andlor part-time).• . Type of project(required): 7. ❑New construction 2 am a sole proprietor or partnership and have no employees working forme in any capacity.[No workers'comp,insurance required] 8: Remodeling 3. [am a homeowner do' all work m self r 9. ❑Demolition ❑ doing y [No workers'comp.insurance required] 4.❑1 am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole I!.[,Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.C]Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.❑goof repairs 6. We are a corporation and its officers have exercised their right 14.L�tJ Dther 4J.✓)Z&-t✓ ❑ �of exemption per MGL c. 152.§1(4),and we have no employees.[No workers'comp.insurance requimctj /tiv�/q re--?e.-77 *A ny applicant that checks bo:c#t must also fill out the section below showing 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-contactors have employees,they must provide their workers'comp.policy number. I ant an employer that 1s providing workers'compensaden insurance for my employees Below is the policy and job site information Insurance Company Name: . WQ . U. C . Policy#or Self-ins.Lic.#;_UXA,31,! = 7-0e Expiration,Date: Job Site Address: 3 `1?,reLl-)e r n City/State/Zip: �Pn�i'Iv�'ll�. WA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation puttishable by 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".A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ce under the p ' penalties of perjury that the information provided above is true and correct Signature: Date: Phone M 4 C21 . a Ofctnl use only: Do not write in this area,to be completed by city or town ofjlciai? m City or Town:_ Permit/License# Issuing Authority(circle. 1.Board of Health 2.Building Department X City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact.Person: Phone#: - DATE(MM/DDIYYYY{ CERTIFICATE OF LIABILITY INSURANCE 12/28/2018 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 AMEND, 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 REPRESENTATIVE 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 endorsement(s). PRODUCERNTACT CoBiz Insurance, Inc.-CO NAME` 1401 Lawrence St., Ste, 1200 PHONE t 303-988-0446 A/c No:303-988-0804 Denver CO 80202 ADDRESS: COMaiI cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO.01Sou INSURERS:Firemens Insurance Company of WA,D.C. 21784 dba Renewal New England enofSWindows, hemLLC INSURERC:Homeland Insurance Company of New York 34452 dba Renewal by Andersen of Southern New England 10 ReserviorRd INSURERD: Smithfield RI 02917 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER:787175890 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 INSURANCE ADD L SU R POLICY EFF POLICY EXP LTR POLICY NUMBER IMMIDDIYYYYI fMMMONYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/112019 1/112020 EACH OCCURRENCE $1,000,000 A CLAIMS-MADE a OCCUR PREMISES Ea occurrence $300.000 MED EXP(Any one person► $10,000 PERSONAL&ADV INJURY $1,0o0,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $21000,000 X POLICY❑JE 0. LOC PRODUCTS-COMP/OP AGG $2,0D0,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1l112019 1Hl2020 COMBINED SINGLE LIMIT a aeeident $1 000 0 0 X ANY AUTO BODILY INJURY(Per person) $ AUUTOLL SS NED AUTOS BODILY INJURY(Per acciderd) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per aocidem $ $ A X UMBRELLA LIAR X OCCUR CPA3158728 111/2019 1/l/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,000,000 DED X RETENTION$ $ B WORKERS COMPENSATION WCA315872924 1/112019 111/2020 X ST TUTE ER AND EMPLOYERS'LIABILITY Y/N ANY OFFFICERIMEMSER�EXCLUDED?ECUTIVE �Ej N/A E.L.EACH ACCIDENT S 1,000.000 I Mandatory in NH) nd E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000.mo C Pollution Liability 7930D73340000 F 1/1/2019 1/1/2620 Each Occurrence $2,000,000 Claims-Made Policy Aggregate $2,000,000 Retroactive Date 0&20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) :- CERTIFICATE HOLDER, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZEDREPRESENiATIVE ©1988-2014 ACORD CORPORATION.-All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD > Town of Barnstable *Permit#, _ - 4 Expires 6 nronihs fr ni issued re * Regulatory Services Fee • EMNSTnsta:, 9$ 1 ,0$ Richard V.Scab,Director �FOMP'ta Building Division • Tom Perry,CBO,Building Commissioner R _ 200 Main Street,Hyannis,MA 02601 AfA y 03 2017 www.town.bamstable.ma.us ro P C�p�- Office: 508-862-4038 FaxIR 1*41vs- EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ABLF Not Valid without Red X Press Imprint Map/parcel Number Z 2 - U Z 6 Property Address 3S '_�rP L n e r L n • �_p/l�e:�d���e Residential Value of Work$ 13, 3 19 — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address S-fie✓e 1 Ow�q�►d �39 3fe7_ne_1- C'e, ley-y;lIf m14 Da2(o3 2. 2 z8— Contractor's Name ndol .i1_1�3WA t //r5o/( Telephone Number(L(01) Horne Improvement Contractor License#(if applicable) 473 z q 57 Email: Construction Supervisor's License#(if applicable) ( 6 5 7 D 7 [�Workman's Compensation Insurance Check one: ❑ I am a sole proprietor- ❑ Lfrn the Homeowner I have Worker's Compensation Insurance Insurance Company Name (20n f`` ,Q�E Workman's Comp.Policy# �� Copy of insurance Compliance Certificate must accompany each permit. Permit Request(check box) ' ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. 3 Going over existing layers of roof) @14e-side eplacement Windows/doors/sliders.U-Value • U (maximum.32)#of windows 4 #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 pith other town department regulations,i.e.Historic,Conservattok etc. ***Note: Property weer must sign Property Owner Letter of Permission. A copy the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE_ C:1Users\DecollikVlppDatalLocallMicrosoft\Windows\Tempomry Internet FilesTontent.Outiook\21`101 DHR\EXPRESS.doc Revised 040215 Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England Steve&Louise Howland Legal Name:Southern New England Windows,LLC 38 Brezner Ln. RI #36079, MA#173245,CT#0634555, Lead Firm#1237 Centerville,MA 02632 WINDOW RE LACEMENT 26 Albion Rd I Lincoln,RI 02865 H:(774)696-0538 Phone:866-563-2235 1 Fax:401-633-6602 1 sales@renewalsne.com Buyer(s)Name: Steve & Louise Howland Contract Date: 04/21/17 Buyer(s) Street Address: 38 Brezner Ln., Centerville, MA 02632 Primary Telephone Number: (774)696-0538 Secondary Telephone Number: Primary Email: steye.howland22@gmail.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $13,319 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $6,659 Balance Due: $6,660 Estimated Start: Estimated Completion: Amount Financed: 6-8 weeks 6-8 weeks $13,319 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: 50% deposit-GREEN SKY, 50% balance due upon completion-GREEN SKY Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 04/25/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) Signature of Sales Person Signature Signature Chris Hutson Steve Howland Louise Howland Print Name of Sales Person Print Name Print Name UPDATED: 04/21/17 Page 2 / 11 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-095707 Lo:nstruction Supervisor BRIAN D DENNISON 7 LAMBS.POND CIRCLE ;, t CHARLTON MA 01507' ., E � ?' t F �{ ( ..M Expiration: Commissioner 09/0812018 �a•�rr;��z a���uec�L� e�C/�� FM , = Office of Consumer Affaus nd Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improve mentf Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERNNEWENGIANDWINDOWSIL Fes, BRIAN DENNISON =tea Expiration: 9/19/2018 26 ALBION RD LINCOLN, RI 02865 __'; Update Address and:return card.Mark reason for change. . —' ❑Address ❑Renewal !J Emplovment ❑Lost:Card SCA1 0 20"501 Mee of Coasamer.Affairs&Basins Regulation ,Registration valid for individual use only before the expiration date If found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ARe9rstratlon.--173245 Type: 10 Park Plaza•Suite 5170 Expiratlon g/19/20.18�. Supplement Card .Boston.MA 02116 SOUTHERN NEW ENGLAND WIN6OWS'1.LC. RENEWAL BYANDE9SONc BRIAN DENNISON . 26'ALBION RD LINCOLN,RI 02865 l:.t{nde mry Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbebrs ` 11 PP Please Print AppLcant Information s Name (Busm M ess/organizationdividual): k(4 Address: Off- 6 I City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): 4. Q 1 am a general contractor and 1 6. Q New construction 1 am a employer with * have hired the sub-contractors employees(full and/or part-time). listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g, Q Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. comp.insurance.1 [No workers'comp.insurance 5 Q We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11.Q Plumbing repairs or additions 3.❑ I am a homeowner doing all work p-exemption of right exem per MGL. thyself. [No workers' comp. g p 12.❑Roof repairs c. 152, §1(4),and we have no insurance required.]t, employees.[No workers' 13. Other �✓r•�c�o✓ comp.insurance required-] I re lu re.- y applicant that checkshireouts *An box#1 must also fill out the section below showing their workers'compensation policy information. then cating such. all work and t Homeowners wlrheck thiis box mit this ust arttached an addit ot indicating they na sheeg howl g the name of the u'b-c ntrac on and state whether or not those�entiti s have $Contractors that c oyees,they must provide their workers'comp.policy number. employees. Irthe sub-contractors have empl I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �B'J�✓7"/� `'✓� Pfi 1 A�f C► � ? j 3� o J Expiration Date: l Policy.#or Self-iris.Lic.#: E City/State/Zip: C4I few,(Ie H Job Site Address: e z✓�t°T ------------- policy number and e Attach a copy of the workers' compensation porn 2de larMGL cation SZ can lead toe Xiration date).' owingtithe imposition of criminap penalties of a Failure to secure coverage as requtred under Secho fine up to$1,500.00 and/or one year imprisonment,as that ll as civil f istStes in the of a STOP WORK ORDER d a fine atement ay be forwarded to the ffic of of up to$250.00 a.day against the 'olator. Be advised a copy Investigations of the DIA for ins ce coverage verification. I do hereby certi der tl:e pa' a d pepalties of perjury that the information provided above is true and correct Date: Si ature: t Phone#: official use only. Do not w file in this area,to be completed by city or town officiaL Permit/License City or Town: # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other t Phone#: Contact Person• t 1 _ SOUTNEW-01 CZOWNGER Ow DATE 291201YYY1'j CERTIFICATE OF LIABILITY INSURANCE srz9►Zo1s 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 AMEND, 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER-. IMPORTANT: .If the certificate holder is an ADDITIONAL.INSURED,the policy(es)must be endors If SUBROGATION IS WANED,subject to ed. the terms and conditions of the policy,cortam policies may require an on A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER NAME: CoB¢Insurance,Inc.-CO PHO11N .(303)988.0446 �"T No (3 )988-0804 821 17th St Denver,CO 80202 E- CoMmInsuran obizinsurance.com INSURER( AFFORDING COVERAGE NAIC 0 INSURERA:continentai Western insurance company 114804 INSURED INSURER B: Southern New England Windows LLC INSURERC- DISIA Renewal by Andersen INSURERD: 26 Albion Road Lincoln,RI 02865 INSURERE: INSURMF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED.BELOW-HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEFOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENL, TERM OR.CONDITION OF ANY CONTRACTOR OTHER-DOCUMENT WITH RESPECTTO WHICIi THIS ED HEREIN ISSUBJECTTOALLTHETERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE.POLICIES DESCRIB IXCLUSIOT AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCEDBY PAID CLAIMS. I PO EFF POLICYEXP LIlDiS TYPE OF INSURANCE �INSp yytlp POLICY NUdIBER D LTSRR A X COMMERCIAL GENERAL LIABILITY I I I EACH OCCURRENCE S i,000,OO j CLAIMSMADE OCCUR I CPA3136080 10710112016I 0 7101120 1 7I pRBy,ISES E-p=-MIg 15 100,00 01 i MED EXP(Any one person) S 10,00 PERSONAL 8 ADV INJURY 5 1,000,000 j I I GENERAL AGGREGATE ti S Z,000;OO GEN'L AGGREGATE LIMIT APPLIES PER I X 00 POLICY L� EPRO- LOC i i PRODUCTS -COMP/OPAGG S �OOO,OQD EMPLOYEE BENEPI 1 s 7,00 ,0 OTHER I COM�wrim=LIMIT i s 1,000 !AUTOMOBILE UABILt7Y j ': I ,t)O A I CPA3136080 j 071.0112016 i OTl01/2017�,BODILY INJURY(Per person). .s_ ALL OWNED :SCHEDULED { ! j i I BODILY INJURY(Per accidera)j S ri AUTOS AUTOS { ;PROPERTY DAMAGE I S f HIREDAUTOS AUTOS NON-OWNED j i Peracddeld I S UMBRELLA LUIB X i i EACH OCCURRENCE S 5,000,000 x j OCCUR A occEss ua6 ,CLAIMS-MADE i CPA3136080 !071011201610710112017 AGGREGATE i s RETENTION S DED X 0 ( j gg�te IS 5;000,0 I—PER WORKERS COMPENSATION 1 j STATUTE I.OER AND EMPLOYERS'LU►BILITY Yl N '1 0D0 00 A ANY EMPLOPRopRiEfRS' ARTNER/EXECU7IVE ! WNCA3136081 07/01/2016 0710112017 EL EACH ACCIDENT S OFFIcENEN w E ER ExcoED� N f A, j ( 1 000 00 L DISEASE-EA EMPLOYED S , , (Man tory in NH) f Itns,dascnbe under I I I E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OFOPERATIONS below j j i f DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Sehed^may be attacbed B mms spa—Is reqdIPK) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE- TH THE POLICY PROVISIONS. AUTHORDEDREPRESENTAMW — - ©1.988-2014 ACORD CORPORATION. All rights reserved- ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD oK y12 A)/ cc_ o�1HE TTown of Barnstable x ermit# Expires 6 months from issue date �^ Regulatory Services Fee lie x BARNSrAB v M^�. $ Thomas F. Geiler,Director �, DER 1639. �0 IT plED N1Ay� Building Division APR 15 2010 Tom Perry, CBO, Building_Commissioner, 200 Main Street, Hyannis,MA 02601 `SOWN OF BARNSTABLE 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 Addressc�y, Residential_ Value of Work Minimum fee of$25.00 for work under S6000.00 Owner's Name&Address. `fcVc_ �� Contractor's Name vfll��01, Ijlr•'Q� Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's,License# (if applicable) p y a ❑Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner ❑ 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) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) . Re-side #of doors ❑. Replacement Windows/doors/sliders.U-Value (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 Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors-License is requir SIGNATURE: 1 - Gf1ee TOa»v�na�uuea o�./�aaaacuaea License or registration valid for individul use only Office of Consumer Affairs& uaACT Regutahon before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration " .140575 10 Park Plaza-Suite 5170 Expiration, 10/27/2011 Tr# 288468 Boston,MA 02116 TYPe�::, BAK HOME AN01, IM�R0 1EMENT BRIAN KLINE 279 DIVISION STREET'' DENNISPORT,MA p263.9.;,;;, Undersecretary Not valid wi hout signature. M ,..,. Massachusetts- Department of Public Sufet�' Board of Building Regulations and Standards Construction Supervisor License License: CS 84289 ., .,..,.. .Restricted to: 00 BRIAN A KLINE ' 279 DIVISION ST DENNIS PORT, MA 02639 Expiration: 6/10/2010 ('nnunissi„nci Tr#: 25011 ' The Commonwealth of Massachusetts Department of Industrial Accidents i Office'of Investigations 600 YYashington Street Boston, MA 02111 y . rvfvw.mass.gov/dia Workers' Compensation Insurance Affidavit: ]builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): .r i q v� IT1 �1�A " Address: `l IV t s I ova S� City/State/Zip: pent iS v Q Da6�`�Phone #: 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 I 6. ❑New construction employees (full and/or part-time),* have hired the sub-contractors 2,A I am a sole proprietor or partner- listed on the attached sheet. 7. ❑,Remodeling ship and have no employees These sub-contractors have g; ❑ Demolition workin for me in an capacity, employees and have workers' g Y P Y 9, ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 0 We 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 or additions right of exemption per MGL mYself,.[No worl�ers__coznp, _ 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'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. lContractors 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 thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. 1. I do hereby ce h under th ain and p alties ofperjury that the information provided above is true and correct. , Signature: Date:76 �5 Phone#: , ' Official use only.'Do not write in this area, to be completed by city 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#: 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 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 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,NIGL-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-contractor(s)name(s),.address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members nr partzieis are not required to carry worker's' compensation insurance.-"--'If an I LC 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. 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 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 roof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each PP P , n ' obtaining a license or permit not related to an business or commercial venture year. Where a home owner or citizen�s g p Y (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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia ax�,ssoaym.�,. carbonless NC3818.50 3 PART PROPOSAL P. Mil l 7ir rrt h,� run 9��4u (`ii0►� ��� JH�TNI3i.•"�•tir r.,,i��+Y {� oATE' 1°- PROPOSAL SUBMITTED TO: .WORK TO BE PERFORMED AT: - ' u trrcu 'KC:R r `• .::Yl.wn , .r w ij. 4 1 tiJ 1 v� w�•'�::�'-Tt i 6�i y ie., P'-e�•' }y �� - .►^•• ..- �f5•Flx .s1- 11i •r - r� ^N'f, nnn - r "^� MIT T T. - � :. � �f§Mena 4 ,...... r«n•.»•e � x .� ,�Pttn a : s.� .�� .. 01 !�L�-� .,�' ,urr, .•,..r ""''., �;s•. .w i,a»p� -Sk b � �'.o�� !'v�i1j a. � , TB IA1+1S aw4 f Seyr Itrr i14 ptfE pp,. 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B., Respectfully submitted Any al►Ctallats ai *viv W,1 hom b0_`va 600-11fioakM invoNin9 6091 Cuilm Wff be oxm!bd ody upon wvttten order:.turd vac tnewme an 60m char;- Per 'awr and above ft esd"W All arc~,$cc+,'m8 d%VA tlriAse - W",of deters oerono ow ow", Note—This proposal-may be withdrawn by ue it not accepted within-days ,A{j\j�f"Il1F•!V�-l7✓r.•�A�i'1,J+7r1i_•'^Y'V1:.�r "r d v as a d r a r•A•VV Y abo�tar cat►Qns arfd ccndlt2orlS,ece:satisfy Y hd are hereby toys 3u a„t'a t '-'ti i •t , e r•, s spet.ltie` �aymlen>;a�wjlkbe'md(ie as oiiUlnt!'atiove. j/J,•) ;Signature Date O /'iJ Signature _......... PROPOSAL >�N urea y