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Tom Perry,CBO, �STA�L� 200 Main Street,Hyannis,MA 02601 www.town.bainstable.ma.us Office: 508-862-4038 . Fax: 508-790-6230 ; EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY --7 Not Valid without Red X-Press Imprint• Map/parcel Number /0 7 � r Property Address [Residential Value of Work ` / e�Q00- Minimum fee of$25.00 for work.under,$6000.00 Owner's Name&Address V, Telephone Number Contractor's Namer 9 b Home Improvement Contractor License#(if applicable) ?7 7 Construction Supervisor's License#(if applicable) 1I �� '31 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Iam the Homeowner have Worker's Compensation Insurance Insurance Company Name �lee Workman's Comp.Policy D 0 —76 rf Z 7�.S 1/6-7) 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• /91/ ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44)+ *Where required: Issuance of this permit dots not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. mu A copy of the me Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 .77 7 �� �✓� E ` r '' Boai d of Bwlding Regulations and Standards,. L[cett c or[eg[st'rat�on valid for�ndi [dud use only HOME IMPROVEMENT CONTRACTOR. tieor T e t j[ir'at[on date if foui[d return toy Boar KPutdd[ng Regulations and Standards Registratwn 1y12977 One' hhurton Place Rm 1301 - Uoiration 5/7/2009. Tr# 128790 -- - - _- BOSO ;%1u.02108 ry Type. 'Individual •. MICHAEL J DANGELQ - MICHAEL IDANGELO 105 HORSESHOE LN ��q,�cQ•a...` _ �Notvalid�ENTERVtI LE MA 02.632 Administrator ut signature r - r �oFTHE, ti Town of Barnstable. Regulatory Services + BAHNSPAELE. , y MSS. Thomas F.Geller,Director 4'AIFD �A,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 vvw w-town.bamstable,ma.us Office: 508-862-403 8 - Fax: 50B-790-6230 Property Oviner'Mu' st Complete and'Sign This Section If Using A Builder as Owner of the subject property h hereb autorize � • y l i7 6 to act on my behalf, in all matters relative to.work authorized bythis budding perm t application for:4� tip,v Uk , N"Q ®St (Address o Job) Ygnat&e of Owner Date Print Name QTORIvIS:OWNERPERMIS SIGN y ' ! The-Commonwealth ofMassaehusettsT Department oflndustrial Mecidents Office of Investigations UV. 600 Washington Street Boston,AM02111 www.m ass.gov/dia Workers"Com ensation Insur�nce.Atfdavit: Builders/Contractors/Electricians/Plumbers P Applicant Information Please Print Le 'bl Name (Business/organization/Individual): •Address: /_0 S �� . City/State/Zip: 0.4w— dip 3Z Phone.#( _521Z) . 75 . :57Qk Are you an employer? Check the appropriate box: Type of project(required):, 1.LEI I am a employer with %74- 4. ❑ I am a general contractor and I * have hired the sub-contractors 5• [-]New construction . . employees(full and/or part time). _ � 2.❑ 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 working for in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$' 9 ❑Building addition required.) 5. ❑ 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 myself: [No workers' comp.° right of exemption per MGL 12.jrRoof 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#1 must also fill out the section below showing their workers'compcasation 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. tContractors 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 providb their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for'my employees Below isihe policy and f ob site information Insurance Company Name: �d-Gt %R ti re Policy#or Self-ins,Lic.#: tv/(_ Q0 Expiration Date: v Job Site Address: tIi City/State/Zip `l / C- /jt 0�-� Attach a copy of the workers' compefasation 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 iip to$1,500.00 and/or one-year imprisonment, as well as civil penaltirs in the form of a STOP WORK ORDER and a fine ,of up to 1151.00 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 coverage verification. I do hereby certify ander the pains•aa/�d penalties ofperlwy that the information provided a ovg is true and correct: Sienature; �G"``� Date: ll U'Phone#i l 5�� -7 S 3 7 U -- Official use only. Do not write in this area,Yb be completed by city or'town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3. City/Town CIerk 4•Electrical Inspector 5-Plumbing Inspector 6. Other Contact Person: Phone#: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER:THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ;St. PO Box 1990 ALTER THE COVERAGE AFFORDED BY.THE POLICIES BELOW. 02601 INSURERS,AFFORDING COVERAGE NAIC# Michael J. Dangelo Building INSURER A: Travelers Insurance Company &Remodeling,Inc. INSURERB:`American International Companies 105 Horseshoe Lane INSURER C: Centerville, MA 02632 INSURER D: INSURER E: ARAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION D TE MM DD A E M D LIMITS - A GENERAL LIABILITY 16808433H175TCT07 01/04/07 01/04/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $100 0 0 PREMISES(Fa necurrapce) CLAIMS MADE FE OCCUR MED EXP(Any one person) $5 OOO X PD Ded:500 PERSONAL&ADV INJURY $1 OOO OOO GENERAL AGGREGATE $2 OOO OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 OQO OQO POLICY PRO. E T LOC AUTOMOBILE LIABILITY LLIABILITY COMBINED SINGLE LIMIT $ I r - (Ea accident) AUTOS f BODILY INJURY D AUTOS (Per person) $' I OS , BODILY INJURY $ D AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) TYAUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $$ RETENTION $ B WORKERS COMPENSATION AND' WC1766359 O2/19IO7 O2/19IO8 X WC STATU- OTH- EMPLOYERS'LIABILITY - TORY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100 000 OFFICERIMEMBER EXCLUDED? If yes,describe under E.L.DISEASE•FA EMPLOYEE $1 OO QOO SPECIAL PROVISIONS below - - -OTHER E.L.DISEASE-POLICY LIMIT $50O OOO DESCRIPTION OF OPERATIONS I LOCATIONS/`VEHICLES I.EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI DATE THEREOF,THE ISSUING IN WILL ENDEAVOR TO MAIL In... ..DAYSWRiTTE „s NOTICE TO THE CERTIFICATE HOLDER NAMED.TO THE LEFT,BUT FAILURE TO DO S0 SHAL Tr I IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER;ITS AGENTS OR `h REPRESENTATIVES, 4 AUTHORIZED R PRESENTATIVE - ACOku za I UU31un of 2 #47256 LS1 © ACORD CORPORATION 1 j ;