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HomeMy WebLinkAbout0033 EDGEWOOD ROAD �_�z..vi.rra_�. _, _._.. _ >... .�.�.dw..lm._., •.nxe..y.r.0 w�Ta�,.� .__ ,. _ u.n. _ .. e ,. .w...0 z,..r iJ.._Sse. ._. _.. _...�n�.�,. u_..�...v�t �. � � F � +r� '3 $ 3 z TS I �/ I { r Town of Barnstable *Permit# Z© I�6��j Regulatory Services Fee date 6�nt ��ae g rY HARNSTA UJi Richard V.Scali,Director o PlIESS Building Division PERMIT Tom Perry,CBO,Building Commissioner AVG 212015 200 Main Street,Hyannis,MA 026 www.town.barnstable.ma.us OWN 'OF BA R N S 1-��tt uu C Office: 508-862-4038 Fax: 5 044-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 248.1127 Property Address 31 Edge-wand Road, Centerville, MA PQ Residential Value of Work$ 3i o 0 n_n o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address T- T)ESANTrS, P-n, Box 1 , WesiT—Hya-nnispart�,- MA- 02672 Contractor's Name NorthevnnCdl6ny�4Builders LLC Telephone Number 5 0 8—7 4 4—3 3 6JI Home Improvement Contractor License#(if applicable) 16 7 7 3 A Email: d a n whc c @*c cam c a s fs_net Construction Supervisor's License#(if applicable) E.S 053638 $Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 52 5t 1 have Worker's Compensation Insurance v Insurance Company N „ti-hhoAShbhnr�TN_surancP Aclency, TNc_ Workman's Comp.Policy# Copy of Insurance Compliance 6AM, a mus accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken tc �� -;2, ❑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. *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 Homj Improvement Contractors License&Construction Supervisors License is SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\W' w'Memporary Internet: iles\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 _ 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/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Northern. Colony Builders LLC Address: PO Box 278, City/State/Zip: West BarnstaBLE, MA 0266hone #: 508-400-7075 Are you an employer?Check the appropriate box: Type of project(required): 1.CK I am a employer with 1 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 workingfor me in an capacity. employees and have workers' y p �'• 9. ❑Building addition [No workers' comp.insurance comp.insurance.: 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 I L E]Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.(K 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#1 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-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 the policy and job site information. Insurance Company Name: Southeastern INsurance Agency, INc. Policy#or Self-ins.Lic.#: WCC 5 01 2 2 8 0 2 01 5 A Expiration Date: 7/8/2 01 6 Job Site Address: 33 Edaewood Road, City/State/Zip:Centerville, MA `? 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 DIA for insurance coverage verification. I do hereb certify under t e pa' s alties of perjury that the information provided above is true and correct Si ature. � Date: 8/21 /2 01 5 Phone#: 508-400-7075 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#: r t y s * BAMSTABM • 3 9. Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder L Jay DESANTIS ,as Owner of the subject property hereby authorize Northern Colony�rBuilders LLC to act on my behalf, in all matters relative to work authorized by this building permit application for: 33 %dg—e-Weead Reacr.PnerIZille, MA (Address otjob) 8/21 /15 Signa Owne Date JAY DESA TIS Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\DecolliklAppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Oudook\2PIOIDHR\EXPRESS.doc Revised 040215 �CD�'� DATE(MMIDDIYYYY) �. CERTIFICATE OF LIABILITY INSURANCE 8/20/2015 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). PRODUCER CONTACT NAA1 E: Karen Bernier Southeastern Insurance Agency, Inc. PHONE (508)997-6061 Nc,No): (50N)990-?731 (A/C,No,Exq: l 439 State Rd. EMAIL kbernier@southeasternins.com _ADDRESS: P.O. Box 79398 INSURER(S)AFFORDING COVERAGE NAIC0 North Dartmouth MA 02747 INSURERA:Arbella Protection Insurance 41360 INSURED INSURER B Merchants Insurance Group Northern Colony Building Cc LLC INSURER C AEIC , P.O.BOx 278 INSURER0: INSURER E: - . W. Barnstable MA 02668 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1582001403 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 SUCIi POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL'SUBR POLICYFF E POLICY EXP L7R TYPE OF INSURANCE 1NCD WVD POLICY NUMBER jMMIDDIYYYYI IMM/DON YVVI. LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE X 'OCCUR PREMISES(Ea occurrence) $ 9520040951 7/8/2015 7/8/2016 MED EXP(Any one parson) S 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN•L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 X PRO- OTHER $ AUTOMOBILE LIABILITY •(Ea OCCidEDI}SINGLE LIMIT $ 1,000,000 ANY AUTO ( BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS MCA7013965 1/5/2015 1/5/2016, BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS ( ) PIP-Basic $ 8,000 UMBRELLA LIAB OCCUR ( EACH OCCURRENCE $ 1 EXCESS LIAB CLAIMS-MADE i AGGREGATE $ DIED RETENTION$ $ WORKERS COMPENSATION X STATUTE XPER ERH AND EMPLOYERS'LIABILITY - - ` ANY PROPRIETOR/PARTNER/EXECUTIVE Y I 1 N/A - EL EACH ACCIDENT $ 1,,000,000 OFFICER/MEMBER in H)F�(CLUOE07 �. WCC50122802015A 7/8/2015 7/8/2016 E L DISEASE-EA EMPLOYEE $ 1,000,000 C (Mandatory In NH) II yea,describe under i DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION ,(508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Karen Bernier/KAB I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD I NS025(201401) *� --------------- Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cuns[ructiun Suhrr%isur License; CS-053638 <. DANIEL J GAL14tH - PO BOX 278 '' 1� West Barnstable NU 62 i.�. c �i i+ � ✓.�..+ ,1J Expiration Commissibn et 10/27/2015 Office of Consumer Affairs and Business Regulation h � 10 Park.Plaza - Suite 5170 Boston, Massa*us\etts 02116 Home Improvement Coractor Registration T Registration: 167739 Type: LLC I �) Expiration: 10/25/2016 Tr# 264780 NORTHERN COLONY BUILDERS LLC;-' DANIEL GALLAGHER "t P.O. BOX 278 � �.-_ _. ��..� 4�F+ ----------------------- ------- ----- WEST BARSTABLE, MA 02668 +� .' 1:/ --------- ------- -- — -- ---- r1� Update Address and return card. Mark reason for change. Address ❑ Renewal I] Employment Lost Card ,CA 1 Ci 20M-05/11 �e�(iarrurrzar��seta�L�o�C�a�cc�ccaeC7i1 -� Office of Consumer Affairs&Business Regulation License or regist ratio n.vaIid for individul use only ^� ( 10ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ;Registration: 1f67739 Type: Office of Consumer Affairs and Business Regulation Expiration:::=-_1;05/2016 10 Park Plaza-Suite 5170 LLC Boston,MA 02116 - NORTHERN COLONY°B.W&DFRS LLC. DANIEL GALLAGHER 180 HIGH ST W. BARN, MA 02668 Undersecretary No4,, ' o. signature ,