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HomeMy WebLinkAbout0267 LONG BEACH ROAD � ! I�i op ,* }}} 1 x A "'d trr_e,,�7�3� t it b 1.. r T t ` 4 a �; d " r-; lfl If I p `3ih !'s' ,t�9ldtk .Y i i r " r. 11 a. Y: ,k f" 42 �, ! yi. �I !� �lO, !{Qr I % pr ,A E p` A A y c 1 o � �Y',� q �a .3 0 at ;, .I.' ,r� t! !u } V .�r .e N !C I _ A ; H� �p - ..,i. e� a�l { a o b w mow, ew ' q.. ;' a ,� o 0 ,�: A N �i 1 ,+a .E, ! a .I: a, r 'y "e 4, ! T t .i J I i 1. �A mr .N.A :. a C 'I f a ..'N AI 4 U 0 �A. 4 a,�r �' Ri x: .ui .:. - : .-. , s I p 7 I u .a A� t ;k ! . r t ':', :s '�: t > -.,.fir I 1 pis .. -, 9 pp d�, !s F F! y F 1 c� 4. { 9 Y� P :i{ a - y S A a 1. y1 R 9. a It ! 1. .. ..I IL �. a.. ., a!✓ . �!� , 0 Y �— --.. y _ —- _ :.r s�. -- a --- — -- v --- --- r �t T Town of Barnstable *Permit X3® w ee 6m sjromissuedate Regulatory Services BARNSTABLE, + FL ` y Mnss. �* •-PRichard V.Scali,Director L 112018 Building Division Paul Roma Building Commissioner 200 Main Street,Hyannis,MA 02601 q www.town.barnstable.ma.us Office: 508-862-4038 Fax: 0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY i 0 � Not Valid without Red X-Press Imprint Map/parcel Number �1 O Property Address abq L-CM(4 ) Residential Value of Work$1f Minimum fee of$35.00 for work under$6000.00 Owner's Name.&Address � ) f PDOi' Vr 3—Ti- 9 fe ar-;a Dy� �— J Contractor's Name 62 0 f►10 Telephone Number5628"q,2R -7(fl0 Home Improvement Contractor License#(if applicable) 5 `��� Email: _SC 1 _ .p2acc)C. t R_r-l �n•f) Construction Supervisor's License#(if applicable) C)`"1 4 Sid UWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner '2,1 have Worker's Compensation Insurance Insurance Company Name C—",-'q/V) Workman's Comp.Policy# lit/c Q-'�7 (,p r 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. Going over existing layers of roof) ❑rside eplacement Windows/door /sliders U-Value (maximum.32)#of windows #of doors:4— *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. r *.**Note: Property Owner m sign Property Owner Letter of Permission. A copy of the Home mprovement Contractors License&Construction Supervisors License is required. SIGNATURE: " �r QAWPHLESTORMS\building permit fonnSIEXPRESS.doC ? 01/25/17 �` " IWe Commoniveaf#h u,f'�assachirsr fs Deparfinent ofludasft ial Accidents - E3f ice i9f invesf gations 3 600 Wayhuigton,5`fr'eet �ostoa,MA 02 lirF4imnass govIdia workers' Compensation InsaranceAffidavit:Builders/Contractors/FIectri_cians/Plumbers Applicant Information Please Print LeT_ihly NaY11e CBusme�lOrgan�ationllnciividn3l)_J�U 1�' 1�'��t C.a%�,iC. �v i'�(�i plc ��' ��.vl'tCi1�-�i r'�Cr 'l L, Address: tp, 0, box i -71 i t✓L4(:, �4Ct i Y) 5 fi S Lft k- 7 City/Stat&zip:C,S to f V) I It- l�l'l' `'� L:S� Phoneme .�L' - LF� fC -7 �%C Are you an employer"Check the apprapriate,box:� 4 s I.� _ of project(required): _ am general contractor and I �".�.T am a employer tivith ❑I g 6-employees(full andforpaA-ume.)* have. su��� ❑New amstr� 2_❑ I am a safe proprietor orpanner listed on the attached sheet 7- ❑Remodeling ship and have no employees The, sob-contractors have g_ ❑Demohition wo:rlcinn for me in any capaczt}�_ employees and have wormers' insurance. g ❑Building addition [No�vorfr..ers' comp_uistii-mace COMP_req 5_ ❑ We area corporafionand its 10-0 metrical repairs or additions 3.❑ I am a homeou nex doinz all work officers have exercised their 1 L[]Plumbing repairs or additions. myself[No workers'comp- right of exemption per MGL 12-0 Roof repairs msurancerequired_I I c-152,§1(4),and wehhweno• 13�]Other employees-WO workers' comp_insurance required_] Any anp&mt mat checks bus Rl roost riso nll out the section belax showing iuek waAea'rnmpensaliau parity i Hnmeawne.s who submit mis c f ndzn indiccyag dLey Sfe doing sn tta*md.men bl a outride contncmrs mast submit anew afdact sn".�suet -Cantmcmrs dwt check this b=mast sttad¢ed sn addWoasr sweet shmemn thename ofthe snb-cmiix-tom aid statewhetherocnot thasa entitiesh3ve mvkryees if the soh taattactatsh-e amoro}-EEs.theym w provide ter warkers'camg.policsnumber- lam an empia}er hurtrsprmddirrg Ttror):crs'eatrrlreruYrtian insrtrtrrtce for trty Rrrrpinyees Belotf is flee polfg and job Are in formatiom y /� Insurance Company Naz*re: C r_C{III! Panty t#or Self-ins-Lim= G I}5 —J 5 y 7 Expiration Date Job Sites Adders:a(Pq �q P_e QCh Zd Gifyr'StafelT_tp:C�-L' (/1 l f �02(�3 Attach.a-copy of the-workers'compensation policy decIaratioia page-(showing thepoficy number.and expiration date). Failure to secure caverage as required under Section 25A of MGL c- I52 can lead to the imposition of'criminal penalties of a fine up to$L500.00 and/or one year imprison en,as well as coal penalties in the form.of a STOP WORK ORDER and a line of ups to$250.00 a day against the violator- Be adtnsed that a copy of this statement maybe forwarded to,the Office of Iurestigations of the DTA for+ overage vesiaca on_ .I`do he ebb,C render \ f"n "I ,panaWeses ofgerjruy dratflie irr�or�sration prated nbot'e/i/s'tru�rtn/d correct Sitmature: vV Y Date= Peons _ �v oZ --7&00 City or Town. PermidUcen_se# \ Lcsuing Authority(circle one): \ .Board of Hexltl> 2.Building 6:03her Department 3.CityfFown.Clerk 4_Electrical Inspector S.Plumbing haspector ` Contact Person: Phone;ff- 6 I Commonwealth of Massachusetts In; Division of Professional Licensure Board of Building Regulations and Standards Constructiri'Supervisor CS-094500 Ekpires:07/22/2020 JAMES S PEACOCK L` r 1046 MAIN Sf UNR7 $ P.O.BOX 171 OSTERVILLE MA;02655 CIL Commissioner C��/e tpanvnao�racoeall�n��iy�aaJacfuvel� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE::Corooration Registration. Expiration 151;853 -07/06/2020 SCOTT PEACOCK BUILDING-&REMODELING INC � i JAMES S.PEACOCK 1046 MAIN STREET SUITE 7 OSTERVILLE,MA 02655 '+ Undersecretary- f ACQ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/22/2018 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 have ADDITIONAL INSURED provisions or 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: Germani Insurance Agency PAIC-No HONE . (508)428-9194 A1C No): (508)428-3068 908 Main Street E-MAIL ADDRESS: certs@germaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: SAFETY INS CO INSURED INSURER B: Granite State-AIU Holdings Scott Peacock Building&Remodeling,Inc. INSURERC: P.O.Box 171 INSURERD: INSURER E: Osterville MA 02655 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP T POLICY NUMBER M/DDfYYYY MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any oneperson) $ A BMA0022118 07/05/2017 07/05/2018 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO- JECT Fj LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident)AUTOS ONLY AUTOS ( ) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ :4EXCESS LIAB CLAIMS-MADE AGGREGATE $ 0ED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N/A WC 005-81-5464 06/22/2018 06/22/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 Scott Peacock Building&Remodeling,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. P.O.BOX 171 AUTHORIZED REPRESENTATIVE Osterville MA 02655 Fax:508-428-7625 Email:scottpeacock@ved7on.net 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 07/06/2018 12:06 5087902398 COMM PRUDENTIAL OFCA PAGE 02/03 Sewn 12^Uepett�t Sort-O� ea ❑ z=ng Bova Cif, El mstad c nixiat ❑ mc Plan Rcdm cifwqm ❑ irm Dqmww& ❑ Ca�servr�uoo� ❑ Far' t work pimm fthyuar to defer�J�orao�L fY'¢ Secd=13--Owner Autl�arimtt�on J,'* s �(0) NO as O w oflhevbjed propertyh=by eatbw�ize S d to act an my belug is m1 math rd2dve to rwark au&odzbd by tMspGomait mliWdm fi= L�q Lc."n act f ad Cevi�e-r�vi �8 ` e- ll oflub} W r PrbtName t .abed 50L5869809 9r1D dogD jsaM WV29:LO MZ 60 lnf ; i Town of Barnstable Permit Expires f,months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building.Divisi0n Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstab le,maxs Office: 508-862-4038 EXPRE MIT SS PER APPLICATION - RESMENTLU ONLY x: 508-790-6230 �} — n Not Valid without Red X Press Imprint Map/parcel Number "VJ v �1 Property Address ��k'.C1 (J I I ( r(1 dResideritial Value of Worki�F J V Minimum fee of$25.00 for work.under$6000.00 Owner's Name&Address 9 ( (I col PC cv- aj 5 CAvvt❑dix- M� Contractor's Name �� Telephone Number 1 -`�%• ' y�)� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Chec�-One: MIT :91 am a sole proprietor X.?RESS PER ❑ I am the Homeowner JUL 3 ® 2009 ❑ I have Worker's Compensation Insurance Insurance Company Name TOWN OF EBARNSTABLF, Wor]Lan's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. 1 Permit Raquest check box) R, roof(stripping old shingles) All construction debris will be taken to # 1�I ► p�S�Q L� ��}, {�r ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) whcrc required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must st n P p -?caner Letter of Permission. copy of e Home mprovi. eContractors License is required. SIGNATURE: Q:Forrns:expmtrg Revise061306 �_ The Commonwealth of Massachusetts UVDepartment oflndustrial Accidents Office ofInvestigations tS00 Washington Street Boston,MA 02111 www.mass.gov/die Workers Compensation lasur9nce Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/organL&tioa&dividual) Nr Address: • (� d�3 City/State/Zip: LN mo MPr -dZ�Ql phone.#: 190 Are you an employee2 Check the appropriate box: 1.❑ I am a employer with 4. [] I am a general contractor and I Type of pro ject(required): . C=Ioyees (full and/orpartytime).* have hired the ea.b-contractors 6• ❑New construction . 2. am a'sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees Thesc sub-contractors have 9. Demolition working for me in any capacity. 'employees and have workers' [No workers'comp.insurance comp.insurance.#' 9• [�Building addition required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑P umbing repairs or additions tnyselE [No workers' comp. right of exemption per MGL insurance:required]t c. 152, §1(4),and we have no 12 Roof repairs employees. [No workers' . •13.❑ Other camm. insurance required] . *Any applicant that cbecks box#1 must also fill out the section below showing thcirwarkm,compensation policymformation. t Homeowners who submit this atiidavit indicating thcy Contractors that arc doing all work and then hire outside contractors must submit anew affidavit indicating such. check this box must attached an additionalsheet showing the name of the sub-contractors and state whether ornot those entities employees. If the sub-contractors Crave carployees,they must providt their workers'comp.policy number. have lam an employer that is providing workers compensation insurance for my employees Belo wislhe policy and fob 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 to secure covers policy declaration page(showing the policy cumber and e Failure a as re expiration date),, g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fins tip to$1,500.00 and/or one-year imprisonment; as well as civil penaltits in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inves ' the for a covers a verification. I do ereby cer[i under the ins-a enalties ofperjury that the information providea above is true and correct Siena �7 • Date: Phone #: — Official use only. Do not write in this area,Yo he completed by city or town official City or 'own: Permit/License# Issuing Authority(circle one): .I:Board of Health 2.BuildingDeparfinent 3.City/Town CIerk 4.Electrical Inspector S.PlutnbingInspector 6. Other Contact Person: Phone#: WHE, : 'town of Barnstable' . Regulatory Services i 1AENSTAHLE, + y .MAC Thomas F. Geller,Director A Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 w-ffv.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and. Sign This Section If Using A•Build•er as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to.work authorized by this building permit application for: . �-� ` dress of Job) -30 21� Signature of Owner Date (;Corvu Print Name WORMS:OWNERPERMIS SION /fin f.pi ngtK' �-� � Bo-a� ot`f� i� ng"isfegu a ions an an ar s License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 124310 Board of Building Regulations and Standards Expiration: 6/1/2011 Tr## 284683 One Ashburton Place Rm 1301 Boston, Ma.02108 Type: Individual .James Curley — James Curley 287 Fuller Rd. �� ` "`_„'$•- ) --� ot valid without signature Centerville,MA 02632 Administrator -=' `IV �- Massachusetts - Department of Public Safety Board of Building Regulations and Standards i Construction Supervisor Specialty License License: CS SL 99138 IY Re_stricted.to: .RF,WS . JAMES CURLEY 287 FULLER ROAD.. CENTERVILLE, MA 02632 i .. Expiration: 1/28/2012 COnmiiNsiuner Tr#: 99138 Board of Building Regulations and Standards License or registration Valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Reg istrafon :-j..24310 Board of Building Regulations and Standards ..Expiration :_jyj}/2009 Tr# 130873 One Ashburton Place Rm 1301 =1_Type individual. Boston,Ma.02108 James Curley =_ James Curley 287 Fuller Rd. Centerville,MA 02632 Administrator Not valid without ure R i neering Dept. 3rd floor) Ma p . ( p � Parcel � - Permit# House# �j� Date Issued Board of Health(3rd floor)(8:15 9:30/1:00-4:30) Fee ✓r 27, 2 Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) Planning Dept. (1st floor/School Admin. Bldg.) �1Ne Definitive Pla oved by Planning Board 19 ; 4 RARMARLE, MAkq 1 TOWN OF BARNSTABLE Building Permit Application Project Street Address Village Owner 0/f v 1J Address Telephone :2?,� 4-Y zt5-y- Permit Request e;1-TAIP / �j —/�f�o� /4-a7yz First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ ;Oe2O Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Used t Proposed Use ��- p Builder Information p Name�f�yL �y Z� � % /! 00�7/�o Telephone Number —�dp— yaG —/l7,-7 Address �U i3�,(' ?j0 License# /'2-(p 52 z /'��'✓'i �o,�v /+'//GGS - Home Improvement Contractor#/0�j 7/ Worker's Compensation# S/C- /70052,00 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO y SIGNATURE DATE BUILDING PER IT D NIED FOR THE LLOWING REASON(S) J FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS . VILLAGE OWNER ' f DATE OF INSPECTION: c FOUNDATION ' FRAME i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f } 4 FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Coininonwealth of Afassachuscus Department of Industrial Accidents Office oflovesllyalions 600 Washing,lon Street Boston, Muss. 02111 Workers' Compensation Insurance Affidavit �,nlir��+ information• Please PRINT Ie�Jy name , ���� location: ��D ®ti�0 ��iG1�4 city phone# Z7,,--- • I am a homeowner performing all work myself. • I am a sole proprietor and have no one working in any capacity - ...:> ... .,, rr�-;+�r.�xr-,-.,, rranowra�w�+.�s ���r ��rr t't �i�"�tR'.",+r.•.... ..•..+t+,' . �''(�- �" —•Jr M.Wwlt].iYi.'70fY.w'uJ..Ywu. -:'��'�•`r�a.,••�lLLI.�V��:,ti:,,.-,L��ii���'•11�1•"�+L.\1 ' _ e• .��• f�:.ir�r...._._._....r_� I am an emplover providing workers' compensation for my employees working on this job. conmanvname: l 07�G�7�/(✓/ �f ��✓7 �t�Dl�/�CJ address phone#: insurance co. policy# ,-. ,, ... .,: ._,.,..... .. ,...,,-.,.�,.,`7.r,......: q•a..�r- rx""•••*•+�•`t''R'R�,.. _ ...MLi...pelX'rG�u ...�3� .. ... i.._. �......._. _..� __._.._.ice._ �..i�"s'•� ..'a�'�"w. , - - - I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: ad(lress• cih: phone#• insurance co I oa licx# .... ......- .4,. _ .... -a�-sh. •^1•�ct;N "`'s L'is3sTY'�"k'' .�1 '}7Cr. . r.+>• `w =✓^�+1�^'� ^+rr. .+`ic n• 5 company nnrne• address, city: phone#: insurance co policy.# Attachaddstt_al sh _ ' ry,.. + - - - oveet tf necessa _:- r�y„ � ;`�: r��_rswi;�� s ��r..;i=� s•cr.: t�. ;«fir. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years' imprisonment as wellas civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certif•i er Je pains and penalt' of perjury that the information provided above is true and correct. 9 Sienaturc Date Print name Phone ' official use only do not write in this area to be completed by city or town official ". 7 city or town: permit/license# r9Building Dcpartmcnt C3Liccnsing Board U check if immediate response is required ❑Selectmen's Office t: OHealth Department contact person: phone#; r1Other oc,isud 3/11;PJAI r` s, ' °fZF18 Tpy, The Town of Barnstable • L+�rnsr�. t 9� . ,0� Department of Health Safety and Environmental Services i°rEo " Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL,c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: _�UO�' Est.Cost Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR -APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: lk�71,q,l Date Contractor Name Registration No. OR Date Owner's Name - - - ` DATE(MMIDDIYY) acoRo.. CERTIFICATE OF LIABILITY INSURANCk. AIIZJ 2: U i-ER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ke, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Lot' s Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. eans MA 02653-0429 COMPANIES AFFORDING COVERAGE .er G Walther COMPANY A Assurance Co. of America 508-255-3212 Fax No. -RED "- - COMPANY B Credit General Insurance Co. Paul J. Cazeault etal DBA Paul COMPANY J. Cazeault & Sons Roofing C - COMPANY D . % jERAGES HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATED,NOTWITHSTANDING ANY REQUIREMENT,T&RM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, XCLUSIONS AND CONDITIONS OF SUCH POLICIES.L11V1ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MMIDDIYY) DATE(MMIDDIYY) GENERAL LIABILITY I GENERAL AGGREGATE $ 1,000,000: }{ GENERAL LIABILITY i CFP25552812 05/01/96 05/0.1/97 PRODUCTS-COMPIOPAGG I $ 1,000 ,000 . .-AIMS MADE . . ;OCCUR i PERSONAL&ADV INJURY $ 50 0,0 0 0:.. .T:^.�r.rR'S s CONTRACTOR'S PROT EACH OCCURRENCE !$ 5OO,OOO __ FIRE DAMAGE(Any one fire) $ 50,000. MED EXP(Any one person) $ 10,000 . aUTOMO6ILE LIABILITY COMBINED SINGLE LIMIT $ ANY=1_ I =G "E'.�.=.UTOS , BODILY INJURY SCHE-SULEG AUTOS (Per person) $ BODILY INJURY (Per accident) NON O:NNEDAUTOS _...-......____ i PROPERTY DAMAGE $ SARAGE LIABILITY 1 AUTO ONLY•EA ACCIDENT I$ — —i ANY l OTHER THAN AUTO ONLY. ' EACH ACCIDENT $ AGGREGATE 1$ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA.F0Rr.9 AGGREGATE OTHER THAN UMBRELLA FORM OTH- 1i $ W 1 ORKERS COMPENSATION AND ER! WC STATU• EMPLOYERS'LIABILITY TORY LIMITS I �EIEACHACCIDENT is 100,000 I EPROP.RIETORI INCL I SWC17005900 08/09/96 j 08/09/97 I EL DISEASE-POLICY LIMIT $ 500,000 . �ARTNERSIEXECU .TIvE . . r ... . )FF10ERE:ARE EXCL j EL DISEASE-EA EMPLOYEE i$ 100,000 . OTHER I ,RIPTION OF OPERATION SILOCATIONSIVEHICLES/SPECIAL ITEMS Ofing Y I I ie .TIFICATE HOLDER <CANCELLATION. trr3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL j 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND ON T E COMPANY,ITS AGENTS OR 5EPRESENTATIVES. . AUTHORIZE EP ATIVE r I JRD 25-S ©ACORD CORPORATION 1988