Loading...
HomeMy WebLinkAbout0029 NAUSET LANE ... f ., ti. _. , i � N t k a l e s 'down of Bitable `l?ermita �. E� fiw 657!V_%e-edaie Regulatory Services� Fee 3 ,6 q , ' Richard V.•Scali,Interim Director Ruflciing Division go Tom Perry,CB©,Building Commissioner 200 Main Street,Hyannis,MA 02601 wtvtiUmmbamstable.ma us �� !�fft Office: 508-862-4038 F "e f -` EXPRESS PERAUT MRLiCATION - RF,81WENTUE &(ii, Not VaHd without Red X-Press bnprint RAISr Map/parcel Number ` Prop erty�Address_ ,& i(l/�[l C�'f� �.l✓/� � P� (/1 Yesidential Value bf Work$ 7/ Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address J.D Se e k K O V i Zq A�/rise-� Ln, - OLD 3Z Contractor's Name ►- �-n tt�,l:_tJ;r atY„S / ?c; ,,,, n i Sr.n i elephone Ivumber(t��117 Z2 k-q k'!"�G Home Improvement Contractor License_(if applicable) Email: Construction Supervisor's License y(if applicable)—O 5 g 7 n- (EfWorkman's Compensation insurance Check one: ❑ I an a sole proprietor " ❑ I'am the Homeowner I have Worker's Compensation Insurance Insurance Company Name__A f oo n ragt anstin t r e - Workman's Comp.Policy 2 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re roof(hurricane nailed)(stripping old shinules) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over. :. existing layers of roof) ❑ Aeside Replacement Windotivs/doors/sliders.U Value_ (m&-dmum 35)r of windows T of doors: - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Elde6ical&fire permits required. *%ii a required: Issuance of the permit does not exempt compliance with other town department regulations,i.e.Hi;Wric.Conservation,etc. ---"'Note.- Properly; veer must Sian Property Ou'ner Letter of Permission. A copyga a the Home Improvement Contractors License&Coastraction&pervisors Incense is d re` rred. + SIG1'4ATUM- i Q rPFILES\FOn6S1but3d'mg pcpidt fortnslEXPRESS.doc Revised 061313 %n MA w-- texasaz by =1 M -4 c�`a t,bSF�SESO in seer a mmagmim, �s' s-t�is]tPE.S3S. ------------------ 8911�.ea'+s,�',savl ,jy�6Kgr I'�d�fb/a . �a.�al Y+y e,�4F S Fm�d GAS •�'i��k?O'liT�'.D194�8. `Y�flli a 4 - tkpc�&weaJ�f5tr5�ed�Co41�/[�e,e - . . •. _e 9Hd.� aga w a] i a of ! i'IF+Ea Fyf ..�ELB _ . dAii✓a� '. �'1.2�8rsdr..EIIAti.SS4I$a�E6,'L�1'!ffi$'fa$Cam`-� z dE�fm`De�® jEL2 A<St(�7j$� p;gC A r mEje$�� `�uaip9a;ffiii�frd� }c ! ., - �asaieer�a�a�del�eas�e, ;b>�cd � B . ,:grew.ain!n,si faatds 'e J7'-- tbis.Agreenwat omnmftfd [ice asi�ar.mi taT!T tie papa;aasd'C1 ae taste of :�Y.106431- er,a las.mod in ,e�1;aaf a$d dated "�ORmo aafgih two aiiiia�d.Nall�of`4�a:a an;omtmdat=�+L.wAC ena�es� Ulu era* am a .yo stkid ,mg oetfte,a>pa�Ea #aslaefifpe :ss8aa afaa<eeaats a n�dar»T sa�ml $ Yt�aa� lcd +eea�y i ' �dse it3. aaefl rah r te, oe p i*OrehuLw of the Sumo o ttad 4e:e� �iq fihr sefita�hi."O � a wa>Smitaaayl aeSaftBiope",Pads de Yo9m fil tt kae:me Cain 4 i"of : e> meai liraair�oi8�eskbwatatf4i3nroa�tlrFaresDaciedav Oka g ap rtha t cam �ae' �. lead6 tl+s> tSs y Laa.�ammtr ao tcor Qn a '- ildeh` - riade.Skws"*Comm teefo crg�x�x�ar cF a> aaafienaf Q Ts � r� C Ikr �' 4' * h 7 S of .. • � s. f ,.r/-..-'. � iP°eamflet�lxp d�c _ a E�lend CcdF 3#�d. + - � E Y".:-b'k,'' / . 4,r ..a L: t. .,,T � s . -Si 1.•,,r.. - x -.t 100: " if TOD,ffi � S IRWWC OIiA1° T P1tT S3�t �>_� 'iD y _$Tf a . ._.. _P{ gAHtYFdffiE: 1Ali'i'�EQ:S�EiT�S. I 'IViIFf7[�OFdr�'�O FORAW _ � D: M�M�, XaY may C&Wd tP2.t*al1Tr—amlt2jaad h YIIUI F tfali alli�IiC'lily'I 'r 9WIy SYItfIOi t�f 1FrItTy01i['tlti� Or'; 7fdt]ifl7 { , .. OUEms. waded ct tnado. t>ra�iti_ fa. P�ttttdar ��JI �a �,,.�the t oa Smiley,and�' abb rat. o �or�1`ey>uldl 1' ®Pelt Yao yr qMp Qqa''be retalFa�-erilfaae f�ii h�oat�'t�s l 1"oa�rrrt�=_� b� .wal be'eebm>gtl.vim l�aiaiea� .fi�iid I r the StdPar of yo MY 1. any R- arsia�,.. aJ,.�a� r�i•�be raaFa>9et 'IL�r �yauu r�a�Fst e�a� tad e!►tq sam r .. a$e�aaL 'ca�ee� rra,r�esaalee a9 a�fe d�#�1 atTaaar stdR(j%Mi'�t Sr,�,taiatf�itty� n aab`valaaeEl l as YOW e+t fn vr3ieit l eceer ,'A i dds ddirrtf ed to you u lidirthis Cbntrael Band.dweea$ +Q+adot Cvtitci o �S►RtI:n1yL7EQrt $ " B 4f f1 MraSafc tlaa Se9izr'reg Nae a ettaan �tlee daaai- rme dos at tftt'= Sete.-A. ax arad ram. f�ao�da �6 Sdkx.% `and a if)do rna%p tiw •arAUabte mil*',Seer aFid dw S dikelAm p� i�p'wathbi m dtia' a�d dw S f i d s• plct j�-w" i lY da�rs of tlir'dafar o#' ar.yov�ret;aaaa as ', Evareealy+- W the date-of cmcdkfion;, W rgwA w of:ilFte roods v�tt waut eaea fia^�aair aab�gaaiun.'!f pew 1 o f a t:Soodlt wiBheat airy tux rra6Eg 'ara If Tofu tae to maims 6i* �errait'afFlep to tW S4er,or rtyaia's traa '1 f a aFafce dae'gaadr tmr tJia s 8er,ear it`traan ajpr as m,rr tseai the pod' >Sd ti ae$ ttasr 1 fail sa,tfnan l m ra•tive.&e gpodr is om Steer,and fag!CA da S%dfeaa.y no iFr�,Tan table laar of a aaidoe Sie reenaf�Ifab7aTbr 1 .af atg obli'lad, W.wwder die CofZtaPacETa Ca:WA dds mrif ur ddi�rer a Q�sr it Cant To cancw me un.!Qtad or defl�¢r.>i sP�a¢d ai>d dayad.'aa►pryr`ef tfais ttiatfa or arry•.azl t, at�l dsttedpl!of tl Aar�€c a'any,offiej wtF,ttaa a�oticeyQssand stir#.�?��to t�[a%I bylkradaaf l w++t�eit aFati�ar artvad a to Retialval'�rAd of Nlevr at At6fon'Romd n10M rj„Srnudtavt l alk' 6 Albabe iCYT L DER 7 M(1i�WOW O�- i L ALES A p@�•�� _ - CflkW"T Q 9#[ 'c.1f#fcELTHIS - n 1 f#16 r.A C L'f /f4�T#I I+ISA�iiQ7�1.' dam"+-�s�• a�fiu� a� �L B>� ar�rt Ft?aa� ' �. Southern New England Windows d.b.a Renewal by Andersen of SINE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor i License: CS4194= gyp. BRIAN D DZNM4 7 LAMBS POND i�'IIt s Charlton MA 01*7 Expiration Commissioner 09/08/2016 Office of Consumer Affairs find Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement,Contractor Registration Regisfratdon: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL•.;' i'arfon: dI/1s2o1s DENNISON.BRIAN — ---- 26 ALBION RD — LINCOLN,RI 02865 'Update Address and return card.Mark reason for change. ScA r 4 2MI4611 ❑Address [:;Renewal ❑Employment Lost Card ce of Coetemcr Affairs&Barloess Regulation License of registration valid for individul use only aAAR.dutWEMENT CONTRACTOR before the expiration date,If found return to:. Office of Consumer Affairs and Business Reguladoa n: IZ3245 Type. 10 Park Plaza-Suite 5170 Explratlon. !1119=16 Supplement.;and Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS L.L.C. RENEWAL BY ANDERSON ON BRIAN 26 ALBI 26 AIBION RD UNCOLN,RI 02865 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, AM 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND. WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you a_n employer? Check the appropriate box: Type of project(required): 20+ 4. am a general contractor and I 1.� I a�a employer with ❑ I g 6. ❑New construction employees (full and/or part-time).*.__ have hired the sub-contractors, 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. Q Demolition working for me in any capacity. employees and have workers' 9 Q Building addition [No workers' comp. insurance comp.insurance required.] 5. Q We are a corporation and its I0.❑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.E R of repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp. insurance required.] . 6 9,,,1 S *Any applicant that checks box#1 must also fill out the section below shoving their workers'compensation policy informatio . 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:ARGONAUT INS. CO. _ Policy#or Self-ins. Lic. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: -ZCj /wSa� ZaAe_ City/State/Zip: C a Vi (e 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--nfMGL 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' urance coverage verification. I do hereby certi&under the and penalties of perjury that the information provided above is true and correct. c 4 Si afore: Date: - 3 U-( Phone# 4012289800 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#: SOUTNEW-01 SHETTYSHT CERTIFICATE OF LIABILITY INSURANCE DATE 11912DIY 819/2015 5 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 endorsemengs). PRODUCER NCAME CT Willis Certificate Center Willis of New Jersey,Inc. PHONE FAX c/o 26 Century Blvd A/C No Et):(877)946-7378 A/ No:(888)467-2378 P.O.Box 305191 ADDRIE Nashville,TN 37230-5191 ss:certificates@vAllis.com INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:Selective Insurance Company of Southeast 39926 INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURER C:Argonaut Insurance Company 19801 D/B/A Renewal by Andersen 26 Albion Road INSURER D: Lincoln,RI02865 INSURERE: INSURER F: I. 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 INSURANCEADDLSUBR POLICY EFF POLICY EXP L� INSD WVD POLICY NUMBER MMID MMID LIMA A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR S 2029459 08/10/2015 08/10/2016 DAMAGE TO RENTEIT PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 I 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY 1 PEI° a LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) ccident $ 1,000,000 A X ANY AUTO S 202%59 08/10/2015 08/10/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ Per acc dent X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 51000,000 A [4EXCESS UAB CLAIMS-MADE S 2029459 08110/2015 08/10/2016 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N❑ N/A 0000068028 0812l/2015 08/21/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Workers Compensation WC928058352394 08/21/2015 08/21/2016 See Attached DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) i 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. AUTHORIZED REPRESENTATIVE Evidence of Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD