HomeMy WebLinkAbout0070 NOTTINGHAM DRIVE }. .. ,t �..i{. c,;U :;;if. �... ,j '>, ,y>.,'-�� "; t �r s>qtp -',�*i{�. �r� x L� ^+e ,f°>. �' ty �'�,e•s,�.
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�IHE rp� 'Town of Barnstable Permit#
Fxpires tonths fr u issue date
Regulatory Services Pee
1: BARYWMLE,
MUM
1639 Richard V.Scali,Interim Director
Bullfrog DflVgStiI®Yfl
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENT , ONLY
] Not Valid without Red X-Press Imprint
Map/parcel Number 1-7Q / 0 1
Property Address !7t) wo,*'inQhc.Lm Q
0 Residential Value of Work SA.,.1 qa. ®O Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address LU in ne- 0B UCh ows K l� �u )JtAnQ h Cv_ 1 ��
Contractor's Name,(D U*ej n IV t� W Ind ol )Aran Telephone Number !}j)I -as y q y by
t�lllvU'�l
Home Improvement Contractor License#(if applicable) 1-7 3a�6 Email:
Construction Supervisor's License#(if applicable) CIA F_ D
®Workunan's Compensation Insurance
S PEIMMOT
Check one:
❑ I am a sole proprietor SEP 04 2014
❑ I am the Homeowner TOWN OF BARNSTABLE
I have Worker's Compensation Insurance
Insurance Company Name AMCM i j± I rysixan u ,
Workman's Comp.Policy# (10 C q 11 h 3 q
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)
❑ Re-side I
Replacement Windows/doors/sliders.U-Value 3 0 (maximum.35)#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 rea lations,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
requ'
l
SIGNATURE:
T:IKEVIN D1Building Changes\EXPRESS PEPMT\EXPRESS.doc
Revised 061313
The Commonwealth of Massachusetts
4-
Department of IndustrialAccidents
Office of Investigations
I Street,Congress tr S
g ,Suite 100
Boston,MA 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 LLC
Address: 26 ALBION ROAD '
Ci /State/Zip: LINCOLN, RI 02865 Phone#: 407-228-9800
Are you an employer?Check the appropriate bog:
1.[]i I am a employer with 20 4• ❑ I am a general contractor and I Type of project(required):
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
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 g repairs11. Plumbin
❑ or additions
myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] I c. 152, §1(4),and we have no
employees. [No workers' 13.a Other WINDOW REPLACEMENT
comp. insurance required.]
i
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '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 checkthis 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 g P
providin workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ARGONAUT INSURANCE COMPANY
Policy#or Self-ins. Lic. #: WC927938352394 08/21/2015
Expiration Date:
Job Site Address: o City/State/Zip MAq
Attach a copy of the workers' compensatio` policy declaration page(showing the policy number and egpiratton 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/of 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 hereby certify under the pants and penalties of perjury that the information provided abo ve and correct.
Si afore: � �
Date:
Phone#: 401-228-9800
Official use only. Do not write in this area,to be completed by city or town official.
3
City or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
{
Alc /R& CERTIFICATE OF LIABILITY INSURANCE DA'E"MI°D"""')
V 08/12/2014
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
REAkESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the cerdficate 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 endorseme s).
CONTACT
PRODUCER Willis of New Jersey, Inc. NAME:
c/o 26 Century Blvd PHONE 1-877- 5- 7 FAX No:1-888-467-2378
Y.O. cos 305191E-MAIL
Nashville, TN 372305191 USA :certificatesewillia.cam
INSURER(S)AFFORDING COVERAGE NAIC B
INSURERA:Belective Insurance of SE 39926
INSURED Southern New England Windows LLC INSURER B:The Beacon Mutual Insurance Company 24017
D/B/A Renewal by Andersen 26 Albion Road INSURER C:Argonaut Insurance CamVany 19801
Lincoln, RI 02865 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER-WS29160 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.
IN SR TYPE OF INSURANCE A L SWVn POLICY NUMBER POLICY EFF POLICY EXP IYYYYI OMITS
X COMMERCIAL GENERAL LIABILITY r EACH OCCURRENCE $ 1,000,000
CLAIMS-AAADE OCCUR DAMAGE
DAMAG PREMISES TO REIM
(Ea occurrence E 100,000
A w
MED EXP(Any one person) $ 10,000
S 2029459 08/10/2014 08/10/2015 PERSONAL AADVINJURY $ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE I$ 3,000,000'
RO-
POLICYJPECT Ux PRODUCTS-COMP/OPAGG I$ 3,000,000
OTHER Is
AUTOMOBILE LIABILITY dUBgNDSINGLE LIMIT
Fa e $ 1,000,000
X ANYAUTO BODILY IKUURY(Per P—) $
A ALL
OWNED SCHEDULED
S' 2029459 08/10/2014 08/10/2015 BODILY INJURY(Per accident) $
X HIRED AUTOS E
NON-OWNED
PROParF DAMAGE $
$
A X UMBREt LA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000
EXCESS LIAS CLAIMS-MADE S 2029459 00/10/2014 08/20/2013 AGGREGATE $ 5,000,000
DED I I RETENTION $
WORKERS COMPENSATION
B AND EMPLOYERS'LIABILITY YIN X ATUTE ERA
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? N NIA E.L.EACH ACCIDENT $ 2,000,000
(Mandatory In NH)
000006802E 08/21/2024 08/22/2015
EL DISEASE-EA EMPLO $ 11000,000
Ir yyeess desalbe under
DESCRIPnON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000
C ork Camp/RL Covg: NC927938352394 08/21/2024 08/21/2015 .L Ea. Accident - $1,000,000
tatutory Limits - WC L. Disease Policy Lmt - $1,000,000
L Disease Ea. Employee - $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sdhedule,may be attached If more spede Is requlmd)
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.
Southern a18 LLC ISE AUTHORD REPRESENTATIVE
26 Albion Road n�
Coln, RI 0266S-0000
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
SR ID:6629625 BATCR:Batch 8: 79627
08I1E.?J2&14 68:32 R883531532 FONN YRl CKSTO? PAGE all:
oD
Renewal � trn� t
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vu4� rrouerrran mncdo.. RandCrrkxwn=r?xlus
.. ��+lklriaa .. Irncvin;RJ(iI{16 i r` uan rim Vim—
Phone 366 6 2M Fax 401-533.6602
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Rown-ai by Ilnder.en of Som6erA Rae Ee�nnd'
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Bnyar(s)henby.lairttp and Rer+erally rally*to rnrrc6ic the Pruduev!mridlor;*en1te,yP sn ithe.rd 4j( PaL&TLd Windtwv LLC wwa Reny-.w I
yYAndaw, of Scttrlient Nrw tq@"i.eUgnirac¢or�'sir amneds"A!M ilh(tr..rerros and coo dons
sgt,-eitmt 6i►�ctl rnti 14�r lie ni artd the i�t'rF�of this enct t+a th r attachtxt xpn entian.heetfR}{mllttti�rly;ui!is,`i r r
' Condo D>rIt?.i..
Told job Rmr iirnt l f SrrrtrrtB,out t2sdhod.af 1147mcnt hoc!! 0 Cash Q Fiiuoed
Deposit Received(33%)::!. i.
Credit acesaa*ie aepastony-MaAftin i arthe
g+raitoe at Stint of Jeb(33 xx £sd!r+alcd Crnplacari bumpry�(� s see Ca�dArxi!enrFanN gl,s;e!!g
q !entiyeuactincwkrfl, .that doe8alsnctMSmn*)*and die
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7a6k b vu
grit ved mist bti rtuee lar�. rased dtedc b:nk ihdek cr asM:
B.esysr(s)'agrees.and mde!tutatlds that thi trva
s Agreement COAretientefc thte en&e.iitderatag beem the pm'tio®.and tbpt
sham are»o verbal mdesstae AgFo 11�[s)advii—led0s.!list 1S�ar's}
difstgs duing0s�aey of the ecr+ns o£sbtsc emmt,
(1)bas;ead tllois'kgreeanent,mdeestande the tarmkof this'Aigewixmnt,and 1r>t!s retie v�d taoeiplgeede siAneslr ai,d dncod
tat+9 of thisAgs,=M eat,iodoia be C"atta4- ed Noeees o>s Ca..odU;9 oA aw dare Srst�. !dtten above'nad(2) is wally
Of$sryer''s*,ht to tr acet this A,gteeaseat.AONOT SIGN THIS CONTIUCT IFTIJE3LE AtMANyBI ANK SPACES.
�Rlkor►s lafand SnTa�Qaly)Noaoo m ften(1)Do not ss,Mn able AVoeraenr f aay of the sp"ime: d , r6 r the o
tot&c eateot o£!bass aasillalble tmfor!mstina s left blanlr.{R)TYbir aria e!atQtded to a.t-W of t Agncement at the time YOU slge
ft{M.N.
reeeitie a aidlal rebate oi-
P tbx Bti9oeso smd nrsase ehwe :{�}The elleoe ltAs an rim to�slnsvfn>�y totes year�UdISM
or oo di any bt eaeb ot<the peace to reF"DWS 064 purehaaed uadrr ibis Agoemen i,(5 may plat i this A,gret�ot
if it)!rae ttnt been algieed at:]u:>x o1Sec of a branch i'IDcc of the seller,Provided Yon= the seller at his or her main
officooirbranch office sh&W' matte e—jt
by s+egletgreel er eoartid ntnil,which a ib posted sat biter ehaa midt!d�lit
a£the d4fd cale"AT day after tlse day an wMrb the hAtyet•edges that Agremneee,esetadisig s naxy avid any ludday on wfoleh .
regular W, 'Qe arc not reoade.4"the accaa►paayra,rawtlee ei cwecaliadon fottmfag tfi explanation of baye�9;1g .
B®gt ]rerrJ►cd Cr cdncatiirn rp!!iteiiats Feed by,the Rhudc tsEaad C.¢tcl'ttwctvp.l3lrstrtttitif! laard t?fvjrr3 r.ifG)
Reuewai by £ uthern irlew d BYCL
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4n014 TH1I $iTYBR(t3) MAY.CANCEL.THIS.TP-U*ACMON AT ANY TMz PWdR Tgo=MG AT,OF T,BE.THIRD
SUSINESSnAYAFTER TkM DATE OtiTAILSTRAl1'S,t1CT1t?N:SEDTIM ATTACHED NOTfC OF CAICELLo.Tit)ik)FORMS
FOR ANl62 L&Xl 71024OFTHIS#ilGiiZ*
Mon .
LON
11iIC1F of CELLATIGN
Date of Transactlnn 1!a Y04 msy tdnetl. 'Date of Transattion ( You MW Cancel
this tra nsaeti m,without any Pe or oblion oe,widen this transaatior►,wtdrtruE anon' nal or nkli atio within.
thM buslneat d fnem the date If u eatic0l g n.
agrs v r i Proles sad W-any�$ G�ntp made If y o 'under anj►
�perkt►traded fry any end tYittdC.Ei under-tfw 1 � �ye� �[�r'1;ow'tasder the...*. , . -
ontrecc or SIde,.arrd airy ssogotiabte tr> rumont eioeetMd, i. Contract or,Sale,arpd any n�lt labltt3testaurtoeat sfaEtuted
by yod wr7Cbe•rvtunned,withrn ten beratnens da�yyss following .i. by.you wiD be PCttlrned wi in,ten buineis days following �.
rooeipe by the Sober of your cancelladon riodpg,®r1d any i reee� br*e Sr]icr of yot caiteelkt{on notice,`and.airy
.I-ity interest" aMng-out Of the'transrtetion wilt be _.lLL,.seearr,}.. inte"M'arGting .Oth' of the 'tsahsactim.'WIN 'be
cance;WxynueanciA�r unjust rjilooangh b1et03ileselter nnoeted.If__7y�woiscancel yyoouu y�p�,` Ieta the Seller
ag your rasiderite,to sttlrRtaritta y as good cortd!tron as tphcn` .l at your 1tCsiderire;in substarrGally is good eondidon as when
reeeired.-V goods delivered to you tinder this Contractor I Vecerved,atty goads delF t:l Lc-you under the Contract on
Sale:sr yotl ef7 r,i/yeu Wi3h;comply with th®nrstrudlons of i Safe;er you nrar,ifyota�.ith;komdy with the lams tietiOns of 1
the Selier.regatt�in 'tM etumsldpmtintofthegoods.atth6 the SmIler,eg�dr'ngthotertur ,shlpnent:0tbeg"dsattb,e!
Ballet+$expense end risk tiy*oy do tnahg tie goods available' Sellee'9 aerie Arid rttk If do make thus avat7ahie
to the Seller and tiffs Seiler dens not pick.them'up:within t :tQ the Seller ,and Soto Staler t.not pick m up riit3tin' '
twvrity days of Hilo date of eaiicaihWo,,ye,of. nrWn or
dispase.af the. ode without �: fib'daps of,dte date of cellation;you rttetjr Merlin 4r
��ff Sa, o ny fitether ebflgeban.'If jrmt f die use of the goods with4sl any further o6liga6on.'If you
t0 Itialte the goods avatfabW to thai Seller,or if"0 agree i a rtiake the&ods araita14 to the Sella!;or If you Agree
to return the goods:40 tho.Selter and fail to do say tihe0 you I ,eo return life goods to tho,Salt r and tail to do.m,then rerttpin liable-for per(ormtinae of all.Obl•tgatlons undet•the �..remain 1Pabte far perfoymin.o of all o�ligttti0ns under the
Contraet:To catlt eI t#th t1A"Ned5N mall or daliv er a Signed t;vntrate>:Tb Wrrccl thls tra►ukildin,—11 or dellveIr a signed
and dated COPY of fibs cancellation notice:or other I and dated copy of this onaaltadlon notice or atty other
w it:tri not6s e,orsend myplegmm t0 3lerte;wai Afrsen of I'wsitten noNcOi4/�satrd a tale to RetleM►at byAndwrs¢n of
Sotidiern New England at 26 Albion Road, l 6S, I Southern New d at 2�on Read,E.incoln,Ri 0296S,
NOT CATER THAN MIdNICiFfr Op 1. NOT]LATER THAN MIDNI
1 �fiT QF
D�tO)
BY CAN ICFiTMISTRANSAGTtON, ((t7ate
di�ERBY CANCELTHIST 'N
WEI(ESACTION.
f "
2V-W% 10Msums cute - �orhilEnrrtNe � PAMNa.w apt '
p1AA CW;WhRe. Buller Copy:Yellow &r1w CcFy!Fork
Southern New England Windows
d.b.a
Renewal by Andersen of SNE
�( Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS4119=7
BRAN D DENN06N
7 LAMBS POND� �`� s �
C6artton MA 01507
Expiration
Commissioner 09/0812016
1
C�J17
he �o Consumer r?> xdJcc �cT
Office o Consumer A airs Business a ation
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
.. Registration: 173245 .
Type: Supplement Card
SOUTHERN NEW ENGLAND WINDOWS LL Expiration: gfi9n014
DENNISON BRIAN ---
1137 PARK EAST DRIVE
WOONSOCKET,RI 02895
Update Address end return nrd.Mark reason for changes se"o raraaw, - - Ci Addroa [-j Renewal 0 Emple7mnt p Lost Card
Ilke of Comaeur A16in d.Bodeen Rraaladaa Ucoafe or registntieo valid for indtvidul nfe nary _
��ry(I E IYPROVEA1pR COR1gACfpR before the efpintiw din(f fwed retnn te: -
+ "'rte9latraanm 173215 Office of Coafamer Atkin and Bueine n Ragulatiee ..
g.,r E�fratbn.8/19/tOta S 10 Park Plan-SakeS170
,mpkmenl t;md Boston,MA 02116
SOUTHERN NEW ENGLAND WINDOWS LLC. _
RENEWAL BYANDERSON' -
DENMSON BRIAN
1137 PARK EAST DRNE
WOONSOCKET.RI 02095 Uaderaecrtury LL—.fNet valid withoat algnshre - -