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HomeMy WebLinkAbout0173 NOTTINGHAM DRIVE Y .; �jrl /4 � - r _ � �� 1 s _ ,a `` .. ,.: ,� � .. G ... " - - .. � .' .: - .: • .. ��� r � Application number......6-17 ....— yDate Issued...........2:.. �. ................................. �O a639• ,0� AUG 29 2013 Building Inspectors Initials....... . ........................... t � �� 1� � Map/Parcel.........�'�Z......�....v......................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY MORMATION Address of Project: _ /7 �j �✓�f�► h,,,., �� ��,�- �� �� NUMBER STREET VILLAGE Owner's Name: Ta,. e s ,C� f, 1,y Phone Number 5 Og-6 g I- 0,), I 1 Email Address: Cell Phone Number l 17 -73 3-6 z,l / Project cost$ 41. S cj — Check one Residential V1 Commercial O V*1VER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: S e,,- 06,4c,14 Date: TYPE OF WOE ❑ Siding ❑ Windows (no header change)#' ❑ Insulation/Weatherization Doors(no header change)#__L_ Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to lff d s- 6-/9'traiJa g Po'!P -1 - ,���c of r► 1 CONTRACTOR'S INFORMATION Contractor's name I�d Gn `�Rn��sor� - E�A-ecrx We J J-I)chowS Home Improvement Contractors Registration(if applicable)# 17 3 2-Lt 5 (attach copy) Construction Supervisor's License# 01 S'7 O: (attach copy) Email of Contractor CCSU)P QRJ- -) ,0 -& Mt_ , ",A Phone number q0l� z Z R RDO ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS 11v A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN RE ISSUED. SR APPLICATION NUMBER............................................................ *For Tents OnIV* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent pf food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval Y.W®®D/COA LJ/PELL ET STOVES ES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S R'S LICENSE EXE TIO Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures; specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date 1C LICAN ll 9 S SIGNATURE A - Signature Date 01> All permit applications are subject to a building official's approval prior to issuance. , Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England James Araby Legal Name:Southern New England Windows,LLC 173 Nottingham Dr. RI#36079,MA#173245,CT#0634555, Lead Firm#1237 Centerville,MA 02632 WINDOW RE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 H:(508)681-0211 - Phone:866-563-2235 1 Fax:401-633-6602 1 sales@renewalsne.com C:617 7336241 Buyer($)Name: James Araby Contract Date: 08/15/18 Buyer(s)Street Address: 173 Nottingham Dr., Centerville, MA 02632 Primary Telephone Number: (508)681-0211 Secondary Telephone Number: 617 7336241 Primary Email: franka317@aol.eom Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this'"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $4,591 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $2,296 Balance Due: $2,295 Estimated Start: Estimated Completion: Amount Financed: $4,591 8 to 10 weeks 8 to 10 weeks Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate..We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. Notes: Taxes paid in Barnstable, Ma. Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 08/18/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:RenewaJ By Andersen ot.Southern New England Buyer(s) Signature of Sales Person Signature Signature Gino Montesi James Araby Print Name of Sales Person Print Name Print Name UPDATED: 08/15/18 Page 2 1 11 f Office.c1, Consumer Affairs and Business Re"flation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NEW ENGLAND WINDOWS L:L BRIAN DENNISON 26 ALBION RD _. . L+NC®LN,. RI 02865 Update Address and return card.Mark reason for c'__a_noe. Address = Renewal - Emplovment = Lost Card _--office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: _ Office of Consumer Affairs and business Regulation Registration: y 3?n6 Type: 10 Park Plaza-Suite 5170 Expiration: 919/2018 Supplement Card Boston..TVA 021Il16 riJTHERN NEW ENGLAND WINDOWS LLC. :NEWAL BY ANDERSON IIAN DENNISON ALBION RD r � o JCOLN, RI 02865 ndersecreiary Not valid without signature vi t n t; vixv' G vi . L"a v`S-`, r f o ' s and Stan707 SR.�_N' D DENNISON ' 7 LAMBS POND CIRCLE "ARLTO IAA 01507, ' The Commonwealth of Massachusetts ' Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 NZ www.mass-gov/dia qp—.Workers'Compensation insurance Affidavit:Builders/Contractors/Electricianslplumbers. TO BE FILED WITH THE pERNIITn NG AUTHORITY. ARDlicant Information . ., Please Print Le ' 1 Name (BusinesslOrganintion/Individual): Address: ,(� � City/state/Zip: p Phone#: '�,D{ _ 2- Are you an employer?Check the appropriate box: Type of project(required): 1,KI am a emplover with Zo femployees.(full and/or part-time).; 7..❑New construction 2❑I am a sole proprietor or partnership and have no employees working for me in any capacity.['-Noworkers'comp.ansurance required.] 8- ❑Remodeling 3.[]I am z homeowner doing all work myself[No workers'comp.insurance required]t 9• ❑Demolition 4.FJ I am a homeowner and wdl be hiring contractors to conduct all work on my P P�ro ,y. I will I O Q Building addition J ' � . ensure that all contractors either haveworkers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees S.Q 1 am ageneral'com listed ractor and I have hired the sub-contractors on the attached sheet 32.[]Plumbing repairs or additions "These sub-contractors have employees and have worker.'comp.insurance? 13_F1Roof repairs 6. We are a corporation and its officers have exercised their right of exemption,per MGL c. ! 2'Oiber��-F'p it�tr 152 Fl(4),and we have no employees.[No workers'.comp.uuwance required.] -Any applicant that checks box g]must also fill out the section below sbowing their workers'compensation policy information V t Homeowners wbo 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 End job sue information. _ nn Insurance Company Name: I rf pile 11) Policy it or Self-ins.Lic.lr: ,Z,q — 2-0 Expiration Date_ Job Site Address /7 3 Not ' c Xa ,,, �� City/State/Zip: vi le A _Attach a copy of the workers'compen Lion policy declaration page(showing the policy number and expir 'on date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation pUnishable by a tine up to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator_A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify under th ains andpenaldes ofperjury that the information provided above is true and correct Si ature: e Dfie: Phone : -10 t-2z e- Official use only. Do not wri[e in this area,to be completed by ci�:or town offiriat 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 P: CERTIFICATE OF LIABILITY INSURANCE rATE(MMID°"""') THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.ITHIS 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). 'RODUCER CONTA CoBi2 Insurance, Inc.-CO NAME: 1401 Lawrence St, Ste. 1200 PHONE e�n,303-988-0446 Denver CO 80202 E-MAIL FAX No•303-988-0804 DRE : COMaiI cobizinsurance.com INSU S AFFORDING COVERAGE NAIL$ NSURED ESLERCO-01 INSURER A:Acadia insurance Company 31325 Southern New England Windows, LLC. INSURER B:Tremens Insurance Companyof WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D Smithfield RI 02917 INSURER E: INSURER F: :OVERAGES CERTIFICATE NUMBER:1252851165 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. ISR ADDL SUER TR TYPE OF INSURANCE COMMERCIAL NUMBER MMND YY MMI1DD YYY)EXP -LIMITS A X COMERCIAL GENERAL LIABILITY .CPA3158728 � 1/'12016 1/12019 EACH OCCURRENCE $1.000.00D CLAIMS-MADE Q OCCUR DAMAGE SES Me occurrence $30D,000 MED EXP(Arry one person) S 1C.000 PERSONAL&ADV INJURY S 1,000,0D0 GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,0D0,()M X POLICY PELT = LOC PRODUCTS-COMPIOP AGG $2.ODD,ODD OTHER: $ A AUTOMOBILE LIABILITY N CPA3156728 1/112016 1/12016 COMBINED SINGLE LIMB X Ea accdent $•ODO DOD ALL OWNED ANY AUTO i BODILY INJURY(Per person) S AUTOS AUTOS BODILY INJURY(Per accdent) $ X HIRED ALITOS X ALFTOS NON-OWNED PROPERTY DAMAGE AUi05 I -Per accident $ 1 '$ A X UMBRELLA UAB X OCCUR CPA315672E 1112016 1112D1f EACH OCCURRENCE I S 10.DDD.00D EXCESS LIAB CLAIMS-MADE AGGREGATE $10.ODO.000 DED I X I RETENTIONS B AND EMPLOYERRS S* S*LIABILITY IONILIT YIN WCA315t372&20 111201E 1h2011? X I PER STATUTE ERµ AND EMPLOYERS'LU1BILiTY ANY PROPRIETORMARTNEROMCUTIVE OFFICERMIEMBER'EXCLUDED? NIA E.L.EACH ACCIDENT $1,ODC,000 (Mandatory in NH) If yes describe under E.L.DISEASE-EA EMPLO $1,000.000 DESCRIPTION OF OPERATIONS below EJ_DISEASE-POLICY LIMB s 1,00000D C Ponution Liab'iPd 7930073MOODO 1h/201E 1/12MS Each Occurrence $1.000:DDC Gaims-Made icy A bbe $10,DDD M Retroactive62 pate 0D2013 'ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) - :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ►CORD 2542014101) The ACORD name and logo are registered marks of ACORD �t r Town of BarnstableifExpi # Regulatory Servicesee 6months fomissue erte • BARNSrABLE, 9cb 16 � Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTUL ONLY Not Valid without Red X-Press Imprint Map/parcel Number, /"`f �,04 Property Address - h5 NO ft-/,w ���t D�?lV, G 0-2 G 32, [Residential Value of Work O O Minimum fee of$.35.00 for work under$6000.00 Owner's Name&Address / 7 NOff I W 6 H19-I►I IQ 1 V i� _GENttRyli� `E Ag a 4 3,1 Contractor's Name 5 f*rlolh A) Af A Z Z 4'4 Telephone Number J,05-— Home Improvement Contractor License#(if applicable) / fi f X-PR E S S PERMIT �e� Construction Supervisor's License#(if applicab �� 5 ❑Workman's Compensation Insurance APR 02 2092 Chk one: am a sole proprietor Z ❑ I am the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit R;7Re-roof t(check box) hurricane nailed (strippingold shin les All( ) shingles) construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑Fence over 6' #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows . *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 Home Improvement Contractors License&Construction Supervisors.License is quired. SIGNATURE: Q:\WPFILESTORMS\building permit formsTYPRESS.doC Revised 051811 r Ct The Connimonweatth of Massachusetts" Department of Industrial'Accide7tts Office of Investigations 600 Washington Street Boston,MA 02111 mo mass gov/dia Workers'Compensation Insurance Affidavit: BmIders/Contracturst'Ele ctricians/Plumbers Applicant Information 'Please Print Legibly Name(Racine nization&dividual): 5�'Ei°ff 1:.Iy A 0 et Address: e AN ri City/State/Zip: A W 1 GcEi' Mfg. 02G4%; Phone# Are you an employer?Check the appropriate box: T of project 4. am a contractor an 1� P ro j (mod): 1.El I am a employer with ❑ I t d I 6. ❑New construction eI mployees(fulland/orparthave hired the sub-contractors2. am a sole propiie#m ar parfioer- 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 wormers' 9. Building addition [No wormers'comp.incarnate comp.mgtvancr I 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 self o workers' right of exemption per MGL �' � �- 12.❑Rovf repairs insurance rid-]I c. 152, §1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks boat#1 mast also fill cot the section below showing their wo3ker'compensation policy inform9tioa Homeowners who submit this affidnit indicating they are doing 9D croak and then hue outside contractors must submit a new affidavit indicating such. rCoutrartan that check this boat must attached an additinRd street dMfing the name of the sub-c�and state whetter or not those entities have employees. If the sub-mutractots have emplo*%they must provide th-workers'romp.pohcynumb- -Taman employer that is prmidirrg nwrkers'compensation irtsnrance for my.en Alojwes. Belau is the policy rand job st`te information. Insurance:Company blame: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:j7-1 NPtl 11✓6,,Yif '1 City'state/zip:_"N ✓/Gat_ #,4, 0 3�- Atttich 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 it STOP WORK ORDER and a fate 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 cerhflr tinder th epain rtd penaties ofpeduty that the inform atian provided above E's true and correct Si tune: Date_ Phone#: 5 0� 2Y' ' 71 1 ;2,- Official use only. Do not write in this area,to be completed by city or town official City or Tovim: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 PROPOSAL Page# of pages ZZLkr Proposal Submitted To: Job Name Job# L77 Sam ell Address , r Job Location See rr��, ,/ Date O� �n � Date of Plans • 0 (0 `9 Ph' # Fax# . ' Architect - We hereby submit specifications and estimates for: 1 Q a-r0 / / r4'5 `171f % jr_ U A la ` -� -tea- �n eA Ie ;-'®® ? i a � p 0a . c V f Ay &Jars.- - We propose hereby to furnish material and.labor—coin plete in accordance with the above specifications for,the.sum of: tP/C000.0 0 $ � k 1. ndrpp � a-nd, ,i o/s/oo oll ars LL_ nts o be' as fo ows: /` O/ In 1,rt d.+�»C deuc on .n or deviation fro a ove spe c ions involving.extra.costs will . Respec lly submi d:only upon written order,and.will become•an extra charge over.andimate. All agreements contingent upon strikes,accidents,or delays ontrol. Note—this proposal may be`withdrawn by us if not accepted within �ays. . 01 ACCEPTANCE. OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do.the work as specified. Payments Signature , '" = r! G% . will be made as outlined above. !! i ; (Date ofAcce lance: � 1 1 � P Signature J . . A-NC3819/T-3850 -. ((�(� ✓/ie TDonvnxoo2cuea`� aaac/up`elta Bu: idl' i3uillli' Kc!-ulatiills un(1 1t:In(1 t, �4 f Office of Consumer Affairs&Business Reguladda I p Construction Supervisor License VYTHHOME IMPROVEMENT CONTRACTORRegistration: `6=1,4,7634 Type: License: CS 104459Expiration 7/25/2013DBA P. MAZZUR ROOFING+,SIDEWALL STEPHEN MAZZUR 9 w/ I t 10 MARK LANE I� STEPHEN MAZZUR �r 02645 I'. HARWICH, MA 10 MARK LANE . i HARWICH, MA 02645 Undersecretary. Expiration: 9/2/201.3: Tr#: 104459 t a".'.•,.di.t N kPs,R1.w.:•JrAW+eu;' .rrrY'�l:c --+.vcw t License or registration valid for indrvidul use only b4ore.the expiration date: If found return to: Office of Consumer Affairs and.Business Regulation 10 Pack Plaza-Suite 5170 r• Boston MA 02116 j ,I sa Not valid without siguOufe f - oFtHE,,� Town of Barnstable *Permit# t �p� Expires 6 m hs j om is ate Regulatory Services Fee • IARNSCA.M x v 1 ; Thomas F.Geiler,Director'AlEn,rw�6 Building Division 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 - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint t>. Map/parcel Number CU. Property Address ' '� N�I I�V(of-Fi4M/1 �!L�V.L EP1T��2�+ LL L M A O,Z G XResidentW Value of Work �� ']CQ. Minimum fee of$35.00 for work under$6000.00 I is o Owner's Name&Address /-7tCe^I Ljo 1V s 1-7-3 /,Jca iI trJ(o4-Y'I __i itv— CF-J'4Te__rLvYLC6, MA-CUU.) Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Iy Construction Supervisor's License#(if applicable) INW C $L_ 10 CG i A_.IFA r1%K M I,W }F NWorkman's Compensation Insurance Check one: N O V d 2 L 010 I. ❑ I am a sole proprietor ❑ I am the Homeowner (��(l [ �A��J�-r��� I have Worker's Compensation Insurance . Insurance Company Name �rYLI EE.S S S�IS'v fL;4l= Workman's Comp.Policy# LJ C 96,2(o 3 3 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 j ❑ Re-side #of doors Q Replacement Windows/doors/sliders.U-Value a 3 0 (maximum.35)#of windows . S *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 Home Improvement Contractors License&Construction Supervisors License is req red. SIGNATURE: C:\Users\de`collik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doe Revised 072110 The Commonwealth of Massachusetts —= Department of hzdustrial Accidents Office oflnvestigations 600 Washington Street �tr Boston, MA 02111 www.nnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly , Name (Business/otganization/Individual): t t C .w,..t V4%1YX^ �{�e7vc CF LiVC Address: City/State/Zip: CzOi Phone M SG& -3 42c� 45Y(o F2O e you an employer? Check the appropriate box: Type of project(required): ] s I'am a employer with � 4• Q I am a general contractor and I employees (full and/or part-time).*. have hired the sub-contiactors 6. �]New construction I am a sole proprietor or partner- listed on the attached.sheet. 7. Remodeling: ship and have no employees These sub-contractors have g• E] Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. 0 Building addition required.] 5. 0 We are a corporation and its Electrical repairs or additions 3.❑ I am a homeowner doing all work.. officers have exercised their 1 I.,,O Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation, 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-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 thepolicy and job site information. Insurance Company Name: � Z �S -1-N S LX1_&rr_J Ct Policy#or Self-ins. Lic. #: W C 1' & (p a.3 3 Expiration Date: Job Site Address:, / 7 3 No?77�.1 �Q y1�1 (�2 i vF- City/State/Zip: CENTP-►-V I L.LE7 G263a 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 hereby cer7ify and r the p ins and p zalti' of perjury that the information provided above is true and correct. Si nature: Date: ' Phone #: 3Ct6- SSVlo Official use only. Do not write in this area, to be completed by city or town of 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#: OFIKE s •'f + BARNSrABM J 6 s6g9. Town of Barnstable �0 prFO MA'I a Regulatory Services Thomas F.Geiler,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 I, EL&4 L.,t®iqs ,as Owner of the subject property hereby authorize 4l vy�s N y m tLv O%jC.TS OF CVf-" to act on my behalf, in all matters relative to work authorized by this building permit application for: PS NO-tTi Nfo l-l�Rizt 1�oLw Ct-1J 1��XL J i�.l t (Address of Job) f / /o1,;20/Q Signature of Owner d Dat Ne-He -1 Lvrrts Print Name { If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. 3 C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc _ Revised 072110 * _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: - .158424 Office of Consumer Affairs and Business Regulation _ Tr# 291469 10 Park Plaza-Suite 5170 Expiration: ,1/23/2012 Type: PriGate Corporation Boston,MA 02116 ALUMINUM PRODUCTS OF°CAPE COD INC, STEPHEN HUNTER-Z 476 MAIN STREET DENNISPORT, MA 02639 Undersecretary Not valid wit out signature J i F a `3 r +_ Massachusetts DclrtrtmcUt of PUhlic sat'ctN 1 Boar(I of Buil(linL Rc,*ulations an(I Stiu)(L11* s Construction Supervisor Specialty License License: CS SL 100160 t; 4a4 Restricted to: WS STEPHEN HUNTER 17 WEST WOODS ; YARMOUTHPORT, MA 02675 Expiration: 7/11/2012 \ ( nmii<.imer Tr#: 100160 i