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Town of Barnstable *Permit# ®ems " Expires 6 months from issue date Regulatory Services Fee PERMIT Thomas F.Geiler,Director �j Z/o6 Building Division DEC 8 - 2006 P 0D^rk Tom Perry,CBO, Building Commissioner TOWN OF ggRNSTABLE 200 Main Street,Hyannis,MA 026016, www.town.ba'mstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint p/parcel Number /f� // 44e,,perty Address Residential Value of Work 46 �O Minimum fee of$25.00 for work and $6000.00 mer's Name&Address 19 VV ntractor's Name Telephone Number,09— —� ime Improvement Contractor License#(if applicable) 5 / Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance ;urance Company Name m' S CO Drkman's Cornp.Policy# 106 U ?UyCo 4e5 A ipy of Insurance Compliance Certificate must be on file. rmit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to / ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this pemvt 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 is required. GNATURE: Forms:expmtrg vise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street �< Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App licant Information Please Print Legibly Name(Business/Organizatio dividual): �D Address: a City/State/Zip: QoZ4(0/61 Phone.#: © 'J 39z/ Are you an employer? Check the appropriate bog: .Type of project(required):, 1.❑ I am a employer with 4. ❑ I am a general contractor and I * have hired the sub-contractors 6• ❑New construction . employees(hill and/or part-tim Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet '7, ❑ ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition comp. # [No workers' comp,insurance co insurance. 10.0 Electrical repairs or additions required.] � 5. ❑ We are a corporation and its 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.D!LRoof repairs insurance required.]t c. 152, §1(4),and we have no 13.0 Other employees. [No workers' 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-contractor;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: ,_ `/"G ��y�I— d/V S �® — Policy#or Self-ins.Liicc..#: V &le, ExpirationDate:'?—/ O`Z OQ City/State/Zip: Job Site Address: 4 Attach a copy of the workers" comp nsation 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 maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct Signature le:--" - Date: /a" � 0 t�2 _ Phone#: �� r 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#: Information and instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction o epair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such a oyment bd dd!rned to be an employer." MGL chapter 152, §25C(6)also stat� that"every state or local licensing a ency shall withhold the issuance or renewal of a license or permit`to operate a business or to construct boil ings in the�commonwealth for any applicant who has not produced acce table evidence of compliance wi the insurance coverage required." AdditionaIly,MGL chapter...152, §25C(7) fates"Neither the commonwea nor any of its political subdivisions shall enter into any contract for,the performance public work until acceptab a evidence of compliance with the insurance requirements of this chapter have been prese ed to the contracting auth rity. Applicants Please fill out the workers' compensation affida\fo ) pletely,by c cking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),ads)and phone mber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) fed Liability arhnerships(LLP)with no employees other than the members or partners,are not required to carry w ' compensati n insurance. If an LLC or LLP does have employees,a policy is required. Be advised thatdavit may a submitted to the Department of Industrial Accidents for confirmation of insurance coveragso be sure t sign and date the affidavit. The affidavit should be returned to the city or town that the applicatiohe ,ermit.o license is being requested,not the Department of Industrial Accidents. Should you have any quesegar ing th law or if you are required to obtain a workers' compensation policy,please call the Departmen num r ed below. Self-insured companies should enter their self-insurance license number on the appropriate City or Town Officials Please be sure that the affidavit is complete and printed legibly Th epartment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inv stigati s has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will a used as reference number. In addition,an applicant that must submit multiple permit/license applications in any iven year,n d only submit one affidavit indicating current policy information(if necessary)and under"Job Site Addre s"the applic should write"all locations in (city'or town)."A copy of the affidavit that has been officially st ed or marked b the city or town may be provided to the applicant as proof that a valid affidavit is on file for future ermits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a licens or permit not relate o any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said pers n is NOT required to c ;plete this affidavit. The Office of Investigations would like to thank you' advance for your cooperatid and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax numbe :. The Co_ onwealth of Massachusetts Depa ent of Industrial Accidents fIce of IUVv Atlgaftons r 00 Wadi ngton Street Tel. ##6,17- 7-4500 ext 406 or 1-877-MASSAFE � Fax##617-727-770 Revised 11-22-06 w .matss.gov/dia jofIKE? Town'of Barnstable Regulatory Services ZAMSTABU, • Thomas F. Geller,Director MASS 9�P 16g9. p.�� Building Division EED MA'S Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r ti as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building p ertnit application for: 0 (Address of Job) )�60 Signature of Owner Date �E NPA A� Print Name Q:FORMS:OWNERPERMI.SSION • �' � �/e Zp�i+�uveall/ o���aoaclzuae�'d ` Board of Building Regulations and Standards HOME IM PAR 01 MIE+NT CONTRACTOR Reg 'straion53529 b zE # 008 Tr# 253575 vidual 6 EVERETT L.SN EVERETT SNOWDE�I� l' 78 CURVE HILL RD. S.YARMOUTH,MA 02664 �� � Administrator 12/07/06 15:52 FAX 5087900249 GOLDMAN ASSOC a0i ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) SNOWE50 12 07 06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION J . 'GOLDMAN & ASSOCIATES INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FINANCIAL SERVICES INC. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 933 F'ALMOUTH RD. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, HYANNIS MA 02601 Phone: 508-775-6010 Fax;508-790-0249 INSURERS AFFORDING COVERAGE NAIL# INSURED INSUR_ERA: AIM MUTUAL INSURANCE CO, �INSURER B: r EVERETT SNOWDEN IINSURERC: 78 CURVE HILL RQpAD INsuRERO: S YARMOUTH MA 02664 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NCTWITHSTANDING 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NA TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/ODNY LIMITS GENERAL LIABILITY I EACH OCCURRENCE S I COMMERCIAL GENERAL LIABILITY h PREMISE I C a nccurGnc®J S CLAIMS MADE F-1 OCCUR MED EXP(Any one person) S --------------------- ------------------ PERSONAL L ADV INJURY S GENERALAGCREGATE S GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO - ac COMBINED SINGLE LIMIT (Eaec -- r (Ea cidenl) S ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNEOAUTOS I (Peraccideni) -- — PROPERTY DAMAGE S (Per accjdanl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO EA ACC S OTHER THAN AUTO ONLY. AGG I S EXCESSIUMBRELLALLABIUTY EACH OCCURRENCE S OCCUR CLAIMS'MADE I AGGREGATE S T_ — $—— DEDUCTIBLE RETENTION S T TATU WORRS COMPENSATION AND TORY LIM KE BS ER i EMPLOYERS'LIABILITY A ANY PROPRIETORMARTNEFUEY.ECUTIVE #VWC6011114012006 11111106 11/11/07 I E.L.EACH ACCIDENT S],00000 OFFICERtMEMBEREXCLUDED? E.L.DISEASE-EAEMPLOYEEI S 100000 IT SPECIAL PEIAL PROVISIONS Delow E.L.DISEASE•POLICY LIMIT S 500000 OTHER I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWNO,B SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRJTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SD SHALL .TOWN OF BARNSTABLE IMPOSE NO ICATION OR LIABIUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BUILDING DEPT 200 MAIN ST REPRE TA ES, HYANNIS MA 02601 AUTHO PR ATIV _ ANN LOU 3E HELANGER ACORD 25(2001108) G ACORD CORPORATION 1981 I I