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HomeMy WebLinkAbout0112 PARK AVENUE » r a • r ra ti ^ r ` n , 4 , x �,v. • .ace., a , L: r . • , , r r z v t ,... .. .' a .. - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel V Application 0,�)/_S Health Division Date Issued 2 b Conservation Division Application Fee Planning Dept. Permit Fee Jr' Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project SrY6�sawk t ddress /Z Village Owner (44ll Address Telephone Permit Request l l 2 �dL �k � F" d�--15 , - � ► b lac O-3 ' � � Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District - Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size n Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family / Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No O_Id King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement UnfinisheArsq.f Number of Baths: Full: existing new Half: exist ►Pa new N Number of Bedrooms: existing _new Total Room Count (not including baths): existing new Fir, Floor Roots Count Heat Type ah1d Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ?f%o If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C ��1 1 - Telephone Number p s 67 , Address l� �' License# �' o �{ Home Improvement Contractor# b Email Worker's Compensation # 6 J ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJE T WI L BE TAKEN TO SIGNATURE DATE L FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. 9 ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Massachusetts Department of Public Safety I V Board of Building Regulations and Standards License: CS-100988 Construction Supervisor nM. i I'S f. HENRY E CASSIDY 8 SHED ROW k WEST YARMOUjH ��"/►� .lam Expiration: Commissioner 11/11/2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 517.0 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE - SO. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. SCA 1 t5 2OM-05/11 [],Address Renewal Employment Lost Card ............ ._..__,.---............. �e epai�urrzo�raeue�cCC�a�C�/�/lccaaac�uoe�. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 4:53567 Type: Office of Consumer Affairs and Business Regulation j xpI ration::.;;1;2115F20:1:6 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATION INC-. HENRY CASSIDY 18 REARDON CIRCLE- SO.YARMOUTH, MA 02664 Undersecretary qNyvalid The Commonwealth of Massachusetts " Department of Industrial Accidents Office of Investigations `'' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual); { � Address: _ f ,�Ir City/State/Zip; ,�' ' ' �'iLomt M. , Phone #: Are you an employer? Check th appropriate box: Type of project (required): '° . ❑4. I am a eneral contractor and I l. ,l am a employer with g 6. ❑ New construction Lr 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, ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. � Building addition [No workers comcomp-insurancecomp. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work o 1 l:[] 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.� Other t comp. insurance required.] f *Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavvit 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. p Insurance Company Name: i� +it'7kybl, Policy # or Self-ins, Lic, 0J Expiration Date: �/ ' ��✓ Job Site Address:" . Z Paff k flot, City/State/Zip:G?L&Vtt( qa 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 insuraW coverage verification. I do hereby certify d the pai an penalties of perjury that the information provided bove is true and correct. z l '� Si nature: Date: _ Phone#: 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#: CAPECOD-27 BDELAWRENCE ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F6/30/2015 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 pblicy(les)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). PRODUCER CONTACT - NAME: ROgers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/C No Ext: A/C No):(877)816-2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED INSURER B:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc. INSURER C: 18 Reardon Circle INSURER D: South Yarmouth,MA 02664 INSURER E: 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. I SR TYPE-OF INSURANCE D BR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS A. X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN CLAIMS-MADE a OCCUR CBP8263063 04/01/2015 04/01/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ECOT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident) ccident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE WCE0043190106/30I2015 06/30/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICEWMEMBER EXCLUDED? N/A - - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If,yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES ()kCORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ax y Town of Barnstable Regulatory Services $")W STAJ= Ricbard V.Sc.%Director Building Division. Tom Perry,Building Commissioner .4 200 Main Street;Hyannis;MA 02601 —All %Tny.towa.barnstable.ma us Off ce: 508-862-4038 Fax: 508-790.=6230 Property Owner Must Complete-and.S.ign This Sectio;i if Usin as C?caner of,-theaubject.property hereby authorize CO-V _ d� to act,on rnybehalf, in all matters.relative to work authorized by this building permit application for '(Address of J:ob) UkI ;:.."Pool fences and alarms are the respons bilityof the applicant. Pools are not:to befilled or utilized'before fence is installeel'and all final inspections are performed and accepted - WAN Owner -Signature of Applicant mc-r are.-+ 9tcj(,:JS Print; `ame Punt Name Date Q:FORMS:O WNEUERMISSIONPOOLS r CAPE COD INSULATION 1lelAlAii HAM 1 IAA AYlOAM fU7A1N010 7Al13 OUTII'Q$A! IN UTATION CIIlINO! ' 1-800-696-661t Town of Barnstable Regulatory Services Building Division s 200 Main St - Hyannis, MA 02601 «; Date: ZE ` Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation Inc. pe rinG& completed the insulation and.weatherization work at the property listed below. Cape Cod Insulation did this.in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner . Property Address Village /W a all Are /4%YO.zalIli Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes Floors ( ) ) ( ) ( ) ( ) Walls ( ) ( ) ( ) ( ) ( ) Dive Gvv r k FP r r0 r,*je01 Sincerely 2eHrE ssi i•, President Ins ation, Inc. C 1� C) Town of Barnstable *Permit# Expires 6 m ro�,issua Ante Regulatory Services Fee MASS' Thomas F.Geiler,Director 639 ��� p MIS O IG I f 1'(G V Building Division „PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 S F P ..- 1 2010 www.town.bamstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 WN OF gARASS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press,lmptint Map/parcel Number Z 0 ® Z Property Address it?, - n-rL V— /1J U e- �]Residential Value of Work�S! �}'� Minimum fee of$35.00 for work under$6000.00 Owner's Name&AddressC -} `< us Contractor's Name_l6bM A S' D&I.10 v= Telephone Number 6_0 k- ct S 7"Y 9 7 Home Improvement Contractor License#(if applicable) ` 6 vZ' Construction Supervisor's License#(if applicable) S Z_ 0 n &Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner [ I have Worker's Compensation Insurance )J Insurance Company Name E/f l2 M Y11 I L y Workman's Comp.Policy# Z a Q 13 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 #of doors Replacement Windows/doors/sliders:U-Value o 2 _(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 required. SIGNATURE. .� C:\Users\decollik\AppData\Local\MicrosoMWindows\Temporary Internet Files\Content.Outlook\DDV87AAkTXPRESS.doc Revised 0721.10.:. . Boar o lVuVi a ns an tan g � One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement.Contractor Registration Registration: 112182 Type: DBA - Expiration: 3=011 Tr# 280922 EZ-TILT WINDOWS THOMAS DALEY P.O. BOX 561 E. FALMOUTH, MA 02536 -.. Update Address and return card.Mark reason for change 0 Address Renewal [] Employment Lost Card OPs-CAI 0 4W-0a10fi-DH,SUF0acwcA10e212M c a . ACORD,. CERTIFICATE OF LIABILITY INSURANCE DA03/0812010 PRODUCER (508)428-0440 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mark Sylvia Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 771 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Osterville MA 02655 INSURERS AFFORDING COVERAGE NAIC# INSURED Daley,Thomas J dba EZ Tilt Windows INSURER A: Farm Family Casualty Insurance PO BOX 561 INSURER B: East Falmouth,MA 02536 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS R MRRA TYPE OF INSURANCE GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 A X 2001XO345 2/1/2010 2/1/2011 DAMAGE TO RENTED 50,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ -- CLAIMS MADE F-X1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTO person) S (Per $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per aocidenl) $ PROPERTY DAMAGE $ (Per accident) . GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 2001 W6193 2/2/2010 2/2/2011 X STI.ATUrS - OTH- A EMPLOYERS'LIABILITY 100,000 ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERlMEMBEREXCLUDED? _ - E.L.DISEASE-EA EMPLOYEE $ - 100,000 If Yes,descnbe under SPECIAL PROVISIONS below Yes E.L.DISEASE-POLICY I wiT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS Carpentry The workers compensation policy does not provide coverage for Thomas J Daley. 4 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Thomas J Daley dba EZ Tilt Windows DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN PO BOX 561 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL East Falmouth,MA 02536 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. . AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 , f, C l , LEW CORPORATION 1090 Bristol Rd.Mountainside,NJ 07092 Pion:(908)654-8068 Fax 1908)654-8069 Certificate of Attendance and Successful Completion Renovator tnrtta1-English Per 40 CFR Part 745.225 THOMAS DALEY , PO BOX 561 EAST FALMOUTH.MA 02536 kh"I fip6on Number.R+18342-10-01860 Course Date:03=0 Examination Date-03r3ono fill E�OaW--03r30r15 0420110 Training ManagedPrmdpal Instna2w Date -Otates Environmental Vroterflon Agentij D . '. 40 D °" EZ-Tilt Windows 0 has fulfilled the requirements of the TwF-c-Substances.Co,�troI Act(TSCA)Se'aion�402,and'h'as received certification to conduct lead- based paint renog,ahon,repair;and�painting activitie pursuant to 40 C�FR Part 745.89 a PROS All EPA Administered States, Tribes, and Territories This certification is valid from the date of issuance and expires January 29, 2015 NAT-19757-1 Certification# y���t o sr'A'0' Michelle Price, Chief January 19, 2010 Lead, Heavy Metals, and Inorganics Branch Issued On Page No. of Pages r P sal - r. e 20 ?� -TILT WINDOWS E. 253 SO"57-4977 tf and- w flit M - ` D i PROPOSAL SUBMITTED TO PHONE DATE STREET Ail g JOB NAME •sfi 2 a CITY,STATE and ZIP CODE JOB LOCATION ARCHITECT s DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. �A'�•=,i i �'$�•�' `—"'ix>-•a<� `'--p" ;�,.. .'��',>'Tw� � �y� �'y 43�"w �;i ',�a"' ��' j�F fig° d�Ed.'� � T .h -,!,_ _,•7„ j a�4 #= 1 ate. ,+°` .i�<.�-'" �� y°"" ! ;'` -'"'° Y"' 3 v< a s f L"a i' Vie. 0 z We propoSt hereby to furnish material and labor—complete in accordance with above specifications,,for the sum of: dollars($ Payment to be made as follows: 15 w All material is guaranteed to be as specified.AD work to be completed in a workmanlike AuthoriZed � manner accordingto standard practices.An alteration or deviation from above i icatiorrs . involving extra costs will be executed only upon written orders,and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control.Owner to carry fire,tomado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workmarfs Compensation Insurance. withdrawn by us if not accepted within days. Arreptanre of Proposal —The above prices,specifications r and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. x Date of Acceptance: Signature The Cominon,vealth of Massacliuseus Department of Industrial Accidents Office of Insesfigations r ' , 600 Washington Street Boston,MA 02111 rvrviv.inass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers . Applicant Information Please Print Legibly Name(Business/OrganizatimAndividual): Address: P--d L5 0 x City/Stateizi : �•PA&b✓z A 4 6 2_1&3APhone#: <5-0 9-— q5 ` L/ g 7 7 Are you an employer?Check the appropriate box: T of project(required): 4. I am a general contractor and I ape p J ( equu�. 1.❑ I am a employer with � g employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2:n I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These subcontractors have g_ ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance. required-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.[1 I am a homeowner doing all work officers have exercised their i LE]Plumbing repairs or additions self. o workers' right.of exemption per MGL insurance ranc[ ��e`r T c. 152,§1(4),and we have no 12.❑Roof repairs ] employees.[No workers' 131D Other comp.insurance required.] •Auy applicant that checks box##I must also till out the section below showing their workers'compensation policy information i Homeowners who subunit this atfdavtt imUatmg they are doing all worts 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-coauactors and stare wheiha or not those entities hare employees. U the sub{outractors have employees,they must provide their workers'comp.policy number. I am an employer that is protriding aoorkers'compensation insurance for my euupla y-eem Below is the policy and job site information. , Insurance Company Name: Policy#or Self-ins.Lic.#: 20®/ Ld 64 R 3 Expiration Date: T Job Site Addrers: //Z 6Lk A—a e City/StatelZip: 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 certifi,under the pains and penalties of perjury that the information presided above is true and correct Si tore: Date: ✓� Phone 4: — 5 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermivLicense# 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#: t�rrsraw.e. Town of Barnstable 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. M e L O4 CA-p ��K l<L ,as Owner of the subject property hereby authorize —^\ 'Dvi-,'a' to act on my behalf, in all matters relative to work authorized by this building permit application for (Address of Job) � O Signature of 0,6er Date. 1 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\APPDataVocaIMcrosoft\Windows\Ternporary Imemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 l ��;iSaacliu�ctt�- l epartincin t►l Pu43liC lallti Beard(W Buildin-u- Reumlatimis.and Standarrls Construction Supervisor SPecia"License License: CS SL 99980 ,.o;� Restricted to: WS THOMAS DALEY P.O.BOX 561 EAST FALMOUTH, MA 02536 Expiration: BINMIl (•mani.. ,err i r#: 9998D t f Sp' � Town of ]Barnstable *Permit# 2,© 'P 7 Expires 6 months from issue date Regulatory Services Fee ;216'T_ 40 Thomas F.Geiler,Director Building Division Torn Perry,CBO, Building Commissioner X-PRESS PERMIT 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us JUL 1 9 2006 Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY. Not Valid without Red X-Press Imprint Map/parcel Number 2 ® a Z Property Address �' Z f 4z , Residential Value of Work KA00. 0.0 Minimum fee of$25.00 for work under$6000.00 oF Owner's Name&Address ,//ix�lla�e 4 Contractor's Name (G Z �, 7�� Telephone Number < ' . Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) [AWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [ I have Worker's Compensation Insurance Insurance Company Name F�y zi1 6C Workman's Comp.Policy# 92" X 43/ Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to li P—..;TM . ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note- Prope Owner must sign Property Owner Letter of Permission. 0 rovement Contractors License is required. SIGNATURE: \ Q:Forms:expmtrg Revise071405 e Commonwelfirn of Njassacnuseas Department of Industrial Accidents Office of Investigations Y 600 Washington Street Boston, M4 02111 �•'' www.rnass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information ;--� Please Print Legibly < Name (Business/Organization/Individual): Address: 2 Pt-t> 'tz� &&I City/State/Zip: /� 02&1,.q Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 0— 4. ❑ I am a general contractor and I 6 employees(full and/or part-time). have hired the sub-contractors � 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 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner do4naa all wnrlc right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t . employees. [No workers' 13.® Other 1Zf--51P~ comp.insurance required.] "Any applicant that checks box#P 1 must also fill out the section below showing their workers'compensation policy information: t Homeowner;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 their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Delores is the policy and job site information. Insurance Company Name: 2'U te't e'-K 7*-.F2f C~ Policy#or Self-*Ms.Lie. #: i ZY Expiration Date: l� Job Site Address: P, f�-_�B City/State/Zip: C � c i 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c t der pains and pe alties of perjury that the information provided above is true and cornett. s Si afore: Date: J �� Phone#: �Y"1 Official use only. Do not write in this area,to be completed by city or town ofjicW City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk a.Electricai lnspector 5.Plumbing Inspector j 6. Other �1 I Contact Person: Phone#: I� Information and. Instructions �+ . Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to th tute, an employee is defined as"...every person in the service of another under any contract of hire, express or imp d,`oral or written." An employer is de ed as "an individual,partnership, association, corporation or other legal e ty, or any two or more of the foregoing enga ed m a joint enterprise, and including the legal re/ainy tatives of a de eased employer, or the receiver or trustee of a individual,partnership, association or other legty, employin employees. However the owner of a dwelling hou having not more than three apartments and wides there' , or the occupant of the dwelling house ofanothe o employs persons to do maintenance, conon or rep it work on such dwelling house or on the grounds or buildin appurtenant thereto shall not because of suploym t be deemed to bean employer." MGL chapter 152, §25C(6)also es that"every state or local licensiency hall withhold the issuance orrenewal of a license or permit to perate a business or to construct g in the commonwealth for.any applicant who has not produced a eptable evidence of compliance insurance coverage required." Additionally,MGL chapter 152, §25 (7)states`Neither the commonwor any of its political subdivisions shall enter into any contract for the perfo ce ofpublic work until acceptaidence of compliance with the insurance requirements of this chapter have been p esented to the contracting auth Applicants Please fill out the workers' compensation a avit completely,b ecking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),a dresses) and ph a number(s)along with their certificate(s) of ass:ranee. United Liability C om,- ies(T i Cl r Limited Lia ity Partnerships(LLP)with no employees other than the members or partners, are not required to carry w keys' comp nsation insurance. If an I.LC or LLP does have employees,a policy is required. Be advised that s affida t may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. sob sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application fo the ermit or license is being requested, not the Department of Industrial Accidents. Should you have any questions a arding the law or if you are required to obtain a workers' compensation policy,please call the Department at the umber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and p ted le ly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of vestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license numb which will used as a reference number. In addition,an applicant that must submit multiple permit/license appli bons in any gi year,need only submit one affidavit indicating current policy information(if necessary)and under" b Site Address" a applicant should write "all locations in (city or town)."A copy of the affidavit that has be officially stamped arked by the city or town may be provided to the applicant as proof that a valid affidavit is o file for future permit licenses. A new affidavit must be filled out each year.Where a homeowner or citizen is ob ining a license or p of related to any business or Commercial venture (i.e. a dog license or permit to burn leaves tc.)said person is NOT r ed to complete this affidavit The Office of Investigations would lie to thank you in advance for yo operation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone andtfax number: Ae Commonwealth of Massachuse s Department_of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tea. -617-727-4900 ext 406 or 1-o77-MASSAFE Fax - 61.7-727-7749 Revised 5-26-05 tivWw.rnass.gov/dia Town of Barnstable Regulatory Services L swx�su►B�+ Thomas F.Geiler,Director ' �AlED►u►�� Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA b2601 www.town.b arnstabI e.ma.us office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and sign This Scction. -If Using ABuilder as.Owner of the subject property hereby authorize to act on m7 behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature Owner Date Print Name Q:FORMS:0WNERPEP1YMSION ice• Town of Barnstableret# . NAP"b- .r date Bee.. « .. .. gms�t Services ,ThonF. er,Director _..rBadhig•Divislon - _. --ToJmparry, BWIdingCommissioner ff im: 50"24038 �A7C'. 98-790-5239. . .. `� ESA sTP��LE-'.. It1H'SIDIa',1�ITIL Q N Orr Not Yaw wkhout Red X-.Press hnprW WparcelNumber v $esidentiat Value of Work Mm°m fee of$25.00 for work under$6000.00 uer's Name&Addressf T' I a trl�' �� ✓ ukactor'sName LE5 D Numb Telephoneer rn0 Improvement Contractor License#(if applicable) MsWmf n Supervisor's License#(if applicable) jfodCman's Compensation Instuance Check one: 0 I am a sole proprietor the Homeowner e Worker's Compensation osurame companyNaae TnC�'U�1.,E��•5 N'orkman's CoNP.Policy-# to-�C, ►Q SA4! Y �c — r �epy sf insurance Gemomee certificate be on fate. �) � �� � Re-roof(stripping old shingles) All construction debris will be taken to [�Re-roof(not stripping. Gomg over existing layers of mot) Re-silo t 0 Repiacemea ilia M— i1-Value t �) s���� tss»ance o�fliis permit dos not exempt compliance with other town depmttiterit mgnlatiws,i.e.j�tgtoriq Conservation.etc. **eNoti: Property Owner must signProperty Owner Letter of Permission. o vemant Contractors License is required. Signature _j� Q:Forms expnomrg Revis�b'3Q04 _ - rTM, r 77 -..--- BOARD OR BUILDING REGULATIONS License:'CONSTRUCTION SUPERVISOR Numb§Q 002881 l31 1943 l i —' 6 Tr.no: 18791 CHAKES E C 'n 1684 FALMOUTH - CENTRI'RVILLE, A ng ner � �1��arnmeaiuoea.�a�.�aaaa�iisaell3 Board 4Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registra 6nna-,136066 d% COREY&COREY 1�tAIOrV MENTS CHARLES COREY 16014 FALMOUT1d it�5 G 4-� ,✓ CENTERVILLE,MA 02632 ,,� Administrator - I TOTAL INVESTMENT $ 69910.00 Including Senior Citizen Discount Payable immediately upon completion. POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards,Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus 20% and Labor at the Rate of$50.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORD SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please Make Checks Payable �Jyto: CHARLE S C Oiyyyy EY d COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years' " and then on a pro-rated basis for 30 Years Total if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a 90 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above specifications,will be executed only upon written orders and will become an extra charge,over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work. This proposal may be withdrawn by us if not accepted within thirty days. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ACCEPTED BY: SUBMITTED BY: " L! , HEWO TH BACKUS CHARL.ES C®REY HOMEOWNER COREY & COREY I - The Commonwealth of Massachusetts �= .T � Department o Industrial Accidents P Office of Investigations `- 600 Washington Street, 7th Floor Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:Buildin lumbinpJElectrical Contractors name: Y�4 city ✓ state: zi hone# a work site locatidn"full address): ` ❑ I am omeowner performing all work myself. Project Type: ❑New Construction❑Remodel - ❑ I a s�ollev proprietor and have no one working �in�any capacity. ❑Building Addition EE :;:'+l�R' .i!'„Fixl' .a..C -r. ti I am an employer providingworkers' compensation compensation for my employees working on this job. comp an ^o y name: C ' M` S/ � L0. Key address• '/S s city- I _- hone#: insurance co. S 011c # ❑ 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 address: city: phone# ` insurance co, company name: address city: phone#• insurance co. OR I # Jill 11 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$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certRderpai an enalties of perjury that the information provided above is true and correct Signature Date / S� Print name Phone# ''e✓�g 7 7s� X4 r,orntact use only do not write in this area to'be completed by city or town official town: permit/license# CIBuilding Department ❑Licensing Board . ck if immediate response is required ❑Selectmen's Office ❑Health Department person: phone#; ❑Other Sop.2003) - - - - - Information and Instructions Massachusetts Gieral Laws chapter 152 section 25 requires all employers to provide workers' comPe sation for their i employees. As quoted from the"law",an employee is defined as every person in the service of anot r under any contract of hire,express or implied,oral or written. An employer is defied as an individual,partnership,association,corporation or other legal enti ,or any two or more of the foregoing engaged\n a joint enterprise,and including the legal representatives of a deceased mployer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. owever the owner of a dwelling house having not more than three apartments and who resides therein,or the occupa of the dwelling house of another who employs per9Qns to do maintenance,construction or repair work on such dwelli house or on the grounds or building appurtenant the}• to shall not because of such employment be deemed to be an a ployer. MGL chapter 152 section 25 a o states that every state or local licensing agency shall thhold the issuance or renewal of a license or permit o operate a business or to construct buildings in the ommonwealth for any . applicant who has not produce acceptable evidence of compliance with the insura ce coverage required. Additionally,neither the commonw alth nor any of its political subdivisions shall ente into any contract for the performance of public work until acc table evidence of compliance with the insuran requirements of this chapter have been presented to the contracting autho 'ty. Applicants Please fill in the workers' compensation affidavi completely,by checking th box that applies to your situation. Please supply company name, address and phone numbers long with a certificate insurance as all affidavits may be submitted to the Department of Industrial Accidents r confirmation of iurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned_to a city or town at the application for the permit or license is being requested,not the Department of Industrial Acciden . Should y, have any questions regarding the "law"or if you are required to obtain a workers' compensation policy,p ase cal the Department at the number listed below. � . . City or Towns . Please be sure that the affidavit is complete and printed legibly. The D artment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations h to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be uted as a referen a number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in/advance for you coope ation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax numlSer: 1 The Comonwealth Of Massachusetts 7Depa• ent of Industrial Accidents Office of Investigations Z 600 Washington Street,7`b Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 . \�