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HomeMy WebLinkAbout0095 PHINNEY'S LANE � � 6" 5 � �� .. �. .. . , � kp� z - �. ,1 n. � .. . .' i ��: .. �. ,, c ,� r c_ � � °� q... �. Town of Barnstable �- �'; ,r,. d sv ,.,l'�'e,,,• �.,.'?.�,. �. � v-,�`�- ., ,,. �*m w.` ? �,; ,r;�t.. `,. �..': � lll g • '��A dthis CardMust be;Ke t Post:Thrs-Gard So That rt rs /isrble Fro,;Lthe Street- pproved flans Must%beRetamed on Job an p &� ~ • 1AIWSCA$l. -" 1 , ': x �. g£ ; k2 s �a ;' s Permit MBA PgHosted Untrl,Finat InspectronHas Bee Made {�� ' r x f6sT- : y<� - - 3s, _'i?„� i:_.3- ' .°S;"• »i.,wF k %. $� k �`e�'". ? 4Y� r1i IlkWhere�aCertrfieate of Occu anc a Is Re, u�red,such BwldrngAsh all Not�be Occupred,untrl a F�nat lnspectronhas been made .per.. ,y ,r< q�K.. ..> R.,. .,...- ,�... i:. .- � _ :... ., <...� > -., .,, �. . ,,,.., ., � . Permit NO. B-18-2786 Applicant Name: GARY J SOUZA Approvals Date Issued: 09/14/2018 Current Use: Structure., Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 03/14/2019 Foundation: Residential Map/Lot 209-052 006 Zoning District:. SPLIT Sheathing: Location: 95 PHINNEY'S LANE,CENTERVILLE ; AACO tractor N me GARYJ SOUZA Framing: 1 Owner on Record: LYNCH,THOMAS K&JENNIFER Contractor License CS 102999 Address: 95 PHINNEY'S LANE N - Est Project Cost: $ 15,000.00 Chimney: CENTERVILLE, MA 02632 �xPer�it Fee: 126.50 $ Insulation: Description: renovation of bathroom &kitchen. Install new shower,the floor, Fee Paid $ 126.50 toilet&sink in bathroom. Install new counter top-&'sink in kitchen Date Final: 9/14/2018 Project Review Req: NO STRUCTURAL CHANGES. NO RECONFIGURATION o REPLACEMENT OF EXISTING FIXTURES `4 ' ; fr Plumbing/Gas Rough Plumbing: -��. _ _.. � Building Official Final Plumbing: gfi Rough Gas: VI A Final Gas: This permit shall be deemed abandoned and invalid unless the work authorized15y this permit is commenced within sin month"ssafterl'issuance. All work authorized by this permit shall conform to the approved appli ation andthe approved construction documents for which this permit has been granted. t Electrical All construction,alterations and changes of use of any building and structures shall be m,compliance wi the local zonmg'by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall5be rnamtamed open;for bli puJ�mspection for the entire duration of the Service: work until the com letion of the same. AN gPRou h: The Certificate of Occupancy will not be issued until all applicable signatur es by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Final: 1.Foundation or Footing 2.Sheathing Inspection Low Voltage Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Final' 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Health 7.Final Inspection before Occupancy Final:. Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Fire Department Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). 0 Application Number.. .4..z ......�.R... ...................... .....O ...........: • s srA> )-Permit Fec.....z S. ........Other Fee........................ KAM tillf� Total Fee Paid '- -� . _.�".`s��� ;�.x. :: ........ .................C....:... A'f SSA o ..... d. . TOWN OF BARNSTABLE o BP,t-NN Permit Appmval by.... ...........^ti....... .. ..� -T0NN1 w BUILDING PERMIT 2dg1oS- C sk..par &. APPLICATION . . M -.. .�. � ...........�............... ......... Section 1—Owner's Information and Project Location Project Address 9,57 pl-lin►.1n1Q��S �-A�� village—' Owners Name 1&MA,S P ur-- 2, Owners Legal Address City Cer�C4.� �f State I ' l Zap— tl-2�=3L LA- Owners Cell# $ °122 6S� T- Is-mail Section 2—Use of Structure Use Grroup ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Sort cture,under,35,000 cubic feet Single/Two Family Dwelling Section 3-Type of Permit ❑ New Construction El Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) k❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar Renovation pool Insulation Insulation Other-Specify t Section 4 -Work Description Vile l > - 1 Tactmx%fed_2/9/2018 Application Number.................................................... Section 5—Detail Cost of Proposed Construction_ocr,�. ,daSquere Footage of Project 2pp gam (' Age of Structure I"SICts- Dig Safe Number. L # Of Bedrooms Existing 2 .Total#Of Bedrooms(proposed) 110 MPH Wmd Zone Compliance Method MA Checklist ❑ WFCM Checklist Design Section 6—Project Specifics 'i] Wince ❑ Oil Tank Storage ❑ Smoke Detectors ,r ; Plumbing ❑ Gas` 'El Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply { 5Public ❑ Private` . g Sewage Disposal ❑ Municipal On Site Historic District Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: JA M,�,"BgR�4 I am nsmg a crane ❑ Ye's'g No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No �J Section S—Zoning Information Zoning District Proposed Use " i t Lot Area Sq.Ft. . Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard ' ' � Regair� . Proposed' Has this property had relief from the-Zoning Board`in the.past? s 0 Yes, F No Last mdatm-MOM • 1 Application Number..................................... Section 9—.Construction Supervisor Name -2 Ll1: j( Telephone Number q,Z 8 r.to� Address City 1 State 1 _Tip � I License Number J))� License Type C � Expiration Date— j Contractors Email �� Q� c��►�� azdb P& Cell#: ' R T �9'm 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 b and the of Barnstable.Attach a copy of your license. Signature -__'f ;�� �^ Y .•fit , Date 3, 8 22 ^jj Section 10—Home Improvement Contractor .; Name a�^9W z.►� Telephone Number y-a g •A I orb Address 4 y s' %A, City Q�; - C a-,�_State tA N,_Tip 8 Registration Number 1 la i{ ��Expiration Date _l CA I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation.required 0 CMR and o of Barnstable.Attach a copy of your H.I.C... Signature Date V �� Section 11—Home Owners License Exemption Home Owners Name: �- F Telephone Number Cell or Work Number 4 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 requu-ed by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Date 8 22 l8 Print Name O Z Telephone Number o E-mail permit to: Qa T...k,....i..a..7.'W innnl 0 Section 12—Department Sign-Offs Health Department © Zoning Board(if re#ixed) ❑ 11istoric District ❑ Site Plan Review(if required ❑ Fire Department , -❑ �, - ' '' 7 For commercial<worh pk&e take your plans directly to the fire deparbnent for..`approval''` Section 13='Owner's Authorization µ L , as Owner of the.-subject property hereby authorize C^A aF to act on my behalf in all matters relative to work authorize y this buildii g permit application for: (Address of job) signaturegf Owner Print Name 4 �: a a ! Y f 4 — _ a JJJ 1 . . ! c�.i%%.t �3 �' :{,,f.,�✓ate „.,,11•�'s' ( +r,: -?' .���>��a+� � ��Y \r% Last undated:Z 2018 I R-. DATE(MM/DDIYYYY) A�® CERTIFICATE OF LIABILITY INSURANCE o7n 7/201 s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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�n lieu of such endorsement(s). PRODUCER CONTACT Kathleen Fuller NAME: Sylvia&Company Insurance Agency,Inc. PAHONN Exo. . (508)995-4553 FAX Na: (508)995-4525 500 Faunce Corner Road E-MAIL ADDRESS: kfuller@sylviagroup.com Building 100 Suite 120 INSURERS AFFORDING COVERAGE NAIC# Dartmouth MA 02747 INSURER A: Merchants Preferred Insurance Company 12901 INSURED - - INSURER B R&S—LaFleur,LLC 7 INSURER C: `d156 La Fleur Electric INSURER D: 45 Plant Road,Unit 101-102 INSURER E: Hyannis MA 02601-1922 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 GL BAP UMB WC 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 COND,'TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUULbUbK POLICY EFF POLICY EXP - - LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000- CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 51000 A CMP9156147 07/01/2018 07/01/2019 PERSONAL&ADV INJURY $ 1,000,000 rGE-':LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 ICY PRO 2,000,000 ©JECT LOC PRODUCTS-COMP/OPAGG $ ER: - _ $ - AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT - g 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED MCA0000184 07/01/2018 07/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPRTY E DAMAGE $ " AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE. - $ 2,000,000 A EXCESS LIAB CLAIMS-MADE CUP9149080 07/01/2018 07/01/2019 AGGREGATE $ 2,000,000 DIED RETENTION S 10,000 $ WORKERS COMPENSATION - X STATUTE. �RH AND EMPLOYERS'LIABILITY - A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 1,000,000 OFFICERIMEMBEREXCLUDED? Q N/A WCA9100869 07/01/2018 07/01/2019 E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000DESCRIPTION OF OPERATIONS below, E.L.DISEASE=POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Rogers&Marney Builders ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Gary Souza AUTHORIZED REPRESENTATIVE 445 W.Barnstable Road Osterville, MA 02655 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ;ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �� - F7/11/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Karen Bernier Eastern Insurance Group ATONE Ext: (508) 997-6061 (A/C No; (508)990-2731 439 State Rd. EMAIL ADDRESS:kbernier@-southeasternins.com P.O. Box 7 93 98 INSURERS AFFORDING COVERAGE NAIC q North Dartmouth MA 02747 INSURERA:Merchants Mutual Insurance Com 23329 INSURED INSURER B:Merchants Insurance Group David G Holcomb-Plumbing1 INSURER C: Heating Inc— --- INSURER0: Po Box 170 INSURER E: - Osterville MA 02655-1061 INSURERF: COVERAGES. CERTIFICATE NUMBER:CL1812304758 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 I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MMIDOIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 BOPI070140 12/18/2017 12/18/2019 MED EXP(Anyone person) $ 15,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE X $ 2,000,000 POLICY❑ JECTPRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: I$ AUTOMOBILE LIABILITY t°aBINEDISINGLE LIMIT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ A O X SCHEDULED , MCAI001546 12/18/2017 12/19/2018 BODILY INJURY Per accident AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS $ included X AUTOS Per accident PIP-Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE X ER ANY PROP RIETORlPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? 1Q NIA E.L.EACH ACCIDENT $ 11000 000 A (Mandatory in NH) WCA9098376 1/3/2018 1/3/2019 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 1 LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional Insured: Rogers & Marney Builders with respect to General Liability. CERTIFICATE HOLDER CANCELLATION (508) 420-3550 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Rogers & Marney Builders THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P 0 Box 310 ACCORDANCE WITH THE POLICY PROVISIONS. Osterville, MA 02655 AUTHORIZED REPRESENTATIVE r <.aren Bernier/KA3 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) AC40RL> CERTIFICATE OF LIABILITY INSURANCE °ATE`MMI°°m"Y' 111 1 02/15/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Teresa Van Ryswood ROGERS & GRAY INSURANCE AGENCY INC PHONEflo_ 508 2582111 FAX No: E-MAIL tvan swood ro ers ra .com ADDRESS: @ g 434 ROUTE 134 INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED I INSURER B ROGERS & MARNEY INC INSURERC: INSURER D P 0 BOX 310 INSURER E OSTERVILLE MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: 240064 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCEINSD-UMPOLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR DAMAGE (RENTED PREMISESS Ea occurrence) S MED EXP(Any one person) S N/A PERSONAL&ADV INJURY S P'OTHER: LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE SPOLICY PRO LOC PRODUCTS-COMP/OP AGG S JECT S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident) _ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S NON-OWNED PROPERTY Oaccident)PERTD SAMAGE HIREDAUTOS AUTOS S UMBRELLA LIAB HOCCUR EACHOCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE: S DED I I RETENTIONS S WORKERS COMPENSATION X SPERTATUTE ORH- AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 500,000 A OFFICER/MEMBER EXCLUDED? N/A NIA NIA 6S60UB4977P25218 01/01/2018 01/01/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS, 367 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601CS� Daniel M.CrD,wJey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-102999 Construction Supervisor GARY J SOUZA N � P.O.Box 310 f.. OSTERVILLE MA 02655 (��^n Expiration: Commissioner 08/16/204P I The Cornnionwetalth of Massachitsetts Department of Indaastrial Accidents a 1 Congress Street, Suite 100 Boston, 11A 02114-2017 www.mass.;ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED bVITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Rogers& Marney, Inc. Address:445 Osterville West Barnstable Road City/State/Zip: Osterville, MA 02655 Phone u: 508-428-6106 Are you an employer"Check the appropriate box: Type of project(required): I.[] I am a emplover with employees(frill an(Uorpart-time).'" 7, F-1 New COnStrUCtiO❑ '_ 1 am a sole proprietor or partnership and have no employees working for me in - S. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.�f am a homeowner doing, work myself.[No workers'comp. insurance required.]' 10 ❑ BUllding addition q.❑l am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.7/ 1 am a seneral contractor and[have hired the sub-contractors listed on the attached sheet. These sub-contractors have emplove-,s and have workers'comp.ins Malice.' l3.❑Roof repairs 6.❑4b"e are a corporation and its officers have exercised their right of exemption per 1001-c. 14.7 Other 1=_'.§10),and we have no employees.(No wor!:ers'comp insurance required.) Any applicant that checks box R 1 must also till 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 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. 1 inn an employer that is providin workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Hartford Underwriters Insurance Company Policy-or Self-ins. Lic.T.6560UB4977P252le Expiration Date:01/01/1 q Job Site Address: —1S � I tJly����G I Cit /State/Zi ',.Q �� oz %sz Y P� �1�J� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a tine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a Fine Of up to S250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DLL for insurance coverage verification. 1 do hereby certify ur r the and per rlti s of perjury that the information provided above is true and correct. Signature: / Date: A-7 A V Phone m: 508-428-6106 Official use only. Do not write in this area, to be completer)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#: I` Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement;Contractor Registration y .a v , a Type: Corporation L Registration: 164688 ROGERS AND MARNEY, INC. Expiration: 10/29/2019 P.O. BOX 310 r ` ' OSTERVILLE,MA 02655 Update Address and Return Card. SCA 1 tS 2OM-05/17 /e �-rrr-rrac-rtinvall�n `�¢darcc�ccdn,/LJ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 164688-=_ - =---;10/29/2019 10 Park Plaza-Suite 5170 C Boston,MA 02116 ROGERS AND MAR� GARY SOUZA 445 WEST BARNSTABLE RD 'f OSTERVILLE,MA 02655 Undersecretary Not Val WI signature Town of Barnstable *Permit# f7 76�L 1 Expires 6 its onflu from issue date * Regulatory Services Fee �sr > snxrtsrnac.E. + . MASS. ��' Thomas F.Geller,Director rED MPI , " Building Division X-PRESS PERMIT Tom Perry, Building Comrnissioner 200 Main Street, Hyannis,MA 02601 JUN 2 8 2004 Office: 508-862-4038 TOWN OF BARNSTABLE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 0�5 b Property Address Y''c Residential Value of Work Owner's Name&Address ►V1Ne\ A1'1 �� Telephone Number L4 &a b u l to Contractor's Name ti Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Worlanan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner n-f-have Worker's Compensation Insurance Insurance Company Name i^T i en V iA V 0 Workman's Comp.Policy#_� 61 (o a 1 6© I a 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 � A�✓1 ��fl��`P PP g ❑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: Pro rty Owner t s' P erty Owner Letter of Permission. me Improv en ors License is required. Signature Q:Forms:expmtrg FLevise053003 • - i t - MARK HERBST 35 Peep Toad Rd. Centerville MA 02632 (508) 420-6216 PROPOSAL SUBNHTTED TO: WORK PERFORMED AT: Jennifer Longly 95 Phinneys Ln. SAME Centerville AM 02632 508 775-6399 J We herby propose to furnish the materials and perform the labor necessary for the K r . y co'npletion of the following; New Roo r Remove 2'layers of existing shingles �xt, _ rnstalZ ' drip edge x Install tce`&water shield at edge & in valleya real d `' < znstallfl5lb_felt paper Q f ' N ?Insldll Certainteed woods cape 30yr AR shingles 3 Cut ridge & install cobra vent F, Re lace all plu Bing.bb' ot. s -.�r �+ 'fix -fir q,...,E =- r •-n �� Y�; Price includes materi"bor&du ees Mouse'} $7466 00(' t_ }Gauge s E` .` .r 4�' Z'lease check chozce:(s� above I�han k You ` µ 54 All niaterial`is guaranteed to be as specified,and above work to performed in ia&o)dance with specifications s ibmifted for,above, and'--eomj%leted w a substaatialF workmanlike manner for the sum of as specified above &.:verified w/yoicr anil�als Dollars( 1L )with payments a§ .61lows�.full amount due upon complefion r { r a * Any alteration(s) 6th',4bove involving extra costs will be added under written agreement, and beco%me an.ea ch ge over and''alove signed estimate/agreement RESPECTFU -�s Signature. - t f fY ACCEP'PANCE OF PROPOSAL The above prices specifications&'�condihons;are satisfactory,we herby accept you are authofized to o the work; and paymen"ts will be as specified above. Signatures) �� "- Date: 6 �-�1• Y _ K r ; * This proposal may be withdrawn by said company if not accepted withi 30 days �y i n, ✓fie L�anvmareeas¢l� o�!�/,izanczcfiu4s;�d -- \ Board of Building Regulations and Standards - HOME IMPROVEMENT CONTRACTOR Re gistr4ti on: 1.26480 Exp i ration,:.618/2006 i I Type: Individual MARK HERBST ,I MARK H'ERBST I 35 PEEP TOAD RD. �� p _. CENTERVILLE, MA 02632 Administrator �41a by .� 3 n* fee• rsac/xurte�`+s:. ' 6'I/1/I120�ILC!/62G41G!Y 4� BOARD OF BUILDtN6 REGULATIONS j License CONSTRUCTION SUPERVISOR Number CS 04`8546 FN 4t "JI Birthdate 01/27/1}85.3 1 f Expires Ot(27f200.6 Tr.na: 13:4.04 J � Restricted.. Oi): MARK D HERBST 35 REET TOAD CE:NTERV1: MA 02632 Administrator