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HomeMy WebLinkAbout0016 PRISCILLA STREET � Co��-isci 11w S4s v a n r r r • Application number ... ..........*..I...i.......... ....................(........................................................ Fee KAM Building Inspectors Initials............... ��............ 163F 16 APR 04 20119' Date Issued....................�./I)..!.4k........*.,............... TOkAIN Ot BAHNS-IABU Map/Parcel........ ................................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGfWINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION -der v( I �� Address of Project: to ri sC,), Ila-, L-&pj;Ej- : �7KA NUMBER STREET VILLAGE 7 Owner's Name: K?-VA ef PR tit Phone Number t 0 l/ 7/ Email Address: Cell Phone Number -1 E3 I Project cost$0 go(" . Check one Residential . Commercial OWNER'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: Date: TYPE OF WORK Siding 0 Windows (no header change)# E] Insulation/Weatherization Do header change)# Commercial Doors require an inspector's review 0400f(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name (va-4va-5t Home Improvement Contractors Registration(if applicable)# 170 7o"0 (attach copy) Construction Supervisor's License# /0(0 /91 (attach copy) Email of Contractor kqvq- (Y� Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY JS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. t APPLICATION NUMBER............................................................ r t *For Tents Only* 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. Purpose of Event 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 Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If 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. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION 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 cons c 'o inspe Lion procedures, specific inspections and documentation required by 780 CMR an a of Barnstable. Signature Date' C� - APPLICANT'S SIGNATURE Signature 'T���� Date All permit applications are subject to a building official's approval prior to issuance. f 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 Legibly + Name(Business/Organization/Individual): tl fheo S1 ' Z_Z (_ Address: r City/State/Zip: / 00 r�- Phone 9 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. Ejtlam a general contractor and I ` employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working forme in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: 10. Electrical repairs or additions .required.] 5. ❑ We are a corporation and its P 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.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no 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-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. 11 Insurance Company Name: Policy#or Self-ins.Lic.#: r .7 V'748 Expiration Date: Job Site Address:.- !r"G' C&C S� City/State/Zip: 1"l Gj G bj"-7- l 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 Investigatiqps cKthe DIA for insurance coverage verification. I do hereby rider the pains and penalties of perjury that the information provided above is true and correct Signature. 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#: n and Instructions information a - �� to provide workers compensation for their employees. ever 1 Laws chapter 152 requires all employers� Massachusetts G a P qP P 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 or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number 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 printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts. Department of Industrial Accidents Office of Investigations -� 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 • wvw.mass.gov/dia Terms and Conditions . Scope of Work: Company will provide services as described in the attached quote.Company will provide all services, materials, labor,tools,and equipment needed for completion of services. Payment Terms:A down payment of 35% is due upon acceptance of quote. 30% is due the day the project begins.35% is due the day of project completion. Change Order:Any deviation from the above quote involving a change in the scope of work or any additional costs will be executed only with a written change order signed and dated by both the Company and Customer.Any plywoodreplacement-will cost$60 per 48 sheet and 4 dollars per linar foot of spring board. ` Warranty: Company warrants all work will be performed in.a good and workmanlike manner.Any warranties for parts or materials are subject to manufacturer terms on such products. Conditions:This proposal is valid for 30 days. Company reserves the•right to withdraw this proposal or re-quote the project if contract acceptance is beyond 30 days. ht1z--- Namv- Date Name Date y�ts ,-C, Northeast.Roofing Contractors LLC I Phone:5087764916 Page 3 of 3 c' Commonwealth of PAassachusetts Division of Professional Licensure Board of Building Regulations and Standards o e e ConstructioSpnfisor Specialty ;�. CSSL-106123 * E" Tres,07/1472021 gip" i• t x SHANE D.MCGUIRE + _» 8 ROYAL CREST DRIVE UNIT ;r MARLBOROUGH MA 017ii2 e" y` -,, t mimissionee ' F 5 I tZSLtO�b�W'.in'lOL'OB �"d4N Registration valid for individual use onlyr £'liNfi 3/tilYJ�71S i before the expiration date If found return to i _ # Office of.Consum r Affairs and Business Regulation , E One Ashburton Pt -Suite 1301 Briton,M 0210 1, i 0-rTSHOl3Vd.LNO3 0NIJ008 A'�d3H.L8ON; ; �r t' 030VOW 'x;, �zOi:LO6l uoy� —xuol ASI aa, uoge'00100:3dA1 Not:valid Without sigriature 8010V81NOO 1NHW3AOHdWi 3WOH f ' *, uogelntia' ssauis s�a {awnsuo F a �, �/� f! T)1Ja7lrld Gfrfx'f2t,�M ei)�,• ; NORTH09 OP ID:WC ACORO� TE(MM1DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE DA04/04/2019 04/04/2019 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 Segreve&Hall Insur.Assoc.lnc PHONE FAX _ One Tech Drive,Suite 135 A/C No xt E :978-975-1300 (A/c,No):978-975-7596 Andover,MA 01810 E-MAIL Sean Segreve ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Ataln Specialty INSURED Northeast Roofing Contractor INSURER B:Commerce Insurance Co. 134754 Shane McGuire 9 Royal Crest Dr INSURER C: Marlborough,MA 01752 INSURER D: 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. INSR TYPE OF INSURANCE PDDL UBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/Y MM/DD/Y LIMITS A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1 1,000,00 CLAIMS-MADE a OCCUR CIP353069 02/09/2019 02/0912020 DAM E TO REND 100,00 ' PREMISES Ea occurrence 1 MED EXP(Any one person) 1 5,000 PERSONAL&ADV INJURY 1 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1 2,000,000 POLICY u ❑ JECTPRO LOC PRODUCTS-COMP/OP AGG 1 2,000,00 OTHER: I I 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 1,000,00 Ea accident B ANY AUTO RXL738 - 02/21/2019 02/21/2020 BODILY INJURY(Per person) 1 ALL OWNED X SCHEDULED BODILY INJURY(Per accident) 1 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE 1 HIRED AUTOS AUTOS Per accident 1 UMBRELLA LIAB OCCUR EACH OCCURRENCE 1 EXCESS LIAB HCLAIMS-MADE AGGREGATE 1 DED I I RETENTIONS 1 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1 OFFICER/MEMBER EXCLUDED? N/A --"—'--- (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 1 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE 1 ©1988-2014 ACORD CORPORATION. All rights reserved. . ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POWECON-01 CPOROWSKI ACORN' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD,vvvv) �-� 4/2/2019 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 in lieu of such endorsement(s). PRODUCER CONTACT NAME:_ AXIA MetroWest PHONE ^-- --- - ---- ------_ —i FAX (A/C,No,Ext): ((A/C,No): E-MAIL -- --- -- _A___D_D_R__E_SS_:_____ ____ _ _ INSURERS)AFFORDING COVERAGE ___ NAIC a3 INSURER A:Penn-America Insurance Company INSURED J INSURER B:The Hartford Insurance Company 119682 Power Construction Roofing&Siding Corp. S Ni URER C: 232 Pond St.Unit 3 ~ i INSURER D: + Natick,MA 01760 —�-- --------�----------�--- -- {INSURER E INSURER I: { 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. INSR 'ADDL SUBR'^ POLICY EFF POLICY EXP 1 — T TYPE OF INSURANCE SD 6 WVD 1 POLICY NUMBER i /DD 1 M D LIMITS A I X_ COMMERCIAL GENERAL LIABILITY { j EACH OCCURRENCE 1 s 1,000,000 CLAIMS-MADE X OCCUR t k 1 DAMAGE TO RENTED i 100,000 I IPAV0192055 ! 12/21/2018 12/21/2019`PREMISES(Ea occurrence) I s MED EXP_(Any_one person) s 5,000 1,000,000 PERSONAL&ADV INJURY t 8 GEN'L AGGREGATE LIMIT APPLIES PER: r GENERAL AGGREGATE I$ 2,000,000 X POLICY Ll JECT ��LOC ? { { PRODUCTS_COMP/OP AGG_ 8_ , 2,000,000 i t 4 pp I OTHER: `e I 1 1 ! t -�$ — _T-- I A [[COMBINED SINGLE LIMIT 1 AUTOMOBILE LIABILITY ( { ' L(Ea accident)___i$ ANY AUTO ) r {BODILY INJURY(Per person) I s IOWNED SCHEDULED ; 1 AUTOS ONLY �FI�;AUTOS { { BODILY INJURY(Per accident) 8 HIRED 1 NppN-OWNED 1 PROPERTY DAMAGE AUTOS ONLY AU70S ONLY (Per accident)_ _ t s UMBRELLA LIAB !_J OCCUR { EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE 1 i LAGGREGATE I DED f RETENTION s { ( I _ 18 B WORKERS COMPENSATION I i PER I OTH- AND EMPLOYERS'LIABILITY i_-I STATUTE_L ER_- I ANY PROPRIETOR/PARTNER/EXECUTIVE YIN (6S60UB-1 K6454-7-18 12/27/2018 12/27/2019 1 500,000 pFFICER/MEMBER EXCLUDED? N/A I E.L.EACH ACCIDENT 8 i(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE?$ 500,000 t If yes,describe under f { I ! I !!DESCRIPTION OF OPERATIONS below ) ; t E.L.DISEASE-POLICY LIMIT t$ 500,000 I I 1 DESCRIPTION OF OPERATIONS/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 Northeast Roofing Contractors LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. P.O.box 145 West Hyannisport,MA 02672 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Northeast Roofing Contractors LLC MA lic#106123 HIC Lic#190720 RI #41897 P.O. Box 145 West Hyannisport, MA 02672 Phone:5087764916 NRCL NORTHEAST Contact:Thumbtack ROOFING Email:justin@northeastroofingcontractors.com CONTRACTORS LLC Customer Address Kevin Keenan 16 Pracilia St West Hyannisport, MA 02672' 7819101171 kkeenan5@verizon.net Quote#: 383 Date: Oct 19, 2018 Description Total 1. Property Protection $0.00 Cover the house,walkways, and shrubs in order to protect from roof debris. 2. Remove existing roof system $975.00 Rip 3. Ice and Water shield $320.00 Install ice and water shield yo the first 6' up from the ever,valleys, cheeks and any penetration (including skylights,vents, pipes and around chimneys) 4. Install Synthetic Underlayment $175.00 Install Synthetic Underlayment to remaining roof areas. S. Drip edge $165.00 Install 8 inch drip edge around the parameter of roof - 6.Starter shingle _- $140.00 Install Certainteed starter around parameter of roof over the drip edge separated seams 7. Chimney Re-flash ' $450.00 Rip out existing lead flashing and caulking. Install new 9" lead base flashing around chimney and weave between shingles. 7. Pipe Boots $15.00 Install new pipe collars around pipes 9.Shingle Installation PRO COBBLESTONE GREY $3,150.00 Install Certainteed Landmark shingles to manufacturer's specification(6 nails per shingle). 10. Ridge vent $276.00 Northeast Roofing contractors LLC I Phone:5087764916 I Pagel of 3 Items continued... Install ridge vent to 1/4 inch open ridge 11. Cap Application $360.00 Apply to the ridge of roof 4 nails per cap 11. Dumpster and disposal $600.00 Disposal of all debris 13. Permit $100.00 Obtain permit from local town 14.Warranty $0.00 10.Year workmanship warranty 14.Warranty $120.00 50 year Certianteed Warranty Soft vents $310.00 Install 30 soffit vents for air intake Remove old pipe, and resheath. $50.00 Total $7,206.00 Northeast Roofing Contractors LLC I Phone:5087764916 Page 2 of 3