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HomeMy WebLinkAbout0773 SHOOTFLYING HILL RD M h6o 72 'r 3 -- _ PBm-pw EXISTING 15' DIA. ABOVE-GROUND POOL N04°41'40"E 100. 1 O s0 DECK 1 8.1'- BIT. CONC. DRIVEWAY 20.0' p� N () No. 773 I STY. WA FR U = o m 28.4'_ x APN 192-015 I 1 2,573±5F s BIT. CONC. DRIVEWAY 10000' SO 1°04'50"W r7 3 5h00T FLYING H ILL RD . (50'-.WIDE) I HEREBY�CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE,' AND IN MY.PROPE5SIONAL OPINION, THE LOCATION OF THE PROPOSED SWIMMING POOL, AS SHOWN HEREON, CONFORM5 WITH THE HORIZONTAL SETBACK REQUIREMENTS OF THE ZONING BY-LAW OF.THE TOWN OF BARNSTABLE. PLOT PLAN JOB No.: 10156 N DATE: 2GAUG 10 BARNSTABLE (cENTERVILLE), MA SCALE: i" = 20' PREPARED FOR VICTOR R. DRAGUNAS r.j. hood Son, Inc. land surveyors - engineers - 18 route 6a - sandwich, ma 02563 Ph: 508.833.7100 Fax: 50(5.633.7101 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map `� Parcel r, -Application #li (.c�0` (O'S ��' Health Division Date Issued ti Conservation Division S � Q � �� Application Fee Planning Dept. Permit Fee` Date Definitive Plan Approved by Planning Board Historic = OKH _ Preservation/ Hyannis Project Street Address '7 S HDo 4:� ►Afi /41 t f 9-epc�_u Village ck-l'i �&g V Q t Owner V 1 C © R R cC G Q ) Tress Telephone y 9 "" 7 Permit Request N 2>Q ye CLto L/ �u d /*,, /+ Al KNd_ ZA-delzL Square feet: 1st floor: existing ' proposed 2nd floor: existing proposed Total new�7c5 � Zoning District Flood Plain Groundwater Overlay Project Valuation -3 o�C?O Construction Type Lv Utz�--! Lot Size 1 . `J 73 5 (: � Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family �C Two Family ❑' Multi-Family (# units) Age of Existing Structure /7 y Historic House: ❑Yes *o On Old King's Highway: ❑Yes ❑ No Basement Type: Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: Gas 0 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: i Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (B UILDER OR HOMEOWNER) Name W M 11n XfJ C4 ®1 �f`S QC,,,�-�� -'Telephone Number (774) 31_)L _®g 9 Address a' +fAtm I&e- License # 13 evoIV I S , yk k- d (o ® � Home Improvement Contractor# 1306 6 c,rcw 4-— S Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 1 SIGNATURE TE 1 I l ' J f FOR OFFICIAL USE ONLY APPLICATION# i DATE ISSUED . -.MAP/PARCEL NO:_v�_ k ! ADDRESS VILLAGE OWNER i ! r x DATE OF INSPECTION: t 4,',.FOUNDATION FRAME Y4INSULATION." =FIREPLACE ELECTRICAL: ROUGH FINAL _ S PLUMBING: ROUGH FINAL 6AS':1 QiA ' i ROUGH ER,,` R=A-' FINAL :F_INAL BU'ILDING6>:A tt`SGWl .i,st : } —DATE DATE CLOSED OUT i ASSOCIATION PLAN NO. c t s f The Commonwealth of Massachusetts . - -- 'Deparf meat oflnd a&WAcd dents QJ We 0flnvesi7gati0ns 6#0 Wiashington Street _ I>:ostor4 MA 02111 www.mamgovldita Workers' Compensatimi hmu 'ance Affidavit:Builders/Contractors/Electricians/Plumbers Anplit antlnforma�ion Please Print`Liv—%iv Name(Business( -W h M M l ijT Atitiress: P, D, 0. - 3&,GL - GW A-1 V o I-f ; 0A.-t 6;z 5 3 City/State/Zip- 1 a. ' A/�i s:e..( �=1`1�'P�ho e ®:g )-7 25.-).y _3 Are you an.employer?Check the a_ppropriate box: '1�ype of project(required):. 1: i am a employer wrth = 4_ ]I arm general contractor and I employees,(full and/or part-time) have hired the sub-contractors 6. ❑New to ow 2, I a sole proprietor or er- listed on the attached sheet: 7. Q Remodeling= Q am s P p etor parts ship and.have no employees These [�Demoliti sub-contractors have - - " _ S: on working for me in any capacity- employees and have workers' 9. ❑Building addition [No workers'comp:insurance_ comp:insurauce- required.]. 5-Q----We are-a corporation and its• a 0.Q Electrical repairs or additions 3.Q I a a homeowner doing all work officers have exercised their, .1-1_Q Phirabing repairs or additions myself: imp o workers'. right of exemption per MGL i2.0 Roofrepairs insurance required.]E C_ 152,�1.4),and we.haste no:.:[No worker - rnplayees: s'_ 23 Other-� - e .. + comp_insurance iegnired.j.. .. S.t,W.im M iN Poo L_ . #may applicant that ehecks boa#1 must also frill out die section below'showin their wo&='.compensatiampolicy infosma M. ' t Homeowners who submit this affidavit indicating they aze doing all wak and then has ouitide contractors must submit a new affidavit indicating such. tContrectors that dwck this boxmast attached an additional sheet showing-am name of a m&-cobra and state whether or not diow entities have . employem lfthe sob-=ft-t s have employes,they must provided ff woricehs'camp.policy number I am an eay&oyer that ispravitgworTrers'ctmepmsaffm insuranee f©r rrry eraplap BeloK*ic thepo}iey acid job site information. Insurance company Name::�o ruN�-�- S-�-fii-�e-- ) Policy#or Self ins:Lic..#: ? -_8 6 7.),5- Expiration Job Site Address l S -� Ly i N ►T 1 Il ( y) p.�@�t,J C�VtLy Attach$copy ofe workers'campeasMtion policy declaration Page(showing flte porky nmml►car and egpiratioa date): Failure to secure coverage as""under Seditin 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one'ym as well as civil penalties In-theform of a STOP WORK ORDER and a fine of up to MO 00 a day against the violator. Be advised that a copy of this statement may bet to the Office of Investigations of the DIA for insurance coverage verification. I do.hereby certify finder thepains andpe 'es ofpe*ay that the informalionprovided above is trae and correct: Si Date: Phone#: -7?5- 4 Off?at use only. Do not write in this area,to be completed by city or fotvn ofeiaL City or Town: Permit/Ucense# Issuing Authority(circle one):: 1.Board of Health 2.Building Department 3.0tyll'ocvn Clerk 4_ElecWcal Inspector--5 Plumbing Inspector. 6.Other I Contact Person: Phone#: i Office of Consumer Affairs and VUSness Regulation - 10 Park Plaza - Suite 5170 Boston, Massac4j4setts 02116 Home Improvement C�r Regisrtratifiri Registration: 130666 - - - Type: DBA 'Expiration: 4t6i2i512 114 22v4 The Swim Pool Spa Sale & Ser, Make,. :_ Steven Senna K E. Falmouth, MA 02536 Update Address and return card.Mark reason for change. -- a Address Renewal lE] Employment Lost Card TS-CA1 0 50M-04/04-G101216 r sasr` It 'p'> :icense or re `stration valid`for individut use only Office of Consumer Affairs&BAness Regulation $i HOME IMPROVEMENT CONTRACTOR before the expiration date. Ufound return to: Registration 130666 Type: Office of Consumer Affairs and Business Regulation _Pxptrataon 4!6/2Q12 DSA 10 Park,Plaza-Suite 5170 Boston,MA 82116 The wim Pool Spa`Sale&S �MaketGrp S:tovwi Senna - 103A Enterpnse Rd E. Falmouth,MA 02536 Undersecretary Not valid without signature Arttoss A ertu is ��m cif ' � € �£i+iI3,EXTEND OR 42'0 SWUM Rd � ci�,�e��sY M POLICES BELOW compAw it RTE FY'�E COMPANY INSURED DPA 5wltr ing Food&Siva ID290v 1 103 Fntnrrd(sa Rd �/'i7��OCEB'Qi�i •at�,,.� a��- Yf11.a=si-'Y..tr �.•_ �'L� ��._ ��r� -A- �a}'� � •> - tlC�Viz THIS IS TO i -?mkY� IAl wiffloet'�E*"CmEoTtll D€S_3't4Ti 8 SH©lilfN tJk�rY HMM GRW4 w=U=BllfiA VLAW- wg i "i` A D fist u* C Am zo sTzra4 semm is GORTWMATE tWU) a } F_. '. Town of Barnstable Regulatory Seces saariscaac� Thomas I+:Geiler,Director Biding Division Tom Perry, $uRdingCommissioner 200 Main Street, Hyannis,MA 02601 ww€ jown,barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 PrOperty Owner Must Complete and Sign This Section If Using A Builder r VIC79 as Owner of the subj�cr property bereby authorize s wuu 7fln/ e�- � �-e-S o�� to act on my behalf, in all matters relative to -work authorized bythis building permit application for. �Addiess of job) Signature of�Rer e s l/ie-�T )ez �/ 6-UlVe Print Narne Q.Fonh S.0VINEki ERMI63 ON ( t ! i±AR POSED 15'DIA. I VE-GROUND POOL " ` N04�41.40"E 100.1 _ I � 1 ca x DECK, BIT.CONC. DMIEWAY z 2o.a- rn o No. 773 j Ln STY_ WD. FR Q rn x APN. 192-015 12,573±SF BIT.CONC.! - QniVEVdAY' . t 100,00' l 501'04'5a'W 51100T FLYING HILL RID. (50' WIDE) I HEREBY CERTIFY THAT,TO THE SE5T OF MY KN OGE, AND IN MY PROFE55IONAL OPINION,THE LOCATIO q OF THE PROP05ED 5WIMMING POOL,A5 5HOWN HEREON,Cot IFORM5 WITH THE HORIZONTAL 5ETBACK REQUIREMENTS OF Ttil ZONING BY-LAW OF THE TOWN OF BARN5TABLE. L- PLOT PLAN i JOB No.: 101 56 (N i DAM.2GAUG10 BARN5TABLE (CENTERVILL MA sCAIF: "1. 2a EL tOF PREPARED FOR . ya = R!CHAR D v I CTO _gg .`V RAGU NA5 f 0 J. is HOOD �+ o No.35031 r.j. hood * son, Inc_ � FFss%a land surveyors-engineers (. 18 route 6a -5andwnch,ma 02563 Ph: 508-833.7 T 00 Fax: 505.533.7101 (� . •.� vron_ccc_on� Ann-in CAA.1nc nnnu MUTT LC nTn9 TC gnu w _ ENCLOSURE FOR OUTDOOR PRIMATE SWIMMING POOL FIGURE 4 COMPLETED ENCLOSURE / II MEETS CPSC, NSPI BOCA&SBCCI BARRIER CODES LATCH 00 0 t N O t . O ' GENERAL MOTES: I. POOL QUI MICES TO BUILOWGS AND PROPERTY TINES SHALL BE IN AOCOROMCE WIN LOCAL NOD STATE MOLRREMEMM 2. THIS PLAN 000 NOT INCLUOE LOCAUON ON PROPERTY AND GRADING.INFE RMAIION. S.ALL CONSIRUCIION SHALL BE DONC IN ACCORDANCE WTIH ALL - LOCAL AND STATE RDGIRATIONS. WALL D►wEIER SUILOING CODE COMPLIANCE: d 1• POOL 15 OEIRIONED AN6 SMALL BE CONSTRLICTEO IN COMPLIANCE WITH THE INTERNATIONAL RESIDENTIAL CODE i 1 (IRC)-EDITION CZOW)IN ACCORDANCE WRH APPENDIX G AND AN5 I NSPI-4 AM ICAN NATIONAL STANDARD FOR AD M- Ir t 2. WALL 9pRR01ER IS IN L0ONFQ$IMAMANCE ANsSVNSPIIN SWIMMIINNC JONLR PLATE P003. NO L REQUVING OBOARD�'L 4,ALL PLUMBING AND E3tCMCAL WORK SHALL C0MPLY WIM INE CURMW ADOPTED CODES. INSTALLATION: ti 1• POOL SHALL BE INSTALLED IN ACCORDANCE WITH �C MLWLFACIURER'S INSFitDCTIONS. - RIM 4DIN)V AL 2.SITE PR&ARATION: MKIVAL OF MASS, SPREAD BASE NTM SANG//B�TONE y LOW LINT: OLFW AND COMPACT AND LEVEL PER MANUFACTUIRHR'S INSTRUCTfONS. N W SPECIFICATIONS AND FEATUREM: ' PLAN aw Au SEE PLAN d, .. - SHAM AREA SEX PLAN .. A 48'11.2.2 M) OR 52' [1.32 Mj, CORRtkAJIW STEEL WALL *Sri PAYLTECINE POLYMER:WALL COATIFIO TOP SEAT STE£IL TOP SEAT - MODEL 106 ROUND SWIMMING - RESIN TOP SFAI - MODEL 186 AND 2i.6 FOOL.SIZE s POLMER NOD STEEL.COPING -'UPRIGHTS - WALL OWEMP .. STEEL UPRK NIS - MODEL 102 AND 180 RESIN LIDRIGHTS - MODEL 206 AND 218 12'-O" (3.661 C:ALVANREO BOTTOM "SECOR-AOCIC'TRACK 18'r0' 14.571. MODEL 106-Id6-70D 3/4'fi.10 CMI OR MODEL 210; 1 F/O•[5.20 ON) � iBa0' [5sTi1 , 20 MIL VINYL LINER WITH TREVICLIP LOCKINO SYSTEM + 21.o' [e.40l w _ 27'%0• [8.23J: 30'.O• . [s_t s)� '"�" MDDEt.TRE1R R90898B�2Q6-P18 [----1 -'DENOTES ME,i '^�i F-7ROUND SWIMPANG POOL Akm"A P �. .•4 - I b� Town of Barnstable *Perm.itft.-)-6026Q5y� O Erpirer d manthsf}om issue date 11AR':SiAFSLE �Reglllatonr Senices Fee. C125160 MAn Thomas F.Geiler,Director ^ `R Building Division Tom Perry,CBO Build.ingCommissioneX-PRESS PERMIT 2GO Main Street,l-lyatmi.s,MA 02601 *mw.town.barnstable.maus SEP O 5 2006 Office: 508-86240`18 TOMF A'Aj&jj' LE EXPRESS PERMIT APPLICATION - RESIDEi ITIAL ONTLY Not Valid it-ilhourRed X-Press Im prim Mapiparcel.Number _.`9 Q. O/S Property Address -; 3 3 jj 06-F FL'�a l tJ C— 1j t LLS P-� ]Residential Value of Work r t?0 itinimunl Ice of$25,40 for work under 56400.44 Owncr's Name&Address y l,cn e- b fl-A»u 10 A 5 Contractor's Name_ aL-t=.g.c D Arr4 m A nr a7k, Telephone Number..'410 Home Improvement Contractor License 0(if applicable)_, ' �)eb d - Construction Supervisor's License#(if applicable)__ ❑workman's]Compensation Insurance Check onc.: ❑ I am a sole proprietor ❑,I ant the homeowner I have Worker's Compensation Insurance Insurance Company Name ►JC 6 C'�d .C�t= .IJ�X- q- /}M69f C.A Workman's Comp.Policy m Copra of Insurance Compliance Certificate must be on Cale. Permit Rcqucst(check box) ❑ Re-:roof(stripping old sbingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side. ❑ .Replacement Windows. U-Value (maximum.44) llklwe required: is=ce.of this permit does not exempt coanpli iwc with othrr town dep3nmcat rcgulalions,i.e.Historic,Conservation,rtc. ***Note: Property Owner must sign Property. ()server Letter of Permission. 13 me Imp ,cmcnt Contractors License is required. SIGNATURE: Q:forms:cxpmn Ro i.%071405 ox� Town of Barnstable 039. 1% Regulatory Services Thomas F.Geiler,Director Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, V1 C'p7?— C—tA- A-S ,as Owner of the subject property hereby authorize --5e0A2S )4kPnC /mPj"(,kth5AlT_ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address offob) (L0&'T"ej4 C-7-- B o2g Signature of Owner Date Print Name Q:Fomis:expmtrg Revise071405 Sent 23/08/2006 at 12:29:59 — from — to 19784625723 p3/3 III�IIIdI il► Job No.: -, Sears Home Improvement Products,Inc. �-rl �� License No.CGC 0125W Phone>t; 1' .. P.O.Ilex 5222 ♦Longwood,FL 32752.2290 ,."�' Sr - Location: Name / rGr'8r>r�' D1ZA611A,rA5 SPhone es.Jf Q7 '� 7 Bus. Address: '7 1-73 Arke T��R ll -i� City: 1ALM Idd, St.: _ Zap: ��7Z-- UWe,the owners of the premises described below,hereinafter referred to as'Purchaser'offer to contract with Seam Home Improvement Products hereinafter referred to as"Contractor*,to furnish,deliver,and arrange for Installation of all materials recessary to improve the premises located at: - (street) (City) (State)- (ZIP) A000rdin;to the following specifications: NOT INCLUDED INCLUDED SPECIFICATIONS PREeARkTION: 1. ® ❑ Obtain all necessary permits and insurances. 2. ❑ Inspect surfaces In work area-renail loose wood,replace rotten surface wo:i where necessary In work excluding roof.deciding or raftere.and structural members. 3. ❑ F maws Exisling eiding: Type: .. - 4 - ❑ - Fir out wafia on bricK block,metal or stucco areas:Location: - 5. &�' ❑ Caulk and seal around all windows&doors in work area as necessary. 0. ❑ I-msraa approved noncorrosive starter strip. INSULATION: 7. ❑ B""Instal insulation on fletwell areas to be shied with*'OF extruded poly-en'rene insulation.(drde one) CUSTOM TRIM: S. Custom Vyna-Klad aluminum fascia system: Color: W I t7 rG 9. Is!' ❑ Remove and re ft Wdnspose of existing guttering. W Ffr9rr- 10. Cover soffit ereae of home with VW soffit system,except thaw areas noted'Mow.,-/ S T`� eatherbeater 0 Max 0 Plus DWeatherbeater 0 Other (cheek one)Wor: W Pattern:_ 11. ❑ Custom Vyna-toad aluminum frieze boards: Location: Color:___ Size: 12. ❑ 9G Iumpieutt window,trim: Location: Color: 13. ❑ G�-'Custom wrap windowa/aihe/mulie/headers with Vyna-IOad aluminum: . Color: 14. ,❑/ "move and reinstall existing storm wlndowa/awnfngs/shtmers. 15. L7 ❑ Custom wrap door IoWnge with Vyna-Kid aluminum: Location: Color: 18. L`T ❑ Custom wrap garage door facings sin glplekfphl "ith Vyna-IOad alu u�ur�m�� t $I DC :Color: 17. ❑ I�mow and reireta9 storm doors . 1S. ❑ I+S Deluxe comer posts: Color: 19. ❑- ;j-"Clip locking system: Location: SIDING: 20. ITS ❑ Install Weatherbeater❑Max❑Plus 0 Weatherbeater ❑Other Solid vinyl sidiog.(check one) /TYPE Har& A&;.., PORCH 21! ❑ hf"✓Porch 09"ings: Location: Color. =MM: 22.' ❑ 10Pl"lord+posts: Color. 23. ❑ Porch beams: Color: SLEAtlLP: 24, © ❑ Clean up and removal of all job related debris: 25. n ❑ Each job Is over-Shipped to avoid delays.Remove excess materials and re-sock WARRApTIE$: 26. ® ❑ Manufacturers warranty sent upon completion.. SPECIAL ITEM t y/LNV®/J Work not to be,don s:` N DRIP DOE ED- � Il AH of the above check boxes and the'work not to be done'secdon have been reNewad and explained tome. s NOTE:THE WARRANTY PROVISIONS AS STATED ON THE REVERSE HAVE BEEN EXPLAINED AND VWE UNDERST ADDITIONAL PROVISIONS AND WARRANTIES ARE STATED ON REVERSE AND ARE PART OF THIS CONTRACT. Please read the following bold type and initial corresponding line. Verbal understandings and agreements with representative shall not be binding.All understandings and agreamsnts forth In writing in this Contract Purchaser Initials: The TOTAL PRICE for all Labor&Materials(including any applicable discount)Is $ 5 oo Contract Price $ Down Payment $�00 Balance Payable$ state sales Fax(_%)$ (If applicable) ARM _�,�� Terms: Credit C (Subject to the approval of the Credit Department) Total Contract Price S AR Cash C (Final payment payaWe to Installer upon completion)Funded by: Bank:. City--._ St.— Acct N 10%Pmlemd Customer Discount(PCD)awarded for any future Sears Home Improvement Products purchases.Covent pricing s%riiable for one(1)year. It this Is a credit transaction,the agrooment for credit is contained in a separate document which is incorporated herein by reference and made a pert - hereof.W/e the undersigned are hereby authorizing Seam Home Improvement Products to verifir and review my/our credit record with an independent credit reporting agency and release them from all liability incurred from inadwrt omissions o IN WITNESS WHEREOF Purcha3sr(s)have hereunto signed chair name(s)this day of; and acknowledge receipt - of a true copy of this Contract and unless otherwise specified,it is understood that the owner is r ady for this work to begin. THIS MESSAGE APPLIES TO DOOR-TO-DOOR SALES ONLY.You the Purchaser(sl may calh:el this transaction any time prior to midnight of the third day after the date of this transaction. See accompanying notice of cancellation cancellati2RIM fqr jIn exiiIiianation of this right. Signature affixed below ads as receipt that Purdwsegs)race wed separate cancellation forms US ?17D re D•t• va.MANZed Sigwure br Sears Pmduota,In. Date Parctia. Dew D2SO -Rev.09/04 - , _ Board of��Wing Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 148607 Type: _Public Corporation SEARS HOME IMPROVEMENT PRODUCT Expiration: 10n1i2007 ALFRED NYMAN JR. 1024 FLORIDA CENTRAL PKWY LONGWOOD, FL 32750 Update Address and return card.Mark reason for change. DPS-CAi 0 50M-04/OS-PC8698 Address 0 Renewal E] Employment Lost Card —TXe 1°ammoxraealt� a�✓lr Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 148607 Board of Building Regulations and Standards Expiration 10/11/2007 One Ashburton Place Rm 1301 Type: Public Corporation Boston,Ma.02108 SEARS HOME IMPROVEMENT PRODUCTS INC. ALFRED NYMAN JR.. 1024 FLORIDA CENTRAL PKWY LONGWOOD,FL 32750 Administrator Not valid without signature FrCrt • '- -- ' ._— =�fl Fr- < = E'_�_ t^at.. �J�o il'3c=fi P1 _. The Commonwealth of tl'iassacftttselts Department of Industrial Accidents 4 Of jrce ojlttvesiigations H 600 V`as/ritto tots Street Boston, MA 02111 wtviv-Mass.;oti/ilia `ti•orkers' Compensation Inyur;lncc Affidavit: Builders!Contractors/Electricians/Plurubers Applicant Information Please Print-Legibly Name S CAL, e 1{L-kiE L��ri P tw 1NrL Address: r:,�, ..Ftz b M Cr -r L City/State/Gip: LiJ (`-[JGt� Z7,5�C: Phone 9: Are you an employer?Check the appropriate box: Type of project(required): 1.Fs' 1 am It employer with _ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired die sub-contractors 2.❑ 1 nm a soli propricttu or partner- listed or the atrachcd sheet. t 7. ❑Rcmodelinng ship and have no emptoyets These sub-contractors have S. ❑ Demolition working for me hi an capacity. �t'crxers' comp,insurance. r o Y P 9. �Building addition • (No workers' comp. insu unce 5. ❑ W-.are a coporation and its required.) officer,have exercised their 10.❑ Electrical repairs or additioirs 3.❑ I ant P.homeowner doing all work rignt of exemption s iv1GL I LE] Plumbing repair's or ndditiors myself.(No worker' comp. c. 152,§I(}),and we have no I2.0 hoof repair's ittsuracce rcquired]t employee:. (No workers' 13.❑Other comp.insurance required.) _ 'Any aj!pvcar.t that ehccks box kt must olio fill vut tlic.icction be!vw yhow(ug their wurk—r3'comp enSmtion pviiey in'ornratinn._ t I lae:cownzr3 tv%o submit,this at'idav(t(ndiattir;they arc a!t wu.k r.nd th:n hire oelsidc urrrraaou trust.Submit a ncW i rf,idavli indicatingg suet. ;Cor. actor.:!ha:ehak t!us box newt a:ach.:d an additional shear 3aa'vin�(ire rune ort4c Sub-cca rectnn and their wurl crs'e,mp.p0liey lnfomtation. I aa+on employer that xs providing workers.•'cnn+petuotior+insurance for n+y cny)loyees. Below is the pollcy and job site b fnnrtafian. Insurance Company Name: IT eD. o� Policy r or Self-ins.Lie.r: 1.) C `t' c���'�C� Expiration Date:'. a L /� bl Job Site Address: #007- Al(r 1-FfrLs lei city/state/zip: InFlil'tlitre F Attach It copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage Its required under Section 25A of?YiGL c. 152 can lead to the imposition of criminal penalties of e tine up to C1,.500.00 and/or une-year imprisonment,m well as civil hcn ?tie;in the form of a STOP FORK ORDER and a fine of up to 5250.00 a day against the violator. 13c advised drat a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverd,e vertication. I th)hereby certify tr der the p ' s and penalties of perjury that the it fortr+ation provided above is true and correct. S'_tta::tre: -Pate: Ff0sla:use only. Do not write In this area,to be coir,,leted by city or town ofjiclal. i - City or Town., _ Permit/License# Issuing Authority(circle one): 1.Board of flealth 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5.PIumbint,Inspector 6. Other Contact Person: Phone#: R_,.__ on 3/'30/2006 11 .30:27 A`.' C3/30/2000 14:56 407-767-853E PERMITS LICENSE P.EPT 03 �y �e y .�,,, pq `p I}� ":r' �JF� s?, ? Cl _C-4!G1° :�.0i G3/1011!'��`' �•'�C..J 4/ 6I fJ I • \Il 4.i `/ �y G�Y �ai-tl Aa 'I -'1 -. - THIS CERTI"rICATE IS ISSU D t�:) ��I,1A1 TEi�L'r lilt AND CONFERS NO RIGHTS UPON THE CE�T1F IOATE ND OR 'zu ONLY R LOCKTON C(DWANTES HOLDER.THIS CERT1FIOATE G I✓S NOT AMEND, E. E 19 523 W,M,,vo-2,Suite 600 -[I:[tttii�COYE�QRI�cfJ��LT � CHICAGO IL 6'Jf61 ('12)�13 5;r,0 1NSt1;:ER5 AFF'ORIJIP G COVERAGE ^— rrlsuR-R A� AGe ArJ.�_ vF Sep—Holr'i 1gs Cot�cr^at'on u,gu�=a d; Ind s ns o (�:tki T - - 0`I` CV01a Saar,Hgn.IntprcremelnftFcducks, - Atrl:FiA Management Ei51778 3333 Be'rarly Rd. HgFinan Estates,IL 60179 TANDING OY CI'VAGr�u '...Y._� I-HE F'OLV_''IES 0=1NSVrANCOER CON OF ANY CONTRAC7 OR OTHER OTHE rSDOCUhI VIM'CT P.E.5PECT TO 0 ALL E7E? yEi CLUS OVS O CATE N riy'C S``OF SUOCH 1 Vf REQUIREMENT,TERI N.AY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED NEREP . jOLICtES.AGGREGATE Lm,,rr SHOWN AW�f FWD BEEN REDUCED 6Y PAIO P�rtc r EFF D TtVE P DA `�(pIRArONI LIMt7s BPI ITYPE OF INSURANCErim- RDO POLlC'f NUMt3FJt I EAC? OCC ENCE c=rtEPALt.IA rLtTY .. Ex.cludcd 1729383 04/01/2006 0"/0112007 FrAc:,�.-- WAGE Ant t�nro S 1 xcluded CONt? RCtAL Gc"NERAAL LIA i.tEG•�'co tAr, and corea�) CLAR.Is reADE l R 1 pEF.'Op Al&ADV INJURY S.BOO 000 RAAGCREGATE�ucTs•caN49 t cc 5-C 00.000 AOvR GATE L1,%ji APPLI:CY p� col:elrtGD s1NCLe u�arr e 5;(100,000 AU ro&IC61LE t walurY (ed xcldenU ____._�^ ISAT-I08219953 04/01/2006 C4/01/2007 A {X j A`{Y AUTO DO:RY INJURY E XXXXXXX ' I ALL OYJNEb f JrOS (?o;Pdr3u�) SCI,EoULEpAUTOS }:}){)th o0I iLY INJURY b HIREO ALT03 NON-0WNED AUTOS 1 ){Xk PnI'1PERT`f Df�tiWAGE (pu•�•cr.') AU O ONLY•Fh ACCIDENT x�_xxh�Xx GARAGEUAW;+1TY ()4/01/2006 04/01/2007 EAAcc X7�:,c XXX AHx,tyA�rro S.I.R.$S,OOO,000 AOU rO ONLY: AGa C X�_ XXX ;HOCCURRENCE Ei;CE�±U.151L�i 4A1: =GnT'c I; 7{XX OCCUR ❑cLAc:,s M�E NOT APPLICABLE �trWELUS DEO'JCTI8LE FOR1I }C XXXXx_I P_Fr�NTON * YY STATU TII �D. 04/01/2006 04/01/2017 A Y17.^,1(EP.3 C0'�FE?15AT10N ACID �VLRC44340850(CA)(D� ) 410112006 04/01/2007 E.L.EACH ACc1DEN'T % _ A EM?LOYEFLS•LwBtLrrY _SCFC44340,972(NI)(RETR01 NVLRC44340959 04l01/2006 04101t2007 I.D,s�SE• . E L.DISEASE-POUCY L!M T I B ALL OTHER STATES S'.F SS.000.000 04101/2007 A oTrfEP S.I.R.S5,000,000 04/011Z006 i C,ara�i'__Fcrs Liabil'�}' _. n rood,FL 32750 and Alfred W.Yynan,Jr.,LiceriSe��iC 1249 i 10 I pE5CP1FT10•I OF OPcRATIONSLO(A r)O�4SJVEHICLES/E7C�.0�70!is ADC BY EtiDral Par-W[ly, Xn rod,PRO F 0N5 Alfred V,.Nytt:ar,,Jr.,License KCGC012538 located @ 1024P.1 orids Central Part.n'm',I< b^ located ne 1024 Florida Central Parlcvmy,Lcmgwood,FL 32750 I A7Dff10NAL IN4UP.ED•1114 RER L 2z�O82 SHOULD ANY OF THE ABOVE D SCR15c':POLE 9E CANCELLED 8i T FOFli.'iHE E%P1Ff'T'O�1 i DAY. CAT;THE 1'IFTT:u' Sear Horne ImprovEmVt PrcdUCt3 R EOF,THE C�SUING IN9UREII WILL ENDEAV u OR TO MAIL .+ -- 1024 Florida Oetltfal P2rkvfa/ N0T1Cd TO THE CERThICATE HOLDER 'IAh1EO70 THE LEF7,bUT FAr.uPE TO so�„ W Longvecd FL 32750 ILt?OSE tt0 09UGATION My UAtnLrrr 3; Y MO UPON THc INSUncP, REYRFSENTATNES- - AUTHORIZED REPWSNTATrrr yet a,a otmk+r snd N vro Troe,.tar rWIgM mnc"vd Spx6p/7w Glare tLN DEI µC:•I', m ACORD CU RP( �F ACORID 25S(7(c�) For cpr%V�h M-fd"K HOME IMPRC3N/E1\AENT PROOU.GTS May 2006 LETTER OF AUTHORIZATION I, A. W. Nyman, Jr., Assistant Secretary for Sears Home Improvement Products, Inc., give permission to Corestates,'Inc. and its' associates,Karen Kirklys to be able to submit permits and licenses,pick up permits and licenses,make changes to permits, licenses and plans and initial changes made by the building department on behalf of Sears Home Improvement Products,Inc. . I also give permission to Corestates, Inca and its' associates, Karen Kirklys to purchase permits and/or licenses with a company check, personal check, personal credit card or cash. This authorization is valid through December 2006. I certify that the above information is true and correct. T ta�SecretarySears Home Improvemenc s, STATE of Florida COUNTY of Seminole SWORN TO AND SUBSCRIBED BEFORE ME THIS 22nd day of May,2006,by Alfred W.Nyman,Jr.,Assistant Secretary for Sears Home Improvement Products, Inc. and who is X personally known to me or has produced a Valid Drivers License. NOTARY PUBLIC-STATE OF FLORIDA Deborah P. Phillips u"Ll ,- Commission#DDS20380 Print Name: Deborah P. Phillips *Expires: AUG. 13, 2007 Notary Public, State of Florida Bonded Thru Adandc Bonding Co.,Inc. MY COMMISSION EXPIRES: Aug. 13,2007