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Thomas F.Geiler,Director �0 p�f0 b Building Division C 4Al 3 Tom Perry;CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �h�WfAAUAQ. 0b_I�Ml 11-C �Residential Value of.Work Minimum fee of$35.00 for work-under$6000.00 Owner's Name&Address Y) -Dd $a 4 0. Contractor's Name n t, Telephone Number ✓ Home Improvement Contractor License#(if applicable) b'853 Construction Supervisor's License#.(if applicable) q X.PRS PERM' �Workman's Compensation Insurance JUL 2 6 2013 Check one. ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name �Mojlt . Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to` U� ❑Re-roof(not stripping. Going over existing layers of roof) ❑. Re-side . . '. ,. #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum..44)#of windows *Where required: Issuance ofthis.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. Li of the a Improvement Contractors License&Construction Supervisors"Liren_se is d.SIGNATURE: �Q p C:\Users\decollik\Ap )to\LoealNicrosoft\Windows\Temporary Internet Files\Content.Outlook\QK I H7J6ETXPRESS.doe Revised 070110' The Commonwealth'of Massachusetts Department of Industrial Accidents ... ol VI-i fice oflnvq,1g.gion600 Washington Street E . Ywn, _ Y{ � Boston, MA 02111 �. =dets/Contractor's/f'leetricians/Plumbers ViaWorkers' Compensation Insurance" rs. Applicant Information Please:Print Le iLI g )' / JI 4 Name Business/Or anization/Individual . Address: City/State/Zip: t . M A 02k5_" Phone #:,' q�0 Are you an employer? Check the ppropriate box: Type of project(required): 1.4 am a employer with 4. ❑ I am a general contractor and l employees(full and/or part-time). have hired the sub-contractors 6. ❑ New.construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' y9. ❑,Building addition i [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 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' 13.❑ Other 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. tContractors 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 emplovees. Below is the policy and job site information. Insurance Company Name: ►1 i� Policy#or Self-ins.Lic. #: l� Expiration Date: 91 OYA PJZ( � Job Site Address: Ifiq City/State/Zip: 62h521, Attach a copy of the workers' compensa ion olicydeclaration' 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 maj be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby ify under the pains a d p allies of perjury that the information provided above is true and correct: Si nature: c Date: Phone#: �Z-T 9 lU 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#: AC40 CERTIFICATE OF LIABILIT DATE(MMIDD""") Y INSURANCE 07/03/2013 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 Germani Insurance Agency NAME: 908 Main Street tPA N o 506 428-9194. aC No: 508 428-3068 Osterville,MA 02655 E-MAIL ADDRESS:certsogermaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:SAFETY INS CO INSURED -INSURERS: Scott Peacock Building&Remodeling,Inc. P.O.BOX 171 INSURER C: Osterville,MA 02655 INSURER D: COmmerce&Indust Ins.Co. 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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD/YYYY LIMITS J. A GENERAL LIABILITY CP00001152 7/5/2012 7/5/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ CLAIMS-MADE F—IOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ 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 HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ D WORKERS COMPENSATION WC 005-81-5464 6/22/2013 6/22/2014 WC STATU- OTH- AND EMPLOYERS'LIABILITY I TRYY/NER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 TT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Scott Peacock Building&Remodeling,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.. AUTHORIZED REPRESENTATIVE - ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r � 1 OF THE T k Town of Barnstable }3ARNSTABLE, . 9q, MASS. ��� Regulatory Services ATFoy a 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, V 1 i`�-�-e ' .((r} ,as Owner of the subject property hereby authorize i �. . to act on my behalf, , in all matters relative to work authorized bythis'building permit application for: (Address Ujoby Signature of Owne• D4e Pnnt Name QAWPFILES\FORMS\building permit forms\EXPRLSS.doc Revise020108 I !r r = r 9�t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SuperNisor License: CS-094500 JAMES S PEACO!(IC PO BOX 171 OSTE VILLE MA7 02632r Expiration Commissioner 07/22/2014 �3--�—,,Office of Consumer Affairs&Busi(ress Regulation/((J License or registration valid for individul use only ! IOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 151853 Type: Office of Consumer Affairs and Business l'; xpiration: 7/ ess Regulation ,vnao 712014 Private g lotion '�,,..._.,, ate Corporation 10 Park Plaza-Suite 5I70 SCOTT PEACOCK BUILDING&REMODELING INC Boston,MA 02116 JAMES PEACOCK 1046 MAIN STREET SUITE 1- OSTERVILLE,MA 02655 Undersecretary — —_ -- ----..--._.Not valid without signature r IL & f q MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) r; A Ill S , Mass. Date_ �II I o1'� 103 Permit tt Building Location RutocAll 164owner's Namel�ll� Q►� �(C • - "� 1 col F�l` Pii/1/1 t�0 Type of Occupancy New Renovation _ Replacement ^ Plans Submitted: Yes[ No G9 Q � W A Y Z 2 yf N N {� rt F = A az N W. O N = T. A C1 N O u < Q ¢ O S m W ", H Q W Z U W z N W < Q o o r = W W 0 J < S V ?, W W . - V Z J P Z r W W O > U. H J W Z < W < C - ~ N m Z O 2 W O to S < W > s W 9 < Q A < O O u a O •1 �- SUB—BSMT. BASEMENT 1ST FLOOR 2NOFLOOR ]AO FLOOR I 4TMFLOOR I STMFLOOR 6TMFLOOR 7TMFLOOR STM FLOOR Installing Company Name SNnwl S PT.i1MRTNr: & HFeTTNr^ Check one: Certificate Address P.O. BOX 39 C Corporation W BARNSTABLE. MA 02668 C Partnership Business Telephone 362-9111 Firm/Co. Name of Ucensed Plumber or Gas Fitter CHRTSTOP FR SNOW INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes XX No ❑ 1 If you have checked M. please indicate the type coverage by checking the appropriate box. A liability insurance policy k Other type of indemnity❑ Bond C OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner orOwner's Agent I hereby certify that all of the details and information I have submitted(or entered)in aboveEs are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issuiicatio will be in complian ith all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen By T of license: `>,�; Plumber n r or Gas—Fitter Title Gasfitter Master License Number 10705 G /Town Journeyman � �� � T�sO-