HomeMy WebLinkAbout1367 SHOOTFLYING HILL RD +r
ik
Town of Barnstable -*Permit
bye' Expires 6 month from issue date
yd Regulatory Services Fee
stustvsresre,
039. ���
Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-86.2-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address �7 � � f %�GC'� Zd• v
g Residential Value of Work I1V Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address*. l�Z kl pw l i'Z
/34 -f- 1 ,QP Rd-.
Contractor's Name �1 � (t to-Q. Telephone Number
Home Improvement Contractor Licerise#(if applicable)
Construction Supervisor's License,#(if applicable)
[`Workman's Compensation Insurance
Check one: 5 F
El I am a sole:proprietor
❑ I am the Homeowner..:. . : _ _ .
�—I have Worker's Compensation Insurance
a OUVNt � aAR1ST �L
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit.Request,(check boz)
❑ 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 (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: Pi fiv�
C\Users\decollikWppDataU ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc.
Revised 072110
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations j
600 Washington Street - a
Boston,MA,02111
www.mass.gov/dia i s
Workers' Compensation Insurance Affidavit: Builders/Con,tractors/Electricians/Plumbe
_Applicant Information rs
Please Pr><nt Legibly
Name(Business/Organization/individual :
• S-
Address:
City/State/Zip: Phone#:rS Z
�5 "2
� -�� � 1_2
Are you an employer?Check the appropriate box:
10 I am a employer with 4. I am a general contractor and I ` Type of project(required):
employees(full and/or part-6me).* ' have hirei eaub-contractors 6• ❑New construction, {,
2.❑ I am a sole proprietor or partner listed on the attached sheet.1 7. ❑Remodeling,
: ship and have no employees � .Igese.s su
b-contractors have �S. []Demolition (,
working for me in any capacity., workers'comp.insurance.
[No workers' comp. insurance 5.:❑ We are a corporation and its 9 Building addition
required.] 10❑Electrical repairs q ] - ,. :officers have exercised their p irs or additions
3.❑ I am a homeowner doing all work right of exemption per ivIGL" l 1.Q Plumbing repairs or additions
myself. (No workers'comp. c. 152,§ .ees1(4),'and we have no
insurance required.]t� ' employees.
mP Y [No workers ,to ' 12 Roof repairs
,comp.insurance required.] 13.9 Other
*Any applicant that checks box#l must also fill out the section below showing their workers'compensation
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside Contractors musttssubmi information.new affidavit indicating such.
=Contra ors 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 or' a to ees Below Is the policy and job sUe
information. f m1' mP y p lacy f
Insurance Company Name: A//YI,�U �L• y x �'
Policy#or Self-ins.Lic.#:_/VITW4 7?rC3�I?�. ° �
Expiration Date:
Job Site Address: ���7 6)w f-qIOU
r City/State/Zip.& r/JA, ryV14.QZ(�Z
Attach a copy of the workers'compensation in
ration 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 certify uiderthepains and penalties of perjury that the informdtion provided above is true and correct:
Si ature: •<
Date:
Phone#: 77 I —q 4
Official use only. Do not write in this area,,to be completed by city or town official 'S'
City or Town:
IPermit/License
IF
Issuing Authority(circle one):'
1.Board of Health 2.Building Department•3:City/Town Clerk 4.Electrical Inspector. 5.Plumbing Inspector[
6.Othec
Contact Person: ' a A
Phone#:
+ ■natvsrnst.>r '
MASS. Town of Barnstable `
Regulatory Services
Thomas F.Geiler,•Director'
Building Division
' Thomas Perry,CBO
Building Commissioner 7 _.
200 Main Street; Hyannis,MA.02601
www.town.barnstable.ma.us
Office .:508 862-.4038 x, Fax: 508-790-6230
{ {.
s Property Owner Must
' Complete and Sign This Section
If Using A Builder"
r
:. � . rs is *. �' r; 1 1 •
LZ as Owner°of the subjectfi Pro perty
hereby authonze /" Icy /� '�U�" �' to act on my behalf,
in all:matters relative to work authorized by this building perrmt,application for:
_ .
39'7
(Address AJA
'
ignature of Own'x, '` ' y. ,r Date -.,
i
{{ Print Name
If Property Owner is applying for permit,please'complete the Homeowners License Exemption Form on the
reverse side. '
' C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\C6ntent.Outlook\DDV87AAZ\EXPRESS.doc *•
Revised 072110:
' z l
NOTICE a ,- = . NOTICE
TO
EMPLOYEES z K ti .' EMPLOYEES
N
The. Commonwealth.' of '�,,M'as sachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS,,,
600 Washington_ . Street, Boston, Massachusetts,`02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30 •this will give you notice
that I (we) have provided for payment fo our injured employees ,underthe above mentioned'chapter by
insuring with:
NorGUARD Insurance Company
NAME OF asITRANCE COMPANY
P.O. Box A-H - 16 South;River Street
Wilkes-Barre, PA 18703-0020
' ADDRESS,•OF- INSURANCE COMPANY
MJWC235303 '. 04/25/2011 04/25/2012
POLICY NT MBER _; 'EFFECTIVE ,DATES"
PAYCHEX INSURANCE AGENCY -
150 Sawgrass Drive _ &77-266-6850
RorhsterFJ Y 1462n -
NAME OF LNSM4LNCE AGENT ADDRESS . m PHONE
MI Nardone Carpentry LLC
299 White's Path
la h Yarmouth MA 02664 '
EMPLOYER ADDRESS
.. , 03/28/2011
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of;personal injuries arising'ou,t of and in the course of
employment"to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy..of the First Report,of Injury must be.given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid ;by the insurer, if the treatment is,necessary and
reasonably connected to the=work related injury. In cases requirin, hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
LWAIME OF.HOSPITAL., ADDRESS
TO BE POSTElJ..BY EMPL0.�ER ..
' _ = Off, m Affairsn usmess Regulation ,
10 Park Plaza - Suite 5170
s' w Boston, Massachusetts 02116
Home Improvement torRegistratiori
4,
Registration: 135887- ,
g <. ..l = — -- 7` TyPe: Ltd Liability Corpor'
Expirati , : 5/16/2012 - Tr# 295044 i
M J NARDONE CARPENTRY LLC.�
MICHAEL NARDONE
947 RT 6A `
YARMOUTH, MA 02675 ,
_ h i
Update ddress nd return card.Mark reason for change.
r` E Addre enewal `� Employment Lost,Card
1 DPS•CA1 0 SOM-04/04-G101216
Mastiachusetfs- Delt.�rtment of Public Safety
Board of Buildin Regulations and Standards
Construction Supervisor, License
License: CS" 81139 ,
MICHAEL J.. NARDONE ;
299 WHITES PATH
i S YARMOOTK MA:02664
• Expiration: 9/16/2013 }
Commissioner iTr#' 1706 • i
, - - f � e �,.to ". .a _ r , . -}'• • �". I ..
)(.PRESS
SEP 2 9 2003 �V
BLE
TA
TOWN'OF BARNS
Town of Barnstable "Permat#11 9 I
4 ILtptra 8 rnoerhrJ!•wn Drua dace
a .�,rR,► . ; Regulatory Services Fee_
Db
MAW Thomas F.Geller,Director
D Building Division j
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230
EXPRESS PERK UT APPLICATION - RESXDENTIA,k. ON L'Y'
r Not-Valtd without Red X Prds 2'erprint
a j '
Map%parcol Number `
Pzoporry Address
Residential Value of Work
Owner's Name 8t Address r pQ M A q
S
Contractor's Name_ G.l) J ��-e + 20 r)S ����T Tdephono Number
Home Improvement Contractor License If(if applicable)
tU371� •
Construction Supervisor's License#(if applicable)
Workman's Compensation Insurance
Check one;
❑ I am a sole proprietor
❑ I am the Homeowner
( I have Worker's Compensation Insurance
Insuranee Company Nasae
I�Gv�IerS d�rnr:,t y .0c). Cf .S UA,I ram,=5 r
�Pj.L)6-gaaXc� S� - Boa-
Workman's Comp.Policy# k
Permit Request(chock box) �,y,� ti
03 Ae-roof(atrippi-U9 a� es) A11 co cti de;b wi be taken to
74 V
❑Re-roof(not stripping• Going over existing lay of roof)
Re-side
` ❑ Replacement Windows. U-Value (maximum.44)
❑ Other(specify)
f
*Where required: Issuance of this pa rnit does not exempt corrtpliancc v ith other town deparetxa►t regulations,i.e.Historic,Consccvstian,ett.
Signature
Q:Forrrts:eVmtrg t
Re4ised1,21901
PROPERTY OWNER MUST COMPLETE AND SIGN THIS
SECTION IF USING A BUILDER / ROOFER
(Please return this form to Cazeault Roofers with your signed proposal/contract)
1 — A e w c'7� as Owner of the subject property.
Hereby authorize Paul J. Cazeault & Sons Roofin
To act on my behalf, in all matters relative to work authorized by this building
Permit application for (address of Job)
- _V1
o3
Sig at�ri -ef-0 f Date
�ISZ eWIC.7-1
Print Name-
r � /
W-leC�fr��Z- o
I
�r Board oFB1_111din(1-RclIula ions and Stand:lrcis
One Ashhl111011 Place - Room 1301
Boston. Massachusetts.02108
Home Improvement Contractor Registratioli,
Registration: 103714
Type: Private Corporation
Expiration: 7/9/2004
PAUL J. CAZEAULT & SONS, INC.
Paul Cazeault
P.O. Box 2781
Orleans, MA 02653.
Update Address and reluru ru•d. Mark reason for chenwe.
J_ • Address I_ I Renely n
.l i I;nlpluNnlet" I.usl Card
.��i; 611•J)GJJiloneve"Z00//, 111./GUk1UA,'1LU,je&j.
1� Board of Building Rcgulatioiisand Standards Liccuse of I cgistration valid for individul nse only
it r n- d
f ( HOME IMPROVEMENT CONTRACTOR Uclore the capiration dale. If found rcltu-u to:
Registration:• 103714 Board of Building Regulations and SL-intlards
-'' Expiration: 7/9/2004 One Ashburton Place Rm 1301
Ma.02108
Type: Private Corporation Boston, - ,
PAUL J.CAZEAULT&SONS, INC.
Paul Cazeault
22 Giddiah Rd. �� � �
Orleans, MA 02653 '
Administrator o' a EIOAI2D OF BUILDING REGULATIONS
d License: -,ONSTIiUCTiON SUPERVISOR
ejA Number: CS- 026325
1 1' Birthdate:. 10/20/1959
" Expires: 10/20/a003 Tr.no: 7310
Restricte,c : 00
PAUL J CAZEAUL'I _
1585 MAIN"ST. a
OSTERVILLE, MA 026`�5
Administrator
677/
-cow
'Board of Buildin Re ulations
One Ashburton Place, Rm 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUP CENSE Birthdate 10/20/1959
Number: CS 0263 Expires: 10/20/2003 Restricted To: 00
4 .
PAUL J CAZEAULT
1585 MAIN ST
OSTERVILLE, MA 02655
Tr. no: 7310
Keep top for receipt and change of address notification.
At,g- 15-03 10: 06A P . 01
DATE(MWDDIYY)
ICADARD- CERTIFICATE OF LIAB LITY INSURANCE I a/15 2,�D3
�nFlDDUCEA THIS CERTIFICATE 13 ISSUED A3 A MATTER OF INFORMATION I
i ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Mc8haa InauranCA Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
749 lain 6tY®®t, Suit®#t: ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ooterville, Ma. 02655
—50�92Q INSURERS AFFORDING COVERAGE
9011_-
INSURED Paul J Caxeault & Bono Roofing inc. tNSUHER A, Weatern Heritgge Zno• CO• .. _
INsunER B: Travelerm Indonaity_ Cn of Mimi
i 1031 Mein $treat INSUREnC
00terville, ma 02655 INSURER
l_ 1 D❑—fi R-5y�,. INSt1HHRE - �I
COVERAGES
THE POLICIES OF INSURANCE:LISTED BLLO'W 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 i
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGR[GATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN�SR�� POLI Y EFFECTIVE POLICY EX%RATION
'NS TYPE OF INSURANCE POLICY NUMBER TE MM/ E IMWDUfYYI LIMITS
OENERAL LIABILITY I ! EACH OCCURRENCE 6 ,00_
COMMERCIAL Ut NFRAL LIABILITY I I FIRE DAMAGE(Any one lira) $
CLAIMS MADE I OCCUR - I MF-O EXP(My one Person) S
j it 11~�tI_.., 9CP0467325 04/30/03 104/30/04 f'EHSONAL6ADV INJURY f _900
I I GENERALAGGRFGATE $2,00 ♦QQ
iii---GCCN'L AGGREUAIIE LIMIT APPLIES PER. PRODUCTS-COMP/OP A(;G S 1 ODO 40Q.. ..-
POLICY{ JE 0 LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMB $
ANY AUTO (Ere accidom)
ALL OWNED AUTOS - - BODILY INJURY
SCHEDULED AU 103
(Per Penion)
j 1 HIRED AUTOS -
BODILY INJURY -$
NON OWNED AUTOS I (Par accldenl)
-�
PROPERTY DAMAGE S
I IPer BCCltlentl
GARAOE
LIABILITY AUTO ONLY-EA ACCIDENT_
ANY AU 10 l EA ACC S ,..
OTHER THAN
AUTO ONLY: AGG S.
EXCESS LIABILITY LACHOCCURRENCE Is
OCCUR I CLAIMS MADE AGGREGATE $
I �
HE:fFNT10N
C WORKERS COMPENSATION AND x T RY LIMITS ER
EMPLOYERS LIABILITY
17PJUB-922X653-502 I08/10/03 i08/10/04 El EACH ACCIDENT �$100.000
DISEASC•EA EMPLOYEE 3 .QD ._
E.L.DISEASE•POI ICY LIMIT IS500.000
i
DESCRIPTION OF OPERATIONSILOCATIONS/VEHICL C&EXCLUSIONS ADDED BY ENDOR6EMENT/SPECIAL PROVISIONS
i
CERYIFICATE HOLDER I j ADDITIONAL INSURED:INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIE6 BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN
.! NOTICE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL
i
IMPOSE NO OBLIGATION OR LIABIL TY.OF ANY KIND ON THE INSURER,ITS AGENTS On
- 11EPRESENTA 1 9. �
- I AUTHORIZED R RE T
ACORO 25-S(7/97) v V. N ACORD CORPORATION Igoe
y
CF Tne Tp�
The Town of Barnstable
Department of Health Safety and Environmental Services
1639.
a � - g
BuildiII Division.
Fn N,pr
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
i
TOWN OF BARNSTABLE Permit:�
SOLID FUEL STOVE PERMIT Date:
II Fee.,6 er
Owner: Ajd SZ eLj)C2 Phone:
Address , � Village:. LcarjkV 1 ate
Map/Parcel: g"" Dater 1' = A?-Roe)e
Stove
A ew Used
B. Type: Radiant/Circulating
C. Manufacturer: K/,Z R R 2- Lab. No.
D. Model No.:
Chimney
A. New/ xistin (If existing,please note date of last cleaning
B. Flue Size
C. Are other appliances attached to Flue? Ir.
D. Pre-fab Type and Manufacturer
E. Masonry: Lined/Unlined
Hearth
A. Materialslq
B. Sub Floor Construction: Ue; c/Pe,4e,
Installer
Name: Se.l� Address:
Phone:
Location of Installation: GOA-6�
APPROVED BY:
Please make checks payable to th Town of Barnstable
*This constitutes an official stove permit after inspection,photographed, and approved by the
Building Inspector
Stove.doc
I