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Home My WebLink About0023 HIGH STREET a3 �,y � �sf� D a� ' o Town of l3arnstable _ *Permit# - _ 9 rr Regulatory Services ExPlres6monrhsfi ss edate 163 n`� Thomas F.Geiler,Director Fee �� Building Division i' z 200 Tom Perry,CBO, Building Commissioner Main Street,Hyannis,MA 02601 Office: 508-862-4038 www-town.barnstable.ma.us ' EGRESS PERMIT IT Fax: 508-790-6230 NotYalidwithoutRedX- RESMENTIAI,ONLY Map/parcel Number P'�S j+nprinr ��sat� � Property Address �� Residential Value of Work �p,�/� I j C _;26 3 .'s Owner's Name& Minimum fee of$25.00 for Address work under$6000.00 Contractor's Name '7 S Home Improvement Contractor License#(if applicable02 ) 1 Telephone Number 50 9— q�� 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 Insurance Company Name _ (1 Worktnan's Comp.Policy# C/ Copy of Insurance Compliance Certificate must be Permit Request(check box) on file. Re-roof(stripping old shingles) All constru ction debris will be taken to ❑Re-roof(not stripping. Going over '7 � existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value `Where required: Issuance of this permit does not exempt (maximum.44) ance with ***Note: ro other town department regulations i.e.Historic,Conservation,etc. Owne ust sign Home t n,wner Letter of Permission. GNATrRE: ense is required. 'orms:expmtrg ,ise071405 r The Commonwealth of'Massachusetts Department of Industrial Accidents Office.of Investigations 600 Washington Street Boston,MA 02111 �,M Sve�y wWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �nplicant Information Please Print Legibly Jame (Business/Organization/Individual): �./i-fi ✓L �� address: 0 C®X V 1Y5- -ity/State/Zip: C,) t 141/, Phone#: re you an employer? Check the-appropriate box:. Type of project(required): 0-I am a employer with '3 4. ❑ I am a general.contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- lasted on the attached sheet � �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its, 10.❑ Electrical repairs or additions required.] officers have exercised their El I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required]t employees. [No workers' 13.0 Other comp..insurance required.] ry applicant that checks box#i must also fill out the section below showing their workers'compensation policy information: `Q omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp.policy information. man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'ormation. urance Company Name: acy#or Self-ins.Lic. #:_��J C/ JL Expiration Date: 16 Site Address: 93 City/State/Zip: 0,2-G 3 S tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of restigations of the DIA for insurance coverage verification. . o hereby cer ' to the ins and p ti f perjury that the information provided above is true and correct a Dater —c 3' one Ofcial 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 M No. 1586. :.`CEICHFICATF OF INSAN-C� " ISSUE�TR PRODIICRC2 '9 7/Oti THIS CERTIFICATE IS CSSUED.4S A bdATTER ON INFORMATION ONLY AND CERTIO ATE DOES NOT AMEND,PXTJL D OR ALTERTIM OVERAGE WISE&QLUNN IN•SMAINCE AGENCY AFFORDED BY Tpe PoLICLBS BELOW, 449 PUASANT ST 9ROCKTON,MA 02301 COh�PA1VJ�S AF'FOP DIN(;CO�V�RaG� COMPANY LET •�# HARTFORD UNDEMMTERS INS CO. COAQANY INSL'A,1rD LeTrB]t FRA&ER CoNSTRITCTION LM10A C F0 BOX 1845 COTUI`I,MA 02635 ODFfPANY D LrilTax . COD�PANY � rnVERAGES: LaTTen THIS IS 70 Cl Q+Y TRwr rj'E YOL1CIBS of IYiSU Al OE LISTED BELOW HAVE aEFN ISSU6n'C()1 FtE;- �CCATE01 NOT'LTT-WANDING ANY • . .,•5 CERTIFICATE 4IAY BE ISSUED OR M 9Y PBRTNN TandOF CONDITION OF ANY CO CN5URED YArixD P SOvs FOR I'HE polkf 'FSCLIOD )ACSUR.4NC3 AFF0ADBD gY THE POLICIES DOER RT ll DOCtIbfSN1�VC7R RWECT TO;vFRLTC THIS AND CONDITIONS OF SUMPOLICIES.Lawn 5MWN MAY B 7 RED`[S SUBJECT TO ALL F REDUCEDBYPAMCLAIMS THE TERMS,SXCLMIONs CO TYPE OF/NSI1RAlrCg I'OLTCYIYUAIBFR ' LTA POLICY POLICY EFPECTIVE BATE EXPIRATION DATE LIMITS GENERAL LIACiIt,1TY WMIDD,YY yAU�YY) C061l-cL4L r'R" ].LIABILITY - MTZtAL A •SE(iATB 3 aAWSnLADa accun. PRO CTS-COMPA]PA00. $ OwHe¢F&WYMAMAS PROT.. PENAL&AD'V.JNxMv S EAC1OCC- \CB $ AUTOMOBILELIA)3ILITY DA1ut38(1wOneF'"c) S ��D.PJt7vENa5(A,qouepmom 5 ,. ' ANYAIIro coM'BcaEDswal�Lum•ALL DWIIHD AUTOS 3 SOMbIJUDAVIOS BODmYp1Y(J Y $ aM AUTOS (hh Parcn) NON•OW-\9DAIITOS BODILY L$Y S OANA0ELMBWTY (Per.f neat) PROPEA7^tDAMAG9 $ Exce3$LIABILITY S. !lil'M""A FORM OTNERTHIN ASLLLPORII! EACROCCULMNC@ AWOUOATB 5 S A WORM'$COMNN8ATIONAND STAIIJTO1tY LMIPS &6860L3-i94X6C9i 09126,106 � EtcNA OTA$1q `xtD�vl S]CJAOO EnLPLa� sLL+BpIrY 09/26.07 DISEA$LPOLCCYL]MIT SSCo,aoO DlsaAse i;AClrsfdPLOYae S!GG,OOD DESCRIPTYONOPOIERpYTON�ypCATtONSf4+DipCLES/SPECYw1,]'fgNg ITS H7CPLACES ANY BR]OR(• TIF]CATE L,$lJEI)TO T2lE C$8TIP1ci1TA`BOLDER AFSSC7L'V'G•WOp�,gR3 COMP COVER�C�g , . CERT�'YGR.'CE.HOI�DE�?•'. fANCELLA7f1QN:• ";,:..; , MASER Co]V8TR17CTIQN gBCOrrLD AYY OF TB8 ABOVE BLLE6 D1Qq-ItIBBb POLTCI�gg !i]�pRE TAE F0110X 1845 Ea T9&RE0PTlaxseURi r=DATE . GODalrlNv CAKC CANC LL VOR VON 10 COMM MA 0163S 'UT FA DAYSII WRrr7rN N"CB TO rW CERTOMATE]IOLbER NAMN71 TO RfE LBPT. LG1RI M OF ANY O kAlL 9UCB NOPIC&SELeLI pyPOS.NO 0➢LICATR7N DJZ 1V')y L°PON THE COMPANY;ITS AGENTS OB REPRESE.NTATIV@$ A�lJ7//�f,•r�PAEp��I.7]fAri'VB /yam 0ACOItb•COR1Oa4i1TIQN 99OL it 671-2 a Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement'.Cortractor Registration Registration: 112536 Type: DBA FRASER CONSTRUCTION CO. Expiration: 3/23/2009 Tr# 127920 DEAN FRASER - P.O. BOX 1845 COTUIT, MA 02635 Update Address and return card.Mark reason for change. DPS-CA1 �, soM-osios-Pceaso Address Renewal Employment ❑ Lost Card 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: 112536 Board of Building Regulations and Standards Expiration: 3/23/2009 Tr# 127920 One Ashburton Place Rm 1301 Type: DBA"~ Boston,Ma.02108 } FRASER CONSTRUCTION CO. DEAN FRASER ` 4556 RT 28. ` COTUIT,MA 02635 Administrator- Not valid without signature . h , 1 FRASER CONSTRUCTION Warranties the labor for 10 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties the shingles and labor: 100% through the Sure Start Warranty duration. CERTAINTEED Warranties the shingles to be ALGAE resistant for the duration of the Sure Start Warranty depending on the shingle that was purchased. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION: Carries Workman's Compensation and Pabhc Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: �� G Homeown r V Fraser C nstruction ILYIY CO 3911d SMIA113S 7IVW VL8TIZZZLL 0£:bT L00Z/50/b0