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Home My WebLink About0012 PINEY ROAD 6� 0 L �FISE Town of Barnstable *Permit Fxplres 6 okoliths from issue.date 6`PAE $,S.•PERM J.`T::Regulato.ry Services:-, fAieN . • _.::__•.Tb:omas:F.Geiler,Director �fo' '� - _• ...._..7 ... :......... v-...:...__ :..Building Division TOWN OF.-BARNtST•ABLETomPerry, Building Commissioner 9 . .200 Main Street, Hyannis,MA 02601- . Office: 508-862-4038 :.. . ._• Fax:,508-790-6230 -MICLT1O NT"EXP S: ERG IAY OTA t Valid without Red X-Press Imprint �Map/parcel Number i Property Address t Z- 4 + [,residential Value of Work S C.,C,y= Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ��.•* s "' ` ' ''"'`s-v-• G l ' hone Number tj o L!-1-7 Contractor's Name 1 15 Home Improvement Contractor License#(if applicable) I o L4�K S Construction Supervisor's License#(if applicable) c4-7 ❑Workman's Compensation Insurance Check one: 0 I am a sole proprietor ❑ am the Homeowner I have Worker's Compensation Insurance A Insurance Company Name �-Ic�. �'t-•-�� Workman's Comp-Policy# Copy of Insurance Compliance Certificate'must be on file. Y Permit Request(check box) ---- [�Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value__(mum•44) *Where required: bsuance of this permit does not exempt compliance with other town depart rient regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature G Q:Forms:expmtrg Revise063004 ACORQM CERTIFICATE OF LIABILITY INSURANCE DATE(M M/DD/YYYY) 9/4/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mc Shea Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 749 Main Street, Suite#H ALTER THE COVERAGE AFFORDED,BY THE POLICIES BELOW. Osterville, Ma. 02655 508-420-9011 INSURERS AFFORDING.COVERAGE NAIC# INSURED Steven P. McElheny Builders,Inc. INSURERA: The St. Paul P.O. Box 460 INSURERB: The Hartford P.O. BOX 460 INSURER C: Cotult, Ma 02635 INSURERD: 508-364-1926 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICY EFFECTIVE POLICYEXPIRATION LIMITS LTR INSRD TYPE OF INSURANCE DATE MM/DD/YY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea o.'urence $ 50,000 CLAIMSMADE CI OCCUR MED EXP(Anyone person) $ 5,000 A NPP916772 09/22/06 09/22/07 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ ALL OWNED AUTOS BODILYINJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Peraccident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CI CLAIMSMADE AGGREGATE $ I RDEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONAND x WCSTATU- OTH- TORYLIMITS ER ANYEMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE B OFFICERIMEMBER EXCLUDED? 0 816 C 17-7-0 5 0 9/0 8/0 7 0 9/0 8/0 8 E.L.DISEASE-EA EMPLOYE $ 100,000 Ifyes,describeundeF SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO Town of Barnstable DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL10 DAYS WRITTEN Building Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Barnstable, MA IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R PRESENTATIVE cy ACORE2 (2001/08) ©ACORD CORPORATION 1988 r aF r Town of Barnstable Regulatory Services 9 zr� Thomas F.Geller,Director 4, ,a�4 �� Building Division QED MAC( TomPerry, Building Commissioner 200 Main Street, liyaunis,MA 02601 www.town.barnstable;ma.us Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This Section If Using ABuilder ✓;.� ,,,,,r ,w Owner of the subject property hereby authonze:_ i '( FLto-act on mybehalf; in all matters relative to work authorized by this building permit application for, (Address of Job) —�Jf / Date Signature of Owner . . Pi7nt�lame ' Board of Building Regulations and.Standar& License or registration v lid for individul'use o HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of BuildingRegulations and Standards Registrabont110485 g Expiration w1OL20/2008 One Ashburton Place Rm 1301 Type DBA Boston,Ma.02108 d GROVER&MCELHENY BUILDERS STEVEN McELHENYr it 523 MAIN ST COTUIT,MA 02635 Deputy Administrator Not valid without signat e —� The Commonwealth of Massachusetts in; Department of Industrial Accidents Office Of UNCStlg8Cl0ns 600 Washington Street, 7`h Floor Boston;Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical/Electrical Contractors �,,,.lica : � for�na#ifl 4: �- � :, °' lei e � _re •� - i name: q iTt:vZr4 cZ_L Hi!r4 Y -jSL,t t_7>Z 2s address: -,�c>ie `EG o city e a K state: &A zip: O-"34 phone# 4'1 _ �9&2- work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole ro rietor and have no one working in any ca aci y. ❑Building Addition ❑ I am an employer providing workers' compensation for my employees working on this job. 77 coin any name :• h t f L Y J f .. ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractorslisted below who have the following workers' compensation polices comaanv-na'ine. ' Cites nlione# insurance.Co. s oLc j#, 77 address r : . , z r - c5ty alone-#. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains a penalties of perjury that the information provided above is true and correct- Signature it—c Date z 4 f O' Print name 9 t E`/�,rJ �"c,�LPi k�� Phone# L*?.Z 9►�,-A- official nly do not write in this area to be completed by city or town official : permit/license# []Building Department ❑Licensing Board . immediate response is required ❑Selectmen's Office❑Health Departmenton: phone#; ❑Other 03) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. _�, . As il i NMI .�: The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 N a o-03 pftr+Ero Town of Barnstable *Permit#_ Expires 6 months from issue date „AM SrABM : Regulatory Services Fee M"SMS +q Thomas F.Geiler,Director �A 1639. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 X-PRESS PERMIT Office: 508-862-4038 Fax: 508-790-6230 MAY 2. 0 2003 EXPRESS PERMIT APPLICATION - RESIDENTUL ONLY Not Valid without Red%Press Imprint I UVVNF 13ARNSTABLE Map/parcel Number Q3 0-zZ j Property Address CZ % ' t �c� Co 1 Residential Value of Work I S� Owner's Name&Address 'e^ s 7> Contractor's Name �-,rwev r l�e j e� a ., Telephone Number 47 G Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 6 4-7 693 Vorkman's Compensation Insurance / Check one: ❑ I am a sole proprietor ' ❑ I am the Homeowner _ ❑ I have Worker's Compensation Insurance tt Insurance Company Name �c�.�e s Workman's Comp.Policy# c vZ 0 3Gd - n Permit Request(check box)' ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) �. . Re-side, 0 Replacement Windows. U-Value, (maximum.44) ti Other(specify) *Where,required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation;etc. ***Note: Property O er must sign Property Owner Letter of Permission. Signature' _ Q:Forms:expmtrg Revised121901 AW SZ, °F1HE,° Town of Barnstable Regulatory Services " sn MASS. " Thomas F.Geiler,Director y nsnss. �' o°ATFD MA'I lk Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, le,.., ' V � -Owner of the subject property hereby authorize C� c v •Z �` L t-11: t J to act on my behalf, in all matters relative to work authorized by this building permit application for: f Z i71 -4 (Address of Job) Signature of Owner Date Print Name Q:FORMS:O W NERPERMIS S ION orb Expirg,6,nonurr1,�..... ... Regulatory Services Fee "t" .P6 Thomas F.Geilu,Dhvictor A ire?a�.e Arf° Building Division Peter F.DIMatteo, Building Commissioner 367..lain Street, Hyamms,MA 0Z601w ' Office: 508•862--n38 Fax: 508•7,90-62?0 EXPRESS PER TIT APPLICATION RESIDENTTAL ONLY Not Valid without&d X-Frm ImP*It .lap: arcel Ntunber Pr erry Address [Z +�� ry��1 �"C,> (?a I u'— Residential Valueofwmt Owner's,N=c&address e H iE, 5 T-v j? Z 7-N Contractor's 1\'ame Telephone Number Home improvement Contractor license (if applicable) i [ti 4�% Construction Supervisor's License=(if applicable) QWoriaaan's Compensation Insurance (Neck one: Q I am a sole proprietor PR 10� ri tam the Homeonmer I have Worker's Compensation Insurance NN f.. insurance Company Nam ,�O` ,; e S ve v S fi �4 .K�� Worlanan•s Comp.PolicY. ;' ®0 0 0 Permit Request(check box) 1 [j Re-roof(stripping old shingles) Re-roof(not strippia-m Going over existing layers ofroof) N B T Q Re-side ri`.. ❑ Replacement Windows. U•Value (tIzIXI=Tm•44) -Other(spccif})- *Where tequired: Issuance of this permit does not exempt conviia=with other town deparv=t regularions.i.e.Historic.Conservation. Sienature C Q:Forms:ejvmtrc:rev•+17060 I