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Home My WebLink About0496 PUTNAM AVENUE 1�".y1 r ,,11 L f � � V� ��.� � �/ t Town of Barnstable *Permit D`'D° 63 Expires 6 montlis from issue date 'PRESS PERMIT Regulatory Services Fee_1�2?5� O C T — 4 2007 Thomas F.Geiler,Director Building Division TOWN OF BARN STABLE. Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 0 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 � 11 ❑Residential Value of Work�D� �('�� Minimum fee of$25.00 for work.under$6000.00 Owner's Name&Address ZQw�&p Contrac.tor'sNameTi,�a EL ��` Telephone Number Home Improvement Contractor License#(if applicable)/ t� 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 �cL W orkman's Comp.Policy# 7 Q I ( cJ CI (o ( �(2 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) [ } Re-roof(stripping old shingles) All construction debris will betaken to L- c�j�LLA ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must ' Property Owner Letter of Permission. me provement Contractors License is required. SIGNAT Q:Forms:expmtrg Revise061306 ell Commonwealth ofMassachusetts Department of Industrial Accidents Office 9f Investigations 600 Washington Street Boston,MA 02111 wwwanass.gov/dia Workers"Compensation Insurance.Affidavit: Builders/Contractors/.Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/organization/Individual):, 'Z Address: Y; 7 City/State/Zip: L/_ Phone.#: 67 i�t( Are you an employer? Check the appropriate bog: -Type of project(required):. 1. I am a employer with -�— 4. ❑ I am a general contractor and T employees(full and/or part- have hired the sub-contractors 6• ❑New construction . 2..❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity, employees and have workers' [No workers' comp,insurance comp.insurance. #• 9. ❑Building addition 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. (Contractors that check this box must attached an additional sheet show ing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below isihe policy and job site information. Insurance Company Name: mac/ Policy#f or Self-ins.Lic.M SIC./L 3tC) l(QY 01 LrQ Expiration Date: Job Site Address: /5 L c e A7_4Tiv�_City/State/Zip: Q4 >C(-) Attach a copy of the workers' compensation policy declaration 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 tip 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: p altie ofperjury that the information provided above is true and correct: Sienature: Date: Phone #: L Official use only. Do not write in this area,'tb be completed by city or town qffllciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4, Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: L �of oho : Town of Barnstable Regulatory Services # a + BAFiNSTABLE, • 9 MASa $ Thomas F. Geller,Director Alen a,$ Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 "v W.town.barnstable.maxs Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section if Using ABuilder I, :90 1y p L7(� �`� �'�� , as Owner of the subject property herebyauthorize �TF:� i -to act on my behalf, in all matters relative to.work authorized by this building permit application for: . CU (Address of Job) Signature of Owner Date Print Name QJ-0R_MS:0WNERPFRMIS S I0N T r/1�nn,f /� r 11� a n ( {,1 ui�c �,`el ± _f: alto �1��! One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home lmprovemer.�tContractor Registration _ Registration: 120362 - Type: DBA _. Expiration: 11/30/2007 PETER FIELD BUILDING & RESTORATION. PETER FIELD - - -- - P. O• BOX 16 COTUiT, MA 02635 _ Update Address and return card-Mark reason for change. Address i Renewal Employment ;:= Lost Card )PS-CAI C, 5011-04104-G10i216 _. -• - — - [3h'�i`f {f�Qi �ri�q$i �Ytfi�r$if5`i+ License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: `- Board of Building Regulations and Standards Registration: 120362 One Ashburton Place Rm 1301 •� Expiratio0:-11/30i2007 Boston,Ma.02108 Type:e• DBA PETER FIELD BEIILDING&RES:TO WIW FIELD p. 857 MAIN ST. -- --- -- ---- COTUIT,MA 02635` Administratnr of valid without a ' Bo dEoildfb�'$t"itgUfntions�rid13i'rfa'r'ii's — 1 • -` Construction Supervisor License License: CS 65638 Birthdate 7/15/1965 y Expiration 7115/2009 Tr# 16160 01 Restriction: .1G _ PETER D FIELD PO BOX 16, COWT,MA 02635 Commissioner V / ( OtkQC((.60 1 vv"� 10/04/290T 10:46 FAX 5084283068 GER9IANI INSURANCE 1?j001 . . _.m•, r.ma>tiiplI aI I.,i.II,4rh,..M,'G,' I a. r 4wig-jil: "D/Y Y)10(/M42007 ACORD e _1 u i, ? 1: i PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 908 MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OSTERVILLE,MA 02655 COMPANIES AFFORDING COVERAGE COMPANY AIM MUTUAL INSURANCE COMPANY A INSURED COMPANY - •' PETER D.FIELD B _ DBA PETER FIELD BUILDING&RESTORATION COMPANY PO BOX 16 C COTUIT,MA 02635 —•- COMPANY • p HUI ,eJ ,�1(��Q� I '�[ t 1hlll+IJp•nl Imt IIH .fn"r'7t!°°t'ryP;°'Y'p•"'!"•cl'°•'•�:I .L-2 . .!,'1�.F „ .:5 Llk. l'�G.'IGL'(I{TFJ��o ,. ., M� �$. IrJ�1pwfllu�+ � y, �,. I _ 07n IV':`:�•:.:;.t;�'.i:..:, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR 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 6 Y 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. CO TYPE OF INSURANCE POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION LJMITS LTR DATE(MMI IMM DATE(MMIDOIYY) GENERAL UA13 UTY GENERAL AGGREGATE S COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG S —1 CLAIMS MADE U OCCUR PERSONAL 8 ADV INJURY 4 OWNER'S&CONTRACTOR'S PROT I EACH OCCURRENCE $ _ FIRE_D_MIAOE(Any one Rre) S MED EXP(Any one pamn) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S ALL OWNED AUTOS BODILY INJURY 3 SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) S PROPERTY DAMAGE j S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT_ 6 _ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT S — AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE 11 UMBRELLA FORM AGGREGATE f OTHER THAN UMBRELLA FORM S A WORKER'S COMPENSATION AND 'AWC 701199601 04/07107 04/07/08 TOR"AT ' I Ea EMPLOYERS'UABILITY EL EACH ACCIDENT S 100,000 THE PRCPRIEYM H INCL EL DISEASE-POLICY LIMIT a500,000 PARTNER81EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE 9 100,000 OTHER ° DESCRIPTION OF OPERATIONSILOCATIONSIVEMCLESISPECIAL ITEMS 1;, 'h'• }'i) ,�}7 r }.. It ��I '(I,I,��Inyr�� U I'�P'�S:�•":"'; !nfi:.•1.,,p - i','y,!::P' .,.,dLr GELFi c'�C �LI; y3r ?v-pi, j). rls5 ?� _ ��pp�a P, In NH1�ry1d I., �:.'�:. - ._A .�t rt. x I. r+l :.J: �,:a:w$Ly.sh� ��., �.•' ',.�..... .,.. �_.11li{1F11�IY'.tl, .u. irpolilk:�_u:u � ; �aa4c�!� ,. �y I SHOULD ANY OF THE ABOVE DESCRIMED POLICIES BE CANCELLED BEFORE THE PETER FIELD ;RATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY I FAX#: 508-428-1393 OF ANY IUND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES, AUTHO�jF.,p TATI1/5„�� Imo,.,. Y 9r^q•rv'cr?: I �`� I ti�w� _ a •:<I•:}:h,VBL'YiYi�7 t B.t •,._ •.nrlla ,I'.. i::!,! ,�.�.;1•,}Iv.,.:�.yd::k r.:IN 1,IMP1 .I.. VOWFI ,auNT, . .,O .05 ;a4kiII.N.Y::i I • I