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Home My WebLink About0140 SHELL LANE �� v Sl��1 �� - � ` �. I "a Town of Barnstable ' *Permit# i Expires 6 months from issu date cf ®,4 gulatory Services Fee - b ANIS ®, Thomas F.Geiler,Director Building Division o rry,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 [ap/parcel Number b 1 roperty Address Vesidential Value of Work '— Minimum fee of$25.00 for work under$6000.00 iwner's Name&Address butractor's Name / � � Telephone Numbe :ome Improvement Contractor License#(if applicable) 's-License-#{if-appfimble) ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor , VIthe Homeownere Worker's Compensation Insurance isurance Company Name Torkman's Comp.Policy# opy of Insurance Compliance Certificatt must be on file. -miit Request(check box) A-R`e-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/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 sign Property Owner Letter of Permission. A cpppy of th ome prove nt Contractors License is required. [GNATURE: Fonns:expmtrg rvise061306 AC® CERTIFICATE OF LIABILITY INSURANCE DANH' a os/`tea 0 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Child-ftnamse ins. Agey.. Inc. HOLDER.THIS CERTIRCATE DOES NOT AMEND,EXTEND OR 60 Temple Place ALTER THE COVERAGE AFFORDED BY THE POUCMS BELOW. Boston MR 02111-1306 Phone:617-350-5511 rax:617-350-5522 INSURERS AFFORDING COVERAGE NAtC# wig WSURER.A: NORNrOLt & DEDXM INSUMCE 23965 INSURERS. Travelers Ins. Co. James Danforth WSURERC: P.Cotmuitax 9 MR 02635 nasuREao INSURER E_ COVERAGES THE POLICIES OF INSiTRANGE usmo BELOWRAVEBEEN msuEo TO THE wwRED wj&OABOVE FOR THE POLICY PERIOD I NDWATED.NOTNUTHSTANDINO ANY REQUIREMENT,TERM OR CCNWMOiN OFANY CONTRACTOR OTHER OOCUfo W WRH RESPECT.TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGV--ATE LUTS SHOWN MAY HAVE BEEN REDUCED BYPAtD OA MS. We FOLWY L7R USAN TTPE OF INSURANCE POLICY NUt DATE DAW4umr Lam GENERALUABL"Y EACH OCCURRENCE S 500,000 A X COMMERCUALGENERALMMILOY R023377 01/01/07 01/02/09 PREARsEs ft accurwrA S 50,000 CLAM MAW MX OCCUR MEDEXPON40epe150e) S 5,000 PERSONAL i ADV INJURY $ 00 RAL AGGREGATE $1,000,000 GENE AOOREDATEUMR APPLIES PER; PRODUCTS-COWMPAW S1,000,000 POLICY T'Rr M LOC Au7na OBILI LIAWTV COMBINED BINDLE LIMIT S ANY AUTO (Ee 8IMMOM ALL Otl WOALITOS BODTLYTRJURY $ SCHEDULEDAUTOS (Per 09 9on) HRREO AUTOS BODILY INAW $ NON•1INNEDAUTOS O'sS PROPERTY DAMAGE (Par ctwert) S GARAGE UABUM AUTO ONLY•EA ACCIDENT S ANYAWTO EAACC $ OTHER THAN AUTO ONLY: JIM S EUVISAISIBRIMMUABUlY EACH OCCURRENCE $ _ OCCUR CLAW MADE AGGREGATE $ $ DEDUCTIBLE S RETENTION $ S WOR COLPEN9071011 kNO XEMKAY UABWW WIN 8 ANYPROPRIETORIPARTNERE(ECURVE GRUS8027AOSIOS 09/28/06 08/29/07 E.L.EACHACCIow $100,000 OFFICERMEMBER EXCLUDED? E.L.DISEASE•EAEMPLOYEE1 S TOO,OOO pra�+�4 E.L.DISEASE•POLICY Lur s 500,000 DINER . VESCRFTION OF OPERATIDNBILOCATIMIVEN6CLE3/ EONS AWED BYSIDMI8EIIIIETIT1SPE I1LPR59"s CERTIFICATE HOLDER CANCELLATION 1000C-1 SHOUW ANT OF 7HE ABOVE DESCRIBED PWCMS BE CMeaLEO MORE THE PJDIRATION DATE THEREOF,THE ISBRRMNG IN9uRER vmL EwEAVOR Ta TAAIL 30 DAYS WRITTEN NOflCe TO TI#CER7I"'M HOUNM NAW TO W LEFT,BUTFAILWiE T0 OQ SO IIWI I 140 SH T-NM NTINX mmasENo onuzAT10N oR uAsuri aF AMY Km uPOH THB iNsuREB,TTB AOENTs oR 60 SHELL L COTUIT HL 02635 REPRIE11ENTAVE& Au iNE ACORD 25 J2001108) 0 ACORD CORPORATION 1988 Board of Building Regulation and Stards HOME IM,P.,ROVEMENT CONTRACTOR Registration 114813 ; E I • I;xPiratiorr 10/27/2007 �` �BA � JAM ES D DANFQR_H REMOD JAM �._ ES DAhFORTHt 1105 OLD POST COTUIT, MA M35 Administrator The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations ' 600 Washington Street . Boston,MA 02111' V�Ow-mass.gov/dia ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers' Applicant Information Please P ' t Le 1 �. Name(Business/Organization/Individual): ' •Address: � , City/State/Zip: c r 4 Phone.#: Are you employer?-Check the appropria a boa: :Type of project(required)*- L-V4 am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time),* • have hired the sub-contractors, 6, ❑New construction . 2.Q I am a bold.p'roprietor or partner- . listed on tt►e'attached sheet 7. Remodeling ship.and have no employees These sub-contractors have g, ❑Demolition:. 'iyorking.for me in any capacity. ,. employees and have workers' [No workers' comp,insurance comp,insurance.$' 9. ❑Building addition . required.] 5. ❑ We area corporation and its 10.❑•Blectrical repairs of additions � ,-- - •3-Q I am-a homeowner•doing-all•work�:-- ----officers-have exercised their- 11:❑Plumbing repairs or additions - myself:[No workers' comp, right bf exemption per MGL insurance.required.]t c. 152, §1(4),and we have no 12, . ofrepaizs . employees,[Nb workers' .1. . Other comp,insurance required.] *Any applicant that checks box#1 must also fill Qut 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 anew affidavit indicating such. Icantraators that check this box must attached M' additional'sheet showing the name of the Sub-contractors and state whether arnot those entities hava employees. If the sub-contractors have employees,they must providb them workers'comp,policy ntanber. lam an employer.that is proviiiing workers'compensation insurance for my employees. Below is the policy and job site': information. Insurance CompanyNa�:ie: -� Policy#or Self-ins.Lic,#; :42. Expiration Date; Job Site Address: City/State/Zip; Attach a copy of the workers' co pensation policy declaration pacre'(shovYing the policy number and expiration date). Failure,to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine tip tb$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP PPORK,ORDER and a fine of up to$250.00 a day against the violatdr, Be advised that a'Copy of this statement maybe forwarded to the.Office of Investi ations.of the b for insura ce covera a verification, I do hereby certi er the poi n nalties of jury that the information provided aho-y is true acid c erect Si tore: - • Date; Phone# Official use only. Do not write in this area,tb be completed by,city or toxin 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#: 1R1Ur1IAUUU.0 'URU Jun u- Uu6.1t.➢na - - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of bite; 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." TZGL chapter 152, §25C(6)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%n the commonwealth for any applicant who has not produced,acceptable evidence of compliance with the insurance coverage required." . Additionally,MGL ehapter.152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into an contract for,the performance of public.work until aceeptab}e evidence of eo3npha�sce�githtbe in gran e' Y , requirements of this chapter have been presented to the contracting authority,.'t Applicants r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-conti:actor(s)name(s),address(es)and phone number(s)along with their certificate(s) of , insurance. Limited Liability,Companies'(LLC) or Limited Liability Partnerships(LLP)with no*employees other than the members'or partners,are not required to carry workers'.compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 pemut.or license is being requested,not the Dapartment 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. Self-insured companies should enter their self-insarance license number on appropriate'line, City or Town Officials 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/li.cense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information,(if necessary)and under"Sob Site Address"the applicant should write"all-locations in._(c%ror town)."A copy of the affidavit that.has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e, a dog license or permit to bum leaves-etc.)said person is-NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance.for.your cooperation and should you have and questions, please'do not hesitate to give us a call TheDeparlment's address,telephone-andfaxnumber:. The Gan=,:AWWth OfMAMCUS8,ds Dtpartmtnt of hdusWaI Aeccts . Office Of lmvestaaozs • • ' �� hi� �t€eet ' =,MA 02111 TO.9 Hai 7-'27 00 ext 406 Or 1-977-M.ASSAFE Fax#617-' 7-77.0 Revised 11-22,06. WWW,ma .&6V'/din ESTIMATE James.Danforth P.O. BOAC 873 COTUIT, MA. 02635 (508) 420-5131 Robert Balentine 140 Shell Lane COW, MA. October 14, 2006 Work to be completed on entire Remove the existing roofing shin j ese and garage roofs as follows. Install 8" aluminum drip edge. g lns#all i-Wabd water s Weld 3ft, up onto the roof, also in valleys. Inst��I �j��)b. felt paper over the roof sheathing.Install a 30- eathing. y year Architectural type. roofing shingle, using Certainteed Woodscap type i`'l 04 Install new vent pipe flashing, e House and shrubs Will be covered with tarps while work is i a Remov l of rubbish. Material and labor$7,580.00 n progress, ra cost of$360.00 if a ridge vent is installed on all the roof peaks. G ceptance of Proposal: Signatute: to of Acceptance: -L�_Signature: . The Commonwealth of Massachusetts Department oflndustrial Accidents ' - Office of InVestigafions ' 600 Washington Street Boston,MA OZIII' o , www.mass.gov/din ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl �. Name(Business/Orgamzatiowhdividu.al): Address: City/State/Zip: c Phone Phone -� � T / Are you mpjoy.er?•Check the appropria a bog: :Type of pioject(required); . I V.1am a employer with 4, ❑ I am a general contractor and I employees(full aud/oz part-time).*• have hired the stab-contractors 6• ❑New construction 2.❑ I am a'sole.proprietor or partner- . listed on the.attached sheet 7. ❑Remodeling ship,andhave no employees These sub-contractors have g, ❑Demolition. Vorldng,for one in any capacity, employees and have workers' 9, Butidin' addition [No workers' comp,insurance comp,insurance.$' 0 g. required.] 5. ❑ We art;'a corporation and its 10,013lectricalrepairs or addition, -have exercised their officers , 11:❑Plumbing repairs or additions myself,[No workers comp, right df exemption per MGL 12 of repairs. insurance.required.]t A. 152, §1(4),and we have no employees, [No workers' ..111n Other ' comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below sbowmg their workers'compensation policy information. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors mutt submit a new affidavit indicating such, #Contractors that check this box must attached an additional sheet showing the name of the pub-contractors and state whether ornot those entities have employees. If the sub-conhactors have employees,they must providb them workers'comp,policy number. I am an employer.fhat is providing workers'compensation insurance for my.employees. Below is the information. policy and job site'00,17 Of ' -� Ar Insurance Company Nabme: Policy#or Self-ins.Lie,#: Expiration Date: Job Site Address: ' City/State/Zip;-�� f Attach a copy of the workers' co p6nsation policy declaration page' showin the policy number �b ( g p y and expiration date); Failure,to secire coverage as required under Section 25A,ofMGL c, 152 can lead to the imposition of criminal penalties of a fine up tb$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'cagy of this statement maybe forwarded to the.Office of Investi atiom of the 1)1&for-insurance-coverage verification, ' I do hereby certi er the.pai n .. nalties of . jury that the information provided ahoy is true acid c rrect. Si afore: Date; Phone#: �- Official use only. Do not write to This area,to be completed by,city or town offictai City or Town:' YernOLicense# . Issuing Authority(circle one) .1.Board of Health .2,Building Department a, City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: . .Phone#: ,