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n oFt�.� Town of Barnstable S6_ 2�
Expires 6 months f e issuaide
Regulatory Services Fee
'* BARNSTABLE, +�
v� '"'39'1639. Richard V.Scali,Director
�0
Arfp�rA
Building Division
Tom Perry,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
Map/parcel Number 207-131
Property Address 180 Horseshoe Lane Centerville, MA 02636
®Residential Value of Work$ 6,000 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Phil Brescia
180 Horseshoe Lane Centerville, MA 02636
Contractor's Name Fraser Construction Telephone Number 508-428-2292
Home Improvement Contractor License#(if applicable) 112536 Email: office@fraserconstructioncapecod.com
Construction Supervisor's License#(if applicable) 097668
❑Workman's Compensation Insurance z4ft A O
Check one: $41
[II am a sole proprietor
❑ I am the Homeowner Qp
® I have Worker's Compensation Insurance Nov
IU
WN
Insurance Company Name Granite State Insurance Company or tfARNS
Workman's Comp.Policy# 009-93-0601
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ 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
® Replacement Windows/doors/sliders.U-Value _28 (maximum.32)#of windows
#of doors: 2
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*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:
C:\Users\Decollik\AppD�ta oLmictoseft\ indows\Temporary Internet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc
Revised 040215
The Commonwealth of Alassadausetts
VJ
Depaphnent of 1•rulristrial_AccidentsOffice of Investigations
bQQ Washirrgt�vra.street
Boston, 02111
warn%mass gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/FlectriciansTlumbers
Applicant Information Please Print Legibly
Name(BusinEftD1gauiz3t1Gw ndividnal): Fraser Construction
Adds : 31 Bowdoin Road
City/State/Zip: Mashpee, MA 02649 phone:47 508-428-2292
Are you an employer?Check the appropriate box: Type of project(required):
L❑x t o 4. I am a general contractor and I }� l�l { ' �=
I am a employes with ❑ g 6- ❑New construction.
employees(foil and/or past-time).s have hired the sub-contracton
2.❑ I am a sole proprietor or partner-- listed on,the attached sheet. 7. D Remodeling
ship and bane no employees These sub-contractors have g. ❑Demolition
w for me in an capacity. employees and have worms'
�€ y � tY- Y 9- ❑Building addition.
[No Ti1i insurance workers'comp.insance comp.insurance.
required] 5-❑ We area corporation and its 10.0 Electrical repairs or additions
3.❑ I ama homeowner doing all work oflioers.have exercised their 11.❑Plumbing repairs or additions
myself.[No workers'comp_ right of exemption per MGL 11 E]Roof repairs
insurance required.]1 c.1.52,§1(4),and we have no
employees.[No workers' 13.0 Other
comp-ins ratim required.]
*Any appficait that checks box#1 also fill out the section below showing their workers'compensation policy infarmatian.
1i^H�omeowners who submit this afl6dmf mating they are doing all work and then hue outside contractors must submit a new affidavit indicating sucb_
tConnucturs that check this box mast attached an additional.sheet showing the name of the sub-ctiltt[murs and state whether or-not those entities bar' -
emp"es.If the stth-contractors bave employees;they must pmvide lheir warkeW comp.policy number.
I am ail employer that isprotfW&g worka:rs'coulpertsation insurance for holy employees: Barlow is the policy and job site
informadom
Insurance Company Name: Granite State Insurance Company
Policy#or self-ins.Lfc.#: 009-93-0601 Expiration hate: 09/26/15
Job Site Address: 180 Horseshoe Lane CitylState/Zip: Centerville,MA 02636
Attach a copy of the workers'compensation policy declaration page(shoving the policy Dumber 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 andlor oche-year imprisonment,as well as civil penalties in the.form of a STOP WORK ORDER and a fie
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 insmmce coverage verification.
I do hereby ndpenalties ofperjury that the information proiRded ab is bw nd carrect
Si Lure: Date: 0 S7 [I
Phone#: 8-428-2292
Official arse only. Do nat write in this area,to he completed by city or town official
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
GRANITE STATE INSURANCE COMPANY 0103090-00 WC 009-93-0601
13102 -
013-82-0915-50
• e e PENN YLVAN
FRASER CON TRUCTION, LLC A
P.O. BOX 1845
COTUIT, MA 02635-2443
An AIG company
EXECUTIVE OFFICES:
SEE EXTENSION OF ITEM 1.OF THE INFORMATION PAGE- WC9906111i0 175 Water Street
New York, NY 10038
I.D# 0001 0646 MA UI#: PRODUCERS NAME AND ADDRESS
KEATING GROUP INC THE
WORKERS COMPENSATION AND EMPLOYERS 144 TURNPIKE ROAD
LIABILITY POLICY INFORMATION PAGE SUITE 150
UTHB GH MA 0 2-00 0
INSURED IS PREVIOUS POLICYNUMBER
LIMITED LIABILITY COMPANY RENEWAL 0099 0601
OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE- WC990610
ITEM 2 POLICY PERIOD 1291 A.M.standard lime at the insured's
mailing address FROM: 09/26/15 To . 09/26/16
ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the polity applies to the work in each state listed in item 3A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ Sao.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH
NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI WV
D. This policy includes these endorsements and schedules:
SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE- WC990612
ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. -
All information required below is subject to verification and change by audit.
Premium Basis Rate Per Estimated
Classifications Code Number Total Remuneration S1000Fite- Premium
OAnnual❑3Y r muncratlon Annual ❑3Year
SEE EXTENSION OF ITEM 4.OF THE INFORMATION PAGE- WC77S4
TAXES/ASSESSMENTS/SURCHARGES
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE)
MINIMUM PREMIUM OO MA TOTAL ESTIMATED ANNUAL PREMIUM
if indicated below.interim adjustments of premium shall be made:
Semi-Annually Quarterly El Monthly DEPOSITPREMIUM
08/25/15 PARSIPPANY 82
Issue Date - Issuing Office Authorized Representative WC 00 00 01A
39967(ReV d WOB)
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 112536
Type: DBA
Expirafon: 3/23/2017 Tit 263597
FRASER CONSTRUCTION CO.
DEAN FRASER
P.O. BOX 1845
CO T UIT, MA 02635
Update Address and return card_mark reason for change.
scAI ES 20M-05/11 Address 0 Renewal [-] Employment Lost Card
�/,�u3�p a�dl/��ac/xue%� � •anamzoatw¢a
� Office of Consumer A ffairs&Business Regulation License or registration valid for individul use only
CONTRACTOR before the expiration date. If found return to:YP ' ce o onsumer rs an nessT e: Offif C Affaid Busi Regulation DBA 10 Park Plaza-Suite 5170
it
Boston,MA 02116
FRASER CONSTRUCTION CO. r
DEAN FRASER
104TWINN VIEW LANE �,c,r_=�•.y—
E FALMOUTH,MA 02536 Undersecretary Not valid without signature
9 Massachusetts %bepartment of Public Safety
Board of Building Regyiafions and Standards
C'tinc rui<ti��n Surcrs"i�)r
'License;CS-097668
DEAN C FRASER-`
104 TWINN'vrvii LANE
EAST FALMOUTH MA(6253t
Expiraiti6n.
Commis'-signer 06/0712017 it
I
R
r Payments'accepted are:
CASH-?.CHECK-MASTERCARD-VISA-AMERICAN�EXPRESS ,
*Any payments hot'immediately paid upon job completion will be charged 0'.005%for every day after the
f given 5 day grace�period upon day of job completion.
Possible Extra ,A' -tted'or other ,.lii6'deterioratedttri n boards, plywood sheathing,
._
..:
lead flashing, or other carpentry,�need ii replacementiw lUFbe done and charged for as
an extra at the rate of$110.001per,hour, plus 20%fmark-up materials.
Any deviation or alteration from abo e,specificatiori will be executed upon written
orders and will become an extra charge ovevand 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 s m withdraw this proposal.
9
Work Permit- (Sign Nam give Fra r Co ruct
e) ion
permission to pull a work permit for the work at fie'
(Address)
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