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Home My WebLink About0057 INDIAN TRAIL E p r � i gs 'Town of Barnstable *Permit# D gOS 7 sY. Expires 6 months from issue date 00 RAPJqSrAZM Regulatory Services Fee �� Thomas F.Geiler,Director ��® �� 1639� 4��` !` Building Division OCT 2 Tom Perry,CBO, Building Commissioner 4 ZOOS T O�N OF Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us SARNSTMLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �A Property Address dResidential Value of Work LA3-p7 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address_;�011� -c, A Contractor's Name O.- LAAJ Z(L 1�-oai x 9� Telephone Numbe6QS fG0Cf (O t Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 2 Workman's Compensation Insurance ' Check one: ❑ I am a sole proprietor 0 am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 3 UL__'- lS 33 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) L Re-roof(stripping old shingles) All construction debris will be to��,a-,a-,A a= ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. 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. Home Improvement Contractors License is required. SIGNATURE: Q:Fonns:expmtrg Revise071405 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations jn 1 i 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �L, j Address: fc Ciiy/State/Zip: Phone #: A,,re�ou an employer? Check the appropriate box: Type of project(required): 1.-J I am a employer with-L— 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the'sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ? ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 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.] *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 showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below.is the policy and job site information. Insurance Company Name: y - Policy#or Self-ins.Lic. 3 IS S n L( O Zr Expiration Date: Job Site Address: r.).O i t t,_ City/State/Zip: Ce'fJ-,CLJ 1 LLY 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 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 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 under thepains andpenallij ofperjury that the information provided above ' true and correct. Si ature: e� Date: Z3 h Phone#• S D% M-S L4 Ll Official 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#: OLIVER KELLY 9 PEREGRINE LANE ` SOUTH YARMOUTH PH/FAX 508 775 4498 MA. REG.# 128957 MA 02664 INSURED. September 1 , 2006 Proposal submitted to Mr. Joe Casey of 57 Indian Trail Centerville MA. We propose to supply all materials and labor necessary to remove and replace the existing roof at the address above All debris to be removed to town transfer. Aluminum drip edge to be installed on all eaves. Ice and water damage protection membrane to be installed on first three feet of eaves Remainder of deck to be covered with#15 felt paper. 25 year limited warranty 3 Tab style shingle to be installed. (Similar to Existing) Bathroom vent pipe boots to be replaced with new. Cobra ridge vent to be installed on entire length of all ridges with hand nailed caps. Protect all walls, windows, decks, plants and shrubs etc. during roof strip Obtaining of town permit. At a total cost of$3900 For use of 30 year limited warranty architect style shingles add $300 Payment Schedule; 40%with signed contract, balance upon completion. Respectfully submitted, Oliver Kelly Proposal accepted by, - Date ' / 6 /2006 If acceptable,please st" awnd return one copy and keep one for your records. This proposal is valid for 45 days from date above 7711`- n �' _ . Liberty Mutual Group . PO Box 7202 Liberty NH 03802-7202 Mu P T�on(M)653-893 Fax(603)431-5693 May 25, 2006 ' TOWN OF BARNSTABLE 720 MAIN.ST - HYANNIS,MA 02601- RE: Certificate of Workers Compensation Insurance Insured: OLIVER KELLY 9.PEREGRINE LANE SOUTH YARMOUTH,MA 02664 006 Policy Number: WC2-31S-338804-025 Effective: 12281L005 Espiration; 12/28/2 Coverage afforded under-Workers Compensation Law of the following state(s): MA FnDlovers Liability. Bodily Injury By Accident: $ 100,000 Each.Aodent Bodily Injury by Disease: S 100,000 Each Person Bodily Injury by Disease: $ 500,000. Policy.Limits As of this date, the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms,exclusions and conditions, and is not altered by any requirement,team or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of infDrmation only and cm&rs no right,upon you,the certificate holder. This certificate is not an insurance policy and does not amend,extend,or alter the coverage afforded by the a policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such �I .cancellation. AUMORIZED REpREMNI V IVE UB-RTYM=AL NKWAWM GROUP Ttacedfiatiseam§dbyl38ERIYMMALnEURAWMGR=--Pclsmd►i uoeuisa bp�ose.eou ies : Insured.:! ,Producer of Record: cc I ed KELLY SANDPIPER INSURANCE AGENCY INC Onsu 9 PBRT�GRINE LANE• 12 ENTERPRISE 8D HyANNIS,MA 02601 SOUTH YARMOUT$MA 02664 - Al /t e Board o ui ing gula ons an �ads One.•Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Irnprov��t:Contractor Registration Reg)strotion: 128067 Types Individual Eacpiratbn: 0/149007 Oliver Kelly Oliver Kelly -9 Peregrtn' �lone , ----- S. Yermot , MA 02664 „ 1 :,.•' 5 �} 7� �•vt V Address ad rotarn Bard Mark meson for a. ottaag . p Address p ReOP94A1 f! BOMB / M 10181® naw p &mplo =t p IM card V"'WJnoaoeA Was euphASCI 0 Aft JOA){0 J, J I �0006 .... ,,..,. Lp®684 tuoq�rgoteosy a0131�tNOO.LNI9W8Ap8tetNN WON a gm"pum pap on e146g palpoonJo ping