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Home My WebLink About1083 OLD STAGE ROAD 1083 ol�S�c.P as� � 3))9A7 JAI G � P Town of Barnstable. *Permit �� Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division PSRMin Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 TI,�®®i www.town.barnstable.ma.us Office: 508-862 I Fax: 508-790-6230 E - S APPLICATION - RESIDENTIAL ONLY =TOWN Ulp Not Valid without RedX-Press Imprint Map/parcel Number Property Address In e5 �a esidential Value of Work 'RSc= ) Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Pb►Nv Iuo 1 1 Via Contractor's Name ✓w�0 YL.-AV Telephone Number-Sb -*7->S &1.7M— Home Improvement Contractor License#(if applicable) 1114644 Construction Supervisor's License#(if applicable) b a QP%l orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name '-Wau►e!v✓ S workman's Comp.Policy#• 1 7��, �/4T�� Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to 5? ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of ome Vent Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 ALI 6 SSE & GARAGE TOTAL INVESTMENT 19 .00 Payable immediately upon completion. `;;� POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra at the Rate of$ 50.00 per Hour Plus Materials Plus 20% Overhead Mark-up on the Total Extras. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt. of Deposit providing the Materials are Available. Please Make Checks Payable to: CHARLESCOREY COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years and then on a pro-rated basis for 30 Years Total if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a 70 MPH WIND WARRANTY. CERTAMTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above specifications;will be executed only upon written orders and will become an extra charge,over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work.. This proposal may be withdrawn by us if not accepted within thirty days. COREY & COREY carries Work-man's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ^ ( 7 ACCEPTED BY: SUBMITTED BY. LAIC ��OAAW CE I�'McENEREY CH LES E HOMEOWNER. COREY fie �anvrnoniueai o� «c�ivaek$ Board of Building Regulations and Standards License or registration valid for individul use 9nly HOME IM.1;20VEMENT CONTRACTOR before the expiration date. If found return to: �, Board of Building Regulations and Standards Registrati'Nn. 36066 One Ashburton Place Rm 1301 3ro�— 6008 Boston,Ma.02108 •Ff - :;OREY&COR R CRY, EMENTS CHARLES COR I — 1684 FALMOU valid without signature CENTERVILLE,MA 02632 Deputy Administrator I ` I JUN-23-2006 00:25 FROM: TO:16e00362017- _ ACORD CERTIFICATE OF LIABILITY, INSURANCE106/22/2006SLOE "Eimmmtvtvv" `" wtoauecR S19 MUM AS A MATTER OF INFORMATION SCHLEGEL 6 SCHLEGEL INSURANCE ONLY AND CONFERS NO RIGHTS UPON 'INE CERTIFICATE HOLDER. THIS CERTWICATE DOES NOT ANAND, GXWM0 OR ALTER THE COVERAGE AFFORDED 13Y THH POLICIES BELOW. 34 MR= STREET ATE 28 REST YARMODTS, ba 02673 INSURERS AFPORD=COVERAGE NAIL* NORTBLAND INSURANCE _ Paul Bnckmiller Isawts-TRAVERLERS — DBR SUCMILLER ROOFING UI'u7ll3R D: i . Hyannia, M 02601 ussl,�tee COVERAGES THE POUCIE0 OF INSURNNGE LISTED BELOW HAVE SEEN ISSUED TO THE :N3URED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOrA:nfTANOING ANY RFMLMEMEW). TERM OR CC`NDMON 0s• A%F! CONTRACT OR'QTHER DOCUMENT 'AM RESPECT TO WHICH THIS CERTIFICATE MAY EIr ISSUFM OR MAY PEFZAIN. THE INSURANCE AFFORDED SY THE POLICIES DESCRIEED HERON iS SUBJECT 70 ALL THE TERMS, EXCLUSIONS ^0 CUNDITICr4s OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -r.....'-..�..._. �`1�Pd LAY VJiICY EfIrtA7101s I LTA;sxslen 71HEOr'EIQi,REAAYE �- POCA:rNui1lTEK DATE sNAA1ol t>#sF.(IIWOE'/YY) Lmm - -' UABU CP46895 r M 05115/06 05/15/01 s1,000,000 n i x coauro cw rani uuTf I I i --� ---- i s SO,OOO csnA Avg l'�i o�xw f rNErie�y�y ma w nor rt s EXCLUDED — 2,000,000 _ _ I GENERALA36REOATE e2,000,000 -Earl lho"e ATB UENY apFusA PWL FROOUCTS COAIPMP AGG ls2,000,000 r- PRO SAC ( ---- POCKY gC� !UTI*000UA U" _ �- � COMBMI®Et.4tCIECNAR I ANY Auto (�actlAaot ALL OYYtED AUMV BO!»L,r 44AJfiY — 17 SG£OtIIIDAItEOG I(P.ww) 5 sUREO AUT08 !IPA s t -- I —--- nomm FROFUM`AAMM $ imw gem" CAR"&NAILM I AUTO OMY_EA AWMW I i ANYAWO dtTER T1tiN1 EAACC I Auto M&Y! aEseAA,EmteLLA uAszm xwR C1NN5YAL PL9(iREGAT -- I -- omwne� i s I �— rtLTs3amn B YYdE(EASCOYPf"ATM AM �04/11/07 X TORYLiifT3 8i t�rLATTEWuNa+m EL FACMACGOENT s100,000 ANYFTEOFRIBTMI/iHiTNER�GUtNt: I _ ________ _._ oFaccR+oaasR E>,cwoEr e.�OIOEAX•Fr>*AAYM— ,s 100,000 tl Vas doom umf -----'---- sPSMILPROUISQNSDefarY$tT I IEl-DISFASB-POUCYUM.r s500,000 OTNEA VMRWTM0FCFtMTRi. ILMAY11"iYEHLI IUVIJBOIA A0m EYEMJOIt BNWl.'KVALFRC1fl/wM PAUL ZUCIQ4XLLLR IS ExCLT11-0 3740I CCVL*ItABE MER THIS Wi1MRS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION CORBYiCOR1CY Y — wruw ANT OF ne Aft FUA�a Ew CA�a�+ rarawe r,� mewAmi+ 1994 FAIA4DUTH RD PATE 7f pmw. Tm maLwo ee8tsR6P vts1. C3i)fiAVOR To MA►21 t:" vffjTTm CF,NMRVILLE ,NA 02632 NOTM TO THE CEII'RG"E slntDEx to w lFit. em FAMM TO oO SO suau . Npou NO 091JOATAN OR 4A8i.ElY 4eIY MpIR U?ON TW DO M L Ro MAMM OR FAX 508-457-7790 R/�IR30RA AVtElOTttlFD !?3VTAliYB . Ill The Commonwealth of Massachusetts Department of Industrial Accidents _ W Office of Investigations a a 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): . awk y f Address' 11,4 V asev7� 4tL City/State/Zip: C yr c. Phone.#: l Are you an employer? Check the appropriate bog:i Type of project(required):. 1.❑ I am a employer with 4• �/ a general contractor and I ,. 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. 1/7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P t3' t, 9. ❑Building addition [No workers' comp.insurance comp,insurance. required.] 5. ❑ We are a corporation and its. 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work of have exercised their,' l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 Q4Loaf 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have . employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. ` Insurance Company Name: i $ Policy#or Self-ins,Lic.#: 7�y�( _�1 VACA7'-O is t Expiration Date: /� Job Site Address: (�n dip �� 'f � City/State/Zip: C . ,A:lk e 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 cedI&under the pains-and penalties of perjury that the informa l n provided above is true and correct. Si ature: Date: Phone#: 7 F Official use only. Do not write in this area,to be completed by city or town offictaL 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#: Information and Instructions ®, 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 hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal/ti ,ty or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives oY' g eased employer,or the eaeiyer nr trus a dual partnership,association or other legal entity,a to However the owner of a dwelling.ho a having not more than three apartments and who resides ther ,or the occupant of the dwelling house of anoth who employs persons to do maintenance,construction or r air work on such dwelling house or on the grounds or buil appurtenant thereto shall not because of such'e`mpl0* ' ent be deemed i6 be ar employer." MGL chapter 152, §25C(6)'als states°that"every state or local licensing age shall.withhold the issuance or renewal of.a license or permit operate a business or to construct buildi . s in the commonwealth for any applicant who has not produced cep table evidence of compliance with a insurance coverage required." Additionally,MGL chapter 152, §2 (7)states"Neither the commonweal nor any of its political subdivisions shall enter into any contract for the perform nce of public work until-acceptabl evidence of compliance with the insurance requirements of this chapter have been esented to the contracting auth Applicants Please fill out the workers'compensationVaffidavit it completely,by ecking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name( resses)and pho number(s)along with their certificate(s)of insurance. Limited Liability Companies( r Limited Liab' ty Partnerships(LLP)with no employees other than the members or partners,are not required to ca rkers'compe anon insurance. If an LLC or LLP does have employees,a policy is required. Be advis � 's affidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance c . so be re to sign and date the affidavit. The affidavit should be returned to the city or town that the apn f. the pe t.or license is being requested,not the Department of Industrial Accidents. Should you have anons gar g the law or if you are required to obtain a workers'compensation policy,please call the Depaat the ber listed below. Self-insured companies should enter their self-insurance license number on the appr line. City or Town Officials 5 Please be sure that the affidavit is complete'and printe egibly. The Department has provided wspace at the bottom of the affidavit for you,to.fill out in the event the Offi of Ines ations has to contact you regarding the applicant. Please be sure to fill in the permit/lice nse number w h will'be us as a reference number. In addition,an applicant that must submit multiple permit/license applicano in any given ye need only submit one affidavit indicating current policy information(if necessary)and under"Job S' Address"the app "`ant should write"all.locations in city or town)."A copy of the affidavit that has been offid y stamped or marke by the city or town may be provided to the applicant as proof that a valid affidavit is on file f r future permits or lieens A new affidavit must be filled out each year.Where a home owner or citizen is obtainin a license or permit not relat to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) id person is NOT required to mplete this affidavit. The Office of Investigations would like to tha you in advance for your cooperati and should you have any questions', please do not hesitate to give us a call. The Department's address",telephone-and fax tuber: , .The C rnmonwealth of Massavhusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 0.2111 Tel.##617-727-4900 ext406 or 1-877-MASSAFE Fax##617-727-7749 Revised 11-22-06 www mass.govldia