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HomeMy WebLinkAbout0449 OLD TOWN ROAD 9 iF�9-f•' C�y/T/ �.,: vg ����}4 a .:'�� ?:',y �ra5 til+a'�s ��c�.� �e '.':�vn� "#i n�d Z' ,;.� �• i � C�,Y ' �'- T Y n ,i,�.. -. ry 'a.,i 'r;:xt'yam ,. , :'M aa' �xr <y' .ry a C{71 q, ., i. '4 •7, +, .. i a.- l. ris ii ..� .p"�i.:i� 2! .,i2;. �za� -•�' ,� .i� w„ a - ����� Yr k�'Y t r�r� -,..37.: '`�' ,. V` ..�, ,.'„ � �..., ..F` tr °,.r i. ti �+i, .[f. .. .. .. -.Z..,r?�. fr+3 � :.'rk,nt :�� o ��:a.t�" ♦ .3� ''" •�''� W.� � "51 '� �� cr sr.".,^ ; ;.i. �'i;•- G �, '� a n a, e,v�. .� �,,, +.. ,,, '�'`,w �a y., z,. ;t•# � A '� Ga C `�r� ,`e �;:� , M r.�_ 4•,.- .' -''� ''a r'4t.+ ,.� ... .•:... .��� r:a .S'..a,�} � '�, a'•.1.'�.h.":t, .g 1' '�, a*�. ��}. ;i3.. �' ��..".r. .. .., .. �.;..?._•-o r,. �-.,-.�;, _ �..•�_.,'c;'�. ,.. :sf�c5...w.. : R- ��'�:t' G• r. 'i_�:, �r� u. •F ?!�'. .�s}� _ _ �. f " �r'y w i r a , r C ��lzgiItspoe Town 'of Barnstable *Permit# ` • - - Re ulatorY Services 8� Richard ca ,Director��A Rihd V.Sli Dit OCT 15 2015 Building Division TOWN OF BARNSTABLE Tom Perry,CBO,Building Commissioner -200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY N q C Not Valid without Red X-Press Imprint Map/parcel Number Property Address -1 —1 a-Wjr) i00A [ 'residential Value of Work$ C_S�IJ� GVMinimum fee of$35.00 for work under$6000.00 Owner's Name&Address wa Contractor's Name a L e,(y\,Cn Telephone Number Home Improvement Contractor License#(if applicable) 'j�0( `3 Email: fY�'L- Construction Supervisor's License#(if applicable) i(00 Wrkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Lam the Homeowner' I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# `� � 5 !V Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ st(check box) [!Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 1 GV ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders:U-Value (maximum.32)#of windows #of doors: ❑ 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. y of the Home Improvement Contractors License&Construction Supervisors License is. �. •requ red. SIGNATURE: C:\Users\Decollik\AppDa cal\Microsoft\ endows\Temporary Internet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,ALL 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name.(Business/Organization/Individual): M 0 L P,rLycn Address: City/State/Zip: f.=` A Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.03 am a employer with _e�r 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees.(full.and/or part,time). . 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. .❑.Demolition working for mein any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 i:❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. oof repairs insurance required.]t a 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 new affidavit indicating such. xContractors 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. Lam an employer that is providing workers'.compensation insurance for my.employees. Below is the policy and job.site information. Insurance Company Name: Policy#or Self-ins.Lic. En �:)Q Expiration Date: Cs �cl O)d �G��1 Ci ry p: `S Job Site Address: /State/Zi 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. T do.hereby certify u;wins andpenalties of perjury that the information-providedabove is true and correct :Si atur c h Date: Phone#: 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#: ain;euSIs;noq;!tA p!leA;ol\i Us;aaaas�apuf] L09Z0 VW'SINNVAH ,e&4 . AVM SNBH011d 06V NOW31 AbVW z NOW31NUVW vw`uo;sog �[ _== uol;ejld 9TIZ0 lenpinlpu l 9 LOZ/6 L/9 OLIS al1°S-ed�Iagd OT :ad�(1 09M3 :uo!;e�; zel s!6a ao!;eln2ag ssau!sng pug sa!sjjV.Iamnsuo31;o aawo ap1O`d211NOO 1N3W3A0TldWI 3W -:o;ujn;aa puno;;i a;gp uo!;el!dxa aq;a Ioaq Qopg�� �ssamsng�+sneUV aawnsuoO3o aa!gp Aluo asn Inp!n!pur ao;pggn u011811912aj Jo asuaa!Z r Jo'x1val,,ItoIff"i«aA u III Massach Board of us. I _pe Building Re uiati.nt of Public Constructio 9ulations Safety Lice pervicor S and Standards n Su License: Standard�- . CSSL-100207 Po VMo Bpg 423 Wg - ST t ,.. Commissioner Expiration O4/pq�2016 ,a►co CERTIFICATE OF LIABILITY INF10/15/2°ATE`M�D°015 � INSURANCE15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANAME:CT Cristina T. Edmund Garrity & Co. , Inc. PHONE (617)354-4640 A/C No):(617)354-5828 545 Concord Ave. -MAIL :cristina@garrity-insurance.com ADDSS INSURERS AFFORDING COVERAGE NAIC p Cambridge MA 02138 INSURERA:Scottsdale Insurance INSURED INSURER B.Hartford Underwriters 30104 Mark Lemon, DBA: ML and Son Construction INsuRERc: 490 Pitchers Way INSURERD: PO BOX 423 INSURERE: West Hyannisport MA 02672 INSURERF: COVERAGES CERTIFICATE NUMBER�GL & WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 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 BY 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. INSR D B - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ ` 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED— PREMISES a occurrence $ 50,000 A CLAIMS-MADE IX OCCUR PS1746423 /7/2015 _ /7/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident)AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ ' $ WORKERS COMPENSATION 0515N280 5/18/2015 O5/18/2016 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N NY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 100 000 B OFFICER/MEMBER EXCLUDED? NIA • - ' (Mandatory In NH) E.L.DISEASE-EA EMPLOYE .$ 100 000 If yes,describe under E.L.DISEASE-.POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES jAttach ACORD 101,Additional Remarks Schedule,If more space is required) The Workers Compensation policy does not provide coverage for Mark Lemon. CERTIFICATE HOLDER CANCELLATION (508)862-4789 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE C Medeiros/CRISTI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r9monst ni Tlru A(^nRn nama 2nel Innn era ranieturarl m*rke of er npn » sARMSTABM '""M Town of Barnstable Regulatory Services , Thomas F.Geiler,Director Building Division • Thomas Perry,CBO ; Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 . p Property Owner Must Complete and Sign This SectionIf Using A Builder Y C .,'as Owner of the subject property hereby authorize _.!1 1 \( to act on my behalf; in all matters relative to work authorized by this building permit application for: n � l� 0 (Address of Job) • 1001 tore of caner Date Print Name if Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. ti C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doe, Revised 05301.2