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Town of.BariastablO - *Permit# LP
�o�ttta r�� ��-
K�iP O�, Expires 6 movlhsfir
Regulatory Services Fee
* BABNgMBLE, #
y� MASS. g Thomas F. Geiler,Director
16yg. �0
pTF p MA,t a
Building Division
Tom.Perry, CBO, Building Commissioner
200 Main'Street, Hyannis, MA 0260.1
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
WRESS.PERMIT�APPLICATIQN RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number--
Pro rty Address a O A'f IJ KS),
._ C,0, er,Vrn e- AlV l/ -a CS
Residential Value of Worl. i um fee of$25.00 for work under$6000.00
Owner's Name&Address J5�. '
Contractor's Name /�/Y}�S a/'/(, � TelephaneNiimberd �/'� O
:.--
Ll r
I lone Improvement Contractor License#(if applicable)
/Workman's
ion Supervisor's License#(if applicable)_ 1� �0
Compensation insurance g� PERMIT
-
Check o , "° °�.
[II a sole proprietor
am the Homeowner �.P ?0)(
I have Worker's impensation Imur ce OF BARNSTABLE
Insurance Company Name ��
Workman's Comp. Policy#. 9�
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. ,Going over. existing layers of roof)
❑ R. ideeme
.��o� . ,
Replacement Windows/doors/sliders:U-Value, •5 (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 the Home Improvement Contractors License is required.
SId'NATUIZE:
Q— W111-11.1-M OIZWbriilding permit fornislEXPRESS.doe
1l(-Vkpri 10M()R
The Common.wealth of Massucht, setts
a
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
i
Name(Business/Organization/Individual): ��(��� Soc j A
l
Address:
City/ (tate/Zi U)W,4IS��ck� � Phone#: �
P•
Are u an employer?Check th appropriate box: Type of prof (required):
1. I am a employer with 4• ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 ❑N construction
listed on the attached sheet.. . emode
2.❑ I am a sole proprietor or partner- 7 R '�
ship and have no employees These sub-contractors have 8. ❑Demolition
working 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 ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself o workers' co right of exemption per MGL
Y � comp. � 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' BE Other
comp.insurance required.]
*Any applicant that checks box#I 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.
tContractors 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 trust 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:
Policy#or Self-ins.Lic.#: �(1 Expiration Date:
(� 1
Job Site Address: City/State/Zip:",I le ���.
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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided�DLVeis true and correct
Signature: Date:
Phone#: d�_ ���✓�(lG7o
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#:
'��` tg�4 ��`[ l.� i �� t T t E t 14.►� M o�1 05/07/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Manville RI 02838-0001
Phone: 401-769-9500 E'ax:401-769-9502 INSURERS AFFORDING COVERAGE TNAIC
INSURED moon Associates Ina. I It,SURERA: ftattonal Graagee Zm_=aace Co_ 14788
DBA_ Gutter helmet
DBA Renewal bgV 'Andersen of RI ` INSURER B: Beacon Mutual 2n5urance Ca.
DSA. Gutter Helmet. Roofing
D82L Maoa 'Works INSURERC �^
1137 Park East Drive INSURERD:
Woonsocket RI 02895
I INSURER E:
COVERAGES
Ti�E POLICIES OF INSURANCE LISTED SELIYW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO i.VITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTIAUH RESPECT TO'AHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES.0 SCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Sir
LTR NSR TYPE OF INSURANCE POLICY NUINBER DATE(N MIDDIYYI'Y} DATE(MhUDI) ITS
GENERAL LIABILITY E:iCHOCCURRENCE $ 1000000
A X COMMERCIAL GENERAL LIABILITY rFPS26619 09/16/09 09/16/10 PREMISES(Eeoourerme) $500000
CLAIMS Mt0E ®OCCUR MED ENR(Any one perdan) $ 10 0 0 0
PERSONAL&ADVINJURY $ 1000000
GENERAL AGGREGATE $2000000
GENL AGGREGATE LIN11T APPLIES PER: PRODUCTS-MiP/OPAGG $2000000
POLICY j LOC
f AUTON16BILE LIABILITY
_ COM6INED SINGLE LIMIT $�,000000.
A X ANY ALTO BIS26619 09/16/09 09/16/10 (Esaocident)
ALL OVYT'IED AUTOS BODILY INJURY
SCHEDULED AUTOS (Par person) $
HIRED AUTOS BODILY INJURY
i NO"ANED AUTOS (Per socident) $
PROPERTY DAMAGE $
(Per accident}
GARAGE LIABILITY AUTO ONLY-EA.ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $1000000
A X OCCUR aAmsFMADE CUS26619 09/16/09 09/16/10 AGGREGATE $
$
DEDUCTIBLE $
IX RETENTION $10000 $
WORKERS COMPENSATION SIATLV
TORY LIMITS Fat
AND EMPLOYERS'LIABILITY
B ANY PROPRIETOPJPARTNER/EXEGUTIVE Q 28586 Y 10/01/09 10/01/10 . E.L.EACH ACCIDENT $500000
OFFICEPIMEMBER EXCLUDE01
(Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $5000 00
It yes,describe under
SPECIAL PROVISIONS blow E.L.DISEASE-POLICY LIMIT $500000
_T OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSE-MEW I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLtM BE CANCELLED BEFORE THE EXPIRATION
REI4mL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 . DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAJLURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Renewal By Anderson REPRESENTATIVE$.
1137 Park East Drive AUTHOR D REPRESENTATIVE
Woonsocket RI 02895
i ,7.
ACORD 25(2009101) O 19MM ACORD CORPORATION. Al rig3Tts reserved.
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0 of Building :gulaflmm and s
Construction SuPefyisorSalty License
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CUMBER LAND,
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Town of Barnstable Permit:
DIME ro Regulatory Services Date: I6_02
Thomas F.Geiler,Director l l
Fee:
BARNSTAEM 1 Building Division
a�. �0� Peter F.DiMatteo Building Commissioner
AlEo�,t A 367 Main Street, Hyannis,MA 02601
Office:. 508-862-4038 Fax: 508-790-6230
TOWN OF BARNSTABLE o\e-i
SOLID FUEL STOVE PERMIT 11 ,n, ;�� Cowmw(y
Owner:l\ \L (kw a0 hone:
� 1
Install at: Q o \J %N\\1C `�"61 a _ ID, Village: C
Map/Parcel: I 0 DO Date:
Stove
'A. New/ sed
' B. Type: Radiant/Circulating C.b '
C. Manufacturer: %M'�W C INSNVE Lab. No.
D. Model No.:
Chimne
A. New Existing (., existing, please note da,`e of last cleaning)
B. Flue 1ze
C. Are other appliances attached to Flue?--
D. Pre-fab Type and M
.,anuf
4cturer_
E Masonry: Line Unlined
Hearth-
fa-7 6
A. Materials:
B. Sub Floor Construction: V-J C-) 0 �0
ti
1 Installer
Name: Address:
Phone:
Loration.of Installation;
APPROVED BY:
Please make checks payable to the Town of Barnstable
*This constitutes an official stove permit after inspection, photographed, and approved by the
Building Inspector
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