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Home My WebLink About0093 FAWCETT LANE a f M Town of Barnstable *Permit# � 7�2 P� Expires 6 months fr m issue date SS eguiatory Services Fee v 3 ` Thomas F.Geiler,Director Building Division `P Tom Perry,CBO, Building Commissioner f y , , 6Tj, 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 Property Address t ,` LCt-n e r A n J?SResidential Value of Work 41 �00 Minimum fee of$25.00 for work under:,'''5000.00 Owner's Name&a"address 3 74 � ((in rl t S 6Yl(-} 6 2-00 Contractor's Name P l A-) Telephone Number Home Improvemei Contractor License#(if applicable) (b 31 Construction Supervisor's License#(if applicable) Zlp a %Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner l have Worker's Compensation Insurance Insurance Comp any Name Workman's Comp.Policy# &D Au (� 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 r VY\n 4)-k ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance ofthis 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 Im rovement Co actors License is required. SIGNATURE: Q:Forms:expmtrg Revisc071405 ff, 4 t . � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations „�•'' 600 Washington Street Boston,MA 02111 ` c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Pat) Nz��_,ko &Y4� n Address: 1(03� l Y\ S City/State/Zip: �S�E'CV I �V-2 fYw3r02k 5-S Phone #: so k-{2 - — )_( `1 Are you an employer?Check the appropriate box: Type of project(required): I�91 I am a employer with Z 4. E1.1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 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 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.❑ l.am a homeowner doing all work right of exemption per MGL l LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.1kRoof repairs insurance required.] t 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. ;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: ( �('( .V+✓t e.;-6 Policy#or Self-ins:Lic.#: L)g oO o S 1D ( q A-o(p Expiration Date:. Q -7 Job Site Address: q3 __IL S City/State/Zip: 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 c under the pains and penaltie of perjury that the information provided above is true and correct. Si nature Date: Phone# �St y 2 �' 1 1 `1 � Official use only. Do not write in this area,to be conepleted 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#: 07/31/2994 13:27 2018619127 JOE GONZALEZ PAGE 02 IIAMWAS 1� Town of MAMB.'a mstable f°D Rc<<ulatory Sei-vices RFD�( . Thomas l,'.Ceiler,Director Building Division Toni Perry,Clio Building Commissioner 200 Main Street, Hyannis,MA,02601 www-town.barnsla ble.ma.us Office: 508-862- ')38 Fug 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder (}wA1ct of the suU cct c prp 3, p rty to act on my behalf, i;.. ..11 matters relative to work authorixcd by this I)LOdinb Pent application tk.>r: (Add:ess of Job) Bate .c Nam(. Q:Fonns:e'cpRurg RcAsc071405 _ Board of Building Regulati ns and Standards One Ashburton Place - Room 1.301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2008 PAUL J. CAZEAULT & SONS, INC. . . Paul Cazeault 1031 MAIN ST OSTERVILLE, MA 02658 Update Address and return card. Mark reason for cli'ange. Address .� Renewal I- j Employment Lost Card DPS-CA1 A 5OM-05/06-PCC8�8490pp ✓x. (OOOr7I)toILlIM2GUL O�✓!(addtcc/tttd¢�6 Board of Building Regulations and Standards License or registration valid for individul use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Re.gistration:.'103714 Board of Building Regulations and Standards Expiration:';s7/g/2008 One Ashburton Place Rm 1301 i. Boston,Ma.02108 i-Type:;.:Private Corporation it a PAUL J.CAZEAULT&iSON$,;INC`: Paul Cazeault 1031 MAIN ST OSTERVILLE,MA 02658''` ' Deputy Administrator Not valid without signature Board of Building egulations One Ashburton Place, Ism 1301 Boston, Ma,02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/20/1959 Number: CS 026325 Expires: 10/20/2007.. , Restricted To: 00 PAUL J CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02655 Tr.no: 7696.0 Keep top for receipt and change of address notification. DPS-CA1 0 5OM-04/05-PC8698 ............ .......... ..,..._..... � �ltC U�oOTLIr1.017,[ueCLGUt o�✓!/(.CLOdILCft[l6P.l� . BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number:c,CS 026325 Birth dzite: 10/20/1959 Expires:"10/20%2007 Tr.no: 7696.0 Restricted: 00:'' PAUL J CAZEAULT " 1031 MAIN ST / ()STr-R\nI I.F V!1 nlr,, � t ".•.••••.•:•�•.•• n..'. r A �a DATE(MM1DD\ r._.,....:... C YY) PRODUCER' T4tiS CERTIFICATE IS ISSl3ED AS A idATTER :QF INr trct�►�c,�w., D0T<LING & O NEIL INS AGC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE: '222.11KEST>I+L;ild .STREET. HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND"OR ;"Po.i,Box" 1990 ALTER.THE COVERAGE AFFORDED HYTHE POLICIES EiELC1w-, HYANNIS PtA 02601 COMPANIES AFFORDING COVERAGE 22 LGR' COMPANY, INSURED A TR.AVF,LERS PROPE:H.TY CASUALTY COMI'AN'( OF' AME11 trA COMPANY 'PAUL J CAZEAULT 6 SONS INC. B 1031't1A.IN STREET OSTERVILLE MA•02655 COMPANY C COMPANY CCJVE"AiHS<.y,, ,,.... D . :.yet '<a: o, THIS IS'TO CERTIFY THAT THE POLICIES—OF INSURANCE LISTED'+BELOW HAVE BEEN ISSUED TD'THINSURED s r E IN,LIKED NAMED* FOR THE POLICY Pi5ii&- � INOICATEO;'NOTVVfrHSTAtJDING 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, r'EXCLUSIONS AND'CON01T ION3 0P 3UCH POLICIES.LIMITS SHOYVN MAY-HAVE BEEN REDUCED BY PAID CI'AIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION' 7717 DATE.(tJL•AD11\YY) DATE(MM%DD\YY).. LIMITS i 'GENERAL LIABILITY CCIMMEROALCENERALUA6IL11Y• GENERALAGGIILGAIE g YNUUULIy-l;lxdF7UP'AUIi. f ^:`^if,''.i: CLAIMS MADE=OCCUR. - PERSONAL R ADV.INJIIRY = GACH OGCRR O1niNE•H'S A QONTRACIORJ PROT. UGNCC S RRE DAMAGE(My one tire) 3 AUTOMOBILE LIABILITY. MED..EXPENSE(Arty onn person) !. ANY AUTO COMOINLD SINGLE f LIMIT ALL OWNED AUTOS SCHEDULED AUTOS BODIEV INJURY (Per Person) S HIREDAUTOS ' NON•OWNED AUTOS BODILY INJURY (Per Accident) 3 PROPERTY DAMAGE $ GARAGE LIABILITY ANY AUTO 'AUTO ONLY-'EAACCIDENr 11- OTi1FR THAN AUTO ONLY'. LACH ACCIDLNr, S EXCESS LIABILITY AGGHCGAIL 3 UMBRELLA FORM EACH OC'.C:URRENCE s OTHER THAN UMUREIIA FORM AGGREGATE ; WORKER'S COMPENSATION AND. .......... A EMPLD.YERSUABILITY' (UB-0095064-A-06) 08-10-06 08-10-07 STATUTORYLIMITS NIA.. 'THE PROPRIETOR/ EACH ACCIDENT PARTNEMEXECUTIVE " INCL OFFICERSARE: EXCL DISEASE-POLICYLIMI'r f DISEASE-f-ACH EMPI.OYEE g Ll: -: TI1I5 REPLACES ANY PRIOR CERTIFICATE ISSUED TO TtIC CERTIFICATE HOLDER AFFECTING WOR[:ER, MP COVERAGE.CO .. . .:.,: .. .e.•n,:,c.8.w :..::::jY?�9 ,n , fit SHOULD ANY OF^THE A80YE DESCRIBED POLICIES BE CANCELLED BEFORE THE r Paul J,Cazeault&Sons EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Roofing,inc. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 1031 Mai T Street LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OI( LIABILITY OF ANY•KIND UPuNTHLCOMFANy,�TSAGGj►TSGpRGDFESfKT/dIyES. . Ostervillc, MA 02655 AUTHORIZED REPRESENTATIVE .......... . � Of�I1:CnHF't�RA1;JCu(199�> w Client#:19989 2CAZEAUI_TPA ACORD. CERTIFICATE OF LIABILITY INSURANCE o5;9/os°'YYYY' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 222 West Main St PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Western World —Aul J.Cazeault$Sons Roofing,Inc. INSURERB: L,31 Main Street INSURER C: '`.+sterville,MA 02655 INSURERD: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.N!,rWITHSTANDING ANY REQUIRE.;AF_NT,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.AG'3REGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR _., DATE MM/DD/YY DATE MMMO LIMITS A GENERAL LIABILITY NPP1012091 04/30/06 04/30/07 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED I occurrence) $50 000 1 CLAIMS MADE ®OCCUR MED EXP(Any one person) $2 500 X �1/pD Ded:1,000 PERSONAL BADVINJURY $1 000000 GENERAL AGGREGATE s2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $1 000 000 JECT ','.';..ICY PRO- LOG AUTO!:`OBILE LIABILITY ' COMBINED SINGLE LIMIT $ A'rY AUTO (Ea accident) L OWNED AUTOS ' BODILY INJURY $ ' '•`�'HEDULED AUTOS (Per person) ?ED AUTOS BODILY INJURY $ 'r'LN-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ , (Per accident) - GARlcLoE LIABILITY AUTO ONLY-EA ACCIDENT $ A=4Y AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCC:;;UMBRELLA LIABILITY EACH OCCURRENCE $ i_."CUR D CLAIMS MADE AGGREGATE $ $ at-.TENTION LDUCTIBLE $ $ WORKERS;:OMPENSATION AND WC STATU- OTH- EMPLOYER_;LIABILITY I ER ANY PROPRt!-TORPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/W MBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes deS(:n1 :.,odor SPECIAL PICCYVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS, Certificate OF insurance will be issued directly by the insurance carrier. CERTIFICATE BOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION S6 dormational purposes only DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL l0_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,iIUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON.111-INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R€PRESENTATIVE ..�k c' ACORD 25(:z.>J1/08)1 Of 2 #42866 LS1 0 ACORD CORPORATION 1988