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HomeMy WebLinkAbout0060 FERNWOOD AVENUE (moo F�en/wvo�' �yvc �� Town of Barnstable *Permit ` ° Expires 6 months from issue date Regulatory Se><-vices T _ Thomas F.Geiler,Director G �, i Building.Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.t o wn.b n rns t a b l e.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. U 1 © F Property Address [Residential Value of Work IU00 . 00� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 11 � u (c 4z;nWa08 "Y1�S Contractor's Name y a3fle-9 CWI t Telephone.Number• I U " 4RYV Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) { ` ❑Workman's Compensation Insurance C'hptk one: L'J 1 am a sole proprietor I am the Homeowner.. I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) dRe-roof(stripping oldishingles) All construction debris will be taken to I � ❑ 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 O t sign P operty caner Letter of Permission. o the Hom pro went tractors License is required: SIGNATURE: i • Q:Forms:expmtrg d, Revise061306 _ f i i ppYHEr 'own of Barmstalble. Regulatory Services snxNSTABIX, y Muss• Thomas,F. Geller,Director 16 i 9. A Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 w�t'w.town.barnstable:ma.us Office: 508-862-403 8 Fax: 50B-790-6230 Property Owner Must Complete and Sign This Section If Using A Buildler as Owner of the subje ct property herebyauthorize �Jaw5, to act on my behalf, in all matters relative to work authorized by this building permit application for: Lc . I (Address of Job) na e ofP- Date. °j Print ame ; j s WORM S:OW NERPERMIS S JON - The COInIHOnwealth ofMassachusetts Departrn et,t nfIndustrial Accidents Office afInvestigations 600 Washington Street _Boston,I-t,4 02II1 m asst.gov/diet Workers" Compel. it Insur,"nce.Affidavit: Builders/Co Applicant Information ntractors/Electricians/Plumbers r� Mon Please Print Legodbi Nana (Business/Organization/Individual): . t l Address: o X City/StatetZip:_ n 5 rl Phone.#f: Are you an employer? heck the appropriate box: L❑ I am a employer with 4. [] I am a general contractor and I -Type of project(required):. mployees (full and/or part.time). have hired the sub-contractors 6. 0 New construction . 2. I am a'sole proprietor or partner- listed on the'attached sheet. 7. Ej Remodeling � ship and have no employees These sub--contractors have working for me in an capacity. em to ees and B. Demolition Y P ty P Y bati e workers [No workers' comp,insurance . comp. insurance,$ 9. []Building addition required_] 5. [] We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their my self 11.❑Pl in repairs or additions [No workers' comp. right of exemption per MGL insurance required-.]t c. 152, §1 4 and We have, 12. oof repairs ( ), ve no employees. [No* workers' ..13.Ej Other camm.insurance required.] 'Any applicant that ebeelcs box#1 must also fill out the section belowshowing their war] t Homeowners who submit this affidavit indicating they are doing all wor k and then cm'emnpcnsalion policy infarrnation: hint outside contractors must submit a new affidavit indicating such. d an additionalshcct sbowing the niune of the sub-contractors and state whether or not those entities have fiContractors that check this box must attache employees. If the sub-contractors have employees,they must pravidt their workers'comp.policy number. tam are employer that isproviding workers'comp information. ensation insurance for my employees th Below is. epolleyand job site Insurance Company Name: Policy 4 or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and e Failure_to secure covers a as re expiration date),, g required under Section 25A of 14GL 6. 152 can lead to the imposition of criminal penalties of a fine up to.11,500.00 and/or one-year imprisonment, as well as civil penalties in the forra of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the bIA for mi ran suce covers e verification. I do here rn er the al s-an enalties ofperjur),that the information provided ubo a is e and correct Siena I C� tore: ! 1 13 • Date: Phone #: •Official use only. Do not wrai in this area,'tb be completed by city or town o fciai City or Town: ' Permit/License# . Issuing Authority(circle one): I.Board of Health 2.Building Department 3. Cify/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone I w _. r _,. .- _. . _ .. r s J m yt5 ,..-v„'w.. -F �' v - „ ... '. ....a.:.vr. ,, t ,�.% n x * -s.. -¢. - 8: tit,'?. a�= -"`u' `x•,: .dt :`"`" ' '.z�£ 'b :.,•.Ii•-1,, i;;r 'S$`'y�:'^": :,'C�:�1 a,n. ,_1 v c y: .,R w �t) d, ;E .x.yQ ,. ?_ l ch A m w=k, :� r, 1 .. R A s s{.• w T` a , _...3,: ,T q;'3t5 et:.r` ° { R i3"^{14 _♦}k.\nr.:Nb 11;i" 9u4' > ^e:Y,n t .:. fk •l.u' 2rd�� ..rS.'i Pk, ^ia'm3 1�, ,.; .. w ...5.F .,u i�.,,- `yam .. .�' r ,rDt ?,.•., � ` 3a ,,` w g k i£wcr<*.sm, 'F i"'.:•x-. ggy ,.,.:�.. 'aE+`.<. _ , ,. 4S -VHfi .....rvn .. 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C.:d :".v S„, w', ., +4•v! iN.',vt• '1, t J ,./i? i .&'»v'rfl�ii .:.- ,,: _ .,.G,. ,L.,,.i, Town of Barnstable *hermit# 8a`4q S� Expires 6 mon tr9yrom is Regulatory Services Fee BABNSTABLE Thomas F.Geiler,Director r� 39. Building Division 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 Not Valid without Red X-Press Imprint Map/parcel Number Property Address (co run (Z)(7 o l Au�_- [�Residential Value of Work � J V= Minimum fee of$25.00 for work under$6000.00 `Owner's Name&Address ��� r• ,LA V (n(��EVnwwr�'� Contractor's Name czcC ,_ 0111 S I' �y L. Telephone Number g 7 -T- G J Home Improvement Contractor License#(if applicable) ( i�J r Workman's Compensation Insurance Check one: X-P E Sa'" `,0 M I ❑ I am a sole proprietor ❑ I am the Homeowner S E P _ 8 2008 /R I have Worker's Compensation Insurance Insurance Company Name t UX,� TOWN 4F BARNSTABL.E Workman's Comp.Policy# 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) ❑ 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 si� roperty Owner Letter of Permission. A copy of the Home provement Contractors License is required. SIGNATUR CO :C Wd 8- Jos 063Z Q:Forms:buildingpermits/express Revised 123107 Town of Barnstable Regulatolry Services KAMThomas F. Geiler,Director, �q 16sp $ - Building ]Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 568-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r ���. , as Owner of the'subject property UU hereby authorize �- -1'ChCbg�G hh U Ly-, to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) WnVZS e 041wner Date Print ame If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. r The.Cornmonwealth of Massachusetts Department of Industrial Aecidents Office oflnvestYgations 600 Washington Street Boston,Mai 02-11, www.mass.gov/dia Workers' Compensation Insurance.A€fidavit;,Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMO(Business/Organization/Individual):, _ 4 -Address: /O S' f/7a/o� Sp� City/State/Zip: 1 X,41V1✓1S /Phone.#: 5D9 ' 7'S- : ; 3 Are ou an employer? Check tl�,appropriate box: Type of project(required):, employer with / 4. [] I am a general contractor and I . employees(full and/orpart--time). have hired the st'b-contractors 6• ❑New construction . 2.❑ I am a'sole proprietor orpartner- listed on the-attached sheet. 7. ❑Remodeling. s and have no a to ees These sub-contractors have �P mP Y 8. ❑Demolition , working for me in any capacity. employees and have workers' co insurance.$' 9. E �Building addition [No workers'comp.insurance �• required.] 5..❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.[�Plumbing repairs or.additions rnyselt: [No workers comp. right of exemption per MGL 1 f repairs insura ncosequired.]t p. 152' §1(4),and we have no 3 ❑Oth P •.13. • employees, [No workers' er comp.insurancetequired.] . 'Any applicant that checks box#1 must also fin out the section below showing their workcrs'compensation policy information. t Homeowners who submit this affidavit indicating They are doing all work and then hire outside contractors must submit anew affidavit indicating such. rContracton 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 tiave employees,they must providt their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below islhe policy and job site information. /J Insurance Company Name: Policy#or Self-ins.Lic.#: � 7 •3 o 6 Expiration Date: to a © 9 Job Site Address: �� r;lr h 'City/StateMp L n n fS 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 agaipj the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the 1DIA/fbYinsurqwcNcovaraRe verification, Ida hereby certify:end r t e ' s• d e of perjury that the information provided above is true and correct Signature: Date: /. G Phone#: '5—.0 Official use only. Do not write in this area,'to be completed by city or town ociaZ City or Town: Permit/License# Issuing Authority(circle one): r I.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector S.PIumbingInspector 6. Other Contact Person: Phone#: J/e �aouuecja a�'� � License or registration valid for individul use only Board of Building Regulations and Standards before the expiration date. If found return to: HOME IMPROS, O ONTRACTOR Board of Baffling Regalations and Standards Re8ls,h-4 oti One Ashburton Place Rm 1301 Tr# zsa l53 Boston,N&02108 Tde: PdVate-Cerporaffon T.L.HCrCHCOCKSEffflC�PIC. TED HITCHCOCK 105 FERNNNIS OC RE) Not witb t signature HYANNIS,MAt}2668 Administmtor achusetts- Department of Public S rfeth Board of Buildim�, . Rc,�ulations and Stundin•ds Construction Supervisor Specialty License License: CS SL 99828 Restricted to ,RF;WS .,TED HITCHCOCK-i ;55 LISA LANE WEST BARNSTABLE, MA 02668 Expiration: 6/1/2012 C mmiisiobci•. Trn 99828 T - Boaron ;la A, g gu ns an ar� One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 158587 Tvpe: Private Corporation Expiration: 2/812010 Tr# 264153 T.L. HITCHCOCK SERVICES INC. TED HITCHCOCK 105 FERNDOC RD HYANNIS, MA 02668 Update Address and return card.Mark reason for change. rot i o�ro;•eca:�90 Address (� Renewal Employment Lost Card otylIIfZVOU ny:01:3 bLR-VMAN & ASSLIG. PAGE 01/01 Ac�pq CERTIFICATE OF LIABILITY INSURANCE CSR A08 $ oATL4(MMrODIYYYY)• PRODUCER HI'ICH50 FINAGOLDNCIAL 6 ASSOCIATES INSURANCE THIS CFIR IS ISSUED A:t A INATTER OF INFORMATION1 08 FINANCIAI, SgRVZCE3 INC. ONLY AS NO RIGHT: UPON THE CERTIFICATE 933 FALMOUTH RD, HOLDETIFICATE DOTS NOT AMEND,EXTEND OR HYANNZS MA 02 601 ALTER AGE AFFORD:D BY THE POLICIES BELOW, Phone:508-775--6010 Fax:508-790-0249 INSURED INSURERG COVERAGIINSURERllAL, VNZONNAIC�tT. L. HITCHCOCK CONSTRUCTION INSURER a: AL G SERVICES INC —PRANG) t2UTUAL 105 FERNDOC gT INSURER C: HYANNiS MA 02601 INSURER D: -- --L-- COVERAGE$ INSURER E: - T11r POLICIES of INSURANCE LISTED BELOW HavE BEEN ISSUED TO THE INS uaED NAMED ABOVE FOR THE POLICY PERIOD tNOtCATf D.NOT J1TlISTANDING ANY PERTAIN. HE I TERM NC AFFORDED OF ANY CONTRACT OR OTHER OOCUMCNT WITH RESPECT TO WHICH THIS NOT MAY BE I! 'IT14 A MAY PERTAIN,THE INSURANCE AFFORDED$T THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND C Y BE 11 N$OF SUCH POLICIES.AGGREGATE LIMIT!SHOWN MAY NAVE BEEN REDUCED By PAID CLAIMS. LTR N TYPE OF INSURANCE POLICY NUMBER _ GENERAL LIABILITY GATE Mlop bA E MM D/YY ~ B R COMMERCIAL —^LIMITS Ai.GENERAL LIABILITY MPS9614(; EACH( )CURRENCE s 2000000 CLAIMS MADE lJ OCCUR 05/23/09 05/23/09 PREMI: Ee a $300000 MEDR),T1yonnpera $10000 PERSOI CL tADVINJURY s 2000000 GEMLAOOREGATELIMITAPPLIES T GENFR, -AGXREGAE POLICY �cT LOC $- 40000� 00 PRObU, TS•COMP s 4000DO` 0 AUTOMOBILE LIABILITY —ANY AUTO ALL OWNED AUT08 - - wck(EeMBIN 0*INGLE LIMIT S SCHF,DULFD AUTOS — BODILY I HIRED AUTOS (Par pars t) q NON-OWNED AUYOS `�- --- (P rDe�k Ju;IY E--~ ._` ) CARAGE LIABILITY PROPP,Ri ;DAMAGE (Per aerie �q $ ANY AUTO AUTO ON/`•;AACCIDENT S OTHERTt IN EA ACC s EXCESSIUMBRELLA LIABILITY AUTO ON, -— • AGO S �_ OCCUR ED CLAIMS MADE EACH OC(•IRF!ENCF a AGOREGA E `— DEDUCTIBLE RETENTION s — s WORKER$COMPENSATION AND F A EMPLOYERS'LIABILITY $ ANY PROPRIETOR/PARTNER/EXECUT1yE 27306 TORYI Mjj6 FR' OFFICE EXCLUDED? 06/05/08 06/05/09 H,L.EACHI ;Cn7Enrr SPECIALPROVISIONSbolow ��_ $500000 OTHER E•L,DISEAS •EAEMPLOYEE $S00000 E.L.DISEAS._POLICY LIMIT $500000 IESC "MON OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMEnti/SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION -~ FOR, ID SHOULD ANY OF THE ABOVE DESCRIBED POLICIES i:CANCe LL EO BEF7EA FOR EVIDENTIARY PURPOSES ONLY i DATE TMERQOR TH!168UING INSURER WILL ENDEADRTO MAILNOTICE TO TNC CERTiFMA1E HOLDER NAMED TO Ti ?LIIiIFT,8UT FAILUxxxm ' IMPOSE NO OBLIGA17ON OR LIABILITY OF ANY MND I poll THE INSURER. REPRESENTATNES. Al 33300000= MA i AUTHORIZED REPRESENTATIVE 1ANN LOU R CORD 25(2"W08) ' ®ACORD CORPORATION 1980