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HomeMy WebLinkAbout0116 FROST LANE Fo4OS7— �t Town-of Barnstable Permit- b� -Regulatory Semices Fee � 4 BIAS& Thomas F.Geller,Director Building Division Tom Perry,CB0, Building commissioner 200 Main Street,Hyatatis,MA 02601 www.town_barnstable.ma-us Office: 508-862-4038 Fax:SQ8-7�0-623Q EXPRESS.PERAM APPLICA110N RE ONLY Not Valid without Red V Prew Imprint Map/parcel Number Pro Address C 1-I—c Property Residential Value of Wo , `� 0 C2 Minimum fee of$35,00 for work under$6000.,00 Owner's Name&Address Contractor's Name a. t �. t "' Telephone Number Home improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 9C {�M�� q+RESS PEA MIT i L &moan's Compensation Insurance Check one: JUN 21 2012 0 Lam a sole proprietor I am the Homeowner I have Worker's-Compensation hwzrance TOWN OF BARNSTABLE Insurance Company Name �� Workman's Comp.Policy# ��-) (,0 Copy nf.Insurance.Compljz ce`Certificate.ninstnecompanty eackpermit. Permit Request.(check box) Re-roof.(laurriesile nailed).(stripping old-shingles).All construction debris Will be taken.to ❑.RL-roof.(hurricanezaW).(riot stripping..Going over existing layers ofroot) El Re-side ' `-� � #of doors _ ' .Replacement Windows/doors/sliders.U-slue 3� (naa�t tn�35)#�of u+indaress totvre department atioets,i e Historic Canservarion,etc- *Where reyturm: Issuance of this pc nftt does not exempt compliance wnh other regal ***Note: Property Owner must sign Property Owner Letterof Permission A.copyy of the Rome Improvement-Contractors-License&ConstractionSuperti-isors-License-is required. SIGNATURE: C_\UsersldecoHWAppDauU,ocalM,,mft\Wiudos'slTemparacy.7ntemet-files\ContmLoudook)DDVX7AAZZ�E►IC RESS.doc Revised 072110 Town of Barnstable Regulatory Services sesivsr�st�. : nAss. Thomas F.Geiler,Director 639. 1. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize ) t. �� '� to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools .. are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted., Signa e of Owner Signature of Applicant Print Name Print Name f / �^ Date QTORMS:OWNERPERMISSIONPOOLS The ConwwnweaUh of Massaehusdts Departunent of Industrial Accidents •:. Office of Invesfigadons b > 600 Washington Street `r 4 Boston,MA 02111 J minv.mass gov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib ly Name(Businesdomanizarionllndividual) Address: l C2 /State/Ztp: � -��`� �� i / Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.MJ am a employer with 4. I am a general contractor and I 6. 0 New construction employees(fall and/or part time).* have hired the sub-contractors 2. I am a sole proprietor arpartner- listed on the attached sheet. 7. ❑Remodeling ❑ ship and have no employees Tbese sub-contractors have & ❑Demolition 1 working for me in any capacity. e�°3'ees and have woikers' 9. ❑Building addition [No workers'comp.insurance comp'in�anc�e-$ 10. Electrical repairs or additions retluirefl 5. We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp right of exemption per MGI. 12.0 Roof repairs insurance��&]t c. 15Z,§1{4),and we have no13.0 Other employees.[No workers' comp.insurance required-] *.Any applicant that chwIm box#1 must also fill out the section below showing their workers compensation policy,information r Homeowners who submit this affidavit indicating they are doing all work and then hire outside coutmetors must submit a new affidavit indicating such. Tcontractm that check this box must attached an additional shed showing the name of the sob-cunt?Auts and state whdher or not those entities have employees. If the sub-eontras'tms have employees,they must provide their workers'comp policy number lam an employer duet is provirl3 ng workffs'eorrapensahon bmurunc:e for my enrloyeem Betmv is the policy mid job she information. e Insurance Company Name: 6V1 Policy#or Self-ins.Lic.#: U Tip(' /�f 3 l t f Z C}.j - Expiration Date: -"-1 Job Site Address: ] T 6T City/State/Zip: Ali a 3 Z Attach a copy of the work'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 ORDl?R and a fine of up to$250.00 a day against the violator- Be advised that a cop;of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do haneby certify under the pains mid penalties of perjury that ike WornmWen provided above is true and correct S r`" Signauue: Date: Phone# Official use only. Do not wrke in ibis area,to be conrleted by city or town offs W City or Town: PennitbUcem# ImmingAetharitt(circ cone): L Board of Heath I Bmlding Department 3 Ckyffown Clerk &electrical inspector 5.Plumbing Impedor ,t 5.Other rl a cad r- =eiarrt-r: .n�t't' ,..tom: DATE(MMID DIYYYY) .�►co `( ERTIFICATE OF LIABILITY INSURANCE 5/30/2012 THIS CERTIFICATE IS ISSUEDU 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). conrracr PRODUCER NA11T Kathy Silvia The Fair Insurance Agency Inc. PHONE (508)775-3131 FAC Np.(508)790-1677 619 Main Street aDD esS:kathy@thefairagency-com P.O. BOX 430 INSURERS AFFORDING COVERAGE NAIC 11 26158 Centerville MA 02632 INSURERAAIM __ INSURERB: _ ':61 se -Bar. stable Brick .Co Inc DBPt, INSURERC: Doug :Williams Custom Building INSURER D: 222 Pine Street / INSURER E Centerville MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1253000274 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. 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 ADDL UBR POLICYF�F POLICYEXP LIMBS LTR -TYPE OF INSURANCE POLICY NUMBER. MMD MMIDD EACH OCCURRENCE $ GENERAL L L45IL 17 Y DAMAGE T RENTED PREMISES Eaoccurrence] $ COMMERCIAL GENERAL LIABILITY MED EXP(Arry one arson) $ CLAIMS-MADE D OCCUR PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS-COMPIOPAGG S GEML AGGREGATE LIMIT APPLIES PER: S POLICY PRO LOC (Ea acpd M erd) N. UR AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA UAB OCCUR AGGREGATE 5 EXCESS LIAB CLAIMS-PMDE pED RETENTION S WC STATU OTH- A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN EL EACH ACCIDENT $ 100,000 ANY PROPRIETOR(PARTNER/EXECUML /8/2012 /8/2013 OFFICER/MEMBEREXCLUDED? NIA C6014354012012 E.L.DISEASE-EA EMPLOY S 100,000 (Mandatory in NH) E ti yes descnbe under L DISEASE--POLICY LIMB $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town. of Barnstable Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Kathy Silvia/FAIKSIc� ACORD 25(2010105) ©'1988-2010 ACORD CORPORATION. AU rights reserved. INS025(211100401 The ACORD name and logo are registered marks of ACORD Massachusetts-Department of Public Safety Board of Building Regulations and Standards i Construction Supers isor License: CS-016981 r rs „ DOUGLAS L WLLIA]kS SR 2,22 PINE STD ,- oo c O Centerville MA 026... =*+ , 10 ro Expiration o y Commissioner 03/07/2014 ' e 1 BE: a c m .-. I _ w 1 P ! t,� y � Office'of Consumer Affairs&B s�ness Regulahon j '' HOME IMPROVEMENT CONTRACTOR i e j Reg istrati on:. 102227 Type' Expiration 7/1/k12 DBA ce D ,.LAS L.WILLIAMS CUSTOM BUILDING Douglas Williams ` c s_ 222 PINE ST. j CENTERVILLE,MA 02632 Undersecretary