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HomeMy WebLinkAbout0049 GLEN ROAD � �� �� f _ - - --- t r 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma . Parcel' 0 Application #'�v 15L91 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village D1Ah'1 Owner 5'6►fr, Address Telephone 2 Permit Request ' i f/1- Le t/•'n �ol�,,. - / ��ySd�e+`tY/JoS° rrv�aU►S e a.� /1 „ y L'dvl� � Mo 6� Square feet: 1st floor: existing/proposed 2nd floor: existing proposed Total new Zoning District Flood Plain P7(G Groundwater Overlay Project Valuation Construction Type 2 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family W1_ Two Family ❑ Multi-Family (# units) Age of Existing Structure fYi Historic House: ❑Yes Jd']To- On Old King's Highway: ❑Yes ©o Basement Type: Erfull ❑ Crawl ❑Walkout ❑ Other := Basement Finished Area (sq.ft.) Basement Unfinished Area,('q.ft) Number of Baths: Full: existing_2 new by Half: existing new Number of Bedrooms: 2 existing PAe&4a�L Total Room Count (not including baths): existing _new hUc .First Floor ;oom Count Heat Type and Fuel: '"Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes Q<o Fireplaces: Existing_L_New1?g1d� Existing wood/coal stove: ❑Yes Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 13 17/ Telephone Number U /r% Address sy'a �� � License # ` yL1 Z i4fe �26v1 Home Improvement Contractor# Email 40*f Worker's Compensation # AWC` 1m-26,13yl 1_2o4�j4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO P,,k �� sti SIGNATURE fZ DATE t1 G/l __ J 1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT , ASSOCIATION PLAN NO. i i 3 `� t - . S � r Q �-�_ �1 _,�� S b � � � d � � _� � I � S � � 3 ` � _� � � � f c � � � �� f � � i � � � � -� � � � -b ..3 � r �' S � � � J i �, �° I _ tom a C� V P a e r� \ J W S a � � s qQ, �1 s barnstable property sign off.JPG(JPEG Image,2550 x 3510 pixels)-... https:/iweb.nail.CorncasLnettservice/hoara/•-..I?autlr-=co&toc-en_US... • r Town of Barnstable Regulatory Services g rJ' Richard V.Scab,Director Building Division Thomas Perry,CBo Building Ctimmissiaaer Wo Main Street, Hyannis,MA 02601 wwwAawn.barnstable.ma us Office: 508-862-1038 Flit: 508-79"2.10 Property®tuner Must Complete and Sign This Section If Using A Builder k� NA n a S H Ya' a per of the subject property hereby autho&e �f LL 1 ►tit [ �S X V 1 2 to act on my behalf, in all matters relative to work authotued by this build ag permit apphcaMn for (Address of job) --5 1-24)1 V l of om-ner 49 Date Print Name If property Owner is applying for permit,please complete the Homeowners Lirsase Exemption Form an the reverse side �. V'-w'1'i=11Es1fMMSU1dinapamh fetm'EXPRESS des Rrvised 061313 l of 1 3123/2015 2:38 PM Aco�D® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/12/2014 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 04740-001 CONTACT NAME: Miller McCartin dba Dowling 8 O'Neil Ins Agcy �a�.No_Ext). (508)775-1620 lac.No.: 973 lyannough Road I EMAIL -- --- Hyannis,MA 02601 ;AD_DRESS:_kbolton@doins.com f INSURER(S)_AFFORDINGCOVERAGE-_ _ __ .NAIC Y _ ----- -------------- —�INsuRERA .A.I.M.Mutual Insurance Company — I 26158 INSURED William W Croston I INSURER B_;-___ William W Croston BuildingContractor iNSURERc_. P 0 Box 138 - ---------- --- — ------ Osterville,MA 02655 INSURER D: , _ I INSURER F COVERAGES CERTIFICATE NUMBER: 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 TYpE OF INSURANCE ADDL$UBR POLICY NUMBER POLICY EFF j POLICY EXP LIMITS LTR INSR Nw/vVD� (MMIDD/YYYY)__(MML_QNYYY)I GENERAL LIABILITY EACH OCCURRENCE $ ------ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ - -� PREMISES Ea occurrence)_ CLAIMS-MADE OCCUR MED EXP(Any one person) $ _ PERSONAL&ADV INJURY I$ GENERALAGGREGATE $ --I - -- - -- --- - ---- ______ _ I i ------�------------------ IGEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG i$ ---PLIC OY ------- ----- — ------- _ _ ---PRO- AUTOMOBILE LIABILITY — COMBINED SINGLE LIMIT (Ea accident), $__________ _ � ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ISCHEDULED I I - I AUTOS AUTOS BODILY INJURY(Per accident) $ I HIRED AUTOS AUTOS NON-OWNED I PROPERTY DAMAGE - $ — �_--I _ AUTOS � I -(Per accident)_ $ UMBRELLA LIAB I OCCUR EACH - i S I , OCCURRENCE EXCESS LIAB CLAIMS MADE I AGGREGATE I$ — �I DED j RETENTION $ W RKERS CPMPENSATIpN t WC gTATU- I OTH- AND EMPLOYERS'LIABILITY _X !TORY LIMITS i ___E,R_; A IANY PRQ,PRIETOR/PARTNEF/EXECUTIVE Yr(� I ! E.L.EACH ACCIDENT i$ 1,000,000.00 OFF ICF.ttvuMEMBEER EXCLUDD D? Y I I N/A: AWC-400-7013419-2014A 9/8/2014 9/8/2015 �- -- -------- (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEEI$ 1,000,000.00 If s des nbbe under �-------- DCRIPfION OF OPERATIONS below _— L— E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 ---—- ----- I ----- - 1-- ---� --- L------ ---DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Worker's Compensation Coverage Applies to Massachusetts Employees Only The workers compensation policy does not provide coverage for William W Croston CERTIFICATE HOLDER CANCELLATION EMCON Associates Inc. 74 Brick Boulevard Suite 102 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Brick,NJ 08723 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I , ' Departrtierrt ofIndurtt-ialAccden& ` Office oflmesfigafionr 600 washnzgton Sfreet BostoY4111A 02RI ' www.n=!rs govKEa Workers' Compensation Insm-ante Affidavit:Bmlders/Contra.ctors/Eledxi'cians/Plmmbers Applicant Information Please Print I!g blY' 'Name PMffi=SS/ �� 1� �f olev 4y ���ar✓ I C_Giyc L� Address: /�e 0 e /d a"Y •/ c3 City/ .lZip: ��S/.WSJ/1 rvn,. ozf-rr Phone#: 6'4'9- 221 9F ll Are you an employer?Check the appropriate bor Type of project(required); 1.I l am a employes with ._- 4. ❑I an a geoetal=trractor and I c apIo=(RII and/or part-time)-* have hind the sub-contractors 6. ❑New cant adieu 2.❑ I an a sole proprietor or partner- listed on the attached sheet 7. Kf22modeling and have no ees These sob--confrackns have ' �P �03' 8. 0 DetnoIiiian . woridng for me m my capacity =Ployees and have workers' 9. I]Building addition [No workers,conlp.iasmzn= comp.kSMMnrr �] S. We are a corporation and its 10-Q Electrical repairs or additions 3.[] I am a homeowner doing all work officers have exercised their I L❑Phnnbing repairs or additions myself [No workers'coin. right of exemption per MGL insurance required-]-t c.152,§I(4),and we have no El Roof repairs anployees.[No woks' 13.❑offer *Amy appliczmtthat ehcrh box#1 mmst also frII oatthc scctiom below showing then worlcca'CGMPeasation poIicy int=326= t gmmeowmers who sahmit this affidavit indicating they are doing Q we do and then hire ontside cantaema mmst submit anew aindavit in�sock. #Coahactors the check this box mart arched an additional short sbowimgtbe name of the and stare whether or not those entities have employees.If the sub-mntmetna have esapimyecs.they mast pnmde tbcic wodca'cormp.policy=abcr. ram an employer that is pravlazgYork=,compensation Aztz ranee jbr my employees Below it the pormy and job site . znformation, . Insarsnce Company Name: /b►-- �„ a-dr �"��� t `S'ry,awe� Policy#or SeIf-M Lic.# AVC yam' «-7G'1 J.Y/f Ulq FQ�PiratienDatE: F Z Job Site Address: GdY/StatC4f4- c,yzr i"t� O-; �� Attach a copy of the Workers'compensation policy declaration page(showing the policy number and expiration date). Faft:re to seame coverage as requirednader SecEion.25A ofMGL a 152 can lead to the imposition of criminal penalties of a Em PP to$1,500.00 and/or one-year imprisamneai;as well as civil penalties iu the.Irm of a STOP WORK ORDER and a fine of np to$250.00 a day ab irist the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for msmaace coverage veaiication. I do hereby certify wzCf=the p emits ofperjmy that the inforn afion prapi led above h true and correrl S Date_ Phone 0117dal use only. Do not write in this are%to be completed by city or town o•,0"uiaL City or Town: Petrra;t/f arPnce# Tsstmtg Authority(circle one): Health 2.BuildingDepartment 3.Crty/Town Clerk 4. L Board of Elecixicallnspector 6 Other S.Plumbinglnspector Contact Person: Phone#; ' Information and Instructions hawach setts GeacraI Laws chapte.r 152 requires all employers to provide workers'compensation for their employees. Putsuantto this statute,an mplayee is defined as`:..every person in the service of another under amy contract of hirr, express or implied,oral or wi tEeu." An m playa-is defined as'anindividual,partnership,association,corporation or other legal entity,or any two or more of the foregoing edged in a joint enterpzise,and inchading the Iegat represeo tafives of a deceased employer,or the receiver or trustee of an individual,pa t=3hip,association or other legal entify,employing employees. However the owner of a dwelling house having not more than three apartments end who resides therein,or the oecopant of the - dwailmg house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appratenmrt thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or ct buildings in the commonwealth for as renewal of a license or permit to operate a business or in construct b dugs Y applicantw•ho has not produced acceptable evidence of cdmpliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C('I)states"Neither the commonwealth nor day of its political subdivisions shall an into any contract for the performance ofpnblio woik until acceptable evidence of compliance with the insuran cd. requirenie uts of this chapter have been presented to the contacting authority." Applicants , Please fill out the workers'compensation affidavit completely,by checlCmg the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(m)and phone number(s) along with their certfficate(s)of insurance. Limited Liablity Companies(LLC)or Limited Liability Partnerships(LU)withno employees other than the members or partners,are not required to carryr workers'compensation fi so nce. If an LLC or LLP does have empIoyees,apolicy is required. Be advisedthatthis affidavrtmaybe submitted to the Department of Industrial Accidents for confirmation ofmsuraTce coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are regal ed to obtain a workers' compensation policy,Please call the Department at the number listed below. Self-insned companies should eater their self irmuzince license number on the appropriate line City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant: Please be sine to fill in the peamL t cane number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applit ations in any given year,need only submit one affidavit indicating cmrent policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the-affidavit that has bey officially stamped or marked by-*&city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses Anew aff davit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would Ifim to thank you na advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. , The CommmWmIth of Mmachusetts ' Depazfmmt of 1ndgial Accidents wn=of I v'esaptio= 600-Washington Sizes Boston,MA W111 TrL#617-7`27-4}Q0 cat 06 or 1-977=MASSAFF, Fax#617-'27 77� Revised 424D7 .mas5gQgfdia Massachusetts -DepartmznY of P��hiic 8afieiy F. Board of Su ldin-' Tom: ��la i� s and Standards Constructifm Super iS,, License: CS-014112 WILLIAM W CR0T0 IR 55 SUOMI RD HYANNIS MA 02601I t v — ,� is Expiratioi; Commissioner 04/2512016 t xe�p ConsMerAffac��zc&B sines�-\ Off- of l � ME IMP `1tTairs&Business Regulation - _� --- - - •IMPROVEMENT CONTRACTOR License or registration valid for individul use only gistration: 100023 ACTOR before the expiration date. If found return to: xpiration: 6/8/2016 Type: I Office of Consumer Affairs and Business Regulation BILL C DBA 10 Park Plaza-Suite 5170 ROSTON BUILDING CONTRACTOR Boston,MA 02116 WILLIAM CROSTON i 55 SUOMI RD HYANNIS,MA 02601 Undersecretary ' Notvali ithout signature r 1 " ` N PKRTMENT OF PUBLIC SAFETY MM ANWEALTH AVE ) r -'COMMONWEALTH D ".`. 01 MONEY O .. CAMMO NWEAL M O bF . .. S7ON:MASS.a.3�0 ENCLOSE CHECK OR. IMA �ETTS FOR REQUIREQ FEE, L I GEN`E r 1 E.1JF'ERVI` (.-.iR TO E(p pATIONDATE Q!,j 3(?j 1 a '! I�NrF MADE PAYABLE + _.d tj LIC-NO 6 s'= a EFFECTIVE DXI -COMMISSIONER OF PUBLIC SAFE L7 I o 1- CI`) i r. RESTRICTIONS 1� `06 jL, T END CASH) i 11 N�1NE p I J T EVERITT pf' WILLIAM I r 1 Goa: ,:.4-"�F 1 a 0 l-.35 / 5 5: # U-:I3TU I T MA PHOTO reusnNa ovR ONLY) FEE: - ���;;;qqq,,, L ABOVE SIGNATURE LINE 1 0(a e ' SIGs • (NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY � . HEIGHT; I STAMPED-OR- NATURE OF THE COOMM�Mp45SpONER DOB;j 1 j 1 x*�1 /J �(/`�/4LICENSIGN NAME IN FULL-ABOVE SIGNATURE_LIN ` � " SIGNATURE .!a THIS DOCUMENE T COMe.11SS10NER - - CARRIED ON TH THE HOLDER WHO T - ED IN THIS OC i - OTHERS RIGHT THUMB PRIN r t✓j,c%•! /. _�.Y_ ... ..._... . I � I V\voo5� - �. g Imo uRet� sr K.�►.1lrb�'� ����� 9 beff RE k� N\c . i �D,t= I axe ovs s 61v 1 14 o \- S FN � v �oocZ W 1 I� 1 IC Assessor's office(1 st Floor): � ' Assessor's map and lot number CO � To` . Board of Health(3rd floor): ' v ` Z ��® � d� �� Sewage Permit number • Engineering Department(3rd floor): c ToVjhq P���lL� LL n a House number l J � TJ t Yp9- ' Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:36-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNST B - BUILDING INSPECTOR APPLICATION FOR PERMIT TO `LA X I to ' 'S u iy 54o 1- ®v\J TYPE OF CONSTRUCTION • 19 IR?- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Proposed Use Zoning District ` Fire District hYkoov�—:-, Name of Owner Address 'TILA ��� l��/ �15 . f V�• Name of Builder VQ��� ���,�—� Address Name of Architect Address Number of Rooms 1 2 15'NS by 0*7 5 Foundation g�( �L7 CpIUCeFTF 3!�6U44, Exterior— Roofing Floors 714.E Interiort9�"� Heating y Plumbing '"L 4 Fireplace Approximate Cost Area Z Diagram of Lot and Building with Dimensions Fee 0 ll (off t �b LEO j a OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name AC ` Construction Supervisor's License t*0 , 6 HAAGSMA, JOY { 7 No �f 3-5.4--5"T Permit For BUILD ADDITION Single Family Dwelling ` Location 4 9 Glen Road Hyannis Owner Joy Haaqsma Type of Construction Frame Plot Lot Permit Granted October 16, 19 -92 _ Date of Inspection 19 Date Completed 19 141 lit �N,) I � , Town of Barnstable ,ofTHEToyti Regulatory ServicesTOWN OF BARNSNLE Thomas F. Geiler,Director +9aAxx5TABLE, Building Division ? €� T 2 9 P'9 3: 24 MA �PTfo fib, Tom Perry,Building Commissioner. 200 Main Street, Hyannis,MA 02601 vww.town.barnstable.ma.us DIVISION Office: 508-862-4038 Fax: 508-790-6230 PERMIT# FEE: �.Se SHED REGISTRATION 120 square feet or less Location of shed(address) Village ya�� Alaa C-- 77/ O&Z. Property lot ner's name Telephone number Size of Shed Map/Parcel# c /o a/Ild Signa Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30 &3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE: PLEASE SEE THE APPROPRIATE COMMISSION FOR.DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506 - Map Page I of I Town of Barnstable Geographic Information System New Search Home Help E3 E3 M I 1 Parcel Viewer Abutters ] Custom Map Abuers Map Size Zoom Out In yr R.r Turn map layers on/off by LP M a 3 P G selecting check boxes below F Town Boundaries Road Names Voter Precincts Map&Parcel Numbers It ry Parcels '4'j ............ FEMA Q3 Flood Zones(Old Maps) Vill Will be Superceded in 2010 AE(100 yr flood) AO(100 yr flood) VE(100 yr flood w/wave action) X500(500 yr flood) F Neighboring Towns A, Water 17 Streams 0 Set Scale 1 F60 I Aerial Photos r I MAP DISCLAIMER Copyright 2005-2010 Town of Barnstable,VA All rights reserved.Send questions or comments to GIS BamstableMA v1.2.3867[Production! http://66.203.95.236/arcims/appgeoapp/map.aspx?propertylD=288024 . 10/21/2010 Town of Barnstable *Permit#Aa 966 Expires 6 months from issue date Regulatory Services Fee- -7, D ij Thomas F.Geiler,Director OCT 1 7 2007 Building Division.. 4 17 TOWN, OF' BA'RINSTABLE Tom Perry,CBO, Building Commissioner' 200 Main Street,Hyannis,MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 . Fax: 508-790-6230 ' EXPRESS PER UT.APPLICATION - RESIDENTIAL ONLY y r �ry Not Valid without Red X-Press Imprint Map/parcel Number Property Address residential Value of Work ^ 6 a® Eti Minimum fee of$25. 0 or work.under$6000.00 Owner's Name&Address tf d, f 0 ' Contractor's Name 16L( Telephone Number Home Improvement Contractor License#(if applicable) Il t 64 F16 Construction Supervisor's License#(if applicable) Eqw-*Orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name I Worl ma n's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) / y, E<-roof(stripping old shingles) All construction debris will be taken to 4f*6 � 7 4 f r"� ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. zA-cC o f the vement Contractors License is required. SIGNATURE; Q:Forms:expmtrg Revise061306 The Commonwealth ofMassachusetts Department oflndustrial-4ecidents Office of Investigations 600 Washington Street Boston, MA 02111 . www.m ass.gov/dia Workers"Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):• �� �(,�` %/� Address: �t G�CQ�ir► i (�1C City/State/Zip: � �P/t/r✓�1.� Phone.#: 7 74 O 1 0 Are yAu an employer? Check the appropriate box: -Type of project(required):. 1. . I am a employer with _ 4. [] lam a general contractor and I . employees (full and/orpart time). * have hired the sttb-contractors 6• El New construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' insurance.$ 9• ❑Built ng addition comp.[No workers'comp.insurance required.] 5. ❑ We are a corporation and its 10.❑-Electrical repairs or additions '3.❑ I am a homeowner doing all officers have exercised their work 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0;PRoof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also M out the section below showing tbeirworkcrs'compcasation 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. 1C6ntracton tlrat 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 provi&their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below islhe policy and job site information. � Insurance Company Name: �J h�� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip Attach a copy of the workers' compensation policy decl atlan 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 S 1,500.00 and/or one-year imprisonment,as well as civil penaltits in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fox insurance coverage verification. 16 hereby certify;cn he pain • d penalties ofperjury that the information provided above is true and correct Date: : Sienature: . _ Phone#; 74 ��r7 rOther only. Do not write in this area,'ib be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumhinglnspector son: Phone#: :, Board of Bulwdln� tegulgpo qud Stagdai ds I N, :l ME IlNP1�OYEMENT CON*AOTQ1t 1 Re is 'I h 26Q9 Tr# 133426 l RLT GQN$T I F INO&RC)OPIN , RONNIE TAYL-6 - tiey _ CEN1 ERVIL4E MA 02Y Adi Slim, II Llc nse or reLnstration valid for hid. dul use only before the e4 6-1 iqp date If found returp tq;.. j Board of B gldin R�egulatioips and Standards f Oae Ashburton P1�gc�1301. . Bosfo�t,lVla.Q��¢8 . of valid w1Eho - ut signature '; :� RightFax H2-1 10/3/2007 5 : 12 : 09 PM PAGE 003/003 Fax Server ♦R ACORD. CERTIFICATE OF INSURANCE DATE(MMIDDIYY) 10-03-07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE EDWARD A GRAZUL INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 337 ALTER THE'COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE MARSTONS MILLS,MA 02649 COMPANY ; 28Y2IC A HARTFORD GROUP INSURED COMPANY x B R L T CONS TRU_ CTION INC COMPANY 31 MANNI CIRCLE C CENTERVILLE,MA 02632 COMPANY I D I COVERAGES 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. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE(MMIDD\YY) LIMITS GENERAL LIABILITY GENERALAGGREGATE $ COMMERCIAL GENERAL PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTORS PROT. EACH OCCURRENCE ' $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Anyone person) $ AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY.INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(Per Acdclent) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-1051C045-06 12-24-06 12-24-07 STATUTORYLIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERS/EXECUTIVE X INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION ITE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF BARNSTABLE THEREOF,THE ISSUING COMPANY WILL ENDEAVORTO MAIL 10 DAYS WRITTEN NOTICE TO THE POSE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL ATTN:BUILDING DEPARTMENT NO OBLIGATION OR L(ABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR 200 MAIN STREET REPRESENTATIVES. HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE Ramani Ayer WORD 25-5(3/93) Island Siding and 2�oo ' .f F Y 4� .. &. V . a dh*ion of RL7Construction Inc. Proposal to: July 26, 2007 Joy Haagsma 49 Glen Rd. Hyannis, Ma. 02601. We are pleased to submit the following specifications and estimates for roof replacement and skylite repair or replacement. Remove existing shingles and flashings. Install aluminum drip edge and pipe flashings. Install 3ft. Ice shield to eaves, valleys,skylites and chimneys. Install 151b. Tar paper to remaining roof. Install 30yr. Architectural grade shingles Install ridge vent. Clean up and haul away debris. We hereby propose to furnish material and labor- complete in accordance with the above specification, for the sum of: FIVE THOUSAND TWO HUNDRED DOLLARS. $5200.00 For lite repair includin2 caulkin2 21ass seal and cover nails w/ice shield.$125.00 or skylite replacement w/venting electric window $1400.00. Not inclu ing � electrician. A.Qr u c" �C G��ar/dw �w «-an GPI �-✓ PAYMENT,TO BE MADE AS FOLLOWS: W-9®r,Payment in full due upon completion. All material is guaranteed to be.as specified. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance. RLT Construction, Inc. carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are • satisfactory and hereby accepted. You are.authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: - �l Signature 31 Manni Circfe Centewdfe, Massachusetts 02632 7efephone 508.420.5243 and 5O8.833.5249 • Fax 508.420.1776 Emaifcaperoofer@caperoofer.com Town of Barnstable *Peru#-,���.� Eepires 6 months from issue date $ Regulatory Services Fee PERMIT >a�BTAaM ' Director Huss. g Thomas F.Geiler, X-PRESS s6s9- FOMPt6 Building Division Peter F.DiMatteo, Building Commissioner OCT 5 2001 367 Main Street, Hyannis,MA 02601w 'TOWN O F BARNSTABLE - Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - gEgIDENTIAL ONLY Not Valid without Red—press Imprint Map/parcel Number tiin 5— property Address � Value of Work /D aOU [Residential Owner's Nacre&Address +�— /:;r. Contractor's Frame ✓ZSJr�t j v Telephone Numb ' 4 Home Improvement Contractor License#(if applicable)_ low .Construction Supervisor's License#(if applicable) t 06 A slworkman's Compensation Insurance , Check one: ❑ 1 am a sole proprietor ❑ am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 't Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maxirnum ) 1�Other(specify) �''' -►✓r.� r e r^�r 6 e— 1/4 tiY.- r[ •Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic.Conservation,ctc. Signature ' Q:Forms:expmtrg:rev-070601 GTEo�'✓�aaoaalruaeQa BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 066391 1 Birthdate: 0111W1961 ,j Exlitpires:01113/2002 Tr.no: 17474 ' i Restricted To: 1G a. t JOHN M CHAPMAN 17 VIRGINIA ST �+ I HYANNIS, MA 02601 Administrator r. r ; x NONE INPROVENENT = TRACTOR z ,s Registration 2I030 y Upira$ion 0003/2002 u Av- CONST Y... ` �k JOHN CHRPPNflN TOR DORM x ADMINISTHAWR YEIIFIEET �yA� 02667 r t aZ— • r