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Home My WebLink About0157 GOSNOLD STREET I5-7 G©SY,o I S , Y IZa11 SINE Town of Barnstable *Permit# - o i,p Expires 6 months from issue date Regulatory Services Fee = snxtvszABLE, MASS. Richard V.Scali,Director 1639. ♦0 AEG MA'I A Building Division Tom Perry,CBO,Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY D/ l� Not Valid without Red X-Press Imprint Map/parcel Number (O Property Address i 5 a—y � o TRe ez VResidential Value of Work$ (90. OD Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �hr/S D)ea L Contractor's Name' Telephone Number Sd(�36�- Home Improvement Contractor License#(if applicable) 1 _2((J l7 Email: �� Q ✓ �,V'C' Construction Supervisor's License#(if applicable) dworkman's Compensation Insurance Check one: JUN 16 2016 ❑ I am a sole proprietor �� ❑ I am the Homeowner N OF SA R N S rA B i C I have Worker's Compensation Innssuur�ance LC Insurance Company NameCe Workman's Comp. Policy# W CC J od r ✓wi�� p2�� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) / Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to clwo i�_ l a l ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required., Separate Electrical&Fire Permits required. *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&Construction Supervisors License is equired. SIGNATURE: vil 44 C:\Users\Decollik\AppData\Local\Microsoft\Windows\Tempo Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 r Zhe Coinmonnwakh of Alassachusetts ,Deparonent ofIndustrialAeddents Office of Investigations 600 Washingion.S`tmet Boston,MA 02111 r st:ntat~.sgotAfto Workers' Compensation Insurance Affidavit:BWde /Contra+ctorsM"triciaus/Plambers licanit Information Please Pratt Laj 'b Names Alf�'d AA&ess. / o - x City/Staftaip v04 l ow;-bone#: , E"` - ;. Are you an employer?Check the appropriate box: T of 1. I am a employer with / 4. ❑ I am a general contractor and I 7 project(r )= employees(full andtor part-time,).* have hired the sub-contractors 6. ❑New consaiusction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no emuployees These sub-contractors s6b-contractors have 8e ❑Ditnolition w for me in an capacity- employees and have workers° ° Y insurance.- 9. []Building addition [No wod ms'comp.ins comp.omp wed,] 5, ❑ We are a corporation and its 10_❑Electrical repairs or additions 3-❑ I am a homeowner all work officers have exercised their l LE]❑Plumbing repairs or additions myself er pelf w ' right of -on per MO 12.0 Roof repairs insurance required-]T c- 152,§1(4), we have.so employees.[No 13.0 Other comp-insurame required.] *Any applicant&at thus boat#i mast also GO out the sectioa below showing&wwo&eW coaWmtionpolicy infounation. Homeowners who submit dais affutam Wdicaung they we doing sM work and then hire owm&coanums toast mbtnit a new affftm indicting such. !Coaaactass that check dais bate Macbed sa Mi tioaat shm showing the nme of the sus-coaatractm anal on whe*s°or not those enddes have 3f the sub-coauacton bale ezal es,.&eV toast pmvide Ow wcadws'camp,policy cumber, I am an employer that is providing wsorkeri`compensation insurance for my empleyee& Below i{s the pol cy and}rrb site information. Insurance Company l+lame: Policy#or Self ins.Uc.9: 02 OJ t X Expiration.Date:�7 Job Site Address: I ! 14ol o cityrstate zip: Attach a copy of the workers'compensapion policy duration page(showing the policy number and expiration date). Failure to secure calerage as required and Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 andlor 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 dais statement way be forwarded to the Office of lm-estigations of the DIA for insurance coverage cserificalon_ I do hereby c n er thpares and penalties of pedisry that the information proWded above is Mtn and correct S' ./� Date: KCill G Official use only: Do not write in this area,to be completed by city or town official City or Tort: Permit/License ft Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City-frown Clerk 4.Electrical Inspector S.Plumbing>mspector 6.Other Contact Person. Phone#: 6 Client#:9742 2BAKERAS ACORD,,, CERTIFICATE O DATE(MMIDDIYYYY)F LIABILITY INSURANCE 4/20/2016 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 ADCiITtONAL'RS-OkIff.D..,the. . p.o.I cy.(I.e.s must.......be endorsed.If SUBROGATION LIS WAIVED,subject t.o............. 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 CONTACT N E; m.11-.............. Dowling&O'Neil Insurance Ag PHONE ]FAX I ,N,Et):508 775-1620 5087781218 973 Iyannough Rd,PO Box 1990 E-MAIL ADDRESS Hyannis,MA 02601 : .................. 508 775-1620 ....................•... INSURER(S .. )AFFORDING COVERAGE NAIC......................_ III INSURER A:National Grange Mutual Insuranc ........................ .................................... INSURED Baker&Associates,ine. INSURER B 1 Associated Employers Insurance INSURER C: I P 0 Box 923 ................... I ................. INSURER D: Centerville,MA 02632-0071 INSURER E: ............. ................................... 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 CONTRACTOR 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 JADDLjSUBRj POLICY EFF POLICY LTR 'INSR lWVO POLICY NUMBER MID LIMITS ............... ARWRL 4M ................. A GENERAL LIABILITY MPJ7223M 0411912016 04119/2017 EACH OCCURRENCE. :$1000 000 .................. 7X COMMERCIAL GENERAL LIABILITY DAM Al T?I�E PREM.feS occurrence) 000 CLAIMS-MADE I Al OCCUR MED EXP(Any one person) 1$10,000 PERSONAL&ADV INJURY 1$1,000,000 ............ ...... .................................... AGGREGATE 2,000,000 ............... ...................................................:$ GEN'L AGGREGATE LIMIT APP LIES PER PRODUCTS-COMP/OP AGG $2,000,000 ......................................... I f h POLICY i J PRO-ECT I LOC ..................................- ....................... ..................- .......... ........... ........... I COMBINED SINGLE UMIT AUTOMOBILE LIABILITY $............................................... (Ea accident) ANY AUTO BODILY INJURY(Per person) $ _7 ALL OWNED SCHEDULED AUTOS j AUTOS BODILY INJURY(Per accident) $ ..... .. ..................... (Per dent i NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS $ acci )............. I$ .......... i UMBRELLA LIAB OCCUR EACH OCCURRENCE $ ................. EXCESS LIAS CLAIMS-MADE! AGGREGATE .............. .......... ................................ ............. ................................... ...................................................... WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY YIN WCC50050024542016A D4/2312016104/2312017 X ' .......... TSYRY I! EEl ...................................... i ANY PROPRIETORtPARTNER?EXECUTIVE7 i I OOO E.L.EACH ACCIDENT $P91OFFICERIMEMBEREXCLUDI --- (Mandatary In NH) E.L.DISEASE-EA EMPLOYEE!s500OOO it yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101'Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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. AUTHORIZED REPRESENTATIVE 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of I The ACORD name and logo are registered marks of ACORD #S168706IM168705 CBD Massachtis tts Department of Pub1ir� Safety Board of Building Regulations and Standards License GS-009714 Construction supervisor RICHARD P GARNEAU,JR PO BOX 476 WEST 13ARNSTABLE Expiration" oftimi ione 134/W2018 _ b Office of Consumer Affairs a LAusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ;. Registration: 162600 ;. Type: Supplement Card Expiration: 3/26/2017 BAKER & ASSOCIATES INC. RICHARD GARNEAU ....�..�.__. ___. .._ _..._.__ _. _ ....... P.O. BOX 923 CENTERVI'LLE, MA 02632 U date:Address and return card.Mark reason for change. WA 1 0 20M•05111 Address Renewal (mm� Employment 1 Lost Card �'i��c��rFJ�rr�resrrcrrr�rjl�c�C`i��xa�crr�ft�rl� cc of Consumer Affairs&Business Regulation License or registration valid for individui use only r E IMPROVEMENT,CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation. egistration 16260t1 Type: 10 Park Plaza-Suite 5170 Explratiori: 3l26/2017' Supplement C<Nd Boston,MA 0211.E BAKER&ASSOCIATES INC: RICHARD GARNEAU 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 (� ____. ..............__........._.._......... __._._ _ Undersecretary Not valid without signatur f 06/13/2016 MON 11: 05 FAX 0004/006 Authorization .Form: I as owner of the subject property, hereby autho ze Baker&Associates to act on my behalf, in all matters relative to work authorized by this building permit application for : Address of property: 157 Gosnold Street Hyannis, N1 Signature of owner: Print Name: Date: ri