HomeMy WebLinkAbout0084 KELLEY ROAD � �eJley ✓"�riv�
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oFt Tom, Town of Barnstable *Permit# 7 r (D
Expires 6 months from issue date
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Regulatory Services Feed,
HAM9�p ����' Thomas F.Geller,Director
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TE ►u`� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 P EE FU r
Office: 508-862-4038 JAN 13 2004
Fax: 508-790-6230
EXPRESS PERTMT APPLICATION - RESIDENTIA.t iF BARNSTABLE
Not Valid without Red&Press Imprint
Map/parcel Number 2- if-
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Property Address
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esidential Value of Work
Owner's Name&Address Wo13,aA : o -
?h tii Y -?11�-P�r ' Telephone NumberF —56'S_, ty 171F 4Y
Contractor's Name s
Home Improvement Contractor License#(if applicable)
a
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check
e:
am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
workman's Comp.Policy#
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)
e-side
Replacement Windows. U-Value o L` (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.
Ho a Improvement Contractors Licens�isrequired.
Signatur
Q:Forms:expmtrg
Revise053003
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°FTME r°�ti Town of Barnstable
Regulatory Services
3 33ARNSTASL , ' Thomas F.Geller,Director
t AMM
9`bpl fD {���� Building Division _
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
0ffice: 508-8624038 Fax: 508 790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I �yQ•. ✓.: _,;as..O�vnet.ofthe.subjectpropetty- ...._..._. .:
y 4 �Jc. /�-�� y� :- :. .to'act on my..behalf,.
. hereby authorize .-- -
in all matters relative to work authoiized.by.this building.permft.application fo-Z
(Ad ess o�fj ob)
$ignatare of Owner Date
Print Name
d
Board of Building Regulations and Standards
HOME IIEM7E7NT CONTRACTOR
Redigur t�,4A___� Y 81
E Cyr fio 3�1'M/2004
t .qgf 'lyidual
PAUL SCHNEIDE
PAUL SCHNEIDEF��.�
P.O.BOX 84/4 WHITE CXCF'LANE ��
SANDWICH,MA 02563 Adr;n;�t.i5rn�
AR WCIP iibexty
ISSUING OFFICE 354 mutual Workers Compensation and
INFORMATION PAGE Employers Liability Policy
:OUNT NO. SUB ACCT NO. Liberty Mutual Ifnsurance Group/Boston
1-331098 0006 LM INSURANCE CORPORATION 27243
POLICY NO. TD/CD SALES OJFFICE CODE SALES CODE N/R 1ST
i-31S-331088-013 XX X WESTON 102 REPRESENTATLVE 3000 2 YEAR
ASSIGNED 12001
Item L Name of PHOENIX REALTY TRUST INC
Insured Paper Senn it r em—i0x.5 FEIN 04-3492280
Address FO BOX 84
RISK ID 420347
SANDWICH,MA 02563
Status 03 CORPORATION
Other workplaces not shown above: SEE ITEM 4
Mo.Day Year Ma Day Year
tern 2.Policy Period:From 09-28-03 to 09-28-04
12:01 AM standard time at the address of the insured as stated herein.
Item 3.Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits
of our liability under Part Two are:
Bodily Injury by Accident 100,000 each.accident
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease .100,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4.Premium- The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating
Plans. All information required below is sub'ect to verification and char e by audit.
Premium B.,W& Rates LINE 110
Estimated Per S100 Estimated
Code Total Annual of RE- Annual
Classifications NO. Premiums muneratior. Premiums
iEE EXTENSION OF INFORMATION PAGE
vlinimun;Premium S 269 ( MA } Total Estimated Annual Premium S 274
nterim adjustment of premium shall be made: ANNUAL
Chis policy,including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710
Authorized Representative Date 09-12-03
s required to provide its policyholders with certain accident prevention services at no additional cost as
equired by Ark Code Ann. 11-9-409(d)and AWCC Rule 32.If you would like more information,call (972) 550-7899
%tension 2100.If you have any questions about this requirement,call the Health and Safety Division,Arkansas
7VorketV Compensation Commission at 1-800.6224472.
w.Code Term. Qper. Audit Basis Periodic Payment Rating Basis I Poi.H.G. I Home State Dividend RENEWAL OF:
09.12.03 NR MA WC1-31S-331088-012
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