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Home My WebLink About0041 LOCUST STREET y I Lo�-� �}---- I, - - Town of Barnstable *PermitQ�a�() /0 Expires tS mont .front issue date Regulatory Services Fee BA MABM KAM 1"9. � Thomas F.Geiler,Director MRt t' 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 - RESIDENTL4L ONLY Not Valid without Red X--Press Imprint Map/parcel Number Property Address y I LOCL {` Residential Value of Work t 3 S i Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address E k Qo_r-,o r Rvztwl— Contractor's Name Sprinkle Home Improvement Telephone Number 508 775-1778 Ext. 10 103757 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) CS 6643 5 IT XWorkman's Compensation Insurance JUN 15 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF SAR�S� ® I have Worker's Compensation Insurance ^� Insurance Company Name Associated Industries of MA / A.I.M Mutual Insurance Co. Workman's comp.Policy# AWC 7004943012012 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 aurmo l vavAe ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance ofthis 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 co e e Improvement Contractors License&Construction Supervisors License is ui SIGNATURE: C:\Users\decollik\AppDataU.ocal\Microsoft\Windows\Temporary Internet Files\ContenLoudook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Sprinkle Home improvement Address: 199 Barnstable Road City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext. 10 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ lama employer with 10-12 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling These sub-contractors have ship and have no employees 8` ❑:Demolition working for me in any capacity. employees and have workers" 9. ❑ Building addition [No workers' comp. insurance comp. insurance.- 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 t l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 1_ roof repairsinsurance required.]' c. l52. §1(4), and we have noemployees. [No workers' 4lther comp. insurance required.] •Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors 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 have employees,'they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Industries of MA./A.I.M Mutual Insurance Co, Policy#or Self-ins. Lic. #: 7004943012012 Expiration Date: 01/01/2013� Job Site Address: l--Oc s�- �t City/State/Zip: yrri I P,`;S M f9 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 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 for i ce verage verification. I do hereby certi andAenaltt4s ofperjuty that the information provided above is true and correct Si ature: C-- 'A '"" Date .Phone#: 508 775-1778 Ext. 10 Official use only. Do not write in this area,to be completed by cio,or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: UOL Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barostable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �E-Q-no 0, PO4R-e- ,as Owner'of the subject property hereby authorize Sprinkle Home Improvement to act on my behalf, in all matters relative to work authorized by this building permit application for. y I l-0 Cu ST i-1yr. (Address of Job) Signature of Owner Date Print Name if Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\i ocal\Micrmft\Windows\Temporary Internet Files\ContentOutlook\DDV87AAZ\EXPRESS.doc i Revised 072110 1212UIZU11 9 : 35 : 33 AM 8740 2 02 /09 CERTIFICATE OF LIABILITY INSURANCE 1DATE i2/v20/2o11za2 ' TNTS CQTS IS ISSUED AS A M "102 or I>rORRW:Os ONLY AMD cogr=p TI So MISS" orot TM CiRrIC#1X SOLDSt. ?Q! CRWXrIC"w DO" NOT Are:RIal1YSLY OR srAATiV"T AlMD, MMUD OR ALTER Tw COVSRAM AM== sY Tax POLICIsa ammoS. THIS c=rzrIc%Ts or f INSURASCX DONS NOT Cosrr2'rUTs A CONTaACT aNTWsis TNs ISSUISO INSURER(S), AUTNORIZOD MPRLYOTATIVS OR PaODDCSQ, AND TQ 1 czaTImam soLDsa. IWORTANT: If the ertificate bolder Is an ADDITIOSAL INSURED, the policy(iss) must he endorsed.. If SUBROGATION IS tAIVW,, suh)eet i to the terms and Conditions of the Polley, certain policies my require an endoreemrnt. A statwat on this certificate does not i confer rights to the Certificate bolder in lieu of such sndorsaaent(s). letsAM ACT Bryden i Sullivan In& ]Agency esm .a: i Inc WC. e., ut), 88 Palmouth Road III Hyannis, M& 02601 cm a I»• Inca" meotf) Metro=$rs.saasf out r Sprinkle Home Ileprave®ent Inc Imman., A.I.M. Mutual Insurance Co 33758 199 Barnstable Road t�,oC. —, IHyannis, NX 02601 co,,,,o,a, -- - nnnm f: IefYm .: COVCOAM CERTIFICATE NUMBER: REVISION NUMBER: as a to esa33sfr Nato m ramNe m or assaa" 14810=Nip are As zssm Ta m means aAAmmi ham rm VON*01MC9 riNOD ZOM:0410D. BUiR7le'al�a ASY xmavzm ' somm as C0SB14NOS or my eownwr as ova ooc7 rrm asarss so aBrw amss Lmram►s my is asOrm ae aAr rasa. us zxxn�AMOmSD ST ISM ros.NeaAs oQeLmID s>:aa D3 sumamw To ALL!am 111MMIi, ExcwxrOSf AND CoSDwrzors or sow rott—. LnEm faces MAY om m 2:0000011)Q ram CLAtm. POLICY{Tr VOL `a- seN or nsaaABcs edLY aaa WY,.wn.,n or rearm LbAIIS7 sNNaaL La,Ba rrr +� fan OCCULA K 1 �eoufAClAi,wn$AL LIAfn.:TT _ A✓�fa »mr0 es Iat tf•..awss.•w l O�QdIIO,war ❑OCCDP { Ono fa law.tr pa•.•1 $ emfs•t c atv IaTSQ $. OWL L.Aa$ffwTf LDtIT A911133 ff: - , f rosaaL aGriaaff $ O►a.ICT aDDW1Q aLOC (! 111A11C75_ C•w/or "a $. ,ofa�.ILB LiABII,i7T r..t:a loom LD.LT an auto WILT outer (pr>r 1 f ALL OefD ADT$! ❑-111M..►— - .QTLT 1AWMITtpr OfIMD AVIV! earmVr&sots - .. � lei•..t•!•tt) $ 1 Ofaa-01e9D AaTCf - i , eeARLA LLAS occur SAM WClamts $. { �lfCfu L[Af ❑ CLA D6 MDl n a9�r$Arf $ onocTlaf f i s i trQ L�r THE erto�va�eA , C.L. fao, .ceDsar _ f BOO.D00 A EXECU E 0rrICWt3 ARE - Ca@ff fsfatetras M IWTraO Q LKMir�, �. - r•L• flfiAQ •eaLICT LWIT Soo,000® loci ❑ excl 7004943012012 01/01/ 012Ol/01/2013f.L. DISRAM fa fILD=f $ 500,000 — it WORKERS' COMPENSATION COVERA(Z APPLIES TO MASSACHUSETTS EMPLOYEES t I ' { i (:W IF ICATE HOTIM C"CELI.AT I ON DROOP OF INSOR7UICC =Ouw'mY or vox Mon Destaiasa so== m CA MUzO woes"M 11mmm OS Os:s TNNRNor, my=W= BE ONUVOND IN amOaDANCi UITa ISZ I , soLxr rao►fsroR:. I 1 YRMQIsn QeQ fsrM fY[ (_� 1 5289 `I. ♦.I 711t I tl- il. li ,,iairsA NUsiorss egulatio11 HOME IMPROVEMENT CONTRACTOR Registration: 103757 Type: 6643 Expiration: 7/9/2012 Private Corporau( y 5?RINKI.i: NUME IMPROVEMENT iNC BRAD K SPRINKLE 4 190 LOTHROPS LANE W BARNSTABLE, MA 02668 • ;' . � 9�)3arnstai;le he t nrler.ccrrr,n Io �A)f3 60,04 ICPII�c ul ic,--istration %alid for individul use ouh Failure it)posses a curt•ent edition of the hctlur ;hr r�piration date. If found return tu: � cause for r�State Building Code t rtficc 1,1 Cmisumer Affair%and Business Regulate•,❑ is cause for rc��rati�n of this liren�c. 111 I':n•l. Plata- 'SuUe 5170 KILI,In. \1 \ II?1 Ih Refer at: WWW.Mass.GoODI'S �.It -alid -ithout sign tore ti C �n Town of Barnstable *Pail Expires 6 months from issue date Regulatory Services Fee 3,5. 1"9. Thomas F.Geiler,Director Building Division P/ Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to wn.b arnstab 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,_7�n 0 S Property Address y _ 5-�— tT Residential Value of Work � �( '-- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address E[P_, V\O Frei S Q►r 3� Fa 4no_ .DP-- A-sA1arldi, /ni or7,1 Contractor's Name Sprinkle Home improvement Telephone Number 508 775-1778 Home Improvement Contractor License#(if applicable) 103757 Construction Supervisor's License#(if applicable) C,:s UP 3 ZWorkman's Compensation Insurance << Check one: K ;,�., a PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner 0 C T 2011 I have Worker's Compensation Insurance Insurance Company Name Associated Inds IStriE?S of MA OWN OF aARNST:ABLE Workman's Comp.Policy#A_WC 70049430 12011 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) J Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ICI rml,\,A Trar1 s�- 144, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.35)#of windows •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 I ment Contractors License&Construction Supervisors License is requir SIGNATURE: C:\Users\decollik\HppData\Local\Microsoft\Windows\Temporary Internet iles\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/individual): Sprinkle Home Improvement Address: 199 Barnstable Road City/State/Zip:Hyannis, MA 02601 Phone#: 508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1. C K I am an employer with 9 4. 0 1 am a general contractor and I 6. ❑New constriction employees(full and/or part time).• have hired the sub-contractors 7. 0 Remodeling 2. 0 I am a sole proprietor or partner- listed on the attached sheet. slip and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers'comp.insurance comp.insurance.$ required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11. 0 Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12oof repairs employees.[no workers' comp.insurance required.] 13. 0 Other -Any appikant that cheeks box#1 most also m out the section below showing their workers'compensation policy hdormadon. tHomeownen who submit this a®davit indicating they are doing ail work and then hire outside contractors must submit a new a®davit hdkadug,such. tCoataerors that check this box must attach an addkiand shect showing the name of the sub-contractors and state whether or not those entities have employees. If the sab-eontraetors have emplovees,they must provide their workers'comw poley amber, I ant an employer that is providing*Yorkers'cot»pensadon insurance for my employees.Below is the policy andiob site nsuro>�Insuranceance Associated Industries of MA Company Name: Policy#or Self-ins.Lic.#: AWC 7004943012011 Expiration Date: 01-01-2012 Job Site Address: y 1 LorS,4 ��. City/State/Zip: AICi M yl(-S 1AP4 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby J- :y::n and penalties of pedury that the information provided above is true and correct Signature. Date: PriatName. Brad Sprinkle Phone#: 508 775-1778 EXt.10 Of)Rcial use only Do-not write in this area to be completed by city or town o ickd City or Town: Permit/license M Issuing Authority(circle one): 1-Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE i za 2010Y' 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(iss) 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 endoreement(a). PRotoota7l COWTACT Bryden 6 Sullivan Ins Agency PROM rAE Inc (A/t:. Nn. Z t): OL/C. No): L-MUL 88 Falmouth Road ADDI'ILSeo PRODUCRR Hyannis, MA 02601 CODTOMER IDe. INSURLD(a) ALrronDlSO C0VzRAa9 NAIC e INSURED IasvRm A: A.I.M. Mutual Insurance CO Sprinkle Home Improvement Inc INOURM B: 199 Barnstable Road INSURER Hyannis, MA 02 601 INSURLR D: INSURLR L: INRURLR r: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAND 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. POLICY EFF POLICY EXP uc� TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILIT7 Luca occsRAllca a COMMERCIAL GENERAL LIABILITY tN11Y(Q To ROIlID e PAIDQ tiB(4.oawzsv,wl []aCIAIM9 MADE ❑OCNR NLD= (Any—P.—) 0 ❑ PLRRONAL i ACV INJURY e e GEN'L AGGREGATE LIMIT APPLIES ER: ozvxRA.AOORLOATz ❑POLICY MPROJEC[ [3LOC PRCDUCT, -CCNa/OP ADO 0 0 AUTOMOBILE LIABILITY COMBINED SINQLZ LIMIT e MANY AUTO MALL OWNED AUTOS BOD ILY INJURY (V—pw..—) 0 SCHEDULED AUTOS BODILY INJVAY(P. -aid--) 0 ❑HIRED AUTOS - PROPItRTY DMDIRL D.—OWNED AUTOS ❑ a e UMBRELLA LIAR O OCCUR LALH OCCVPA31iCt e OEXCESS LIAB ❑ CLAIMS MADE / AOORLUATL e DEDUCTIBLE 0 ❑RETENTION b e WORMERS COMPENSATION rat LINiT� AND EMPLOYEES LLABILITY ER THE PROPRIETOR/PARTNERS/ a.L. LACH ACCIDLNI 0 500,000 A EXECUTIVE OFFICERS ARE ® incl ❑ excl 7004943012011 01/01/2011 01/01/2012 :.L. OxsLAss-POLICY LIMIT 0 500,000 L.L. DIRLABs -LA ns➢LOYLL 0 500,000 66GE Ts DLBCRIPTnw ay OPB9ATx01U DR Lo(aTIOWs: WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES • i CERTIFICATE HOLDER CANCELLATION PROOF OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE ( POLICY PROVISIONS. AVTNORI SLD ALPA—TATIVL�--'C'� v i ' Town of Barnstable Regulatory Services Thomas F.Geller,Dhvdor Building Division Tbomas Perry,CBO BoUdigg Commlesioner 200 Main Shvet, Hyannis,MA 02601 , www.towGJxw stable ma.us O We: 508-8624038 Fax: 508.79"230 Property owner Must Complete and Sign This Section If Using A Builder leA-noe-- as Owner of the subject property hey authorize Sprinkle Home Improvement to act on my behalf in all matters relative to work authorized by this building permit application for. &ayiA Ls (Address of Job) Signature of Owner to EI a ems, a�.—,Q, . Print Name If Property Owner 4 ap*ft for permit,please complete the Ibmeowners License Ezempdon Form on the reverse stile. , RrWsW 72116 .Mw�,�T lateen=Fiba�ContmcovtlooldDDv87nnz�RBSsdoc Revised 072110 Nla.a.tchtnctl. - Departnicnt of Public ' 1A'CtN Bnart of Building Rc. lt[i n�. .uid C t.urd.0 Ofc lonsume k air' B�s.m,e1�cKrv�t�oc6,hdoend t la _._ HOME IMPROVEMENT CONTRACTOR Construction Supervisor .License Registration: ,,.103757 Type: License: CS 6643 Expiration 7/9/2012 Private Corporatic SPNINKLE HOME IMPROVEMENl,'INC. BRAD K SPRINKLE 1 190 LOTHROPS LANE Brad Sprinkle M tr W BARNSTABLE, MA 02668 :. 199 Barnstable.Rd. Hyannis, MA 02601 Undersecretary Expiration: 10/8/2013 t nimi..iu�u•r Tr': 6004 License or registration valid for individul use only Failure to possess a current edition of the before the expiration date. If found return to: Massachusetts State Building Code Office ce of Consumer Affair is cause for revocation of this license. s and Business Regulation � 10 Park Plaza-Suite 5170 Boston,MA 02116 Refer to: WWW.Mass.Gov/DPS . j ^Not valid without sign ture ��'